Journal of Perinatology (2015), 1–6 © 2015 Nature America, Inc. All rights reserved 0743-8346/15 www.nature.com/jp
ORIGINAL ARTICLE
Management of breech presentation at term: a retrospective cohort study of 10 years of experience J Burgos, L Rodríguez, P Cobos, C Osuna, M del Mar Centeno, R Larrieta, T Martínez-Astorquiza and L Fernández-Llebrez OBJECTIVE: To evaluate the impact of management of childbirth (external cephalic version (ECV) plus planned vaginal delivery (PVD)) of breech presentation at term (⩾37 weeks of gestation). STUDY DESIGN: This retrospective cohort study was based on data collected of singleton breech presentations at term in the Obstetrics and Gynaecology Service, Cruces University Hospital (Biscay, Spain), from January 2003 to December 2012. RESULT: We attended 2377 singleton breech pregnancies at term. We attended 1684 singleton breech term deliveries, attempting vaginal delivery after selection in 52.9% of cases and were successful in 57.5% of attempts. A total of 1360 ECV were attempted, with a success rate of 50.3% of those attempted. The use of ECV has decreased the rate of breech presentation at delivery by 39.0%, the rate of breech presentation as a caesarean section (CS) indication by 47.1% (CS due to breech presentation/total of CS) and the rate of CS for breech presentation out of the total of deliveries by 39.1% (CS due to breech presentation/total of deliveries). Early postnatal parameters (5-min Apgar score, umbilical cord arterial pH and acid-base analysis) were significantly lower following PVD compared with planned CS for breech presentation. However, we did not find any differences in the rates of admissions to the neonatal unit or neonatal mortality. CONCLUSION: Management of breech presentation with a protocol that includes ECV, careful selection criteria and active management of vaginal delivery achieve a great decrease in the rate of CS for breech presentation. Journal of Perinatology advance online publication, 16 July 2015; doi:10.1038/jp.2015.75
INTRODUCTION Breech presentation occurs in 3–4% of gestations at term. The preferred mode of delivery has varied over recent years. Following the publication of the ‘Term Breech Trial',1 there was a marked change in the management of breech presentation based on short-term results of the clinical trial. These short-term results showed less neonatal morbi-mortality in elective caesarean section (CS) and the rates of CSs soaring to 100% in many hospitals.2–4 The authors published the long-term results of the trial showing no differences in neonatal morbi-mortality between planned vaginal delivery (PVD) and elective CS. Furthermore, several critical reviews were published as inter-center heterogeneity, no imaging evaluation of fetal head attitude, serious violation of inclusion criteria, non-professional expert assistant at delivery and most of perinatal death were not associated with the delivery.5–9 At the same time, the results of the PREMODA study were published concluding that in places where PVD is a common practice and when strict criteria are met before and during labour, PVD of singleton fetuses in breech presentation at term remains a safe option that can be offered to women.10 The main scientific societies (RCOG, ACOG, SOGC, SEGO and RANZCOG) updated their guidelines recommending an active management of breech presentation at term offering external cephalic version (ECV) at term and attempting vaginal breech delivery in well-selected pregnancies.11–15 Despite these recommendations, many groups have not implemented ECV or allowed vaginal delivery and, in such cases, the current rate of CS in this presentation is still close to 100%.
The aim of the study was to evaluate the impact of management (ECV and PVD) of breech presentation at term. METHODS This was a retrospective cohort study at Cruces University Hospital (Biscay, Spain). We included all singleton breech presentations at term (⩾37 weeks of gestation) that were identified at Hospital ECV Register or Hospital Delivery Register, except fetuses with congenital malformations or antenatal death, with or without ECV, delivered in our hospital between 2003 and 2012. During antenatal care, the obstetrician provided the woman with oral information about our management of breech presentation at term, supported by written material.16 If the fetus was in breech presentation at 37 weeks of gestation, then ECV was offered. When ECV was unsuccessful or the mother refused it, a PVD was allowed for selected pregnancies. The selection was made mainly at the beginning of the labour. In our hospital, caesarean indication was done based on the medical criteria. CS in breech delivery with medical criteria of PVD was not allowed by maternal request. ECV was considered for all women with singleton breech presentations at term and the maneuver was performed following our guidelines.17 Briefly, exclusion criteria for the use of ECV in our hospital were placenta praevia, premature placental abruption, oligohydramnios (amniotic fluid index o 5), signs of fetal compromise, fetal death, severe fetal malformations, multiple gestation, isoimmunization, maternal coagulation disorders, and indications for CS not related to fetal presentation. Prior CS and estimated fetal weight 44000 g were not contraindications to ECV. All women were informed in detail about the procedure, explaining the benefits and risks. Before ECV, cardiotocography was performed to confirm fetal wellbeing. As a tocolytic, we used intravenous ritodrine (Prepar; Laboratorios Reig Jofre SA, Barcelona, Spain). It was administered via
Obstetrics and Gynaecology Service, BioCruces Health Research Institute, Hospital Universitario Cruces (UPV/EHU), Biscay, Spain. Correspondence: Professor J Burgos, Obstetrics and Gynaecology Service, BioCruces Health Research Institute, Hospital Universitario Cruces, C/Plaza de Cruces 12, Baracaldo 48903, Vizcaya, Spain. E-mail: [email protected] Received 23 November 2014; revised 4 May 2015; accepted 5 May 2015
Management of breech presentation at term J Burgos et al
2 continuous 200 μg infusion pump starting 30 min before the version and maintained during the maneuver. Atosiban was only used if the woman had any contraindication for ritodrine (Tractocile; Laboratorios Ferring SA, Madrid, Spain), and in such cases, it was administered intravenously in a single 0.9 ml bolus 2 min before starting the maneuver. The ECV was considered to be successful if the breech presentation rotated to cephalic. For 60 min following the version attempt, continuous cardiotocography was performed to assess fetal status and the woman was monitored to detect any adverse effects. Anti-D immunoglobulin was also administered if indicated. If no complications arose during this period, then the woman was discharged and monitored until delivery. There was a protocol for patient selection and intrapartum management for vaginal breech delivery. Induction was performed based on maternal or obstetric indications. Vaginal delivery was allowed when the type of breech was frank or complete, the fetal neck was not hyperextended, there was no apparent fetopelvic disproportion (clinical evaluation based on good progress of labour or by pelvimetry pelvic inlet measurement of 410.5 cm in the obstetric conjugate diameter), the estimated fetal weight was ⩽ 3800 g and the biparietal diameter was o 98 mm. In 2011, we changed the estimated fetal weight limit to ⩽ 4000 g and the biparietal diameter-based criterion was dropped. All the variables were evaluated at the beginning of labour. Estimated fetal weight was also evaluated in the outpatient department, and if it is 44000 g, then CS was indicated. Women who did not meet the criteria for attempting vaginal delivery as well as those with an indication for CS for other reasons (placenta praevia or two previous CSs, among others) underwent planned caesarean section (PCS). We performed continuous electronic fetal monitoring throughout the intrapartum management. In the absence of regular spontaneous contractions, oxytocin and amniotomy were used to simulate uterine activity. An obstetrician closely monitored the rate of dilation in all cases. In the cases of breech presentation, more than 2 h with the same degree of dilation despite adequate uterine activity was considered to indicate dystocia. At complete dilatation, the upper limits set for the duration of the passive (a rest period for fetal passive descent without maternal pushing) and active (active maternal pushing for fetal descent) stages of labour were 90 min and 60 min, respectively. There is no variation by parity or epidural status. In all cases, the deliveries were attended by two obstetricians and a paediatrician. In the event of cardiotocographic parameters indicating a possible deterioration in fetal wellbeing, dilation not progressing adequately or the baby failing to descend despite maternal pushing, we carried out an intrapartum CS. Data were obtained from the Hospital ECV Register or Hospital Delivery Register, completed after the delivery and/or the ECV by the health professionals in charge, as well by reviewing patient medical records. As secondary outcomes, we carried out a descriptive analysis of the obstetric data and perinatal parameters (5-min Apgar score, umbilical cord arterial pH, base excess (BE) ⩽ − 12 mmol l−1, rate of admission to the neonatal intensive care unit (NICU), perinatal composite morbidity (umbilical cord arterial pH o7+BE ⩽ − 12 mmol l−1+5-min Apgar score o7+NICU) and neonatal mortality). It was considered that a newborn has perinatal composite morbidity when all criteria were met. We compared the perinatal parameters from PCS with those from PVDs (both those resulting in vaginal births and those converted to CSs). Ethical approval was obtained for this cohort study. We performed statistical analysis using IBM SPSS Statistics (version 22; IBM, Armonk, NY, USA). Chi-square or Fisher exact tests were used for qualitative and Student's T test or Mann–Whitney U tests for quantitative variables according to fulfillment of theoretical assumptions by the study data (expected cell frequencies and Gaussian distribution, respectively). The threshold for significance was set at Po0.05.
RESULTS We attended 2377 singleton breech pregnancies at term. A total of 1360 ECVs were attempted, with a success rate of 50.3%. We attended 1684 singleton breech term deliveries, attempting vaginal delivery after selection in 52.9% of cases and were successful in 57.5% of attempts. The mean maternal age was 33 ± 4.4 and body mass index was 28.3 ± 4.3. The median gestational age at ECV was 37 (range 6) and gestational age at delivery was 39 (range 6). Figure 1 shows the distribution of the 2377 pregnancies with breech presentation at term by year during the study period. ECV was progressively introduced over 6 years, Journal of Perinatology (2015), 1 – 6
Figure 1. Number of breech presentations at term (before external cephalic version (ECV)), ECVs attempted (successful+unsuccessful) and breech presentations at delivery (planned vaginal+planned c-section) by year.
Figure 2. Rate of external cephalic version (ECV) and breech presentations at term after ECV out of the total number of breech presentations at term before ECV.
since when, use of the maneuver has stabilised (bars). The lines represent the number of breech presentations at term, before ECV, and at delivery. Figure 2 shows the rate of ECVs and the rate of breech presentation at delivery after ECV, both as a function of the total number of breech presentations at term. The rate of breech presentation at delivery has decreased with the increase in the rate of ECV for breech presentation. In the last 2 years (2011–2012), we have attempted ECVs in 73% (n = 340) of the 466 cases of singleton breech presentation at term. Over the whole 10-year period, we have carried out 1360 ECVs with a success rate of 50.3% and a rate of cephalic presentation at term of 51%. The rate of spontaneous reversion to breech was 2.3% and that of spontaneous cephalic version was 3.7% (Figure 3). We did not observe any serious complications. The rate of emergency CS (n = 14) was 1.03%, and there were no maternal and fetal complications in these cases. In the years 2000 and 2001, we did not perform any ECVs. In those years, breech deliveries represented 4.1% of all the singleton deliveries at term and 3.8% of all the deliveries. A total of 232 women had CSs for breech presentation, representing 28.6% © 2015 Nature America, Inc.
Management of breech presentation at term J Burgos et al
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Figure 3.
Table 1.
Management of breech presentation at term. Cruces University Hospital 2003–2012. ECV, external cephalic version.
Importance of breech presentation at term: before and after the implementation of ECV 2001–2002
2011–2012
388
466
Ratio of breech at term of Total of pregnancies singleton deliveries at term Total of deliveries (24–42 weeks) Total of ECV Total of breech at delivery
4.1% (388/9426) 3.8% (388/10 273) 0 388
4% (466/11 769) 3.6% (466/12 909) 340 299
Ratio of breech at delivery of Total of pregnancies at term Total of deliveries (24–42 weeks) Caesarean rate of breech presentation at term
4.1% (388/9426) 3.8% (388/10 273) 59.8% (232/388)
2.5% (299/11 769) 2.3% (299/12 909) 44.4% (182 breech+25 cephalic after ECV/466)
Ratio of caesarean by breech presentation at term of Total caesarean rate at term Total caesarean Total deliveries
28.6% (232/810) 22.7% (232/1023) 2.3% (232/10 273)
15.1% (182/1204) 12% (182/1513) 1.4% (182/12 909)
Total breech at term
Abbreviation: ECV, external cephalic version.
of CSs in singleton pregnancies at term, 22.7% of the total number of CSs and 2.3% of all the deliveries. In contrast, in 2011 and 2012, we carried out ECVs in 73% of cases of breech presentation at term. As a consequence, breech deliveries represented just 2.5% of singleton deliveries at term and 2.3% of all the deliveries. In these years, we carried out 182 CSs for breech presentation. These represented 15.1% of CSs in singleton pregnancies at term, 12% of the total number of CSs and 1.4% of all the deliveries (Table 1). Comparing the results, the introduction of ECV has led to a 39% decrease (from 4.1 to 2.5%) in breech deliveries, a 47.1% decrease (from 22.7 to 12%) in breech presentation as an indication for CS, and a 39.1% decrease (from 2.3 to 1.4%) in the rate of CS for breech presentation as a function of all the deliveries (Figure 4). The use of ECV has decreased the overall rate of CS for breech presentation at term by 27%, from 60% (232/388) in 2000–2001 to 44% (207/466) in 2011–2012. In a hypothetical scenario, if we had attempted ECV in all cases of breech presentation, there would have been a 37% decrease in the rate of CS for breech © 2015 Nature America, Inc.
presentation (from 60 to 38%), 4.6 ECVs (95% confidence interval (CI), 2.8–11.9) being needed to avoid one CS. This theoretical decrease would be, in a hospital that systematically relies on PCS for this type presentation at delivery, from 96.5% (total breech at term except spontaneous version to cephalic (≈3.5%) to 57%, just 2.53 ECVs (95% CI, 2.01–3.43) being necessary to prevent one CS. During the study period, we attended 1684 breech presentations at delivery, 667 following ECV attempts and 1017 in which version had not been attempted. Of these, 47.1% did not meet the criteria for vaginal deliveries and hence PCS was indicated. In the other cases (n = 891), a vaginal birth was attempted. This approach was successful over half the time, while others were converted to caesareans (57.5% vaginal delivery vs 42.5% intrapartum CS). The overall rate of breech vaginal delivery was 30.4%, the other 69.6% of breech presentations being delivered by caesarean. On the other hand, in 693 cases, the presentation was cephalic at delivery, 83.5% of these resulting in successful vaginal deliveries. The Journal of Perinatology (2015), 1 – 6
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Figure 4. Distribution of breech deliveries at term (caesarean and vaginal) without (2000–2001) and with (2011–2012) ECV. ECV, external cephalic version.
overall rate of CS was 54.1% in the cohort of 2377 breech presentations at term (Figure 3). In the PVD and PCS groups, the mean ages of the pregnant women were 32 ± 4 and 33 ± 4 years old, respectively. The gestational age at birth was similar in the two groups (39 ± 1.3 weeks, PVD vs 39.1 ± 1.2 weeks, PCS; P = 0.10). In the PVD group, 3.3% of women had one previous CS compared with 7.6% in the PCS group (P o0.01), while the percentages of multiparous women were 21.9 and 27.5%, respectively (Po 0.01). Table 2 summarises the comparison of perinatal outcomes in the PVD and PCS groups. We observed differences in the following variables: mean umbilical cord arterial pH, and the percentage of infants with pH o 7.00, BE ⩽ − 12 mmol l−1, 5-min Apgar score o 4 and 5-min Apgar score o 7. We did not, however, observe significant differences in the rates of admission to the NICU, primary perinatal morbidity or perinatal mortality. There was one case of fetal intrapartum death in a vaginal delivery due to complications in the second stage of labour (head entrapment with both arms being behind the neck). Among the PVDs, we only found differences between vaginal births and intrapartum CSs in the mean umbilical cord arterial pH (7.18 ± 0.8 vs 7.21 ± 0.9, Po 0.01, respectively) and the rate of BE ⩽ − 12 mmol l−1 (14.5% vs 8.8%, P = 0.01, respectively). DISCUSSION We have described our experience and results over 10 years with the introduction of ECV in the management for breech presentation at term. Our hospital has traditionally advocated the use of vaginal delivery for breech presentation in selected cases. In the last 2 years of the study period, we have updated our protocol, modifying one selection criterion and dropping another. Over these 10 years, we have introduced ECV as a key part of the clinical management of breech presentation. As for every new procedure, there is a learning curve, in this instance, both for health professionals and for pregnant women themselves. In our case, the number of ECVs progressively increased over a period of 6 years. In the last 2 years, we have performed ECVs in 73% of singleton breech presentations at term. This clinical management of breech presentation at term has made that CS for breech presentation has deceased form 2.3 to 1.4% of the total of deliveries, even though the caesarean rate of the hospital has increased from 10 to 11.7% in the same period. ECV is a simple maneuver that halves the number of breech presentations at delivery, that is, when successful, this maneuver eliminates one of the most important intrapartum obstetric risk factors, and it carries little additional risk. There is no other intrapartum obstetric risk factor (previous CS and multiple pregnancy, among others) that can be avoided. However, to have this positive impact, ECV needs to be implemented. In our hospital, when we did not perform ECVs, the caesarean rate of breech presentation at term was 60%. By the last 2 years, after 8 years of progressive implementation, in which we performed EVC Journal of Perinatology (2015), 1 – 6
in 73% of breech presentations at term, ECV has led to a 39% decrease in breech deliveries and a 47.1% decrease in breech presentation as an indication for CS. This clinical consequence of the implantation of the ECV is the reason why this technique is rising in popularity and even more hospitals carry it out. Although we consider that these results are good, we consider that is still margin for improvement. If we performed ECV for all breech presentations at term, then the rate of CS could potentially decrease to 38%, 4.6 ECVs being required to avoid one CS. The benefit would be even more apparent in hospitals that do not currently allow vaginal delivery of breech presentations. In this type of hospital, the rate of CS could decrease from 96.5 to 57%, 2.53 ECVs being required to avoid one CS. Despite these estimates being theoretical, it should be possible to get close to these figures, if we are able to make all health professionals and patients aware of the risk-benefit balance of this maneuver.18 Given that the complication rate is very low,19 few extra resources are required and the benefit is proven,20 we consider that one of the main objectives of all obstetric units should be to introduce ECV to their clinical practice and attempt versions in as many patients as possible. Such changes would achieve a large decrease in the rates of breech presentation at delivery and of CSs. All obstetric units, without exception, should now offer this procedure and a common health policy should be developed to promote its use. Our results on breech presentation at delivery are comparable to those published by other research groups. A total of 52.9% of cases met the criteria for indicating vaginal delivery, a significantly higher percentage than in the PREMODA study (31%) and higher than that in the Dutch cohort (40%). This is attributable to the application of more restrictive selection criteria than those used by our group. Specifically, the PREMODA study did not include complete breech presentations but did include CSs performed on maternal request. Our success rate for attempted vaginal birth was 57.5%, somewhat lower than that in the PREMODA study (71%) and similar to that in the Dutch cohort (≈50%).10,21 A vaginal breech delivery entails short-term fetal distress and this is reflected in the early perinatal parameters. Indeed, the overall results at this stage are better for PCS than for PVD. However, the rate of admission in the NICU was not significantly different in the two groups and nor was the composite neonatal morbidity, whose objective was to identify the neonates with high risk of serious acute intrapartum hypoxic event. It is clear that breech delivery is stressful, the birth process drawing more on fetal reserves than it would under other circumstances. Nevertheless, as in other published series, more than 97% of infants from PVDs progressed well without the need for extra neonatal care.10,21 We had one case of intrapartum death, the baby dying in the birth canal secondary to complications during assisted vaginal delivery, producing a mortality rate of 1.1‰ (1/891) in the PVD group. This rate is lower than in the overall results presented in the Term Breech Trial (12.5‰ (13/1039)) and in the subgroup of countries with low perinatal mortality rates (5.8‰ (3/511)),1 and similar to figures published by other groups experienced in © 2015 Nature America, Inc.
Abbreviations: BE, base excess; CI, confidence interval; NICU, neonatal intensive care unit; OR, odds ratio. Perinatal composite morbidity: umbilical cord arterial pH o7+BE ⩽ − 12 mmol l−1+5-min Apgar score o 7+NICU.
7.21 ± 0.9 3.8% 8.8% 0.5% 1.3% 2.2% 2.6‰ (1) 0 7.18 ± 0.8 2.4% 14.5% 0.8% 2.9% 2.1% 0 1.9‰ (1)
© 2015 Nature America, Inc.
Mean umbilical arterial cord pH Umbilical cord arterial pH o 7.00 Umbilical arterial cord BE ⩽ − 12 mmol l−1 5-min Apgar o4 5-min Apgar o7 Admission to NICU Intrapartum perinatal composite morbidity Intrapartum and neonatal death
Intrapartum caesarean Vaginal birth
Planned vaginal birth
Table 2.
Perinatal outcomes of planned vaginal delivery and elective caesarean
P
o 0.01 0.25 0.01 0.65 0.11 0.82 1 0.51
OR
0.63 1.76 1.48 2.26 0.90 — —
95% CI
0.29–1.39 1.12–2.77 0.27–8.15 0.81–6.27 0.37–2.20 — —
7.19 ± 0.9 3.0% 11.9% 0.7% 2.2% 2.2% 1.1‰ (1) 1.1‰ (1)
Planned vaginal birth
7.25 ± 0.6 0.7% (5) 1.7% 0 0.4% 2% 0 0
Planned caesarean
P
o 0.01 o 0.01 o 0.01 0.03 o 0.01 0.86 1 1
OR
4.71 7.91 — 6.05 1.12 — —
95% CI
1.80–12-32 4.20–14.90 — 1.79–20.43 0.57–2.17 — —
Management of breech presentation at term J Burgos et al
vaginal breech deliveries (0.8‰ (2/2502)10 and 1.6‰ (30/18 388)21). The Dutch study, considering more than 58 000 breech deliveries at term from a 10-year period, found that the mortality remained constant over time, not varying despite an increase in PCS and intrapartum CS, and failed to discover any factors that identified subgroups with different levels of risk. The alternative to vaginal birth is PCS. When this option is considered, we should take into account the gestational week in which the operation is to be performed. From week 39, there is a lower risk of perinatal morbidity (respiratory distress, jaundice, and so on22). Further, PCS, in principle, improves perinatal parameters, at the expense of increasing the risk of maternal morbidity and mortality, as well as the risk for future pregnancies. A study conducted in the Netherlands, for recording and assessing maternal deaths secondary to PCS for breech presentation, found the rate of maternal mortality to be 0.5‰.23 Another study from the Netherlands estimated that the increase by about 8500 in the number of PCS, in the 4 years after publication of the Term Breech Trial,1 probably prevented 19 perinatal deaths. It also resulted in four maternal deaths. Additionally, it was estimated that, in future pregnancies, 9 perinatal deaths could be expected as a result of the uterine scar, and 140 women would have potentially life-threatening complications from the uterine scar.24,25 In short, opting for PCS may avoid 10 fetal deaths, but does so at the expense of 4 maternal deaths and 140 serious uterine scar complications. Attending births, we have to manage cases with different levels of risk. Without any doubt, attempting vaginal birth in breech presentations carries a greater risk of perinatal mortality, but this is not the only obstetric situation in which there is an increase in perinatal mortality. The rate of uterine rupture during labour after a previous CS is 5–7‰ (rising to 10–15‰ in induction) with a perinatal mortality rate of 1.1–1.4‰ (37‰ in the case of uterine rupture).26–28 In twin deliveries, the mortality rate is higher for the second baby (1.1–2.4‰).29–31 Published studies in all these situations have not found a benefit in CS and the main scientific societies support vaginal delivery with a series of recommendations in terms of selection criteria and intrapartum management. Our study provides data on the management of breech presentation at term. Previous studies have focused on ECV itself or on vaginal delivery, but have not provided an overall picture of the results of the combination as recommended by scientific societies. The results show the clinical application of these recommendations, although implantation of ECV has been progressive and must be taken into account when interpreting the results. We recognise that this is a single-center retrospective study with the intrinsic limitations of this type of research, especially in the power of the study to find differences and perinatal mortality. However, this characteristic should not markedly affect the interpretation of the findings, given the agreement of our results with other groups and the standardised protocol used for the management of the pregnant women. To conclude, breech presentation at term should be managed in a holistic way. The use of ECV avoids breech presentation at delivery, halving the number of deliveries with this risk factor. This not only decreases the rate of CS but also the morbidity and mortality rates in both mother and baby associated with this type of presentation. It should not be an option to fail to introduce and spread the use of ECV. Attempting a vaginal delivery of breech presentations is associated with a risk for the baby, but we should not forget that CS is associated with higher maternal morbidity and mortality. As is the case for other obstetric risk situations, previous studies have not demonstrated better perinatal outcomes with PCS. To optimise our perinatal outcomes, it is essential to develop hospital protocols and simulators for training health professionals in the different types of complications that may arise. Journal of Perinatology (2015), 1 – 6
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CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS This study was based on data from the Perinatal Register of Cruces University Hospital. We acknowledge all midwives, obstetricians, paediatricians, nurses and residents who routinely collect perinatal data for this register.
REFERENCES 1 Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000; 356: 1375–1383. 2 Rietberg CC, Elferink-Stinkens PM, Visser GH. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants. BJOG 2005; 112: 205–209. 3 Sullivan EA, Moran K, Chapman M. Term breech singletons and caesarean section: a population study, Australia 1991-2005. Aust N Z J Obstet Gynaecol 2009; 49: 456–460. 4 Hartnack Tharin JE, Rasmussen S, Krebs L. Consequences of the Term Breech Trial in Denmark. Acta Obstet Gynecol Scand. 2011; 90: 767–771. 5 Daviss BA, Johnson KC, Lalonde AB. Evolving evidence since the term breech trial: Canadian response, European dissent, and potential solutions. J Obstet Gynaecol Can 2010; 32: 217–224. 6 Rietberg CC, Elferink-Stinkens PM, Brand R, van Loon AJ, Van Hemel OJ, Visser GH. Term breech presentation in The Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33824 infants. BJOG 2003; 110: 604–609. 7 Hauth JC, Cunningham FG. Vaginal breech delivery is still justified. Obstet Gynecol 2002; 99: 1115–1116. 8 Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol 2004; 191: 864–871. 9 Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol 2006; 194: 20–25. 10 Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006; 194: 1002–1011. 11 The Management of Breech Presentation. RCOG Guidelines, 2006. Available from http://www.rcog.org.uk (accessed 1 August 2014). 12 ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 340. Mode of term singleton breech delivery. Obstet Gynecol 2006; 108: 235–237. 13 Kotaska A, Menticoglou S, Gagnon R, Farine D, Basso M, Bos H et al. Vaginal delivery of breech presentation. J Obstet Gynaecol Can 2009; 31: 557–566. 14 Breech Delivery at Term. Protocolos SEGO, 2011. Available from http://www.sego.es/ (accessed 1 August 2014). 15 Management of Breech Presentation at Term. RANZCOG College Statement, 2013. Available from http://www.ranzcog.edu.au (accessed 1 August 2014).
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16 Breech Delivery and External Cephalic Version. Information for Patients. Hospital Universitario Cruces, 2003. Available from http://www.hospitalcruces.com/pdfs/ maternidad/FOLLETO%20PARTO%20castellano_peque.pdf (accessed 1 August 2014). 17 Burgos J, Melchor JC, Pijoán JI, Cobos P, Fernández-Llebrez L, Martínez-Astorquiza T. A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term. Int J Gynaecol Obstet 2011; 112: 48–51. 18 Rosman AN, Vlemmix F, Beuckens A, Rijnders ME, Opmeer BC, Mol BW et al. Facilitators and barriers to external cephalic version for breech presentation at term among health care providers in the Netherlands: a quantitative analysis. Midwifery 2014; 30: e145–e150. 19 Collins S, Ellaway P, Harrington D, Pandit M, Impey L. The complications of external cephalic version: results from 805 consecutive attempts. BJOG 2007; 114: 636–638. 20 Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database Syst Rev 2012; 10: CD000083. 21 Vlemmix F, Bergenhenegouwen L, Schaaf JM, Ensing S, Rosman AN, Ravelli AC et al. Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study. Acta Obstet Gynecol Scand 2014; 93: 888–896. 22 Glavind J, Kindberg SF, Uldbjerg N, Khalil M, Møller AM, Mortensen BB et al. Elective caesarean section at 38 weeks versus 39 weeks: neonatal and maternal outcomes in a randomised controlled trial. BJOG 2013; 120: 1123–1132. 23 Schutte JM, Steegers EA, Santema JG, Schuitemaker NW, van Roosmalen J. Maternal Mortality Committee Of The Netherlands Society Of Obstetrics. Maternal deaths after elective cesarean section for breech presentation in the Netherlands. Acta Obstet Gynecol Scand 2007; 86: 240–243. 24 Verhoeven AT, de Leeuw JP, Bruinse HW. Breech presentation at term: elective caesarean section is the wrong choice as a standard treatment because of too high risks for the mother and her future children. Ned Tijdschr Geneeskd 2005; 149: 2207–2210. 25 Visser GHA, Rietberg CC, Oepkes D, Vandenbussche F. Stuitligging: kind versus moeder. Ned Tijdschr Geneeskd 2005; 149: 2211–2214. 26 Cunningham FG, Bangdiwala SI, Brown SS, Dean TM, Frederiksen M, Rowland Hogue CJ et al. NIH consensus development conference draft statement on vaginal birth after cesarean: new insights. NIH Consens State Sci Statements 2010; 27: 1–42. 27 Al-Zirqi I, Stray-Pedersen B, Forsén L, Vangen S. Uterine rupture after previous caesarean section. BJOG 2010; 117: 809–820. 28 Guise JM, Denman MA, Emeis C, Marshall N, Walker M, Fu R et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol 2010; 115: 1267–1278. 29 Smith GC, Fleming KM, White IR. Birth order of twins and risk of perinatal death related to delivery in England, Northern Ireland, and Wales, 1994-2003: retrospective cohort study. BMJ 2007; 334: 576. 30 Wen SW, Fung Kee Fung K, Oppenheimer L, Demissie K, Yang Q, Walker M. Neonatal mortality in second twin according to cause of death, gestational age, and mode of delivery. Am J Obstet Gynecol 2004; 191: 778–783. 31 Quintana E, Burgos J, Eguiguren N, Melchor JC, Fernández-Llebrez L, MartínezAstorquiza T. Influence of chorionicity in intra-partum management of twin deliveries. J Matern Fetal Neonatal Med 2013; 26: 407–411.
© 2015 Nature America, Inc.
ORIGINAL ARTICLE
Management of breech presentation at term: a retrospective cohort study of 10 years of experience J Burgos, L Rodríguez, P Cobos, C Osuna, M del Mar Centeno, R Larrieta, T Martínez-Astorquiza and L Fernández-Llebrez OBJECTIVE: To evaluate the impact of management of childbirth (external cephalic version (ECV) plus planned vaginal delivery (PVD)) of breech presentation at term (⩾37 weeks of gestation). STUDY DESIGN: This retrospective cohort study was based on data collected of singleton breech presentations at term in the Obstetrics and Gynaecology Service, Cruces University Hospital (Biscay, Spain), from January 2003 to December 2012. RESULT: We attended 2377 singleton breech pregnancies at term. We attended 1684 singleton breech term deliveries, attempting vaginal delivery after selection in 52.9% of cases and were successful in 57.5% of attempts. A total of 1360 ECV were attempted, with a success rate of 50.3% of those attempted. The use of ECV has decreased the rate of breech presentation at delivery by 39.0%, the rate of breech presentation as a caesarean section (CS) indication by 47.1% (CS due to breech presentation/total of CS) and the rate of CS for breech presentation out of the total of deliveries by 39.1% (CS due to breech presentation/total of deliveries). Early postnatal parameters (5-min Apgar score, umbilical cord arterial pH and acid-base analysis) were significantly lower following PVD compared with planned CS for breech presentation. However, we did not find any differences in the rates of admissions to the neonatal unit or neonatal mortality. CONCLUSION: Management of breech presentation with a protocol that includes ECV, careful selection criteria and active management of vaginal delivery achieve a great decrease in the rate of CS for breech presentation. Journal of Perinatology advance online publication, 16 July 2015; doi:10.1038/jp.2015.75
INTRODUCTION Breech presentation occurs in 3–4% of gestations at term. The preferred mode of delivery has varied over recent years. Following the publication of the ‘Term Breech Trial',1 there was a marked change in the management of breech presentation based on short-term results of the clinical trial. These short-term results showed less neonatal morbi-mortality in elective caesarean section (CS) and the rates of CSs soaring to 100% in many hospitals.2–4 The authors published the long-term results of the trial showing no differences in neonatal morbi-mortality between planned vaginal delivery (PVD) and elective CS. Furthermore, several critical reviews were published as inter-center heterogeneity, no imaging evaluation of fetal head attitude, serious violation of inclusion criteria, non-professional expert assistant at delivery and most of perinatal death were not associated with the delivery.5–9 At the same time, the results of the PREMODA study were published concluding that in places where PVD is a common practice and when strict criteria are met before and during labour, PVD of singleton fetuses in breech presentation at term remains a safe option that can be offered to women.10 The main scientific societies (RCOG, ACOG, SOGC, SEGO and RANZCOG) updated their guidelines recommending an active management of breech presentation at term offering external cephalic version (ECV) at term and attempting vaginal breech delivery in well-selected pregnancies.11–15 Despite these recommendations, many groups have not implemented ECV or allowed vaginal delivery and, in such cases, the current rate of CS in this presentation is still close to 100%.
The aim of the study was to evaluate the impact of management (ECV and PVD) of breech presentation at term. METHODS This was a retrospective cohort study at Cruces University Hospital (Biscay, Spain). We included all singleton breech presentations at term (⩾37 weeks of gestation) that were identified at Hospital ECV Register or Hospital Delivery Register, except fetuses with congenital malformations or antenatal death, with or without ECV, delivered in our hospital between 2003 and 2012. During antenatal care, the obstetrician provided the woman with oral information about our management of breech presentation at term, supported by written material.16 If the fetus was in breech presentation at 37 weeks of gestation, then ECV was offered. When ECV was unsuccessful or the mother refused it, a PVD was allowed for selected pregnancies. The selection was made mainly at the beginning of the labour. In our hospital, caesarean indication was done based on the medical criteria. CS in breech delivery with medical criteria of PVD was not allowed by maternal request. ECV was considered for all women with singleton breech presentations at term and the maneuver was performed following our guidelines.17 Briefly, exclusion criteria for the use of ECV in our hospital were placenta praevia, premature placental abruption, oligohydramnios (amniotic fluid index o 5), signs of fetal compromise, fetal death, severe fetal malformations, multiple gestation, isoimmunization, maternal coagulation disorders, and indications for CS not related to fetal presentation. Prior CS and estimated fetal weight 44000 g were not contraindications to ECV. All women were informed in detail about the procedure, explaining the benefits and risks. Before ECV, cardiotocography was performed to confirm fetal wellbeing. As a tocolytic, we used intravenous ritodrine (Prepar; Laboratorios Reig Jofre SA, Barcelona, Spain). It was administered via
Obstetrics and Gynaecology Service, BioCruces Health Research Institute, Hospital Universitario Cruces (UPV/EHU), Biscay, Spain. Correspondence: Professor J Burgos, Obstetrics and Gynaecology Service, BioCruces Health Research Institute, Hospital Universitario Cruces, C/Plaza de Cruces 12, Baracaldo 48903, Vizcaya, Spain. E-mail: [email protected] Received 23 November 2014; revised 4 May 2015; accepted 5 May 2015
Management of breech presentation at term J Burgos et al
2 continuous 200 μg infusion pump starting 30 min before the version and maintained during the maneuver. Atosiban was only used if the woman had any contraindication for ritodrine (Tractocile; Laboratorios Ferring SA, Madrid, Spain), and in such cases, it was administered intravenously in a single 0.9 ml bolus 2 min before starting the maneuver. The ECV was considered to be successful if the breech presentation rotated to cephalic. For 60 min following the version attempt, continuous cardiotocography was performed to assess fetal status and the woman was monitored to detect any adverse effects. Anti-D immunoglobulin was also administered if indicated. If no complications arose during this period, then the woman was discharged and monitored until delivery. There was a protocol for patient selection and intrapartum management for vaginal breech delivery. Induction was performed based on maternal or obstetric indications. Vaginal delivery was allowed when the type of breech was frank or complete, the fetal neck was not hyperextended, there was no apparent fetopelvic disproportion (clinical evaluation based on good progress of labour or by pelvimetry pelvic inlet measurement of 410.5 cm in the obstetric conjugate diameter), the estimated fetal weight was ⩽ 3800 g and the biparietal diameter was o 98 mm. In 2011, we changed the estimated fetal weight limit to ⩽ 4000 g and the biparietal diameter-based criterion was dropped. All the variables were evaluated at the beginning of labour. Estimated fetal weight was also evaluated in the outpatient department, and if it is 44000 g, then CS was indicated. Women who did not meet the criteria for attempting vaginal delivery as well as those with an indication for CS for other reasons (placenta praevia or two previous CSs, among others) underwent planned caesarean section (PCS). We performed continuous electronic fetal monitoring throughout the intrapartum management. In the absence of regular spontaneous contractions, oxytocin and amniotomy were used to simulate uterine activity. An obstetrician closely monitored the rate of dilation in all cases. In the cases of breech presentation, more than 2 h with the same degree of dilation despite adequate uterine activity was considered to indicate dystocia. At complete dilatation, the upper limits set for the duration of the passive (a rest period for fetal passive descent without maternal pushing) and active (active maternal pushing for fetal descent) stages of labour were 90 min and 60 min, respectively. There is no variation by parity or epidural status. In all cases, the deliveries were attended by two obstetricians and a paediatrician. In the event of cardiotocographic parameters indicating a possible deterioration in fetal wellbeing, dilation not progressing adequately or the baby failing to descend despite maternal pushing, we carried out an intrapartum CS. Data were obtained from the Hospital ECV Register or Hospital Delivery Register, completed after the delivery and/or the ECV by the health professionals in charge, as well by reviewing patient medical records. As secondary outcomes, we carried out a descriptive analysis of the obstetric data and perinatal parameters (5-min Apgar score, umbilical cord arterial pH, base excess (BE) ⩽ − 12 mmol l−1, rate of admission to the neonatal intensive care unit (NICU), perinatal composite morbidity (umbilical cord arterial pH o7+BE ⩽ − 12 mmol l−1+5-min Apgar score o7+NICU) and neonatal mortality). It was considered that a newborn has perinatal composite morbidity when all criteria were met. We compared the perinatal parameters from PCS with those from PVDs (both those resulting in vaginal births and those converted to CSs). Ethical approval was obtained for this cohort study. We performed statistical analysis using IBM SPSS Statistics (version 22; IBM, Armonk, NY, USA). Chi-square or Fisher exact tests were used for qualitative and Student's T test or Mann–Whitney U tests for quantitative variables according to fulfillment of theoretical assumptions by the study data (expected cell frequencies and Gaussian distribution, respectively). The threshold for significance was set at Po0.05.
RESULTS We attended 2377 singleton breech pregnancies at term. A total of 1360 ECVs were attempted, with a success rate of 50.3%. We attended 1684 singleton breech term deliveries, attempting vaginal delivery after selection in 52.9% of cases and were successful in 57.5% of attempts. The mean maternal age was 33 ± 4.4 and body mass index was 28.3 ± 4.3. The median gestational age at ECV was 37 (range 6) and gestational age at delivery was 39 (range 6). Figure 1 shows the distribution of the 2377 pregnancies with breech presentation at term by year during the study period. ECV was progressively introduced over 6 years, Journal of Perinatology (2015), 1 – 6
Figure 1. Number of breech presentations at term (before external cephalic version (ECV)), ECVs attempted (successful+unsuccessful) and breech presentations at delivery (planned vaginal+planned c-section) by year.
Figure 2. Rate of external cephalic version (ECV) and breech presentations at term after ECV out of the total number of breech presentations at term before ECV.
since when, use of the maneuver has stabilised (bars). The lines represent the number of breech presentations at term, before ECV, and at delivery. Figure 2 shows the rate of ECVs and the rate of breech presentation at delivery after ECV, both as a function of the total number of breech presentations at term. The rate of breech presentation at delivery has decreased with the increase in the rate of ECV for breech presentation. In the last 2 years (2011–2012), we have attempted ECVs in 73% (n = 340) of the 466 cases of singleton breech presentation at term. Over the whole 10-year period, we have carried out 1360 ECVs with a success rate of 50.3% and a rate of cephalic presentation at term of 51%. The rate of spontaneous reversion to breech was 2.3% and that of spontaneous cephalic version was 3.7% (Figure 3). We did not observe any serious complications. The rate of emergency CS (n = 14) was 1.03%, and there were no maternal and fetal complications in these cases. In the years 2000 and 2001, we did not perform any ECVs. In those years, breech deliveries represented 4.1% of all the singleton deliveries at term and 3.8% of all the deliveries. A total of 232 women had CSs for breech presentation, representing 28.6% © 2015 Nature America, Inc.
Management of breech presentation at term J Burgos et al
3
Figure 3.
Table 1.
Management of breech presentation at term. Cruces University Hospital 2003–2012. ECV, external cephalic version.
Importance of breech presentation at term: before and after the implementation of ECV 2001–2002
2011–2012
388
466
Ratio of breech at term of Total of pregnancies singleton deliveries at term Total of deliveries (24–42 weeks) Total of ECV Total of breech at delivery
4.1% (388/9426) 3.8% (388/10 273) 0 388
4% (466/11 769) 3.6% (466/12 909) 340 299
Ratio of breech at delivery of Total of pregnancies at term Total of deliveries (24–42 weeks) Caesarean rate of breech presentation at term
4.1% (388/9426) 3.8% (388/10 273) 59.8% (232/388)
2.5% (299/11 769) 2.3% (299/12 909) 44.4% (182 breech+25 cephalic after ECV/466)
Ratio of caesarean by breech presentation at term of Total caesarean rate at term Total caesarean Total deliveries
28.6% (232/810) 22.7% (232/1023) 2.3% (232/10 273)
15.1% (182/1204) 12% (182/1513) 1.4% (182/12 909)
Total breech at term
Abbreviation: ECV, external cephalic version.
of CSs in singleton pregnancies at term, 22.7% of the total number of CSs and 2.3% of all the deliveries. In contrast, in 2011 and 2012, we carried out ECVs in 73% of cases of breech presentation at term. As a consequence, breech deliveries represented just 2.5% of singleton deliveries at term and 2.3% of all the deliveries. In these years, we carried out 182 CSs for breech presentation. These represented 15.1% of CSs in singleton pregnancies at term, 12% of the total number of CSs and 1.4% of all the deliveries (Table 1). Comparing the results, the introduction of ECV has led to a 39% decrease (from 4.1 to 2.5%) in breech deliveries, a 47.1% decrease (from 22.7 to 12%) in breech presentation as an indication for CS, and a 39.1% decrease (from 2.3 to 1.4%) in the rate of CS for breech presentation as a function of all the deliveries (Figure 4). The use of ECV has decreased the overall rate of CS for breech presentation at term by 27%, from 60% (232/388) in 2000–2001 to 44% (207/466) in 2011–2012. In a hypothetical scenario, if we had attempted ECV in all cases of breech presentation, there would have been a 37% decrease in the rate of CS for breech © 2015 Nature America, Inc.
presentation (from 60 to 38%), 4.6 ECVs (95% confidence interval (CI), 2.8–11.9) being needed to avoid one CS. This theoretical decrease would be, in a hospital that systematically relies on PCS for this type presentation at delivery, from 96.5% (total breech at term except spontaneous version to cephalic (≈3.5%) to 57%, just 2.53 ECVs (95% CI, 2.01–3.43) being necessary to prevent one CS. During the study period, we attended 1684 breech presentations at delivery, 667 following ECV attempts and 1017 in which version had not been attempted. Of these, 47.1% did not meet the criteria for vaginal deliveries and hence PCS was indicated. In the other cases (n = 891), a vaginal birth was attempted. This approach was successful over half the time, while others were converted to caesareans (57.5% vaginal delivery vs 42.5% intrapartum CS). The overall rate of breech vaginal delivery was 30.4%, the other 69.6% of breech presentations being delivered by caesarean. On the other hand, in 693 cases, the presentation was cephalic at delivery, 83.5% of these resulting in successful vaginal deliveries. The Journal of Perinatology (2015), 1 – 6
Management of breech presentation at term J Burgos et al
4
Figure 4. Distribution of breech deliveries at term (caesarean and vaginal) without (2000–2001) and with (2011–2012) ECV. ECV, external cephalic version.
overall rate of CS was 54.1% in the cohort of 2377 breech presentations at term (Figure 3). In the PVD and PCS groups, the mean ages of the pregnant women were 32 ± 4 and 33 ± 4 years old, respectively. The gestational age at birth was similar in the two groups (39 ± 1.3 weeks, PVD vs 39.1 ± 1.2 weeks, PCS; P = 0.10). In the PVD group, 3.3% of women had one previous CS compared with 7.6% in the PCS group (P o0.01), while the percentages of multiparous women were 21.9 and 27.5%, respectively (Po 0.01). Table 2 summarises the comparison of perinatal outcomes in the PVD and PCS groups. We observed differences in the following variables: mean umbilical cord arterial pH, and the percentage of infants with pH o 7.00, BE ⩽ − 12 mmol l−1, 5-min Apgar score o 4 and 5-min Apgar score o 7. We did not, however, observe significant differences in the rates of admission to the NICU, primary perinatal morbidity or perinatal mortality. There was one case of fetal intrapartum death in a vaginal delivery due to complications in the second stage of labour (head entrapment with both arms being behind the neck). Among the PVDs, we only found differences between vaginal births and intrapartum CSs in the mean umbilical cord arterial pH (7.18 ± 0.8 vs 7.21 ± 0.9, Po 0.01, respectively) and the rate of BE ⩽ − 12 mmol l−1 (14.5% vs 8.8%, P = 0.01, respectively). DISCUSSION We have described our experience and results over 10 years with the introduction of ECV in the management for breech presentation at term. Our hospital has traditionally advocated the use of vaginal delivery for breech presentation in selected cases. In the last 2 years of the study period, we have updated our protocol, modifying one selection criterion and dropping another. Over these 10 years, we have introduced ECV as a key part of the clinical management of breech presentation. As for every new procedure, there is a learning curve, in this instance, both for health professionals and for pregnant women themselves. In our case, the number of ECVs progressively increased over a period of 6 years. In the last 2 years, we have performed ECVs in 73% of singleton breech presentations at term. This clinical management of breech presentation at term has made that CS for breech presentation has deceased form 2.3 to 1.4% of the total of deliveries, even though the caesarean rate of the hospital has increased from 10 to 11.7% in the same period. ECV is a simple maneuver that halves the number of breech presentations at delivery, that is, when successful, this maneuver eliminates one of the most important intrapartum obstetric risk factors, and it carries little additional risk. There is no other intrapartum obstetric risk factor (previous CS and multiple pregnancy, among others) that can be avoided. However, to have this positive impact, ECV needs to be implemented. In our hospital, when we did not perform ECVs, the caesarean rate of breech presentation at term was 60%. By the last 2 years, after 8 years of progressive implementation, in which we performed EVC Journal of Perinatology (2015), 1 – 6
in 73% of breech presentations at term, ECV has led to a 39% decrease in breech deliveries and a 47.1% decrease in breech presentation as an indication for CS. This clinical consequence of the implantation of the ECV is the reason why this technique is rising in popularity and even more hospitals carry it out. Although we consider that these results are good, we consider that is still margin for improvement. If we performed ECV for all breech presentations at term, then the rate of CS could potentially decrease to 38%, 4.6 ECVs being required to avoid one CS. The benefit would be even more apparent in hospitals that do not currently allow vaginal delivery of breech presentations. In this type of hospital, the rate of CS could decrease from 96.5 to 57%, 2.53 ECVs being required to avoid one CS. Despite these estimates being theoretical, it should be possible to get close to these figures, if we are able to make all health professionals and patients aware of the risk-benefit balance of this maneuver.18 Given that the complication rate is very low,19 few extra resources are required and the benefit is proven,20 we consider that one of the main objectives of all obstetric units should be to introduce ECV to their clinical practice and attempt versions in as many patients as possible. Such changes would achieve a large decrease in the rates of breech presentation at delivery and of CSs. All obstetric units, without exception, should now offer this procedure and a common health policy should be developed to promote its use. Our results on breech presentation at delivery are comparable to those published by other research groups. A total of 52.9% of cases met the criteria for indicating vaginal delivery, a significantly higher percentage than in the PREMODA study (31%) and higher than that in the Dutch cohort (40%). This is attributable to the application of more restrictive selection criteria than those used by our group. Specifically, the PREMODA study did not include complete breech presentations but did include CSs performed on maternal request. Our success rate for attempted vaginal birth was 57.5%, somewhat lower than that in the PREMODA study (71%) and similar to that in the Dutch cohort (≈50%).10,21 A vaginal breech delivery entails short-term fetal distress and this is reflected in the early perinatal parameters. Indeed, the overall results at this stage are better for PCS than for PVD. However, the rate of admission in the NICU was not significantly different in the two groups and nor was the composite neonatal morbidity, whose objective was to identify the neonates with high risk of serious acute intrapartum hypoxic event. It is clear that breech delivery is stressful, the birth process drawing more on fetal reserves than it would under other circumstances. Nevertheless, as in other published series, more than 97% of infants from PVDs progressed well without the need for extra neonatal care.10,21 We had one case of intrapartum death, the baby dying in the birth canal secondary to complications during assisted vaginal delivery, producing a mortality rate of 1.1‰ (1/891) in the PVD group. This rate is lower than in the overall results presented in the Term Breech Trial (12.5‰ (13/1039)) and in the subgroup of countries with low perinatal mortality rates (5.8‰ (3/511)),1 and similar to figures published by other groups experienced in © 2015 Nature America, Inc.
Abbreviations: BE, base excess; CI, confidence interval; NICU, neonatal intensive care unit; OR, odds ratio. Perinatal composite morbidity: umbilical cord arterial pH o7+BE ⩽ − 12 mmol l−1+5-min Apgar score o 7+NICU.
7.21 ± 0.9 3.8% 8.8% 0.5% 1.3% 2.2% 2.6‰ (1) 0 7.18 ± 0.8 2.4% 14.5% 0.8% 2.9% 2.1% 0 1.9‰ (1)
© 2015 Nature America, Inc.
Mean umbilical arterial cord pH Umbilical cord arterial pH o 7.00 Umbilical arterial cord BE ⩽ − 12 mmol l−1 5-min Apgar o4 5-min Apgar o7 Admission to NICU Intrapartum perinatal composite morbidity Intrapartum and neonatal death
Intrapartum caesarean Vaginal birth
Planned vaginal birth
Table 2.
Perinatal outcomes of planned vaginal delivery and elective caesarean
P
o 0.01 0.25 0.01 0.65 0.11 0.82 1 0.51
OR
0.63 1.76 1.48 2.26 0.90 — —
95% CI
0.29–1.39 1.12–2.77 0.27–8.15 0.81–6.27 0.37–2.20 — —
7.19 ± 0.9 3.0% 11.9% 0.7% 2.2% 2.2% 1.1‰ (1) 1.1‰ (1)
Planned vaginal birth
7.25 ± 0.6 0.7% (5) 1.7% 0 0.4% 2% 0 0
Planned caesarean
P
o 0.01 o 0.01 o 0.01 0.03 o 0.01 0.86 1 1
OR
4.71 7.91 — 6.05 1.12 — —
95% CI
1.80–12-32 4.20–14.90 — 1.79–20.43 0.57–2.17 — —
Management of breech presentation at term J Burgos et al
vaginal breech deliveries (0.8‰ (2/2502)10 and 1.6‰ (30/18 388)21). The Dutch study, considering more than 58 000 breech deliveries at term from a 10-year period, found that the mortality remained constant over time, not varying despite an increase in PCS and intrapartum CS, and failed to discover any factors that identified subgroups with different levels of risk. The alternative to vaginal birth is PCS. When this option is considered, we should take into account the gestational week in which the operation is to be performed. From week 39, there is a lower risk of perinatal morbidity (respiratory distress, jaundice, and so on22). Further, PCS, in principle, improves perinatal parameters, at the expense of increasing the risk of maternal morbidity and mortality, as well as the risk for future pregnancies. A study conducted in the Netherlands, for recording and assessing maternal deaths secondary to PCS for breech presentation, found the rate of maternal mortality to be 0.5‰.23 Another study from the Netherlands estimated that the increase by about 8500 in the number of PCS, in the 4 years after publication of the Term Breech Trial,1 probably prevented 19 perinatal deaths. It also resulted in four maternal deaths. Additionally, it was estimated that, in future pregnancies, 9 perinatal deaths could be expected as a result of the uterine scar, and 140 women would have potentially life-threatening complications from the uterine scar.24,25 In short, opting for PCS may avoid 10 fetal deaths, but does so at the expense of 4 maternal deaths and 140 serious uterine scar complications. Attending births, we have to manage cases with different levels of risk. Without any doubt, attempting vaginal birth in breech presentations carries a greater risk of perinatal mortality, but this is not the only obstetric situation in which there is an increase in perinatal mortality. The rate of uterine rupture during labour after a previous CS is 5–7‰ (rising to 10–15‰ in induction) with a perinatal mortality rate of 1.1–1.4‰ (37‰ in the case of uterine rupture).26–28 In twin deliveries, the mortality rate is higher for the second baby (1.1–2.4‰).29–31 Published studies in all these situations have not found a benefit in CS and the main scientific societies support vaginal delivery with a series of recommendations in terms of selection criteria and intrapartum management. Our study provides data on the management of breech presentation at term. Previous studies have focused on ECV itself or on vaginal delivery, but have not provided an overall picture of the results of the combination as recommended by scientific societies. The results show the clinical application of these recommendations, although implantation of ECV has been progressive and must be taken into account when interpreting the results. We recognise that this is a single-center retrospective study with the intrinsic limitations of this type of research, especially in the power of the study to find differences and perinatal mortality. However, this characteristic should not markedly affect the interpretation of the findings, given the agreement of our results with other groups and the standardised protocol used for the management of the pregnant women. To conclude, breech presentation at term should be managed in a holistic way. The use of ECV avoids breech presentation at delivery, halving the number of deliveries with this risk factor. This not only decreases the rate of CS but also the morbidity and mortality rates in both mother and baby associated with this type of presentation. It should not be an option to fail to introduce and spread the use of ECV. Attempting a vaginal delivery of breech presentations is associated with a risk for the baby, but we should not forget that CS is associated with higher maternal morbidity and mortality. As is the case for other obstetric risk situations, previous studies have not demonstrated better perinatal outcomes with PCS. To optimise our perinatal outcomes, it is essential to develop hospital protocols and simulators for training health professionals in the different types of complications that may arise. Journal of Perinatology (2015), 1 – 6
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CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS This study was based on data from the Perinatal Register of Cruces University Hospital. We acknowledge all midwives, obstetricians, paediatricians, nurses and residents who routinely collect perinatal data for this register.
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