http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, Early Online: 1–5 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2015.1067768
ORIGINAL ARTICLE
Vaginal delivery or cesarean section at term breech delivery – chance or risk?
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 08/03/15 For personal use only.
Ivana Babovic´, Milica Arandjelovic´, Snezˇana Plesˇinac, and Radmila Sparic´ Department of Gynecology and Obstetrics, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
Abstract
Keywords
Aim: The aim of the study was to examine maternal age, parity, and estimated neonatal birth weight (BW) depending on the mode of a full-term breech presentation (BP) birth delivery and neonatal outcomes. Material and methods: One hundred and forty-six singleton term breech presentation pregnancies were included in a retrospective study conducted at the Department of Gynecology/Obstetrics, Clinical Center of Serbia in Belgrade in 2013. Statistical analysis: Student’s-t test, 2 likelihood ratio, and the Fisher’s exact test. The level of statistical significance was set at p50.05. Results: An ECS was the most common mode of delivery in (81.2%) nulliparous older than 35 years and most of the neonates (66.67%) with an estimated birth weight (BW) above 3500 grams were delivered by elective cesarean section (ECS). Perinatal asphyxia remained increased in the successful vaginal delivery (SVD) group (23.8%) compared with the urgent CS (UCS) group (13.3%) (p ¼ 0.035). Birth asphyxia was the most common in neonates were delivered by SVD (23.8%). There were no cases of perinatal deaths. Conclusion: ECS remained the recommended mode of breech term delivery in nulliparous women older than 35 years, as well as in neonates with an estimated BW above 3500 grams.
Cesarean section, neonatal outcome, term breech delivery, vaginal delivery
Introduction According to previous research, the incidence of a breech presentation during a full-term pregnancy is 7%, while the incidence during a full-term delivery is 3–4% [1]. The failure to change from a breech presentation during pregnancy results from endogenous and exogenous factors. Endogenous factors involve the inability of the fetus to adequately move, whereas exogenous factors include insufficient intrauterine space available for fetal movements. The incidence of a breech presentation at delivery includes various exogenous factors, such as maternal and medical factors. Maternal constitutional factors include nulliparity, grand multiparity, contracted pelvis, older maternal age and uterine anomalies such as fibroma. Pregnancy complications include fetal malformations, fetal growth retardation, hydramnion, oligohydramnion, placenta previa, and a short umbilical cord [2]. An ultrasound examination is the most common diagnostic procedure for determining the breech presentation for term births, such as complete breeches, frank breeches, footling breeches and finally, kneeling breeches [3].
Address for correspondence: Ivana Babovic´, Department of Gynecology and Obstetrics, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia. E-mail: [email protected]
History Received 8 April 2015 Revised 19 June 2015 Accepted 27 June 2015 Published online 28 July 2015
Over the past decade, there has been an increasing trend in the United States to perform cesarean delivery for full-term singleton fetuses in a breech presentation. In 2002, the rate of cesarean deliveries for women in labor with a breech presentation was 86.9% [4]. Perinatal mortality (Mt) increases 2 - to 4-fold during a breech presentation, regardless of the mode of delivery. Vaginal delivery (VD) may lead to several complications (e.g. umbilical cord prolapse and dystocia) and higher early neonatal morbidity (Mb), including intrapartum-related hypoxia (formerly called ‘‘birth asphyxia’’), intra-cranial hemorrhage, birth injuries (e.g. spinal cord injury, injury of plexus brachialis, and clavicula fracture). VD is a potential recommended option for properly selected patient. The initial criteria used in these reports were similar, as follows: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g, excluding fetopelvic disproportion (as any clinically significant mismatch between the size or shape of the presenting breech of the fetus and the size or shape of the maternal pelvis and soft tissue). In addition, the protocol involved a fetal head flexion, ultrasound examination for adequate amniotic fluid volume, defined as a 3-cm vertical pocket. Oxytocin induction or augmentation was not offered, and strict criteria were established for a normal labor progress [5,6].
2
I. Babovic´ et al.
The aim of the study The aim of study was to examine maternal age, parity, and estimated neonatal birth weight (BW) depending on the mode of a full-term breech presentation birth delivery and neonatal outcomes.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 08/03/15 For personal use only.
Material and methods One hundred and forty-six singleton term breech presentation pregnancies were included in a retrospective study conducted at the Department of Gyn/Obstet, Clinical Center of Serbia in Belgrade in 2013. We evaluated the influence of maternal age and parity as well as, the duration and mode of delivery on neonatal outcomes (BW), Apgar score at the 5th min (Ap5), duration in neonatal intensive care unit (NICU), early neonatal Mb and Mt. The following groups were included based on their mode of delivery: group A – elective cesarean section group (ECS group) and group B – planned vaginal delivery group (PVD group). Group B was sub-divided into the following two groups: group B1 – successful vaginal delivery (SVD group) and group B2 – urgent (emergency) cesarean section group (UCS group). The most prevalent indication for ESC was: fetopelvic disproportion for an UCS. In addition to, the fetopelvic disproportion, the other indication for UCS was fetal distress. For the statistical analysis, we used descriptive analyses Student’s-t test, 2 likelihood ratio, and the Fisher’s exact test. The level of statistical significance was set at p50.05. The following exclusion criteria were used in this study: fetuses or neonates with severe malformations determined before or after birth, neonates with hemolytic disease, as well as cases of intrauterine fetal death. A computer database search was performed to identify all full-term breech presentations and neonatal outcomes. Our study missed dates of neonatal outcomes for seven (7/146; 4.79%) neonates. Patients were informed of the potential risks and benefits to the mother and babies of both vaginal breech deliveries and cesarean delivery and they provided signed informed consent.
Results A retrospective study of neonatal outcomes of 146 full-terms breech deliveries found that 74 (50.7%) planned ECS deliveries and 72 (49.3%) had PVD. The mean age of the patients in the PVD group was 30.4 ± 4.53 years and 31.8 ± 4.61 years in the ECS group. Student’s-t test did not identify a statistically significant difference in the mother’s ages between the groups (p ¼ 0.053). In the PVD group, 36 mothers (50%) were nulliparous, but in 49 (66.2%) nulliparous mothers, an ESC was performed. In the PVD group, 50% (36/72) were multiparous, but an ESC was performed in 25 multiparous mothers (33.8%). The study confirmed that more nulliparous mothers were delivered by ESC than multiparous mothers (p ¼ 0.047). In the PVD group, 33 mothers (47.8%) were nulliparous, and 27 mothers (64.2%) were multiparous and younger than 35 years of age. An ECS were performed in 36 (52.2%) nulliparous women and in 15 (35.7%) mothers who were
J Matern Fetal Neonatal Med, Early Online: 1–5
multiparous and younger than 35 years of age (Table 1). The study did not confirm a statistically significant correlation between parity and the mode of delivery in patients who were younger than 35 years of age (p ¼ 0.213). In a group of patients older than 35 years of age, 16 (45.7%) were nulliparous and 19 (54.2%) were multiparous. In group of nulliparous women, only three patients delivered vaginally, but an ECS was the most common mode of delivery in 13 (81.2%) patients. In the group of multiparous women, 10 (52.6%) were older than 35 years of age; in these women, ECS was the most common mode of delivery. An ECS was more frequently performed than VD in nulliparous women older than 35 years of age (p ¼ 0.034). Fetopelvic disproportion was the most common indication for ECS in 24 (32.4%) deliveries. The mean body weight (BW) of neonates was 3225.42 ± 584.5 g in the PVD group and 3168.24 ± 553.1 g in the ECS group. There was no statistically difference in the neonatal BW between the two groups (p ¼ 0.545). Most of the neonates (10, 55.5%) with an estimated BW below 2500 g were delivered by ECS, and 8 (44.4%) neonates with an estimated BW below 2500 g were delivered by PVD. Finally, most of the neonates 34(66.67%) with an estimated BW above 3500 g were delivered by ECS, but 17 (33.3%) of these neonates had PVD (Table 2). There was a statistically significant difference between the estimated BW and the mode of delivery (p ¼ 0.008). Most neonates had an estimated
Table 1. The mode of delivery, maternal age and parity. Parity Nulliparous 535 years
Multiparous
435 years
535 years
435 years
Mode of delivery
n
%
n
%
n
%
n
%
A (ECS)* B (PVD)y Total
36 33 69
(52.17) (47.83) 100
13 3 16
(81.25) (18.75) 100
15 27 42
(35.71) (64.29) 100
10 9 19
(52.63) (47.37) 100
*ECS, elective cesarean section. yPVD, planned vaginal delivery. An ECS was more frequently performed than VD in nulliparous women older than 35 years of age (p ¼ 0.034).
Table 2. The mode of delivery and neonatal birth weight. Neonatal birth weight 52500 g
43500 g
2500 g–3500 g
Mode of delivery
n
%
n
%
n
%
A (ECS)* B (PVD)y Total
10 8 18
(55.56) (44.44) 100
30 47 77
(38.96) (61.04) 100
34 17 51
(66.67) (33.33) 100
*ECS, elective cesarean section. yPVD, planned vaginal delivery. There was a statistically significant difference between the estimated BW and the mode of delivery (p ¼ 0.008). Most neonates had an estimated BW below 2500 g, because neonates with an estimated BW above 3500 g were delivered by ESC.
Vaginal delivery or cesarean section at term breech delivery
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 08/03/15 For personal use only.
DOI: 10.3109/14767058.2015.1067768
BW below 2500 g, because neonates with an estimated BW above 3500 g were delivered by ESC. An Apgar score at the 5th min 8 was observed in 62 (86.1%) of the neonates in the PVD group and in 66 (89.1%) of the neonates in the ECS group. The mode of delivery was not correlated with an neonatal Apgar score at the 5th min (p ¼ 0.597). Neonatal macrosomia (estimated BW above the 90th percentile for gestational age) was diagnosed in 4 (5.4%) of the neonates in the ECS group, but in 7 (9.4%) neonates in this group had neonatal hypotrophia (BW below the 10th percentile for estimated GW). A sonographic finding, such as fetal macrosomia or intrauterine growth restriction (IUGR), required further meticulous consideration for term breech delivery by ECS. Early neonatal well-being was diagnosed in 54 (72.9%) of the neonates in the ECS group and in 41 (56.9%) of the neonates in the PVD group (Table 3). For those with a breech presentation, perinatal asphyxia increased in the PVD group (19.4%) compared with the ECS group. There was a statistically significant correlation between the structure of perinatal Mb and the mode of delivery (p ¼ 0.042). The duration of being in a NICU was significantly shorter after PVD compared with ECS (4.08 ± 3.1 d versus 5.66 ± 5.3 d; p ¼ 0.033). Group B was sub-divided into the following two groups: group B1 – SVD group and group B2 – UCS group (emergency). There were 42 (58.3%) patients in group B1 and 30 (41.6%) patients in group B2. In the SVD group, 31 mothers (75.60%) were assisted and 11 (26.82%) were spontaneous deliveries. The mean age of patients in the SVD group was 30.14 ± 4.6 years and 30.77 ± 4.49 years in the UCS group. In Student’s-t test, there was no statistically significant difference in the mother’s age between the groups (p ¼ 0.568). Sixteen nulliparous neonates (38.1%) were delivered by SVD and 20 (66.7%) were delivered by UCS. Of the most multiparous neonates, 26 (61.9%) were delivered by SVD. In 10 multiparous mothers (33.3%), an UCS was performed. The study confirmed that a significantly higher number of nulliparous neonates were delivered by UCS than by SVD, and a significantly higher number of multiparous women were delivered by SVD than by UCS. The mode of delivery was determined by parity in our study (p ¼ 0.017).
3
A UCS was performed in 18 (54.6%) nulliparous women who were younger than 35 years, but 21 (77.7%) multiparous mothers were delivered by SVD. The mode of delivery was not determined by the mother’s age in patients younger than 35 years of age (p ¼ 0.585). Only one patient delivered vaginally among the nulliparous women who were older than 35 years of age, and UCS was more frequent mode of delivery for the other two women in this group of patients. In a group of nine multiparous women, older than 35 years of age, five (55.7%) delivered by SVD (Table 4). This study did not confirm that the mode of delivery was determined by the mother’s age among these patients (p ¼ 0.193). Fetopelvic disproportion was the most common indication for UCS (11women, 36.7%) and distocia [failure to progress in labor, either because the cervix will not dilate (expand) further or (after full dilation) the breech does not descend through the mother’s pelvis] occurred in nine women (30%). In addition to the fetopelvic disproportion, an indication for UCS was an acute increase in maternal blood of pressure above 140 mmHg in six (20%) and fetal distress in four (13.3%) deliveries. Spontaneous VD occurred in 11 of 42 women (26.2%) with a mean duration of 4.49 ± 2.1 h, and was augmented by Syntocinon in 31 deliveries (73.8%), with a mean duration of 6.13 ± 1.7 h. Oxytocin augmentation of VD was associated with the duration of labor (p ¼ 0.015). The Lo¨vset maneuver was most frequently performed in 34 (80.9%) of the SVD cases. The Bracht maneuver was performed in six women (14%) and the Smellie–Veit maneuver was performed in 2 (4.76%) of the women undergoing SVD. The mean BW of the neonates was 3107 ± 384 g in the SVD group and 3165 ± 621 g in the UCS group. There was no statistically significant difference in neonatal BW between the two groups (p ¼ 0.627). There were similar number of neonates with an estimated BW below 2500 g who were delivered by UCS and SVD (4/8; 50%). Neonates with an estimated BW above 3500 g delivered by UCS in 9/17 (52, 9%) cases, but 8/17 (47, 06%) neonates were delivered by SVD. The study did not report a difference between the groups (p ¼ 0.429). The Apgar score at the 5th min (8) was observed in 35 (83.3%) of the neonates in the SVD group and in 27(90%) of the neonates in the UCS group. The mode of delivery was not
Table 3. The mode of delivery and neonatal outcome. Table 4. The mode of delivery and neonatal outcome.
The mode of delivery A (ECS)*
B (PVD)y
Neonatal morbidity
n
%
n
%
Neonatal well-being Birth asphyxia Intrauterine growth restriction Neonatal macrosomia
54 9 7 4
(72, 9) (12, 1) (9, 4) (5, 4)
41 14 6 4
(56, 9) (19, 4) (8, 3) (5, 5)
*ECS, elective cesarean section. yPVD, planned vaginal delivery (missed dates of neonatal outcome for seven neonates). There was a statistically significant correlation between the structure of perinatal Mb and the mode of delivery (p ¼ 0.042). Birth asphyxia increased in the VD group (19.4%) compared with the ECS group (12.1%).
The mode of delivery B1 (SVD)*
B2 (UCS)y
Neonatal morbidity
n
%
n
%
Neonatal well-being Birth asphyxia Intrauterine growth restriction Neonatal macrosomia
20 10 3 2
(46, 6) (23, 8) (7, 1) (4, 7)
21 4 3 2
(70) (13, 3) (1) (6, 6)
*SVD, successful vaginal delivery. yUCS, urgent cesarean section (missed dates of neonatal outcome for seven neonates). In breech presentation, birth asphyxia remained increased in the SVD group (23.8%) compared with the UCS group (13.3%) (p ¼ 0.035).
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I. Babovic´ et al.
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associated with the early neonatal Apgar score at the 5th min (p ¼ 0.416). Neonatal macrosomia was diagnosed in two (6.67%) of the neonates in the UCS group. Hypotrophic neonates 3(10%) were delivered by UCS. Early neonatal well-being was diagnosed in 21 (70%) of the neonates in the UCS group and in 20 (46.62%) of the neonates in the SVD (Table 4). In breech presentation, perinatal asphyxia remained increased in the SVD group (23.8%) compared with the UCS group (13.3%) (p ¼ 0.035). The duration of stay in the NICU was significantly shorter after VD compared with UCS (3.12 ± 1.9 d versus 5.43 ± 3.9 d; p ¼ 0.002). There were no neonatal deaths in each of the groups.
Discussion Before Hannah et al. published a study in the Lancet about the neonatal outcomes of term breech presentation, VD was commonly used in clinical practice (October 2000) [5]. This international randomized study found a significant decline in neonatal Mb after planned cesarean section compared with PVD. In our study, more than 50% of term breech deliveries were completed by ECS [6]. From 2007 to 2008, a similar study observed that ECS remained the recommended mode of delivery in nulliparous women older than 35 years of age. VD in term breech presentation was considered to be an optional mode of delivery in multiparous women younger than 35 years of age [7]. Five years later, this study confirmed a continuing trend observed in previous research. We found approximately the same number of nulliparous women who were delivered by ECS (73.9%/66.2), as was reported by Babovic´ et al. [7]. Parity is one of the most important factors of the mode of delivery in breech term presentation as well as estimated fetal BW by an ultrasound examination. The only documented risk related to parity is cord prolapse, which was 2-fold higher in parous women than in primigravidas [8]. More recent studies have documented that estimated fetal BW above 3500 g is an absolute indication for ECS. VD was controversial for term neonates in breech presentation with an estimated BW below 2500 g. Most term breech presentation neonates with an estimated BW below 2500 g in our study were delivered almost by ECS (55.5%). Our study also confirmed that fetal macrosomia, especially after sonographic examination or adequately diagnosed feto–maternal etiological factors of IUGR in fetuses (e.g. chronic hypertension, preeclampsia) indicate that ECS is one the most reasonable modes of delivery [5,8]. We found that mode of delivery did not determine the neonatal Apgar score at the 5th min. Although Apgar score at the 5th min was not a specific indicator of fetal viability, it was a good predictor of long-term neonatal sequelae in our study. The healthiest neonates (Apgar score in 5th min 8) in our study were delivered by PVD, and those with a lower Apgar score at the 5th min were delivered by UCS. VD represents an acute stress test for fetuses. Stress is a necessary condition for accelerating fetal lung maturation in labor. This finding could be an explanation for better neonatal outcomes after VD compared with UCS [9]. The results of our study
J Matern Fetal Neonatal Med, Early Online: 1–5
confirmed that vaginally delivered neonates had significantly shorter stays in NICU compared with neonates delivered by ECS or UCR, as has been seen in previous studies [10]. Superimposed intrapartal asphyxia on chronic fetal hypoxia or acute hypoxic insult (e.g. abruptio placentae, prolapse of the umbilical cord) were the most common indications for UCS and caused lower Apgar scores at the 5th min [11]. Early neonatal well-being was diagnosed in 70% neonates in the UCS group, which was similar to the 72.9% seen among the neonates in the ECS group. The results of our study do not support the results of other research. The similar number of patients in each group (UCS and ECS group) in our study could be an explanation for observed results. We used oxytocin augmentation only for dysfunctional labor. Oxytocin augmentation was used in more than half of the VDs and was the main reason for the study, unexpectedly shorter duration of spontaneous VD that was observed in our study. In our study, birth asphyxia, increased twice in the VD group compared with the UCS and ECS, groups, as was observed in the study of Al-Mulhim et al. [12]. The most often cited etiological factor for that in our study was failure to progress into labor or prolonged expulsion phases. The Lo¨wset maneuver was applied because it significantly reduces the risk of birth injuries, which occur frequently in breech VDs compared with the cephalic presentation of the fetus [13].
Conclusion VD can be considered as safe option especially in multiparous women younger than 35 years of age as well as in neonates with an estimated BW of 2500–3500 g. ECS remained the recommended mode of breech term delivery in nulliparous women older than 35 years, as well as in neonates with an estimated BW above 3500 g. Early neonatal well-being is more frequently diagnosed in neonates born by ECS. Finally, the decision-making process for handling a term breech presentation is very controversial. The most frequent complication for these neonates in such cases is birth asphyxia and a longer duration of stay in NICU; thus, we should ascertain that our decision is correct.
Declaration of interest The authors report no declarations of interest.
References 1. Yamamura Y, Ramin KD, Ramin SM. Trail of vaginal breech delivery: current role. Clin Obstet Gynecol 2007;50: 526–36. 2. Vendittelli F, Rivie`re O, Crenn-He´bert C, et al. Is a breech presentation at term more frequent in women with a history of cesarean delivery? Am J Obstet Gynecol 2008;198:521.e1–6. 3. Kotaska A, Menticoglou S, Gagnon R. Vaginal delivery of breech presentation. J Obstet Gynaecol Can 2009;226:557–66. 4. Goffinet F, Carayol M, Foidart JM, 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;194:1002–11. 5. Hannah ME, Hannah WJ, Hewson SA, et al. Planned cesarean section vs planned vaginal birth for breech presentation at term; a randomised multicentre trial. Lancet 2000;356:1375–83.
DOI: 10.3109/14767058.2015.1067768
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6. American College of Obstetricians and Gynecologists. Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. Obstet Gynecol 2006;108:235–7. 7. Babovic´ I, Plesiinac S, Radojicic´ Z, et al. Vaginal delivery versus caesarean section for term breech delivery. Vojnosanit Pregl 2010; 67:807–11. 8. Dammer U. Sonographic weight estimation in fetuses with breech presentation. Arch Gynecol Obstet 2013;287:851–58. 9. Igwegbe AO, Monago EN, Ugboaja JO. Caesarean versus vaginal delivery for term breech presentation: a comparative analysis. Afr J Biomed Res 2010;13:15–18.
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10. Vistad I, Cvancarova M, Hustad BL, Henriksen T. Vaginal breech delivery: results of a prospective registration study. BMC Pregn Childbirth 2013;13:1–7. 11. Va´zquez JA, Villanueva LA, Lara FG, et al. Associated factors to Apgar score in newborns delivery by breech presentation. Rev Hosp M Gea Glz 2000;3:16–18 (Spanish). 12. Al-Mulhim A, Gasim TG. Breech delivery at term: do the perinatal results justify a trial of labor? Bahrain Med Bull 2002;24:23–7. 13. Bergsjo P. Breech births at term revisited: new contributions from Finland and Norway. Acta Obstet Gynecol Scand 2004;83: 121–3.
ORIGINAL ARTICLE
Vaginal delivery or cesarean section at term breech delivery – chance or risk?
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 08/03/15 For personal use only.
Ivana Babovic´, Milica Arandjelovic´, Snezˇana Plesˇinac, and Radmila Sparic´ Department of Gynecology and Obstetrics, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
Abstract
Keywords
Aim: The aim of the study was to examine maternal age, parity, and estimated neonatal birth weight (BW) depending on the mode of a full-term breech presentation (BP) birth delivery and neonatal outcomes. Material and methods: One hundred and forty-six singleton term breech presentation pregnancies were included in a retrospective study conducted at the Department of Gynecology/Obstetrics, Clinical Center of Serbia in Belgrade in 2013. Statistical analysis: Student’s-t test, 2 likelihood ratio, and the Fisher’s exact test. The level of statistical significance was set at p50.05. Results: An ECS was the most common mode of delivery in (81.2%) nulliparous older than 35 years and most of the neonates (66.67%) with an estimated birth weight (BW) above 3500 grams were delivered by elective cesarean section (ECS). Perinatal asphyxia remained increased in the successful vaginal delivery (SVD) group (23.8%) compared with the urgent CS (UCS) group (13.3%) (p ¼ 0.035). Birth asphyxia was the most common in neonates were delivered by SVD (23.8%). There were no cases of perinatal deaths. Conclusion: ECS remained the recommended mode of breech term delivery in nulliparous women older than 35 years, as well as in neonates with an estimated BW above 3500 grams.
Cesarean section, neonatal outcome, term breech delivery, vaginal delivery
Introduction According to previous research, the incidence of a breech presentation during a full-term pregnancy is 7%, while the incidence during a full-term delivery is 3–4% [1]. The failure to change from a breech presentation during pregnancy results from endogenous and exogenous factors. Endogenous factors involve the inability of the fetus to adequately move, whereas exogenous factors include insufficient intrauterine space available for fetal movements. The incidence of a breech presentation at delivery includes various exogenous factors, such as maternal and medical factors. Maternal constitutional factors include nulliparity, grand multiparity, contracted pelvis, older maternal age and uterine anomalies such as fibroma. Pregnancy complications include fetal malformations, fetal growth retardation, hydramnion, oligohydramnion, placenta previa, and a short umbilical cord [2]. An ultrasound examination is the most common diagnostic procedure for determining the breech presentation for term births, such as complete breeches, frank breeches, footling breeches and finally, kneeling breeches [3].
Address for correspondence: Ivana Babovic´, Department of Gynecology and Obstetrics, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia. E-mail: [email protected]
History Received 8 April 2015 Revised 19 June 2015 Accepted 27 June 2015 Published online 28 July 2015
Over the past decade, there has been an increasing trend in the United States to perform cesarean delivery for full-term singleton fetuses in a breech presentation. In 2002, the rate of cesarean deliveries for women in labor with a breech presentation was 86.9% [4]. Perinatal mortality (Mt) increases 2 - to 4-fold during a breech presentation, regardless of the mode of delivery. Vaginal delivery (VD) may lead to several complications (e.g. umbilical cord prolapse and dystocia) and higher early neonatal morbidity (Mb), including intrapartum-related hypoxia (formerly called ‘‘birth asphyxia’’), intra-cranial hemorrhage, birth injuries (e.g. spinal cord injury, injury of plexus brachialis, and clavicula fracture). VD is a potential recommended option for properly selected patient. The initial criteria used in these reports were similar, as follows: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g, excluding fetopelvic disproportion (as any clinically significant mismatch between the size or shape of the presenting breech of the fetus and the size or shape of the maternal pelvis and soft tissue). In addition, the protocol involved a fetal head flexion, ultrasound examination for adequate amniotic fluid volume, defined as a 3-cm vertical pocket. Oxytocin induction or augmentation was not offered, and strict criteria were established for a normal labor progress [5,6].
2
I. Babovic´ et al.
The aim of the study The aim of study was to examine maternal age, parity, and estimated neonatal birth weight (BW) depending on the mode of a full-term breech presentation birth delivery and neonatal outcomes.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 08/03/15 For personal use only.
Material and methods One hundred and forty-six singleton term breech presentation pregnancies were included in a retrospective study conducted at the Department of Gyn/Obstet, Clinical Center of Serbia in Belgrade in 2013. We evaluated the influence of maternal age and parity as well as, the duration and mode of delivery on neonatal outcomes (BW), Apgar score at the 5th min (Ap5), duration in neonatal intensive care unit (NICU), early neonatal Mb and Mt. The following groups were included based on their mode of delivery: group A – elective cesarean section group (ECS group) and group B – planned vaginal delivery group (PVD group). Group B was sub-divided into the following two groups: group B1 – successful vaginal delivery (SVD group) and group B2 – urgent (emergency) cesarean section group (UCS group). The most prevalent indication for ESC was: fetopelvic disproportion for an UCS. In addition to, the fetopelvic disproportion, the other indication for UCS was fetal distress. For the statistical analysis, we used descriptive analyses Student’s-t test, 2 likelihood ratio, and the Fisher’s exact test. The level of statistical significance was set at p50.05. The following exclusion criteria were used in this study: fetuses or neonates with severe malformations determined before or after birth, neonates with hemolytic disease, as well as cases of intrauterine fetal death. A computer database search was performed to identify all full-term breech presentations and neonatal outcomes. Our study missed dates of neonatal outcomes for seven (7/146; 4.79%) neonates. Patients were informed of the potential risks and benefits to the mother and babies of both vaginal breech deliveries and cesarean delivery and they provided signed informed consent.
Results A retrospective study of neonatal outcomes of 146 full-terms breech deliveries found that 74 (50.7%) planned ECS deliveries and 72 (49.3%) had PVD. The mean age of the patients in the PVD group was 30.4 ± 4.53 years and 31.8 ± 4.61 years in the ECS group. Student’s-t test did not identify a statistically significant difference in the mother’s ages between the groups (p ¼ 0.053). In the PVD group, 36 mothers (50%) were nulliparous, but in 49 (66.2%) nulliparous mothers, an ESC was performed. In the PVD group, 50% (36/72) were multiparous, but an ESC was performed in 25 multiparous mothers (33.8%). The study confirmed that more nulliparous mothers were delivered by ESC than multiparous mothers (p ¼ 0.047). In the PVD group, 33 mothers (47.8%) were nulliparous, and 27 mothers (64.2%) were multiparous and younger than 35 years of age. An ECS were performed in 36 (52.2%) nulliparous women and in 15 (35.7%) mothers who were
J Matern Fetal Neonatal Med, Early Online: 1–5
multiparous and younger than 35 years of age (Table 1). The study did not confirm a statistically significant correlation between parity and the mode of delivery in patients who were younger than 35 years of age (p ¼ 0.213). In a group of patients older than 35 years of age, 16 (45.7%) were nulliparous and 19 (54.2%) were multiparous. In group of nulliparous women, only three patients delivered vaginally, but an ECS was the most common mode of delivery in 13 (81.2%) patients. In the group of multiparous women, 10 (52.6%) were older than 35 years of age; in these women, ECS was the most common mode of delivery. An ECS was more frequently performed than VD in nulliparous women older than 35 years of age (p ¼ 0.034). Fetopelvic disproportion was the most common indication for ECS in 24 (32.4%) deliveries. The mean body weight (BW) of neonates was 3225.42 ± 584.5 g in the PVD group and 3168.24 ± 553.1 g in the ECS group. There was no statistically difference in the neonatal BW between the two groups (p ¼ 0.545). Most of the neonates (10, 55.5%) with an estimated BW below 2500 g were delivered by ECS, and 8 (44.4%) neonates with an estimated BW below 2500 g were delivered by PVD. Finally, most of the neonates 34(66.67%) with an estimated BW above 3500 g were delivered by ECS, but 17 (33.3%) of these neonates had PVD (Table 2). There was a statistically significant difference between the estimated BW and the mode of delivery (p ¼ 0.008). Most neonates had an estimated
Table 1. The mode of delivery, maternal age and parity. Parity Nulliparous 535 years
Multiparous
435 years
535 years
435 years
Mode of delivery
n
%
n
%
n
%
n
%
A (ECS)* B (PVD)y Total
36 33 69
(52.17) (47.83) 100
13 3 16
(81.25) (18.75) 100
15 27 42
(35.71) (64.29) 100
10 9 19
(52.63) (47.37) 100
*ECS, elective cesarean section. yPVD, planned vaginal delivery. An ECS was more frequently performed than VD in nulliparous women older than 35 years of age (p ¼ 0.034).
Table 2. The mode of delivery and neonatal birth weight. Neonatal birth weight 52500 g
43500 g
2500 g–3500 g
Mode of delivery
n
%
n
%
n
%
A (ECS)* B (PVD)y Total
10 8 18
(55.56) (44.44) 100
30 47 77
(38.96) (61.04) 100
34 17 51
(66.67) (33.33) 100
*ECS, elective cesarean section. yPVD, planned vaginal delivery. There was a statistically significant difference between the estimated BW and the mode of delivery (p ¼ 0.008). Most neonates had an estimated BW below 2500 g, because neonates with an estimated BW above 3500 g were delivered by ESC.
Vaginal delivery or cesarean section at term breech delivery
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DOI: 10.3109/14767058.2015.1067768
BW below 2500 g, because neonates with an estimated BW above 3500 g were delivered by ESC. An Apgar score at the 5th min 8 was observed in 62 (86.1%) of the neonates in the PVD group and in 66 (89.1%) of the neonates in the ECS group. The mode of delivery was not correlated with an neonatal Apgar score at the 5th min (p ¼ 0.597). Neonatal macrosomia (estimated BW above the 90th percentile for gestational age) was diagnosed in 4 (5.4%) of the neonates in the ECS group, but in 7 (9.4%) neonates in this group had neonatal hypotrophia (BW below the 10th percentile for estimated GW). A sonographic finding, such as fetal macrosomia or intrauterine growth restriction (IUGR), required further meticulous consideration for term breech delivery by ECS. Early neonatal well-being was diagnosed in 54 (72.9%) of the neonates in the ECS group and in 41 (56.9%) of the neonates in the PVD group (Table 3). For those with a breech presentation, perinatal asphyxia increased in the PVD group (19.4%) compared with the ECS group. There was a statistically significant correlation between the structure of perinatal Mb and the mode of delivery (p ¼ 0.042). The duration of being in a NICU was significantly shorter after PVD compared with ECS (4.08 ± 3.1 d versus 5.66 ± 5.3 d; p ¼ 0.033). Group B was sub-divided into the following two groups: group B1 – SVD group and group B2 – UCS group (emergency). There were 42 (58.3%) patients in group B1 and 30 (41.6%) patients in group B2. In the SVD group, 31 mothers (75.60%) were assisted and 11 (26.82%) were spontaneous deliveries. The mean age of patients in the SVD group was 30.14 ± 4.6 years and 30.77 ± 4.49 years in the UCS group. In Student’s-t test, there was no statistically significant difference in the mother’s age between the groups (p ¼ 0.568). Sixteen nulliparous neonates (38.1%) were delivered by SVD and 20 (66.7%) were delivered by UCS. Of the most multiparous neonates, 26 (61.9%) were delivered by SVD. In 10 multiparous mothers (33.3%), an UCS was performed. The study confirmed that a significantly higher number of nulliparous neonates were delivered by UCS than by SVD, and a significantly higher number of multiparous women were delivered by SVD than by UCS. The mode of delivery was determined by parity in our study (p ¼ 0.017).
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A UCS was performed in 18 (54.6%) nulliparous women who were younger than 35 years, but 21 (77.7%) multiparous mothers were delivered by SVD. The mode of delivery was not determined by the mother’s age in patients younger than 35 years of age (p ¼ 0.585). Only one patient delivered vaginally among the nulliparous women who were older than 35 years of age, and UCS was more frequent mode of delivery for the other two women in this group of patients. In a group of nine multiparous women, older than 35 years of age, five (55.7%) delivered by SVD (Table 4). This study did not confirm that the mode of delivery was determined by the mother’s age among these patients (p ¼ 0.193). Fetopelvic disproportion was the most common indication for UCS (11women, 36.7%) and distocia [failure to progress in labor, either because the cervix will not dilate (expand) further or (after full dilation) the breech does not descend through the mother’s pelvis] occurred in nine women (30%). In addition to the fetopelvic disproportion, an indication for UCS was an acute increase in maternal blood of pressure above 140 mmHg in six (20%) and fetal distress in four (13.3%) deliveries. Spontaneous VD occurred in 11 of 42 women (26.2%) with a mean duration of 4.49 ± 2.1 h, and was augmented by Syntocinon in 31 deliveries (73.8%), with a mean duration of 6.13 ± 1.7 h. Oxytocin augmentation of VD was associated with the duration of labor (p ¼ 0.015). The Lo¨vset maneuver was most frequently performed in 34 (80.9%) of the SVD cases. The Bracht maneuver was performed in six women (14%) and the Smellie–Veit maneuver was performed in 2 (4.76%) of the women undergoing SVD. The mean BW of the neonates was 3107 ± 384 g in the SVD group and 3165 ± 621 g in the UCS group. There was no statistically significant difference in neonatal BW between the two groups (p ¼ 0.627). There were similar number of neonates with an estimated BW below 2500 g who were delivered by UCS and SVD (4/8; 50%). Neonates with an estimated BW above 3500 g delivered by UCS in 9/17 (52, 9%) cases, but 8/17 (47, 06%) neonates were delivered by SVD. The study did not report a difference between the groups (p ¼ 0.429). The Apgar score at the 5th min (8) was observed in 35 (83.3%) of the neonates in the SVD group and in 27(90%) of the neonates in the UCS group. The mode of delivery was not
Table 3. The mode of delivery and neonatal outcome. Table 4. The mode of delivery and neonatal outcome.
The mode of delivery A (ECS)*
B (PVD)y
Neonatal morbidity
n
%
n
%
Neonatal well-being Birth asphyxia Intrauterine growth restriction Neonatal macrosomia
54 9 7 4
(72, 9) (12, 1) (9, 4) (5, 4)
41 14 6 4
(56, 9) (19, 4) (8, 3) (5, 5)
*ECS, elective cesarean section. yPVD, planned vaginal delivery (missed dates of neonatal outcome for seven neonates). There was a statistically significant correlation between the structure of perinatal Mb and the mode of delivery (p ¼ 0.042). Birth asphyxia increased in the VD group (19.4%) compared with the ECS group (12.1%).
The mode of delivery B1 (SVD)*
B2 (UCS)y
Neonatal morbidity
n
%
n
%
Neonatal well-being Birth asphyxia Intrauterine growth restriction Neonatal macrosomia
20 10 3 2
(46, 6) (23, 8) (7, 1) (4, 7)
21 4 3 2
(70) (13, 3) (1) (6, 6)
*SVD, successful vaginal delivery. yUCS, urgent cesarean section (missed dates of neonatal outcome for seven neonates). In breech presentation, birth asphyxia remained increased in the SVD group (23.8%) compared with the UCS group (13.3%) (p ¼ 0.035).
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I. Babovic´ et al.
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associated with the early neonatal Apgar score at the 5th min (p ¼ 0.416). Neonatal macrosomia was diagnosed in two (6.67%) of the neonates in the UCS group. Hypotrophic neonates 3(10%) were delivered by UCS. Early neonatal well-being was diagnosed in 21 (70%) of the neonates in the UCS group and in 20 (46.62%) of the neonates in the SVD (Table 4). In breech presentation, perinatal asphyxia remained increased in the SVD group (23.8%) compared with the UCS group (13.3%) (p ¼ 0.035). The duration of stay in the NICU was significantly shorter after VD compared with UCS (3.12 ± 1.9 d versus 5.43 ± 3.9 d; p ¼ 0.002). There were no neonatal deaths in each of the groups.
Discussion Before Hannah et al. published a study in the Lancet about the neonatal outcomes of term breech presentation, VD was commonly used in clinical practice (October 2000) [5]. This international randomized study found a significant decline in neonatal Mb after planned cesarean section compared with PVD. In our study, more than 50% of term breech deliveries were completed by ECS [6]. From 2007 to 2008, a similar study observed that ECS remained the recommended mode of delivery in nulliparous women older than 35 years of age. VD in term breech presentation was considered to be an optional mode of delivery in multiparous women younger than 35 years of age [7]. Five years later, this study confirmed a continuing trend observed in previous research. We found approximately the same number of nulliparous women who were delivered by ECS (73.9%/66.2), as was reported by Babovic´ et al. [7]. Parity is one of the most important factors of the mode of delivery in breech term presentation as well as estimated fetal BW by an ultrasound examination. The only documented risk related to parity is cord prolapse, which was 2-fold higher in parous women than in primigravidas [8]. More recent studies have documented that estimated fetal BW above 3500 g is an absolute indication for ECS. VD was controversial for term neonates in breech presentation with an estimated BW below 2500 g. Most term breech presentation neonates with an estimated BW below 2500 g in our study were delivered almost by ECS (55.5%). Our study also confirmed that fetal macrosomia, especially after sonographic examination or adequately diagnosed feto–maternal etiological factors of IUGR in fetuses (e.g. chronic hypertension, preeclampsia) indicate that ECS is one the most reasonable modes of delivery [5,8]. We found that mode of delivery did not determine the neonatal Apgar score at the 5th min. Although Apgar score at the 5th min was not a specific indicator of fetal viability, it was a good predictor of long-term neonatal sequelae in our study. The healthiest neonates (Apgar score in 5th min 8) in our study were delivered by PVD, and those with a lower Apgar score at the 5th min were delivered by UCS. VD represents an acute stress test for fetuses. Stress is a necessary condition for accelerating fetal lung maturation in labor. This finding could be an explanation for better neonatal outcomes after VD compared with UCS [9]. The results of our study
J Matern Fetal Neonatal Med, Early Online: 1–5
confirmed that vaginally delivered neonates had significantly shorter stays in NICU compared with neonates delivered by ECS or UCR, as has been seen in previous studies [10]. Superimposed intrapartal asphyxia on chronic fetal hypoxia or acute hypoxic insult (e.g. abruptio placentae, prolapse of the umbilical cord) were the most common indications for UCS and caused lower Apgar scores at the 5th min [11]. Early neonatal well-being was diagnosed in 70% neonates in the UCS group, which was similar to the 72.9% seen among the neonates in the ECS group. The results of our study do not support the results of other research. The similar number of patients in each group (UCS and ECS group) in our study could be an explanation for observed results. We used oxytocin augmentation only for dysfunctional labor. Oxytocin augmentation was used in more than half of the VDs and was the main reason for the study, unexpectedly shorter duration of spontaneous VD that was observed in our study. In our study, birth asphyxia, increased twice in the VD group compared with the UCS and ECS, groups, as was observed in the study of Al-Mulhim et al. [12]. The most often cited etiological factor for that in our study was failure to progress into labor or prolonged expulsion phases. The Lo¨wset maneuver was applied because it significantly reduces the risk of birth injuries, which occur frequently in breech VDs compared with the cephalic presentation of the fetus [13].
Conclusion VD can be considered as safe option especially in multiparous women younger than 35 years of age as well as in neonates with an estimated BW of 2500–3500 g. ECS remained the recommended mode of breech term delivery in nulliparous women older than 35 years, as well as in neonates with an estimated BW above 3500 g. Early neonatal well-being is more frequently diagnosed in neonates born by ECS. Finally, the decision-making process for handling a term breech presentation is very controversial. The most frequent complication for these neonates in such cases is birth asphyxia and a longer duration of stay in NICU; thus, we should ascertain that our decision is correct.
Declaration of interest The authors report no declarations of interest.
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