Int. J. Gym-co/. Obstet., 1990,33: 99-102 International Federation of Gynecology and Obstetrics
99
Breech vaginal delivery after one cesarean section: a retrospective study N.A.El
M. El Gammal,
K.B. Jallad
and H.M.S.
O’deh
Farwania Hospital, Farwania (Ku wait) (Received March 8th. 1989) (Revised and accepted July 1lth, 1989)
Abstract This retrospective study evaluates the prospects of allowing a vaginal breech to follow a previous lower segment cesarean section by examining data from Farwania Hospital, Kuwait where 33 (38.4Yo) of 86patients with a previous cesarean section with fetuses in breech presentation were given a chance for vaginal delivery. The remaining 53 patients were deliverd by lower segment cesarean section. Out of 53 patients, 34 patients were sectioned because of the presence of uterine scar. The other 19 patients were sectioned because of the additional presence of other obstetric complications such as diabetes, pre-eclamptic toxemia or large fetus. This group of patients was excluded from comparison. Keywords: Introduction There are many obstetricians who deliver all their breech presentations by cesarean section, a policy which from the fetal point of view is undoubtedly sound. It is only when one assesses the maternal risk that a case can be made for selecting women for vaginal breech delivery on the grounds that cesarean 002&7292/90/$03.50
0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
section carries a maternal mortalitiy rate five times that for vaginal delivery [ 11, not to mention the greater morbidity rate which is harder to define in objective terms. The selection of cases presenting with breech for vaginal delivery depends on many factors: the type of breech, size of pelvis, gestational age, estimated fetal weight, past obstetric history, concurrent obstetric problems and clinician experience. The outcome of vaginal breech delivery in appropriately selected full term pregnancies conducted in a unit with the necessary facilities shows no difference in neurological testing from those delivered abdominally [2]. In the very low birthweight, less than 1500 g, there is convincing evidence that abdominal delivery significantly improves perinatal mortality [3] although it has been argued that this is at the expense of increased morbidity [4] as it can be both traumatic for the baby and hazardous for the mother if, because of a poorly formed lower segment, the obstetrician has to perform a vertical low midline or worse, an inverted T uterine incision [5,6]. In the presence of lower segment cesarean section scar, there was a wide spread agreement to deliver all patients with breech presentation by repeat cesarean section. Singh et al. [7] among others, allowed vaginal breech delivery in 14 patients with previous cesarean section without affecting the outClinical and Clinical Research
100
El Gammai et al.
come of fetuses and without maternal morbidity or mortality. The aim of this retrospective study was to evaluate the outcome of both policies in our hospital. Materials and methods Data for all cases of breech presentation with a maternal scar from one previous cesarean section who attended the labor ward in the period from January lst, 1981 until December 3 1st, 1987 were revised. Results There was a total of 86 patients. Vaginal delivery was allowed in 33 patients; 21 were full term pregnancies while the other 12 were preterm. Apgar score 5 min after delivery, was 7 or more in 31 newborns; while in the remaining two it was less and both ended in neonatal death. The first was in a para 2 + 0, term pregnancy, who was admitted in labor with cervical OS fully dilated and breech outside the vagina, there was difficulty in delivering the head of an infant weighing 4.120 kg. Apgar score was 1 in the first minute. The second was in a patient para 5 + 0, 34 weeks pregnant; the progress of labor was satisfactory, but the outcome was bad, Tabk I.
because the delivery was carried out by junior staff. The first death was unavoidable as it was an emergency admission in a non-selected case while the second death was avoidable. Fifty-three patients were delivered by cesarean section either because of the presence of another risk factor such as diabetes (4 patients) pre-eclampsia (2 patients), large fetus (13 patients); this group of patients were excluded from the comparison. The remaining 34 patients were sectioned only because of the presence of uterine scar with breech presentation. The outcome in these was: 29 infants had Apgar score 7 or more after 5 min of delivery. Five had Apgar score less than 7. Four of these five infants were preterm, two of them died within the first day of extrauterine life. The first was born of a mother para 1 + 0, 30 weeks pregnant, previous cesarean section and fetus presented with breech. The outcome was a female with multiple congenital anomalies weighing 1.9 kg and Apgar score 1 at 1 min. The second mother was para 5 + 2,36 weeks pregnant sectioned because of preterm breech and previous cesarean section. The result was a male weighing 2.350 kg with Apgar score 1 at 2 min and multiple congenital anomalies. The other two preterm infants were discharged from the special care baby unit well
Fetal outcome. Mode of delivery P Assisted breech (n = 33) @Jo)
Birthweight < 15oog 1500-2300 g 2500-3500 > 3500 Apgar score after 5 min ,l 35 Urinary tract infection
(n = 33)(%)
Ccsarean section (n = 34)(%)
32 (96.96) l(3) -
31(91.1) 3 (8.8)
Nil
0.01 0.01
2 (5.88)
31 (93.9) 2 (6)
24 (70.58) 19 (29.41)
0.01 0.01
3 (9) 30 (90.9)
12 (35.29) 22 (64.7)
0.01 0.01
2 (5.88)
NS’
l(3)
‘NS = not significant by Z-test.
after 40 and 64 days, respectively. The fifth was a full term who did well after delivery. Comparison between the 33 vaginal deliveries and 34 cesarean section deliveries as regards fetal outcome, maternal outcome and demographics of patients is shown in Tables I -111.
Table III.
Discussion At Farwania Hospital, Kuwait, the incidence of breech presentation at labor varies between 3-4% while the incidence of lower segment cesarean section in patients presenting with breech was 25%. In patients with
Demographic. Mode of delivery P
Maternal age 35 years Parity (4 35 Gestational age 28-37 weeks 238 weeks
Assisted breech (n = 33)(%)
Cesarean section (n = 34) (%)
29(87.87) 4(12.12)
31 (91) 3 (8.8)
NS’ NS
lS(54.5) 15 (45.45)
26 (76.47) 8 (23.5)
NS NS
12 (36.4) 21(63.6)
4(11.7) 30(88.3)
0.05 0.05
‘NS = not significant by Z-test. Clinical and Clinical Research
102
El Gamma/et al.
previous cesarean section, a vaginal breech delivery should be considered when the sole complication present is the malpresentation. The uterine scar should be sound and the previous section performed for a non-recurring indication. The fetus should be of average size 2000-3500 g, pelvic capacity should not be in doubt antero posterior inlet 11 cm, transverse inlet 12 cm, and interspinous distance 10 cm, with a well-formed middle and lower pelvis, close intrapartum fetal monitoring, a satisfactory rate of cervical dilatition in labor (1 cm/h), immediate facilities for cesarean section and no other concurrent obstetric problems, such as ’preeclampsia or antepartum hemorrhage. Using ultrasound, we have recently gained good experience in predicting fetal weight but we are not very good at detection of congenital anomalies. Thus if a large fetus is clinically suspected, assessment of fetal weight by ultrasonography is mandatory. Our results shows that if the fetal weight exceeds 3500 g, the possibility of delivery by cesarean section is twice that by vaginal route. Also we are in favor of vaginal delivery in preterm breech fetuses weighing 1500-2500 g as there is no difference in perinatal mortality and morbidity if attended by a senior obstetrician. This is in agreement with other studies P,91. As regards Apgar score, there was a difference between the two groups, as low Apgar score (less than 7 at 5 min) was noticed more in the cesarean section group (1.5 times that of the vaginal delivery group). The study shows an incidence of prematurity of 23.2% (20 out of 86) compared to 6.8% in our total deliveries for the same period. This compares with reports of Rovinsky et al. [lo] and Kauppila [ 111. There is a tendency in our hospital to deliver premature fetuses presenting with breech vaginally. This tendancy might have saved two mothers the hazards of repeat cesarean section on congenitally malformed fetuses. As regards the maternal morbidity, there Int J Gynecol Obstet 33
was a significant difference between the two groups (P = 0.01) as shown in Table II. In conclusion our results show that after one cesarean section performed for nonrecurring indication with a sound scar, a fetus weighing 3500 g or less presenting with breech can be delivered safely vaginally, if attended by a senior experienced obstetrician with radiographic and ultrasound available facilities to aid in fetal weight and pelvic assessment, in addition to those prerequisites of safety which should be met prior to attempting any vaginal breech delivery without cesarean section scar. References 1
2
3
4
5
6
I 8 9 10
11
HMSO: Report on confidential enquiries into maternal death in England and Wales, 1973-1975. HMSO, London, 1979. Faber Nijholt R, Huisjes HJ, Touwen BCL, Fiddl VJ: Neurological follow up of 281 children born in breech presentation a controlled study. Br Med J 286: 9.1983. Ingermarsson I, Westgren M, Svermingsen NW: Long term followup of preterm infants in breech presentation delivered by cesarean section. Lancet ii: 172,1978. Cox C, Kendall AC, Hommers M: Changed prognosis of breech presenting low biih weight infants. Br J Obstet Gynaecol89: 881,1982. Westgren M. Ingemarsson I, Ahlstrom H: Delivery and long term outlook of very low birth weight infants. Acta Obstet Gynaecol Stand 62: 25.1982. Walker E, Pate1 N: The mortality and morbidity of infants delivered between 20 and 28 weeks gestation - a population study. In press, 1986. Kishor T, Singh C. Barman SD, Gupta AN: Austr NZ J Obstet Gynaecol26: 2451986. Crowley P, Hawkins DF: J Obstet Gynaecol I: 2.1980. Bowes, Taylor ES, O’Briess M: Am J Obstet Gynecol 135: 965.1979. Rovinsky JJ, Miller JA, Kaplan S: Management of breech presentation at term. Am J Obstet Gynecol 130: 558,1973. Kauppila 0: Perinatal mortality in breech delivery and observations on affecting factors. A retrospective study of 2227 cases. Acta Obstet Gynaecol Stand suppl39: 1. 1975.
Address for reprints: N. El Gammal P.O.Box No. 18278 Farwarda81003 Farwanir, Kuwait
99
Breech vaginal delivery after one cesarean section: a retrospective study N.A.El
M. El Gammal,
K.B. Jallad
and H.M.S.
O’deh
Farwania Hospital, Farwania (Ku wait) (Received March 8th. 1989) (Revised and accepted July 1lth, 1989)
Abstract This retrospective study evaluates the prospects of allowing a vaginal breech to follow a previous lower segment cesarean section by examining data from Farwania Hospital, Kuwait where 33 (38.4Yo) of 86patients with a previous cesarean section with fetuses in breech presentation were given a chance for vaginal delivery. The remaining 53 patients were deliverd by lower segment cesarean section. Out of 53 patients, 34 patients were sectioned because of the presence of uterine scar. The other 19 patients were sectioned because of the additional presence of other obstetric complications such as diabetes, pre-eclamptic toxemia or large fetus. This group of patients was excluded from comparison. Keywords: Introduction There are many obstetricians who deliver all their breech presentations by cesarean section, a policy which from the fetal point of view is undoubtedly sound. It is only when one assesses the maternal risk that a case can be made for selecting women for vaginal breech delivery on the grounds that cesarean 002&7292/90/$03.50
0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
section carries a maternal mortalitiy rate five times that for vaginal delivery [ 11, not to mention the greater morbidity rate which is harder to define in objective terms. The selection of cases presenting with breech for vaginal delivery depends on many factors: the type of breech, size of pelvis, gestational age, estimated fetal weight, past obstetric history, concurrent obstetric problems and clinician experience. The outcome of vaginal breech delivery in appropriately selected full term pregnancies conducted in a unit with the necessary facilities shows no difference in neurological testing from those delivered abdominally [2]. In the very low birthweight, less than 1500 g, there is convincing evidence that abdominal delivery significantly improves perinatal mortality [3] although it has been argued that this is at the expense of increased morbidity [4] as it can be both traumatic for the baby and hazardous for the mother if, because of a poorly formed lower segment, the obstetrician has to perform a vertical low midline or worse, an inverted T uterine incision [5,6]. In the presence of lower segment cesarean section scar, there was a wide spread agreement to deliver all patients with breech presentation by repeat cesarean section. Singh et al. [7] among others, allowed vaginal breech delivery in 14 patients with previous cesarean section without affecting the outClinical and Clinical Research
100
El Gammai et al.
come of fetuses and without maternal morbidity or mortality. The aim of this retrospective study was to evaluate the outcome of both policies in our hospital. Materials and methods Data for all cases of breech presentation with a maternal scar from one previous cesarean section who attended the labor ward in the period from January lst, 1981 until December 3 1st, 1987 were revised. Results There was a total of 86 patients. Vaginal delivery was allowed in 33 patients; 21 were full term pregnancies while the other 12 were preterm. Apgar score 5 min after delivery, was 7 or more in 31 newborns; while in the remaining two it was less and both ended in neonatal death. The first was in a para 2 + 0, term pregnancy, who was admitted in labor with cervical OS fully dilated and breech outside the vagina, there was difficulty in delivering the head of an infant weighing 4.120 kg. Apgar score was 1 in the first minute. The second was in a patient para 5 + 0, 34 weeks pregnant; the progress of labor was satisfactory, but the outcome was bad, Tabk I.
because the delivery was carried out by junior staff. The first death was unavoidable as it was an emergency admission in a non-selected case while the second death was avoidable. Fifty-three patients were delivered by cesarean section either because of the presence of another risk factor such as diabetes (4 patients) pre-eclampsia (2 patients), large fetus (13 patients); this group of patients were excluded from the comparison. The remaining 34 patients were sectioned only because of the presence of uterine scar with breech presentation. The outcome in these was: 29 infants had Apgar score 7 or more after 5 min of delivery. Five had Apgar score less than 7. Four of these five infants were preterm, two of them died within the first day of extrauterine life. The first was born of a mother para 1 + 0, 30 weeks pregnant, previous cesarean section and fetus presented with breech. The outcome was a female with multiple congenital anomalies weighing 1.9 kg and Apgar score 1 at 1 min. The second mother was para 5 + 2,36 weeks pregnant sectioned because of preterm breech and previous cesarean section. The result was a male weighing 2.350 kg with Apgar score 1 at 2 min and multiple congenital anomalies. The other two preterm infants were discharged from the special care baby unit well
Fetal outcome. Mode of delivery P Assisted breech (n = 33) @Jo)
Birthweight < 15oog 1500-2300 g 2500-3500 > 3500 Apgar score after 5 min ,l 35 Urinary tract infection
(n = 33)(%)
Ccsarean section (n = 34)(%)
32 (96.96) l(3) -
31(91.1) 3 (8.8)
Nil
0.01 0.01
2 (5.88)
31 (93.9) 2 (6)
24 (70.58) 19 (29.41)
0.01 0.01
3 (9) 30 (90.9)
12 (35.29) 22 (64.7)
0.01 0.01
2 (5.88)
NS’
l(3)
‘NS = not significant by Z-test.
after 40 and 64 days, respectively. The fifth was a full term who did well after delivery. Comparison between the 33 vaginal deliveries and 34 cesarean section deliveries as regards fetal outcome, maternal outcome and demographics of patients is shown in Tables I -111.
Table III.
Discussion At Farwania Hospital, Kuwait, the incidence of breech presentation at labor varies between 3-4% while the incidence of lower segment cesarean section in patients presenting with breech was 25%. In patients with
Demographic. Mode of delivery P
Maternal age 35 years Parity (4 35 Gestational age 28-37 weeks 238 weeks
Assisted breech (n = 33)(%)
Cesarean section (n = 34) (%)
29(87.87) 4(12.12)
31 (91) 3 (8.8)
NS’ NS
lS(54.5) 15 (45.45)
26 (76.47) 8 (23.5)
NS NS
12 (36.4) 21(63.6)
4(11.7) 30(88.3)
0.05 0.05
‘NS = not significant by Z-test. Clinical and Clinical Research
102
El Gamma/et al.
previous cesarean section, a vaginal breech delivery should be considered when the sole complication present is the malpresentation. The uterine scar should be sound and the previous section performed for a non-recurring indication. The fetus should be of average size 2000-3500 g, pelvic capacity should not be in doubt antero posterior inlet 11 cm, transverse inlet 12 cm, and interspinous distance 10 cm, with a well-formed middle and lower pelvis, close intrapartum fetal monitoring, a satisfactory rate of cervical dilatition in labor (1 cm/h), immediate facilities for cesarean section and no other concurrent obstetric problems, such as ’preeclampsia or antepartum hemorrhage. Using ultrasound, we have recently gained good experience in predicting fetal weight but we are not very good at detection of congenital anomalies. Thus if a large fetus is clinically suspected, assessment of fetal weight by ultrasonography is mandatory. Our results shows that if the fetal weight exceeds 3500 g, the possibility of delivery by cesarean section is twice that by vaginal route. Also we are in favor of vaginal delivery in preterm breech fetuses weighing 1500-2500 g as there is no difference in perinatal mortality and morbidity if attended by a senior obstetrician. This is in agreement with other studies P,91. As regards Apgar score, there was a difference between the two groups, as low Apgar score (less than 7 at 5 min) was noticed more in the cesarean section group (1.5 times that of the vaginal delivery group). The study shows an incidence of prematurity of 23.2% (20 out of 86) compared to 6.8% in our total deliveries for the same period. This compares with reports of Rovinsky et al. [lo] and Kauppila [ 111. There is a tendency in our hospital to deliver premature fetuses presenting with breech vaginally. This tendancy might have saved two mothers the hazards of repeat cesarean section on congenitally malformed fetuses. As regards the maternal morbidity, there Int J Gynecol Obstet 33
was a significant difference between the two groups (P = 0.01) as shown in Table II. In conclusion our results show that after one cesarean section performed for nonrecurring indication with a sound scar, a fetus weighing 3500 g or less presenting with breech can be delivered safely vaginally, if attended by a senior experienced obstetrician with radiographic and ultrasound available facilities to aid in fetal weight and pelvic assessment, in addition to those prerequisites of safety which should be met prior to attempting any vaginal breech delivery without cesarean section scar. References 1
2
3
4
5
6
I 8 9 10
11
HMSO: Report on confidential enquiries into maternal death in England and Wales, 1973-1975. HMSO, London, 1979. Faber Nijholt R, Huisjes HJ, Touwen BCL, Fiddl VJ: Neurological follow up of 281 children born in breech presentation a controlled study. Br Med J 286: 9.1983. Ingermarsson I, Westgren M, Svermingsen NW: Long term followup of preterm infants in breech presentation delivered by cesarean section. Lancet ii: 172,1978. Cox C, Kendall AC, Hommers M: Changed prognosis of breech presenting low biih weight infants. Br J Obstet Gynaecol89: 881,1982. Westgren M. Ingemarsson I, Ahlstrom H: Delivery and long term outlook of very low birth weight infants. Acta Obstet Gynaecol Stand 62: 25.1982. Walker E, Pate1 N: The mortality and morbidity of infants delivered between 20 and 28 weeks gestation - a population study. In press, 1986. Kishor T, Singh C. Barman SD, Gupta AN: Austr NZ J Obstet Gynaecol26: 2451986. Crowley P, Hawkins DF: J Obstet Gynaecol I: 2.1980. Bowes, Taylor ES, O’Briess M: Am J Obstet Gynecol 135: 965.1979. Rovinsky JJ, Miller JA, Kaplan S: Management of breech presentation at term. Am J Obstet Gynecol 130: 558,1973. Kauppila 0: Perinatal mortality in breech delivery and observations on affecting factors. A retrospective study of 2227 cases. Acta Obstet Gynaecol Stand suppl39: 1. 1975.
Address for reprints: N. El Gammal P.O.Box No. 18278 Farwarda81003 Farwanir, Kuwait
![[Vaginal delivery after cesarean section].](/assets/img/hold.png)
