Breech deliveries in OLVG, the Netherlands: a retrospective cohort study of seven years

Journal Pre-proof Breech deliveries in OLVG, the Netherlands: a retrospective cohort study of seven years Danniek A.M. Vinkenvleugel, Tessa J. Slutter, Leonie E. van Rheenen-Flach, Catherine M.W. de Sonnaville, Brenda B. Hermsen, Joost Velzel, Maria G. van Pampus

PII:

S0301-2115(20)30099-3

DOI:

https://doi.org/10.1016/j.ejogrb.2020.02.031

Reference:

EURO 11210

To appear in: Biology

European Journal of Obstetrics & Gynecology and Reproductive

Received Date:

26 November 2019

Revised Date:

19 February 2020

Accepted Date:

21 February 2020

Please cite this article as: Vinkenvleugel DAM, Slutter TJ, van Rheenen-Flach LE, de Sonnaville CMW, Hermsen BB, Velzel J, van Pampus MG, Breech deliveries in OLVG, the Netherlands: a retrospective cohort study of seven years, European Journal of Obstetrics and amp; Gynecology and Reproductive Biology (2020), doi: https://doi.org/10.1016/j.ejogrb.2020.02.031

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.

[Typ hier] Breech deliveries in OLVG, the Netherlands: a retrospective cohort study of seven years Danniek A.M. Vinkenvleugela, Tessa J. Sluttera, Leonie E. van Rheenen-Flacha, Catherine M.W. de Sonnavillea, Brenda B. Hermsena, Joost Velzela,b, Maria G. van Pampusa,* [email protected] a

Department of Obstetrics and Gynaecology, OLVG, Amsterdam, The Netherlands

b

Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands

*Corresponding author at: Maria G. van Pampus OLVG, Amsterdam, department of Obstetrics and

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Gynaecology, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands

Abstract

Background: The clinical dilemma on the preferred mode of delivery for breech position still exists. Elective caesarean delivery (CD) could be safer for neonates, whereas vaginal breech delivery (VBD)

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remains a safe option when conducted by an experienced person. Besides successful VBD is beneficial for mothers and subsequent pregnancies.

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Objectives: To evaluate breech deliveries on mode of delivery, maternal and neonatal outcomes. Study Design: A single center, retrospective, cohort study was performed of women who delivered a

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singleton fetus in breech position from 32 weeks’ gestation onwards from January 2011 to December 2017. Primary outcome measure was mode of delivery defined as an elective CD and planned VBD.

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Secondary outcome measures were neonatal and maternal outcome. For neonatal outcome, we used neonatal mortality and a composite measure neonatal morbidity. Maternal outcome included maternal mortality and maternal morbidity divided in severe and non-severe complications. We subcategorized

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onwards).

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for preterm (32 weeks to 37 weeks of gestation) and term pregnancies (from 37 weeks of gestation

Results: 1.774 women delivered a child in breech position, 73% opted for an elective CD. Of the 484 women that had a planned VBD (preterm 38% (n=59), term 26% (n=425)) 71% were successful. Neonatal mortality occurred twice in the VBD cohort. Preterm neonatal morbidity occurred in the elective CD and VBD cohort equally (both 66%), at term significantly more in the VBD cohort (12% v 4%, OR 3.2, 95% CI 2.1 to 4.8). For the total cohort, severe maternal postpartum complications occurred more often in the elective CD compared to successful VBD (2% v 0.3%, OR 6.0, 95% CI 0.80 to 44.3).

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[Typ hier] Conclusion: A high rate of successful VBD after opting for a planned VBD was found in our center. Nevertheless, compromised neonatal outcome at term was more frequent in the planned VBD group compared to the elective CD group. Severe maternal postpartum complications were more frequent in the elective CD group compared to the VBD group. Future research should focus alternations in the management of breech presentation.

Keywords: Breech presentation, mode of delivery, centralization Introduction Breech presentation occurs in up to 4% of singleton pregnancies at term.1 Until 2000, the VBD of a baby

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in breech position was still common practice in the Netherlands.2 In 2000 the results of the Term Breech Trial (TBT) had an impact on the clinical practice worldwide.3 The trial demonstrated a reduction in overall risk of perinatal and neonatal mortality and morbidity in favor of elective CD compared to VBD. Consequently, the implementation of the TBT resulted in a lot of criticism, mostly regarding

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methodological issues, incomplete follow-up and questions on clinical capability to perform breech deliveries.4-6 In 2016, a meta-analysis on the preferred mode of delivery was published, including the

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TBT and all cohort studies.7 They concluded that although the relative risk of neonatal mortality and morbidity is higher after vaginal birth, the absolute risk stays low. Therefore, the clinical dilemma on the

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preferred mode of delivery for breech still exists.7 The impact of the TBT was also observed in the Netherlands whereas vaginal breech deliveries for preterm and term pregnancies were common before

presentation.

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2000; the rate of elective CD increased from 24% in 1999 to 60% in 2001 in cases of breech

However, while elective CD may be better for the neonatal outcome, it should be weighed against the

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consequences for the mother. Women undergoing CD are at three-fold higher risk of mortality and short-

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term morbidity compared to VBD (2.7% v 0.9%).10 They have an increased risk of serious maternal morbidity like hemorrhage requiring hysterectomy or transfusion, anesthetic complications, lesions of bladder, ureteric and bowel, venous thromboembolic event and major infection.10,11,12,13 Additionally, risks can occur during subsequent pregnancies, due to abnormal placentation, placenta praevia and rupture of the uterine scar.14,15 In 2006, an observational prospective study conducted by Goffinet et al, was performed in hospitals in France and Belgium where vaginal breech deliveries were still common.16 They demonstrated no significant difference in neonatal outcome between VBD and elective CD (OR 1.10, 95% CI 0.75 to 1.6).

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[Typ hier] Therefore, they concluded that VBD remains safe. However, in order for medical staff to gain experience and confidence with vaginal breech deliveries, the amount of VBD had to remain high. Only then it is a realistic option for patients. Considerations can be made to centralize the care of pregnant women for example in regional breech centers. Centralization has already shown benefits for (women with ovarian) cancer; a high level of specialization is strongly related to the best treatment and overall survival.17,18 Centralization could have a positive impact on the specialization of health care professionals, which might improve the quality of care. Due to improvement of the quality of care, centralization can also contribute to value-based healthcare.19 The aim of this retrospective study is to gain insight into data of one center on mode of delivery, maternal and neonatal outcomes regarding breech deliveries and to

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initiate a discussion about centralization of care.

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Materials and methods Study design and participants

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We performed a single center, cohort study in the OLVG and recorded data from 1 January 2011 to 31 December 2017 retrospectively. The OLVG is a hospital with two locations based in Amsterdam, the

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Netherlands. This hospital is responsible for 6.000 increased risk deliveries a year. Both locations are equally in number of annual deliveries and both have a comparable neonatal ward. Women with a singleton fetus in breech position who delivered from 32 weeks of gestation onwards were included.

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Exclusion criteria were antenatal fetal death, transverse position of the fetus, multiple pregnancies and any contraindication to vaginal birth (such as placenta praevia). Our study was

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Procedure

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approved by our local medical ethical committee in advance (WO 18.058).

All patients with a breech presentation were counseled for an external cephalic version (ECV) attempt before 36 weeks of gestation, and ECV was performed after consent from 36 weeks onwards. In case of persistent breech presentation, women were counseled regarding the mode of delivery. Counseling took place in an outpatient setting by an obstetrician, resident or midwife and was based on data from the guideline breech presentation version 2.0, offered by Dutch Society for Obstetrics and Gynecology.20 After counseling, the mode of delivery was agreed and documented. If counseling did not take place before labor started, counseling took place during labor.

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[Typ hier] On both locations of the OLVG, experienced gynecologists assisted or supervised vaginal breech birth. Annually, multiple simulation-based team training for breech delivery were performed. Induction for obstetrical reasons was allowed. If necessary, pain relief with remifentanil or epidural analgesia was available upon request 24 hours a day. During labor, continuous CTG was performed to assess fetal condition. Also, in case of non-progressive labor due to a lack of contractions, augmentation with intravenously oxytocin was performed. All fours position during active phase was optional for women. During active phase of labor, an operation team was stand-by. Elective CD was performed from 39 weeks of gestation onwards or before in case of spontaneous start of labor. Antenatal corticosteroid therapy for respiratory distress prevention before elective CD was not standardized care over 38 weeks

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of gestation. In case elective CD was performed before 38 weeks of gestation, antenatal corticosteroid therapy was provided in individual cases after counseling.

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Outcomes

All women were categorized to preterm (32 to 37 weeks of gestation) or term (37 weeks of gestation

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onwards) delivery and to their planned mode of delivery in elective CD or planned VBD. Planned VBD was further specified in successful VBD (spontaneous and breech extraction) or emergency CD (for no

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progress of labor in first or second stage, suspected fetal distress and fetal position not compliant for VBD during planned VBD). Spontaneous breech birth included Bracht maneuver. Breech extraction included both partial and total breech extraction and includes the use of maneuvers (such as Lovset and

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Mauriceau). For all women, we recorded the characteristics gestational age at delivery, age, parity (we characterized multiparous women with none previous successful vaginal delivery as nulliparous, women

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were characterized as multiparous as women with one or more previous successful vaginal deliveries), Body Mass Index, ECV attempt in pregnancy and type of breech presentation (complete breech,

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incomplete breech and frank breech). Primary outcome measure was mode of delivery defined as an elective CD and planned VBD (successful VBD or emergency CD). Secondary outcome measures were neonatal and maternal outcomes. For neonatal outcome we used a composite measure of neonatal mortality and neonatal morbidity. Neonatal outcome measures were neonatal mortality, Apgar <7 at 5 minutes, arterial pH <7.10 and <7.00, admission to a neonatal ward, gender and birth weight. The outcome combined neonatal morbidity was a neonate with at least one of the following: Apgar <7 at 5 min, arterial pH <7.00,

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[Typ hier] admission to neonatal ward >24 hours. Maternal outcome was a composite measure of poor maternal outcome defined as maternal mortality and maternal morbidity. Maternal outcome measures were blood loss, maternal admission in hospital postpartum in days, non-severe maternal complication postpartum (hemorrhage defined as >1000ml, placental rest requiring further treatment, infection: urinary tract or endometritis or mastitis, urinary retention, venous thromboembolic event) and severe maternal postpartum complications (hemorrhage postpartum requiring re-laparotomy or hysterectomy or transfusion, uterine rupture, suspected bladder or ureteric or bowel injury, anesthetic complications, major infections: defined as wound infection or wound disruption).21

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Data analysis

Baseline data were analyzed descriptively for the women and their pregnancies. The χ2 test was used to compare the rates of the primary and secondary outcomes between the comparison elective CD and

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planned VBD (both successful VBD and emergency CD), and for the comparison successful VBD and emergency CD separately. For our analysis, we distinguished between preterm and term. We

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considered a p value of less than 0.05 to indicate statistical significance. In case of a significant difference, we demonstrate odds ratios and appropriate 95% confidence interval. All analysis was done

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for complete cases and missing data are reported separately as total available number. Statistical analyses were performed using SPSS 21.0 for Windows (IBM SPSS Statistics, IBM Corporation,

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Armonk, NY)

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Results Mode of delivery

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Between January 2011 to December 2017, 1.774 women with a singleton breech presentation were included. In the preterm delivery group, of the 59 women that chose for a planned VBD, 43 (73%) had a successful VBD. In the term delivery group, 425 opted for a planned VBD and 301 (71%) had a successful VBD (figure 1). Baseline characteristics of the preterm delivery group (n=154) and term delivery group (n=1620) are presented in table 1. For the preterm delivery, significant differences were found between the groups regarding gestational age at delivery in weeks and ECV attempt during pregnancy. In the term delivery group, significantly more nulliparous chose for an elective CD compared

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[Typ hier] to a planned VBD (85% v 74%, p<0,05). In the term delivery group, ECV was attempted in 78% of the women in elective CD group and in 86% of the women in the planned VBD group. In table 2 we demonstrate more detailed the mode of delivery among the cohort, between the preterm and term delivery cohort and for parity separately. In the whole cohort, 344 women had a successful vaginal breech delivery of which 45% had a spontaneous VBD and 55% had a breech extraction. Caesarean delivery occurred in 1430 women in the whole cohort of which 90% had an elective, 4% for non-progressive labor and 3% for suspected fetal distress. Emergency CD for fetal distress was more common the preterm delivery group compared to the term delivery group (10% v 3%, OR 2.9, 95% CI

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1.41 to 5.9).

Neonatal outcome

The frequency of poor neonatal outcome for the preterm and term delivery group are demonstrated in

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table 3. After elective CD, no neonatal mortality occurred whereas two children died in the VBD group (one in the preterm and one in the term delivery cohort). In both cases, breech extraction was performed

intensive

care

unit

(NICU)

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in nulliparous woman due to suspected fetal distress. Both babies were transferred to a neonatal and

died

from

severe

asphyxia.

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Neonatal morbidity as combined outcome occurred in the preterm delivery group 66% in the elective CD group and 66% in the planned vaginal group. In the term delivery group, combined neonatal morbidity occurred significantly less in the elective CD group compared to the planned vaginal group

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(4% v 12%, OR 3.2, 95% CI 2.1 to 4.8).

In total, at term seven neonates were transferred to a NICU from the planned VBD group and none of

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the elective CD group. Four neonates were suspected for asphyxia, of which two had hypothermia as treatment. One needed transfusion due to hyperbilirubinemia and the other two were transferred for the

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need investigation for suspected chromosomal abnormalities.

Maternal outcome

The frequency of maternal outcome in our cohort is summarized in table 4. Maternal mortality did not occur. After planned VBD, non-severe maternal postpartum complications occurred significantly more compared to elective CD (10% in the successful VBD group and 18% in the emergency CD group and 7% in the elective CD group). Severe maternal postpartum complications occurred more in the elective

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[Typ hier] CD compared to successful VBD (2% v 0.3%, OR 6.0, 95% CI 0.80 to 44.3) The severe complication in the VBD was hemorrhage requiring blood transfusion (n=1), whereas elective CD included hemorrhage requiring re-laparotomy (n=2), hemorrhage requiring hysterectomy (n=2), hemorrhage requiring blood transfusion (n=9) and major infection (n=9). Episiotomy was performed in 184 (54%) women. Mean duration of hospital stay in days differed significantly among the modes of delivery, whereas successful VBD was the shortest (2.0 days), and hospital stay after emergency CD was the longest (4.2 days).

Comment Main findings

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In this retrospective single center cohort study, a high rate of successful VBD after opting for a planned VBD was found for both nulliparous (65%) and multiparous women (86%). Nevertheless, in the term delivery cohort compromised neonatal outcome was more frequent in the planned VBD group compared

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to the elective CD group. Severe maternal outcome was more frequent in the elective CD group

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compared to the VBD group.

Strengths and limitations

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So far, this is the largest single center study on breech delivery and their outcome conducted. Therefore, we are able to use our own data for counseling women for breech delivery in our clinic, which contributes to personalized medicine. Even though this study is performed retrospectively, which

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increases the chance for bias and therefore less interpretable data, we believe this study contains an adequate cohort of women representing the clinical dilemma how to deliver a baby in breech position.

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In order to reduce the chance of selection bias, inevitable with a retrospective cohort study, collecting data was standardized . Also, we reported all important outcomes for professionals as demonstrated by

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the ICHOM Standard Set for Pregnancy and Childbirth.21 Therefore, this study could be the first step to value-based healthcare. Nevertheless, for future studies, patient reported outcomes should be measured as well. Another limitation of our study is that our local protocol allowed a great variance in practice to increase patient centered care in terms of the accessibility of epidural analgesia, immersion in water in first stage of labor, augmentation and upright breech delivery. This makes our study a clear reflection of our local policy, however, it might be less generalizable due to this variability. For VBD, it remains important to comprehend that there is practice variation. Many questions are still unanswered, such as induction and augmentation of labor, and preferred position in the active phase; this needs to

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[Typ hier] be a matter of future research. In our data, we found that a planned VBD might be better for maternal outcome, and an elective CD for neonatal outcome, which is comparable to previous studies.3,9,16 However, opting for an elective CD could affect subsequent pregnancies.15 To further analyze the effect on determining the mode of delivery for a baby in breech position, outcomes on future pregnancies are important as well, as family planning is an essential topic to discuss during shared decision making. However, we were not able to collect outcome on subsequent pregnancies.

Interpretation Compared to nationwide data, fewer women opted for a planned VBD in our center (27% v 35%),

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however, fewer planned VBD resulted in an emergency CD (29% v 42%). Therefore, the success rate of planned VBD was higher in our center compared to nationwide (71% v 58%).22 The higher chance of a successful VBD could be the result of case selection. However, characteristics on type of breech

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presentation and gestational age at delivery were similar. Macrosomia occurred more in the elective CD group, which is in line with our restrictive criteria not to perform a VBD in case of an expected birth

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weight above 4.000 grams.

In case of the clinical dilemma on breech birth, neonatal mortality is usually the most important outcome

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measure for both the opting patient and the clinician. For preterm breech deliveries, a systematic review on seven small retrospective cohort studies (n=3557 women), demonstrated a severe increased risk on neonatal mortality for VBD compared to CD (pooled RR 0.63, 95% CI 0.48 to 0.81) between 28 and 37

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weeks of gestation.23 Above 32 weeks of gestation, the authors could not pool the risk for neonatal mortality since the studies did not analyze the same subgroups, however, two studies reported neonatal

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mortality by different subgroups and showed a non-significant trend towards planned VBD for gestational age 30 to 34 weeks (RR 1.1, 95% CI 0.32 to 3.8) and a non-significant trend favoring elective CD for 34

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to 37 weeks of gestation (RR 0.67, 95% CI 0.19 to 2.4). However, the results of this systematic review should be interpreted with caution as the included studies are relatively small and heterogeneity was severe. Prospective cohort studies and RCTs are non-existing and previous conducted RCTs on this subject were preliminary stopped due to recruitment difficulties. Therefore, clear evidence on the preferred mode of delivery for preterm breech babies is still lacking and needs to be investigated in the future. For breech deliveries at term, Berhan et al published a systematic review in 2016 (n=258 953 women).7 They report that the chance of neonatal mortality after planned VBD was 2/1000, which

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[Typ hier] corresponds to the same finding in our study (also 0.2%). Further, the same authors found a 0.5/1000 neonatal mortality rate after elective CD. In our study, no neonatal mortality after elective CD occurred. This study also addresses a first step in discussing alterations for the Nationwide organization of breech deliveries as specialized teams or centers could be beneficial. Centralization of care mainly relates to improve outcome for low-volume high-complex procedures and especially in surgical oncology, centralization of these procedures resulted in better outcome for patients.17,18 In case of VBD, on nation level, low-volume is obvious as approximately 1250 women opting for VBD in the Netherlands annually.22 On center level, our data demonstrated that gynecologists assist 1 to 4 planned VBDs each year. In our center, VBD is considered common practice, therefore, the question arises how this number

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relates to other centers who are more reluctant towards VBD and if this number is sufficient to remain experienced. Another argument for centralization of breech management is that a recent published survey among Dutch gynecological residents concluded that half of the responders judge the current

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residency program to be insufficient for guiding vaginal breech deliveries.24 This seems to be highly related to the low overall exposure. Considering the overall low incidence of breech presentation at term,

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the results of our study and the outcome of the survey among Dutch residents, one could hypothesize the upcoming downward spiral from less exposure to performing mainly elective CD. This overuse of

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CD will cause an increase in the incidence of severe maternal complications. To further optimize breech management, future research should focus on two important matters. First, reducing the risk in VBD. Second optimizing the change of succeeding in VBD. Therefore, we should study the antepartum factors

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(e.g. estimated fetal weight) that can help us counselling the patient about risk and success rates. In consequence, we should know what the mechanism is in physiologic breech birth and how to restore

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this mechanism. In these studies, preterm and term VBD should be handled separately, likewise this study. Additionally, the safety and success changes of induction, augmentation and positions during

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breech birth should be determined. Furthermore, organizational changes to enhance both neonatal and maternal outcomes should be studies carefully and suggested alterations could be designated teams within one region or centralizing breech birth to hospitals with a regional referral status. These teams should be well trained by simulationbased team training and should assist or supervise VBD on a regular base. To improve quality of the team, filming breech birth and analyzing afterwards should be standard. A cluster RCT to examine best possible management for breech presentation is highly needed.

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Conclusion In conclusion, a high rate of successful VBD after opting for a planned VBD was found in our center. Nevertheless, compromised neonatal outcome at term was more frequent in the planned VBD group compared to the elective CD group. Severe maternal outcome was more frequent in the elective CD group compared to the VBD group. Future research should focus on alternations of the management of

Conflicts of interest The authors did not report any potential conflicts of interest. Funding source

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The authors did not report any funding source.

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breech presentation.

Contributors

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LvR, BH, JV and MvP conceived and designed the study. DV, TS, CdS and JV acquired the data. DV and JV carried out the statistical analysis. LvR, BH, JV and MvP supervised the study and are

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guarantors. All authors analyzed and interpreted the data, drafted the manuscript, critically revised the manuscript for important intellectual content, had full access to all of the data in the study, and rake

Ethical approval

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responsibility for the integrity of the data and the accuracy of data analysis.

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This study was approved, 2-02-2018, by the research ethics committee (ACWO) of the OLVG in Amsterdam (reference No MEC; WO 18.058). Participants gave consent was not obtained but the

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presented data are anonymized and risk of identification is low.

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Table 1. Baseline characteristics of study participants.

ECV attempt during pregnancy (%)§ Frank breech presentation (%)|| Term (1620) Gestational age at delivery (weeks) Age (years) Nulliparous (%)

95 35  1,1

59 35  1.4

33  4,6

33  4,9

p Value*

Planned VBD VBD Emergency (n=344) CD (n=140)

17 (31)

0.03

50 (63)

37 (64)

0.87

29 (69)

1195 39  0.8

425 39  1,2

<0.001

72 (76) 23  3,9

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28 (44)

43 35  1,3 33  4,5 23 (53) 23  3,4 14 (35)

0.03 0.86

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Nulliparous (%) BMI (kg/m2)‡

Planned VBD (n=484)

36 (61) 24  3,4

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Characteristics Preterm (154) Gestational age at delivery (weeks) Age (years)

Elective CD (n=1290)

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Figure 1. Study flowchart. The total number of women with a breech presentation categorised by preterm and term delivery, and then subcategorised by planned mode of delivery follow by actual mode of delivery for the planned VBD group. Data shown as numbers (n) and %.

0.34 0.38

p value†

16 35  1,5

0.79

32  5,7

0.33

13 (81) 24  3,5

0.03 0.66

3 (19)

0.05

8 (50)

0.4

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301 124 <0.001 39  39  1,2 1,2 0.65 32  4,1 33  4,3 <0.001 32  4 32  4,5 1010 313 (74) <0.001 205 108 (87) <0.001 (85) (68) BMI (kg/m2)** 0.05 23  3,9 22  3,0 0.004 22  23  3,2 2.8 ECV attempt during 756 (78) 325 (86) 0.04 235 90 (87) 0.04 pregnancy (%)†† (85) Frank breech 757 (76) 327 (77) 0.6 247 80 (66) 0.001 presentation (%)‡‡ (82) Values are n (%) or mean  standard deviation. Missing data is reported as total number available. CD, caesarean delivery; VBD, vaginal breech delivery; BMI, body mass index; ECV, external cephalic version. * P value elective CD as reference in comparison planned VBD † P value VBD as reference in comparison to emergency CD ‡ Available number due to missing data: n=63 for elective CD; n=39 for planned VBD; n=30 for VBD; n=9 for emergency CD § Available number due to missing data: n=55 for elective CD; n=56 for planned VBD; n=40 for VBD || Available number due to missing data: n=80 for elective CD; n=58 for planned VBD; n=42 for VBD

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[Typ hier] ** Available number due to missing data: n=951 for elective CD; n=378 for planned VBD; n=275 for VBD; n=103 for emergency CD †† Available number due to missing data: n=964 for elective CD; n=378 for planned VBD; n=275 for VBD; n=103 for emergency CD ‡‡ Available number due to missing data: n=996 for elective CD; n=423 for planned VBD; n=301 for VBD; n=122 for emergency CD Table 2. Mode of delivery split into preterm and term, nulliparous and multiparous. Nulliparous (n=1431) 228 98 (43) 130 (57) 1203 1082 (90) 26 (2) 27 (2) 40 (3) 19 (2) 9 (1)

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Cohort Preterm Term (n=1774) (n=154) (n=1620) Total VBD 344 43 301 Spontaneous 155 (45) 23 (53) 132 (44) Breech extraction 189 (55) 20 (47) 169 (56) Total CD 1430 111 1319 Elective 1290 (90) 95 (85) 1195 (90) No progress of labor in first stage 29 (2) 1 (1) 28 (2) No progress of labor in second stage 28 (2) 1 (1) 27 (2) Suspected fetal distress 49 (3) 11 (10) 38 (3) Position not compliant for VBD 23 (2) 0 23 (2) Other 11 (1) 3 (3) 8 (1) Values are n (%). VBD, vaginal breech delivery; CD, caesarean delivery.

Multiparous (n=343) 116 57 (49) 59 (51) 227 208 (92) 3 (1) 1 (<1%) 9 (4) 4 (1) 2 (1)

59 1 39 (66)

0.98

3 (3) 62 (65)

5 (9) 35 (59)

0.15 0.46

Transfer NICU Apgar score <7 after 5

1 (1) 3 (3)

4 (7) 4 (7)

0.05 0.28

pH arterial <7,10§ pH arterial <7,00§ Female gender

2 (6) 1 (3) 53 (56)

4 (16) 1 (4) 25 (42)

0.25 0.88 0.10

Birthweight < p10 p10-p90

8 (8) 75 (79)

0 (0) 52 (88)

12 (13) 1195 0 49 (4)

7 (12) 425 1 51 (12)

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95 0 63 (66)

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Preterm (154) Neonatal mortality Combined neonatal morbidity Admission to neonatal ward < 24hrs ≥ 24hrs

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Table 3. Neonatal outcomes for planned mode of delivery and in actual mode of delivery after planned VBD. Planned VBD Elective Planned P VBD p CD VBD value* Emergency value† CD

≥ p90 Term (1620) Neonatal mortality Combined neonatal morbidity Admission to neonatal ward

<0.01

43 1 28 (65)

16 0 11 (69)

0.79

2 (5) 25 (58) 3 (7) 3 (7)

3 (18) 10 (63)

0.08 0.76

1 (6) 1 (7)

0.92 0.97

2 (11) 1 (6) 16 (37)

2 (28) 0 (0) 9 (56)

0.29 0.52 0.18

0 (0) 39 (91) 4 (9) 301 1 35 (12)

0 (0) 13 (81) 3 (19) 124 0 16 (13)

0.71

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[Typ hier] 30 (3) 41 (3) 0 (0) 10 (0)

22 (5) 18 (4) 7 (2) 30 (7)

0.007 0.45 <0.01 <0.001

12 (4) 13 (4) 6 (2) 23 (8)

10 (8) 5 (4) 1 (1) 7 (6)

0.09 0.9 0.38 0.46

7 (3)

48 (29)

<0.001

10 (17)

0.14

pH arterial <7,00** Female gender

3 (1) 650 (54)

12 (6) 253 (60)

<0.01 0.07

38 (27) 7 (5) 183 (61)

5 (9) 70 (56)

0.33 0.41

Birthweight < p10

56 (6)

45 (11)

14 (11)

p10-p90

964 (81)

357 (84)

≥ p90

164 (14)

23 (5)

31 (10) 158 (86) 12 (4)

99 (80) 11 (9)

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< 24hrs ≥ 24hrs Transfer NICU Apgar score <7 after 5 minutes|| pH arterial <7,10**

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Values are n (%). Missing data is reported as total number available. CD, caesarean delivery; VBD, vaginal breech delivery; NICU, neonatal intensive care unit. * P value elective CD as reference in comparison to planned VBD † P value VBD as reference in comparison to emergency CD ‡ Available number due to missing data: n=15 for emergency CD § Available number due to missing data: n=31 for elective CD; n=25 for planned VBD; n=18 for VBD; n=7 for emergency CD || Available number due to missing data: n=1193 for elective CD; n=423 for planned VBD; n=299 for VBD ** Available number due to missing data: n=203 for elective CD; n=202 for planned VBD; n=143 for VBD; n=59 for emergency CD

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Table 4 Maternal outcome for mode of delivery Elective Successful CD VBD (n=1290) (n=344) Blood loss (ml)§ 420  374  21,3 9,6 Total maternal complications 116 (9) 39 (11) Non-severe maternal 91 (7) 36 (10) postpartum complications|| 61 18 Hemorrhage 5 10 postpartum 29 6 Placental rest 2 Infection (urine tract, endometritis or mastitis) Urinary retention Venous thromboembolic event Severe maternal postpartum 22 (2) 1 (0.3) complications** 13 1 Hemorrhage requiring 9 re-laparotomy, hysterectomy or blood transfusion Wound infection and wound disruption Episiotomy†† 184 (54) Rupture‡‡ - First degree 49 (14) - Second degree 55 (16)

Emergency CD (n=140)

p value*

p value†

p value‡

453  46,8

0.03

0.31

0.08

0.04

<0.001

0.01

0.08

0.86

0.15

29 (21) 25 (18) 13 4 7 1 -

2 (1) 1 1

15

[Typ hier] -

Third degree

8 (2)

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Maternal postpartum hospital <0.001 <0.001 <0.001 3.31  2.04  0.1 4.21  0.1 stay (days) ‡‡ 0.04 Values are n (%) or mean  standard deviation. Missing data is reported as total number available. CD, caesarean delivery; VBD, vaginal breech delivery * P value elective CD as reference in comparison to VBD † P value elective CD in comparison to emergency CD ‡ P value VBD as reference in comparison to emergency CD § Available number due to missing data: n=1259 for elective CD; n=332 for VBD; n=139 for emergency CD || Women could experience more complications ** Severe maternal postpartum complications: uterine rupture, suspected bladder or ureteric or bowel injury did not occur †† Available number due to missing data: n= 342 for VBD ‡‡ Available number due to missing data: n=1287 for elective CD

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