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Maternal and neonatal outcome after vaginal breech delivery at term after cesarean section – a prospective cohort study of the Frankfurt breech at term cohort (FRABAT)
Abstract
Objective
To compare the neonatal and maternal outcomes as well as the mode of delivery of intended vaginal breech deliveries in women with a prior cesarean section to primiparous patients.
Study design
The prospective monocenter cohort study was conducted among 604 women who presented for an intended vaginal singleton breech delivery at term between January 2007 and December 2016.
Results
Out of 37 women with a prior cesarean 19 had a successful vaginal delivery. 344 of 567 primiparous women had a successful vaginal delivery. Neonatal morbidity and mortality as well as maternal outcome were not significantly different in successful vaginal deliveries of women with prior cesarean compared to primiparous patients. The cesarean section rate was not significantly higher in the group of women with a prior cesarean (49%) compared to the group of primipara (39%).
Conclusion
A prior cesarean should not be taken as an exclusion criterion for a planned vaginal delivery out of a breech presentation at term. Large multicenter, case-controlled studies are necessary to implement international guidelines.
... Numerous papers were published in the past few years that clearly underline the safety of vaginal breech delivery-particularly in an upright birth position-regarding neonatal and maternal outcomes and these refute guideline-based restrictions and concerns. In this regard, nulliparity, high birth weight, overdue pregnancy, birth induction and previous cesarean section do not seem to affect neonatal or maternal morbidity substantially [7][8][9][10][11][12]. More importantly, slightly elevated rates in short-term morbidity did not translate into long-term morbidity in vaginally intended breech deliveries [13]. ...
... The counseling process, the FRABAT cohort, the modified PREMODA morbidity score as well as patient selection and procedures at our center have been previously described [7][8][9][10][11]. ...
... Again, parity, BMI and fetal birth weight were not different in both groups, underlining comparability (Table 4). Fetal morbidity, measured with a modified PREMODA Score adapted from Goffinet et al. [13,19] and used in previous publications [7][8][9][10][11] did not show a significant difference. Since obstetricians have had training before supervising vaginal breech birth on their own, a difference in fetal outcome in this analysis would have been surprising and of great concern. ...
Background:
Vaginal breech delivery is becoming an extinct art although national guidelines underline its safety and vaginal breech delivery in an upright position has been shown to be a safe birth mode option. In order to spread clinical knowledge and be able to implement vaginal breech delivery into obstetricians' daily practice, we need to gather knowledge from facilities who teach specialized obstetrical management.
Methods:
We performed a prospective cohort study on 140 vaginal deliveries out of breech presentation solely-managed by seven newly-trained physicians and compared fetal outcome as well as rates of manual assistance in respect to preexisting experience.
Results:
Fetal morbidity rate measured with a modified PREMODA score was not significantly different in three sub-cohorts sorted by preexisting expertise levels of managing obstetricians (experience groups EG, EG0: 2, 5%; EG1: 3, 7.5%; EG2: 1, 1.7%; p = 0.357). Manual assistance rate was significantly higher in EG1 (low experience level in breech delivery and only in dorsal position) compared to EG0 and EG2 (EG1 28, 70%; EG0: 14, 25%; EG2: 21, 35%; p = 0.0008).
Conclusions:
Our study shows that vaginal breech delivery with newly-trained obstetricians is a safe option whether or not they have advanced preexisting expertise in breech delivery. These data should encourage implementing vaginal breech delivery in clinical routine.
... There is plenty discussion on the selection criteria upon which pregnant women are eligible for trial of labor when breech presentation occurs. The largest prospective cohort study collective on vaginally intended breech deliveries was able to show that parity, birth induction, fetal birth weight, birth after cesarean, and fetal leg posture impact emergency cesarean section rate but not fetal morbidity when deliveries are performed in an upright maternal position [12][13][14][15][16][17]. Still there are only few obstetrical centers offering vaginal birth out of breech presentation, depriving many women of the ability to choose their preferred intended birth mode. ...
... The probability to need manual assistance in vaginal deliveries also was not significantly associated with IPBUES (Table 4). Vaginal birth out of breech presentation is a safe delivery mode, even if cesarean section or manual assistance is of need in the process [12,13,17]. Hence, affected fetal or maternal morbidity was not expected. ...
Purpose: In order to spread competence in vaginal breech deliveries, it is necessary to develop new and easily applicable tools for birth progression and safety evaluation. Ultrasound is a useful and ubiquitously available tool with already documented value for birth progression observation. In deliveries out of breech presentation, an established ultrasound examination is missing. We determined the descent of the fetal buttocks in relation to the maternal pelvic inlet using intrapartum ultrasound. We evaluated these results in comparison to the clinical vaginal examination with the aim to establish an easily applicable method for birth outcome prediction. Therefore, we analyzed the predictive value of our examinations on birth outcome parameters, such as cesarean section rate, as well as fetal and maternal outcome parameters.
Methods: We performed a prospective blinded study on 106 mothers with vaginally intended breech delivery. At beginning of stage two in labor, the descent of the fetal buttocks into the mother's pelvic inlet was detected with transabdominal ultra-sound and vaginal examination by different observers. Primary outcome variable: Cesarean section rate. Secondary outcome variables: rate of manual assistance in vaginal deliveries, birth duration, 5′ APGAR score, umbilical arterial pH, maternal blood loss, and perineal injury. For non-parametric values, Wilcoxon's χ 2 test was performed. In order to analyze the predictive value of our examination, lack-of-fit analysis was conducted. Reliability evaluation of the sonographic examination was done with a matched-pair analysis.
Results: Women with positive intrapartum ultrasound breech engagement sign (+ IPUBES) had a significantly lower rate of cesarean section in comparison with those with negative IPUBES (5/67; 7.5% vs. 18/39; 46.2%; p < 0.0001). The area under the ROC curve for the prediction of CS for negative IPUBES was 0.765 with a sensitivity of 78.3% and a specificity of 74.7%. Sonographic examination showed an excellent reliability in a matched-pair analysis comparing vaginal and sonographic examinations with a mean difference of 0.012 (SD ± 0.027, 95% CI − 0.014 to 0.065). Mean birth duration was significantly longer in deliveries with negative IPUBES (533 min vs. 440 min; p = 0.0011). Fetal and maternal outcome parameters were not significantly different between deliveries with positive and negative IPUBES. Conclusions: Sonographic evaluation of the fetal descent in relation to the mother's pelvic inlet screens reliably for emergency cesarean section. This newly presented method for birth progression observation might be a powerful tool for distribution of expertise in vaginal breech delivery and is able to give reference for clinical vaginal examination by obstetricians in training.
Trail registry Clinical trial. Date of registration: 13.03.2019; Date of initial participant enrollment: 20.03.2019; DRKS00016885; https:// www. drks. de; German clinical trials register.
... Inclusion criteria were patients who presented at 34-36 weeks of gestation with breech presentation at our outpatient clinic for delivery planning and registration. The standardized counseling process as well as the clinical management has been published in several studies of the FRABAT study collective [15,16,[19][20][21][22][23]. ...
Purpose
Obesity is a worldwide and growing issue affecting women in childbearing age, complicating surgical procedures as well as pregnancy. Through a reduction of not necessarily required cesarean deliveries—for instance in pregnancies with breech presentation—obesity mediated and surgery-associated morbidity might be contained. Date on the impact of maternal BMI in vaginally attempted breech delivery is not existing. To give insight into whether an elevated BMI leads to an increased perinatal morbidity in vaginally intended deliveries out of breech presentation, we analyzed delivery outcome of laboring women with a singleton baby in breech presentation with overweight and obesity (BMI ≥ 25 kg/m²) in comparison to women with a BMI of below 25 kg/m².
Methods
Based on data from January 2004 to December 2020, a cohort study was performed on 1641 women presenting with breech presentation at term (> 37 weeks). The influence of maternal BMI on perinatal outcome was analyzed with Chi² testing for group differences and logistic regression analysis. Patients with a hyperglycemic metabolism were excluded from the study.
Results
Fetal morbidity was not different when patients with a BMI of ≥ 25 kg/m² (PREMODA morbidity score 2.16%) were compared to patients with a BMI of below 25 kg/m² (1.97%, p = 0.821). Cesarean delivery rates were significantly higher in overweight and obese women with 43.9% compared to 29.3% (p < 0.0001). BMI and cesarean delivery were significantly associated in a logistic regression analysis (Chi² coefficient 18.05, p < 0.0001). In successful vaginal deliveries out of breech presentation, maternal perineal injury rates (vaginal birth in normal-BMI women 48.4%; vaginal birth in overweight and obese women: 44.2%; p = 0.273) and rates of manually assisted delivery (vaginal birth in normal-BMI women: 44.4%; vaginal birth in obese and overweight women: 44.2%; p = 0.958) were not different between BMI groups.
Conclusions
Obesity and overweight are not associated with peripartum maternal or newborn morbidity in vaginally attempted breech delivery, if the patient cohort is thoroughly selected and vaginal breech delivery is in an upright maternal position. Reduction of cesarean delivery rates, especially in overweight and obese women might, have an important positive impact on maternal and newborn morbidity.
... Other studies with intersection cohorts have been published by different authors of the FRABAT group within previous publications. [15][16][17][18][19]. ...
Introduction
Epidural anesthesia is a well-established procedure in obstetrics for pain relief in labor and has been well researched as it comes to cephalic presentation. However, in vaginal intended breech delivery less research has addressed the influence of epidural anesthesia. The Greentop guideline on breech delivery states that there’s little evidence and recommends further evaluation.
Objective
The aim of this study was to compare maternal and neonatal outcomes in vaginally intended breech deliveries at term with and without an epidural anesthesia.
Design
This study was a retrospective cohort study.
Sample
This study included 2122 women at term with a singleton breech pregnancy from 37 + 0 weeks of pregnancy on and a birth weight of at least 2500 g at the obstetric department of University hospital Frankfurt from January 2007 to December 2018.
Methods
Neonatal and maternal outcome was analyzed and compared between women receiving “walking” epidural anesthesia and women without an epidural anesthesia.
Results
Fetal morbidity, measured with a modified PREMODA score, showed no significant difference between deliveries with (2.96%) or without (1.79%; p = 0.168) an epidural anesthesia. Cesarean delivery rates were significantly higher in deliveries with an epidural (35 vs. 26.2%, p = 0.0003), but after exclusion of multiparous women, cesarean delivery rates were not significantly different (40.2% cesarean deliveries with an epidural vs. 41.5%, p = 0.717). As compared to no epidurals, epidural anesthesia in vaginal delivery was associated with a significantly higher rate of manual assistance (33.8 versus 52.1%) and a longer duration of birth (223.7 ± 194 versus 516.2 ± 310 min) (both p < 0.0001)".
Conclusion
Epidural anesthesia can be offered as a safe option for pain relief without increasing neonatal or maternal morbidity and mortality. Nevertheless, it is associated with a longer birth duration and manually assisted delivery.
: (1) Background: Guidelines on vaginal breech delivery require birth weight restrictions
and neglect the impact of pelvic measurements despite contradicting evidence. There is a great need
for more evidence on delivery outcome predicting factors for patients counselling. (2) Methods: We
performed a prospective cohort study on 748 primiparous women intending vaginal breech birth
and analyzed combined influence of fetal birth weight (BW) and the obstetric conjugate (conjugate
vera obstetrica, CVO) on delivery outcome. (3) Results: We generated a BW/CVO ratio and devided
our study cohort at median (257.8 g/cm) into a low ratio group (LR, with low birth weight and wide
obstetric conjugate) and a high ratio group (HR, high birth weight and narrow obstetric conjugate).
Cesarean section (CS) rate was significantly higher in HR (50.3%) as compared to LR (28.3%, p <
0.0001). Fetal morbidity was not different. In vaginally completed deliveries duration of birth was
significantly longer in vHR (557 min) as in vLR (414 min, p < 0.001). Manual assistance to deliver
the arms (‘Louwen maneuver’) positively correlated with birth weight (r2 = 0.215; p = 0.005) and the
BW/CVO ratio (r2 = 0.0147; p = 0.02). (4) Conclusions: A high fetal birth weight combined with a tiny
CVO predicts higher cesarean section probability, longer birth duration and the necessity to per‐
form arm delivery assistance. Birth weight and pelvic measurements should be topics of great im‐
portance in patients counselling.
This authoritative textbook provides a much-needed guide for postgraduate trainees preparing for the European Board and College of Obstetrics and Gynaecology (EBCOG) Fellowship examination. Published in association with EBCOG, it fully addresses the competencies defined by the EBCOG curriculum and builds the clinical practice related to these competencies upon the basic science foundations. Volume 1 covers the depth and breadth of obstetrics, and draws on the specialist knowledge of four highly experienced Editors and over 100 contributors from across Europe, reflecting the high-quality training needed to ensure the safety and quality of healthcare for women and their babies. It incorporates key international guidelines throughout, along with colour diagrams and photographs for easy understanding. This is an invaluable resource, not only for postgraduate trainees planning to sit the EFOG examination, but also for practising specialists looking to update their knowledge and skills to meet the ever-evolving complexity of clinical practice.
Introduction
The clinical management of breech presentations at term is still a controversially discussed issue among clinicians. Clear predictive criteria for planned vaginal breech deliveries are desperately needed to prevent adverse fetal and maternal outcomes and to reduce elective cesarean section rates. The green-top guideline considers an estimated birth weight of 3.8 kg or more an indication to plan a cesarean section despite the lack of respective evidence.
Objective
To compare maternal and neonatal outcome of vaginal intended breech deliveries of births with children with a birth weight of 2.5 kg– 3.79 kg and children with a birth weight of 3.8 kg and more.
Design
Prospective cohort study.
Sample
All vaginal intended deliveries out of a breech position of newborns weighing between 2.5 kg and 4.5 kg at the Obstetrics department at Goethe University Hospital Frankfurt from January 2004 until December 2016
Methods
Neonatal and maternal outcome of a light weight group (LWG) (< 3.8 kg) was compared to and a high weight group (HWG) (≥ 3.8 kg) using Pearson’s Chi Square test and Fishers exact test. A logistic regression analysis was performed to detect an association between cesarean section rates, fetal outcome and the birth weight.
Results
No difference in neonatal morbidity was detected between the HWG (1.8%, n = 166) and the LWG (2.6%, n = 888). Cesarean section rate was significantly higher in the HWG with 45.2% in comparison to 28.8% in the LWG with an odds ratio of 1.57 (95% CI 1.29–1.91, p<0.0001). In vaginal deliveries, a high birth weight was not associated with an increased risk of maternal birth injuries (LWG in vaginal deliveries: 74.3%, HWG in vaginal deliveries: 73.6%; p = 0.887; OR = 1.9 (95% CI 0.9–1.1))
Conclusion
A fetal weight above 3.79 kg does not predict increased maternal or infant morbidity after delivery from breech presentation at term. Neither the literature nor our analyses document evidence for threshold of estimated birth weight that is associated with maternal and/or infant morbidity. However, patients should be informed about an increased likelihood of cesarean sections during labor when attempting vaginal birth from breech position at term in order to reach an informed shared decision concerning the birth strategy. Further investigations in multi center settings are needed to advance international guidelines on vaginal breech deliveries in the context of estimated birth weight and its impact on perinatal outcome.
Objective:
To compare breech outcomes when mothers delivering vaginally are upright, on their back, or planning cesareans.
Methods:
A retrospective cohort study was undertaken of all women who presented for singleton breech delivery at a center in Frankfurt, Germany, between January 2004 and June 2011.
Results:
Of 750 women with term breech delivery, 315 (42.0%) planned and received a cesarean. Of 269 successful vaginal deliveries of neonates, 229 in the upright position were compared with 40 in the dorsal position. Upright deliveries were associated with significantly fewer delivery maneuvers (OR 0.45, 95% CI 0.31-0.68) and neonatal birth injuries (OR 0.08, 95% CI 0.01-0.58), second stages that were 42% shorter on average (1.02 vs 1.77 hours), and nonsignificantly decreased serious perineal lacerations (OR 0.34, 95% CI 0.05-3.99). When upright position was used almost exclusively, the cesarean rate decreased. Serious fetal and neonatal morbidity potentially related to birth mode was low, and similar for upright vaginal deliveries compared with planned cesareans (OR 1.37, 95% CI 0.10-19.11). Three neonates died; all had lethal birth defects. Forceps were never required.
Conclusion:
Upright vaginal breech delivery was associated with reductions in duration of the second stage of labor, maneuvers required, maternal/neonatal injuries, and cesarean rate when compared with vaginal delivery in the dorsal position.
Objective: To examine the outcomes of vaginal birth after cesarean (VBAC) in women, in spontaneous labor, delivering after 37 weeks gestation at an institution where trial of labor after caesarean section (TOLAC) is encouraged and management of labor standardized.
Methods: This retrospective cohort study included 3071 women with one previous caesarean only and no vaginal delivery who underwent a trial of labor from 2001-2011. Women were managed using the standardized “Active Management of Labour” intrapartum protocol. Outcomes and characteristics of women who delivered vaginally were compared with those who required cesarean delivery.
Results: In spontaneous labor in their second pregnancy, those who attempted TOLAC had a 72.5% (1611/2222) rate of successful VBAC. Women who had a successful VBAC had smaller babies (3584 ± 452g vs. 3799 ± 489g; p < 0.0001) at earlier gestations than those who had a repeat intrapartum cesarean delivery. They also required less intrapartum intervention, such as oxytocin augmentation (14.5% [234/1611] vs. 41% [251/611]; p < 0.0001) and epidural anaesthesia (64.8% [1044/1611] vs. 82.8% [506/611]; p < 0.0001). The rate of uterine rupture was 0.54% (12/2222), while the rate of peri-partum hysterectomy was 0.18% (4/2222).
Conclusion: This study shows that serious complications associated with TOLAC are rare providing intrapartum care and decision-making is made simple for the benefit of staff and patients alike. This is achieved through a standardized labor management protocol.
Most countries recommend planned cesarean section in breech deliveries, which is considered safer than vaginal delivery. As one of few countries in the western world Norway has continued to practice planned vaginal delivery in selected women. The aim of this study is to evaluate prospectively registered neonatal and maternal outcomes in term singleton breech deliveries in a Norwegian hospital during a ten years period. We aim to compare maternal and neonatal outcomes in term breech pregnancies subjected either to planned vaginal or elective cesarean section.
A prospective registration study including 568 women with term breech deliveries (>37 weeks) consecutively registered at Sorlandet Hospital Kristiansand between 2001 and 2011. Fetal and maternal outcomes were compared according to delivery method; planned vaginal delivery versus planned cesarean section.
Of 568 women, elective cesarean section was planned in 279 (49%) cases and vaginal delivery was planned in 289 (51%) cases. Acute cesarean section was performed in 104 of the planned vaginal deliveries (36.3%). There were no neonatal deaths. Two cases of serious neonatal morbidity were reported in the planned vaginal group. One infant had seizures, brachial plexus injury, and cephalhematoma. The other infant had 5-minutes Apgar < 4. Twenty-nine in the planned vaginal group (10.0%) and eight in the planned cesarean section group (2.9%) (p < 0.001) were transferred to the neonatal intensive care unit. However, only one infant was admitted for >=4 days. According to follow-up data (median six years) none of these infants had long-term sequelae. Regarding maternal morbidity, blood loss was the only variable that was significantly higher in the planned cesarean section group versus in the vaginal delivery group (p < 0.001).
Strict guidelines were followed in all cases. There were no neonatal deaths. Two infants had serious neonatal morbidity in the planned vaginal group without long-term sequelae.
A large trial published in 2000 concluded that planned vaginal delivery of term breech births is associated with high neonatal risks. Because the obstetric practices in that study differed from those in countries where planned vaginal delivery is still common, we conducted an observational prospective study to describe neonatal outcome according to the planned mode of delivery for term breech births in 2 such countries.
Observational prospective study with an intent-to-treat analysis to compare the groups for which cesarean and vaginal deliveries were planned. Associations between the outcome and planned mode of delivery were controlled for confounding by multivariate analysis. The main outcome measure was a variable that combined fetal and neonatal mortality and severe neonatal morbidity. The study population consisted of 8105 pregnant women delivering singleton fetuses in breech presentation at term in 138 French and 36 Belgian maternity units.
Cesarean delivery was planned for 5579 women (68.8%) and vaginal delivery for 2526 (31.2%). Of the women with planned vaginal deliveries, 1796 delivered vaginally (71.0%). The rate of the combined neonatal outcome measure was low in the overall population (1.59%; 95% CI [1.33-1.89]) and in the planned vaginal delivery group (1.60%; 95% CI [1.14-2.17]). It did not differ significantly between the planned vaginal and cesarean delivery groups (unadjusted odds ratio = 1.10, 95% CI [0.75-1.61]), even after controlling for confounding variables (adjusted odds ratio = 1.40, 95% CI [0.89-2.23]).
In places where planned vaginal delivery is a common practice and when strict criteria are met before and during labor, planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women.
Background:
The use of trial of labor after cesarean delivery calculators in the prediction of successful vaginal birth after cesarean delivery gives physicians an evidence-based tool to assist with patient counseling and risk stratification. Before deployment of prediction models for routine care at an institutional level, it is recommended to test their performance initially in the institution's target population. This allows the institution to understand not only the overall accuracy of the model for the intended population but also to comprehend where the accuracy of the model is most limited when predicting across the range of predictions (calibration).
Objective:
The purpose of this study was to compare 3 models that predict successful vaginal birth after cesarean delivery with the use of a single tertiary referral cohort before continuous model deployment in the electronic medical record.
Study design:
All cesarean births for failed trial of labor after cesarean delivery and successful vaginal birth after cesarean delivery at an academic health system between May 2013 and March 2016 were reviewed. Women with a history of 1 previous cesarean birth who underwent a trial of labor with a term (≥37 weeks gestation), cephalic, and singleton gestation were included. Women with antepartum intrauterine fetal death or fetal anomalies were excluded. The probability of successful vaginal birth after cesarean delivery was calculated with the use of 3 prediction models: Grobman 2007, Grobman 2009, and Metz 2013 and compared with actual vaginal birth after cesarean delivery success. Each model's performance was measured with the use of concordance indices, Brier scores, and calibration plots. Decision curve analysis identified the range of threshold probabilities for which the best prediction model would be of clinical value.
Results:
Four hundred four women met the eligibility criteria. The observed rate of successful vaginal birth after cesarean delivery was 75% (305/404). Concordance indices were 0.717 (95% confidence interval, 0.659-0.778), 0.703 (95% confidence interval, 0.647-0.758), and 0.727 (95% confidence interval, 0.669-0.779), respectively. Brier scores were 0.172, 0.205, and 0.179, respectively. Calibration demonstrated that Grobman 2007 and Metz vaginal birth after cesarean delivery models were most accurate when predicted probabilities were >60% and were beneficial for counseling women who did not desire to have vaginal birth after cesarean delivery but had a predicted success rates of 60-90%. The models underpredicted actual probabilities when predicting success at <60%. The Grobman 2007 and Metz vaginal birth after cesarean delivery models provided greatest net benefit between threshold probabilities of 60-90% but did not provide a net benefit with lower predicted probabilities of success compared with a strategy of recommending vaginal birth after cesarean delivery for all women .
Conclusion:
When 3 commonly used vaginal birth after cesarean delivery prediction models are compared in the same population, there are differences in performance that may affect an institution's choice of which model to use.
Importance
Planned cesarean delivery comprises a significant proportion of births globally, with combined rates of planned and unscheduled cesarean delivery in a number of regions approaching 50%. Observational studies have shown that offspring born by cesarean delivery are at increased risk of ill health in childhood, but these studies have been unable to adjust for some key confounding variables. Additionally, risk of death beyond the neonatal period has not yet been reported for offspring born by planned cesarean delivery.Objective
To investigate the relationship between planned cesarean delivery and offspring health problems or death in childhood.Design, Setting, and Participants
Population-based data-linkage study of 321 287 term singleton first-born offspring born in Scotland, United Kingdom, between 1993 and 2007, with follow-up until February 2015.Exposures
Offspring born by planned cesarean delivery in a first pregnancy were compared with offspring born by unscheduled cesarean delivery and with offspring delivered vaginally.Main Outcomes and Measures
The primary outcome was asthma requiring hospital admission; secondary outcomes were salbutamol inhaler prescription at age 5 years, obesity at age 5 years, inflammatory bowel disease, type 1 diabetes, cancer, and death.Results
Compared with offspring born by unscheduled cesarean delivery (n = 56 015 [17.4%]), those born by planned cesarean delivery (12 355 [3.8%]) were at no significantly different risk of asthma requiring hospital admission, salbutamol inhaler prescription at age 5 years, obesity at age 5 years, inflammatory bowel disease, cancer, or death but were at increased risk of type 1 diabetes (0.66% vs 0.44%; difference, 0.22% [95% CI, 0.13%-0.31%]; adjusted hazard ratio [HR], 1.35 [95% CI, 1.05-1.75]). In comparison with children born vaginally (n = 252 917 [78.7%]), offspring born by planned cesarean delivery were at increased risk of asthma requiring hospital admission (3.73% vs 3.41%; difference, 0.32% [95% CI, 0.21%-0.42%]; adjusted HR, 1.22 [95% CI, 1.11-1.34]), salbutamol inhaler prescription at age 5 years (10.34% vs 9.62%; difference, 0.72% [95% CI, 0.36%-1.07%]; adjusted HR, 1.13 [95% CI, 1.01-1.26]), and death (0.40% vs 0.32%; difference, 0.08% [95% CI, 0.02%-1.00%]; adjusted HR, 1.41 [95% CI, 1.05-1.90]), whereas there were no significant differences in risk of obesity at age 5 years, inflammatory bowel disease, type 1 diabetes, or cancer.Conclusions and Relevance
Among offspring of women with first births in Scotland between 1993 and 2007, planned cesarean delivery compared with vaginal delivery (but not compared with unscheduled cesarean delivery) was associated with a small absolute increased risk of asthma requiring hospital admission, salbutamol inhaler prescription at age 5 years, and all-cause death by age 21 years. Further investigation is needed to understand whether the observed associations are causal.
The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3).
Objective:
To compare the neonatal outcome between planned vaginal or planned cesarean section (CS) breech delivery and planned vaginal vertex delivery at term with singleton fetuses.
Design:
A cohort study.
Setting:
Delivery Unit, Tampere University Hospital, Finland, with 5200 annual deliveries.
Population:
The term breech deliveries over a period of five years (January 2004 to January 2009), a total of 751 breech deliveries, and 257 vertex controls.
Methods:
The data were collected from the mother's medical records, including a summary of the newborn. In the case of neonatal health problems, the pediatric records were also examined.
Main outcome measures:
Maternal and neonatal mortality and morbidity as defined in the Term Breech Trial. Low Apgar scores or umbilical cord pH as secondary end-points.
Results:
There was no neonatal mortality. Severe morbidity was rare in all groups, with no differences between groups. The Apgar scores at one minute were lower in the planned vaginal delivery group compared with the other groups, but there was no difference at the age of five minutes. Significantly more infants in the vaginal delivery group had a cord pH < 7.05. There was one maternal death due to a complicated CS in the planned CS group and none in the other groups. Mothers in the planned CS group suffered significantly more often from massive bleeding and needed transfusions.
Conclusions:
Vaginal delivery remains an acceptable option for breech delivery in selected cases.
From a study of birth records, breech presentation at delivery for each gestational age was found to be less frequent as compared with other reports about antenatal ultrasonographic examination. Selection bias or the effect of labor may account for the observed difference.
Each year in the United States, approximately 60 percent of women with a prior cesarean delivery who become pregnant again attempt labor. Concern persists that a trial of labor may increase the risk of uterine rupture, an uncommon but serious obstetrical complication.
We conducted a population-based, retrospective cohort analysis using data from all primiparous women who gave birth to live singleton infants by cesarean section in civilian hospitals in Washington State from 1987 through 1996 and who delivered a second singleton child during the same period (a total of 20,095 women). We assessed the risk of uterine rupture for deliveries with spontaneous onset of labor, those with labor induced by prostaglandins, and those in which labor was induced by other means; these three groups of deliveries were compared with repeated cesarean delivery without labor.
Uterine rupture occurred at a rate of 1.6 per 1000 among women with repeated cesarean delivery without labor (11 women), 5.2 per 1000 among women with spontaneous onset of labor (56 women), 7.7 per 1000 among women whose labor was induced without prostaglandins (15 women), and 24.5 per 1000 among women with prostaglandin-induced labor (9 women). As compared with the risk in women with repeated cesarean delivery without labor, uterine rupture was more likely among women with spontaneous onset of labor (relative risk, 3.3; 95 percent confidence interval, 1.8 to 6.0), induction of labor without prostaglandins (relative risk, 4.9; 95 percent confidence interval, 2.4 to 9.7), and induction with prostaglandins (relative risk, 15.6; 95 percent confidence interval, 8.1 to 30.0).
For women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than among those with repeated cesarean delivery without labor. Labor induced with a prostaglandin confers the highest risk.
Elective cesarean delivery has been postulated to improve the outcome of term fetuses in breech presentation. We retrospectively compared the short- and long-term outcomes of term infants who were delivered from a breech presentation at a single center.
We reviewed 699 consecutive term breech presentations according to the intended mode of delivery at a single center between January 1993 and December 1999. The short-term outcome measures were perinatal death, neonatal death, or serious neonatal morbidity; the long-term outcome measures were developmental delay and spasticity.
The rate of serious perinatal morbidity in the trial-of-labor and cesarean delivery groups was 2.3% and 0.5%, respectively (P =.12). There was no perinatal or neonatal death in either group. With a median follow-up period of 57 months (range, 13-100 months), the rate of developmental delay was 1.9% and 0.5%, respectively (P =.29). Spasticity was not noted in any of the children.
Our data suggest that planned vaginal delivery remains an option for selected term breech presentations.
This study was undertaken to assess the safety of trial of labor after previous cesarean delivery.
Retrospective cohort study of 308,755 Canadian women with previous cesarean delivery between 1988 and 2000. Occurrences of in-hospital maternal death, uterine rupture, and other severe maternal morbidity were compared between women with a trial of labor and those with an elective cesarean section.
Rates of uterine rupture (0.65%), transfusion (0.19%), and hysterectomy (0.10%) were significantly higher in the trial-of-labor group. Maternal in-hospital death rate, however, was lower in the trial-of-labor group (1.6 per 100,000) than in the elective cesarean section group (5.6 per 100,000). The association between trial of labor and uterine rupture was stronger in low volume (<500) than in high volume (> or =500 births per year) obstetric units.
Trial of labor is associated with increased risk of uterine rupture, but elective cesarean section may increase the risk of maternal death.
To review the short and long term outcomes among singleton infants with breech presentation at term delivered in a geographically defined population over a 10-year period.
Retrospective, cohort study.
District General Hospital.
1433 term breech infants alive at the onset of labour and born between January 1991 and December 2000.
Data abstracted from birth registers, neonatal discharge summaries and the child health database system were used to compare the short and long term outcomes of singleton term breech infants born by two different modes of delivery (prelabour caesarean section and vaginal or caesarean section in labour). Fisher's exact test was used to compare the categorical variables.
Short term outcomes: perinatal mortality, Apgar scores, admission to the neonatal unit, birth trauma and neonatal convulsions. Long term outcomes: deaths during infancy, cerebral palsy, long term morbidity (development of special needs and special educational needs).
Of 1433 singleton term infants in breech presentation at onset of labour, 881 (61.5%) were delivered vaginally or by caesarean section in labour and 552 (38.5%) were born by prelabour caesarean section. There were three (0.3%) non-malformed perinatal deaths among infants born by vaginal delivery or caesarean section in labour compared with none in the prelabour caesarean section cohort. Compared with infants born by prelabour caesarean section, those delivered vaginally or by caesarean section in labour were significantly more likely to have low 5-minute Apgar scores (0.9% vs 5.9%, P < 0.0001) and require admission to the neonatal unit (1.6% vs 4%, P= 0.0119). However, there was no significant difference in the long term morbidity between the two groups (5.3% in the vaginal/caesarean section in labour group vs 3.8% in the prelabour caesarean group, P= 0.26); no difference in rates of cerebral palsy; and none of the eight infant deaths were related to the mode of delivery.
Vaginal breech delivery or caesarean section in labour was associated with a small but unequivocal increase in the short term mortality and morbidity. However, the long term outcome was not influenced by the mode of delivery.
The altered attitude of the obstetrician with regard to term breech delivery after the first results of the Term breech trial in 2000 has led to an increase in elective caesarean section in the Netherlands from 25% in 1999 to 64% in 2004 and a decrease in emergency caesarean section for term breech delivery from 26% in 1999 to I8% in 2004. This increase of about 8500 elective caesarean sections in the last four years probably prevented 19 perinatal deaths. However, this rise in caesarean section also resulted in four maternal deaths that may have been avoidable. Furthermore, in the future, nine perinatal deaths as a result of the uterine scar and 140 women with potentially life-threatening complications from that uterine scar during their future pregnancies can be expected. Information to the patient should take into account not only the short-term benefits but also the higher long-term risks. Vaginal delivery following strict selection is now preferred.
A continuous rise in the rate of cesarean delivery has been reported in many countries during the past decades. This trend has prompted the emergence of a controversial debate on the risks and benefits associated with cesarean delivery. Our objective was to provide a valid estimate of the risk of postpartum maternal death directly associated with cesarean as compared with vaginal delivery.
A population-based case-control study was designed, with subjects selected from recent nationwide surveys in France. To control for indication bias, maternal deaths due to antenatal morbidities were excluded. For the 5-year study period 1996-2000, 65 cases were included. The control group was selected from the 1998 French National Perinatal Survey and included 10,244 women. Multivariable logistic regression analysis was used to adjust for confounders.
After adjustment for potential confounders, the risk of postpartum death was 3.6 times higher after cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15-6.19). Both prepartum and intrapartum cesarean delivery were associated with a significantly increased risk. Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism. The risk of death from postpartum hemorrhage did not differ significantly between vaginal and cesarean deliveries.
Cesarean delivery is associated with an increased risk of postpartum maternal death. Knowledge of the causes of death associated with this excess risk informs contemporary discussion about cesarean delivery on request and should inform preventive strategies.
The cesarean section rate for term singleton breech babies in the Netherlands rose from 57 to 81% after the Term Breech Trial in 2000. The Dutch Maternal Mortality Committee registered and evaluated maternal mortality due to elective cesarean section for breech.
Four maternal deaths after elective cesarean section for breech presentation, from 2000 to 2002 inclusive, were registered, 7% of total direct maternal mortality in that period. Two women died due to massive pulmonary embolism, both were obese, and thromboprophylaxis was not adjusted to their weight. The other two women died from sepsis, one had not receive perioperative prophylactic antibiotics. The case fatality rate for elective cesarean section for breech presentation was 0.47/1,000 operations. No death after emergency cesarean section for breech presentation was registered at the committee.
Elective cesarean section does not guarantee the improved outcome of the child, but may increase risks for the mother, compared to vaginal delivery.
To investigate whether short or long interpregnancy interval is associated with uterine rupture and other major maternal morbidities in women who attempt vaginal birth after cesarean delivery (VBAC).
We performed a secondary analysis of a U.S. multi-center, record-based, retrospective cohort study of 13,331 pregnant women, identified by a validated International Classification of Disease, 9th Revision, code search, with at least one prior cesarean delivery, who attempted VBAC between 1995 and 2000. We performed univariable and multivariable logistic regression analyses to evaluate the association between long or short interpregnancy interval and three maternal outcomes: 1) uterine rupture, 2) composite major morbidity (including rupture, bladder or bowel injury, and uterine artery laceration), and 3) blood transfusion. We evaluated short interpregnancy interval with cutoffs at less than 6, less than 12, and less than 18 months between prior delivery and conception and defined long interval as 60 months or more.
A total of 128 cases (0.9%) of uterine rupture occurred, and 286 (2.2%), 1,109 (8.3%), 1,741 (13.1%), and 2,631 (19.7%) women had interpregnancy intervals of less than 6, 6-11, 12-17, and 60 months or more, respectively. An interval less than 6 months was associated with increased risk of uterine rupture (adjusted odds ratio [aOR] 2.66, 95% confidence interval [CI] 1.21-5.82), major morbidity (aOR 1.95, 95% CI 1.04-3.65), and blood transfusion (aOR 3.14, 95% CI 1.42-6.95). Long interpregnancy interval was not associated with an increase in major morbidity.
Short interpregnancy interval increases risk for uterine rupture and other major morbidities twofold to threefold in VBAC candidates.
II.
Labour and Childbirth After Previous Caesarean Section: Recommendations of the Austrian Society of Obstetrics and Gynaecology (OEGGG)
- Reif