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Breech presentation in the primigravida
Breech presentation SAM
P.
PATTERSON,
ROBERT PHIL Memphis,
C. C.
M.D.
MULLINIKS,
SCHREIER,
in the primigrawida
JR.,
M.D.
M.D.
Tennessee
Breech presentation continues to seriously concern obstetricians, particularly since various neurological abnormalities have been found in these children years after birth. This clinical study concerns 208 primigravidas with single breech presentation. The corrected perinatal mortality was 13 per cent compared with an over-all perinatal mortality of 3.3 per cent. Cerebral trauma and anoxia are implicated as serious hazards associated with delivery of the aftercoming head. Breech extraction was associated with a prohibitively high perinatal wastage. Intravenous oxytocin was employed to augment labor of a very small and very select group of patients with no associated perinatal loss. A IO0 per cent fetal salvage following cesarean section compared with the perinatal loss associated with vaginal delivery, even in a small series such as this, warrants liberalization of cesarean section in the management of breech presentation in the primigravida.
B R E E c H presentation continues to be a challenge to the obstetrician, even with what might be considered improved obstetric techniques and more scientific knowledge of medicine in general. Journals of this discipline regularly contain articles dealing with breech presentation and the problems associated with its management. The increased perinatal wastage attributable to breech presentation is well documented in the literature. Less well documented, however, is morbidity in terms of major and minor neurological abnormalities in these children discovered months or years later. Loss of or damage to an infant as a result of labor and delivery remains among the most distressing circumstances in obstetrics. The importance of this problem is recognized when one recalls that the perinatal mortality associated with breech presentation From the Department of Obstetrics and Gynecology, The University of Tennessee College of Medicine, and The City of Memphis Hospitals. Presented at the Thirty-fourth Annual Meeting of the Central As.rociation of Obstetricians and Gynecologists, Biloxi, Mississippi, Oct. 20-22, 1966.
is reported to be five times that of all perinatal deaths in genera1.l If corrected for prematurity, the permatal loss for term breech infants is three to four times as high as the perinatal mortality for all term infants.lv * Hall and Kohl3 reported a corrected premature breech delivery perinatal mortality rate of 26.9 per cent and a corrected term breech delivery mortality rate of 4.7 per cent. Breech presentation has associated with it certain problems that by and large are not associated with cephalic presentation. The largest part of the infant is delivered last, so that a trial of labor with the largest part is not possible as it is with cephalic presentation. In addition, when there are borderline relationships between the fetal head and the pelvis, there is no time for gradual molding of the head. Another difference is the rapidity with which this unmolded head traverses the pelvis, particularly when the delivery is “hurried along” by the obstetrician or when fetal distress occurs and extraction is performed. Also, further complicating the breech presentation is an associated increased incidence of prolapse of the umbilical cord.3q 4
Volume Number
98 3
Version and extraction have been practically discarded from obstetric practice, and high and midforceps deliveries have been virtually abandoned for good reason and rightly so. Therefore, vaginal delivery of an infant in breech presentation is the main “technique” left in the so-called “art of obstetrics.” For this reason, many have been reluctant to perform cesarean section for breech presentation and have continued to practice and advocate vaginal delivery if at all feasible. Ralph C. Wright, in 1959, was first to advocate routine cesarean section for all gravidas with breech presentation after 35 weeks’ gestation provided that the fetus is living and there is no maternal disease contraindicating abdominal delivery.5 He points out that various reports indicate at least two thirds of term infants lost with breech delivery could be saved by cesarean section, since mortality figures are two-thirds less for term breech deliveries carried out abdominally. In addition, he cites known cases of minor brain damage, mental retardation, and cerebral palsy that are not recognized in the perinatal period and not reflected in most statistics. He refers to Churchill’s report of 92 cases of epilepsy in which 19.6 per cent were breech deliveries-over five times the normal 3.5 per cent incidence of breech delivery.6 Other similar reports include that of Steer and Bonney’ who note that, of 317 cerebral palsy cases, 9 per cent were delivered in breech presentation. Fuldners reports 7.1 to 16.6 per cent of athetoid and spastic hemiplegic patients were delivered in breech presentation. In another article, Churchill reports that of 297 patients with cerebral palsy, epilepsy, and mental retardation, 10 per cent were delivered in breech presentation. When reviewing these statistics, however, one must recall that prematurity was a factor in these series and may indeed have been the major factor. Although breech presentation in general has been the topic of many studies, breech presentation in the primigravida seems to be the major challenge. Varner,lO in 1962, re-
Breech
presentation
405
ported a ninefold increase in perinatal mortality for term breech deliveries in primigravidas delivered vaginally as compared with all term vaginal deliveries. Records of breech deliveries in primigravidas from the Department of Obstetrics and Gynecology of The City of Memphis Hospitals were reported in 1961.11 For the years 1953 through 1958 there were 189 single breech deliveries in primigravidas with a corrected perinatal mortality of 11 per cent. Perinatal mortality for the premature infants was 28 per cent and for the term group 6.3 per cent.The possible influence of intravenous oxytocin stimulation was also reported. Thirty labors were augmented with intravenous oxytocin because of uterine dysfunction. The perinatal mortality for this group was 20 per cent. The mortality for the non-oxytocintreated group was 9.5 per cent. Thus, there was a twofold increase in perinatal mortality when intravenous oxytocin was used to augment labor when uterine dysfunction complicated breech presentation in the primigravida. The incidence of cesarean section was 8.7 per cent with the indications being elderly primigravidas, prolapsed cords, and prolonged labors. It was concluded that uterine dysfunction with breech presentation will respond to intravenous oxytocin but with an almost prohibitively high fetal mortality. In this department since 1959 there has been marked liberalization of the indications for cesarean section for the management of breech deliveries. At the same time there has been a marked reduction in the use of intravenous oxytocin to augment or complete the breech delivery. Material
The material for this study was obtained from the records of 208 primigravidas with single breech presentations. These patients were delivered on the Obstetric Service of The City of Memphis Hospitals and The University of Tennessee from Jan, 1, 1959, through Dec. 31, 1965. During this 7 year period there were 46,420 deliveries at this institution. Not included in this study were multiple pregnancies or infants weighing less
406
Patterson,
Mulliniks,
and
June 1, 1967 Am. J. Obst. & Gym.
Schreier
with pulmonary stenosis, and 4 infants exhibiting multiple anomalies. The corrected figures contain those infants whose deaths were more probably associated with labor and delivery. The corrected group contains 198 infants with an over-all perinatal mortality of 13 per cent (Table II) . This compares to a 3.3 per cent perinatal mortality for all infants (not shown in this table) weighing 1,000 grams or more delivered at this institution during the same period, a fourfold increase. The mortality for the premature breech deliveries in this series was 31 per cent and for the term breech deliveries, 5.1 per cent. The types of breech presentation were recorded in 145 of the cases in this study. As in the previous report from this institution the most common type was frank breech, and the second most frequent was double
than 1,000 grams. All gravidas were service patients and approximately 98 per cent were Negro.
Results The uncorrected group contains 208 single breech deliveries of primigravidas resulting in infants weighing 1,000 grams or more (Table I). One hundred and forty infants were mature (2,500 grams or more) and 68 were premature (1,000 to 2,499 grams). Stillbirths and neonatal deaths are reported including deaths through the first 28 days of life providing death occurred in this hospital. Excluded from this series are severely macerated stillbirths showing evidence of longstanding intrauterine death and congenital anomalies incompatible with life. The congenital anomalies excluded were hydrocephalus, hypoplastic right heart syndrome
Table I. Perinatal Uncorrected
mortality
(uncorrected)
(208)
Discharged Stillborn Neonatal
(2,500
deaths
Total
Table II. Perinatal
mortality
Term grams
Premature (l,OOO-2,499 grams)
+)
130 6 4
42 9 17
140
68
(198)
Discharged Stillborn Neonatal
No. of cases
137
Breech
extraction
cord second
Term Prolapsed cord Prolonged second Fetal distress
stage
stage
Total
No. of cases
%
%
42
5.1
69.0
No. of cases
%
172
87.0
26
13.0
198
100.0
145------31.0 61
(8 cases) 1 No.
Indication Premature Prolapsed Prolonged
17.0%
Premature
94.9
3 4-----------,
Total
Table III.
1
130 death
loss
(corrected) Term
Corrected
Perinatal
of cases
Outcome
2 1
1 neonatal 1 neonatal
3 1 1
1 stillborn Good Good
Cause
I death death
Meningitis Torn tentorium
Anoxia
of
death
cerebelli
due to trapped
head
Volume Number
98 3
footling. Single footling and complete breech presentations occurred least often. Prolapse of the umbilical cord occurred in 12 cases, an over-all incidence of 5.7 per cent. All prolapses occurred with footling or full breech presentations. In this series no cord prolapse occurred with frank breech presentation. The corrected perinatal loss associated with cord prolapse was 27 per cent. For prematures, it was 33 per cent and for term 25 per cent. In the corrected group, breech extraction was performed in 8 cases, 3 for premature and 5 for term infants (Table III). Indications for extraction were prolapsed cord, prolonged second stage, and fetal distress. Two of the 3 premature extracted infants died neonatally, one from meningitis and one from cerebral hemorrhage due to a torn tentorium cerebelli, giving a perinatal mortality of 67 per cent. One of the 5 term infants extracted was stillborn as a result of anoxia due to a trapped head, giving a perinatal mortality of 20 per cent. Intravenous oxytocin was used for stimulation of labor in 9 uery select cases and for induction in one (Table IV). Indications for oxytocin augmentation were uterine dysfunction in 8 cases and fetal distress in one case. Induction of labor was employed in one case for severe pre-eclampsia. There was no perinatal mortality in the corrected group. Cesarean section was employed for delivery of 31 infants in the corrected group for a section rate of 15.6 per cent (Table V). Twenty-eight of these infants were term and 3 weighed less than 2,500 grams, the smallest weighing 2,183 grams. There were no stillbirths or neonatal deaths in the corrected cesarean section group. One infant in the uncorrected group died neonatally with congestive heart failure due to hypoplastic heart syndrome with pulmonary stenosis. Indications for cesarean section were primarily uterine dysfunction, failure of continuous progress and/or descent, fetopelvic disproportion, prolapsed cord, and fetal distress. There were 159 spontaneous and assisted vaginal breech deliveries in the corrected group. The over-all perinatal mortality rate
Breech
Table IV. Oxytocin
presentation
stimulation
407
(10 cases)
No. of cases
Outcome
Uterine dysfunction Fetal distress
3 1
Good Good
Term Uterine dysfunction Severe pre-eclampsia (induction j
5 1
GOOd Good
Indication Premature
Table V. Cesarean
section
No. of cases
Indication Uterine
(corrected) Mortality
dysfunction
Without- oxytocin With oxytocin Failure to descend Fetopelvic disproportion Prolapsed cord Fetal distress Abruptio placentae, partial Toxemia Prolonged ruptured bag of water Total
8 1 8 3 ,i 1 1
0 0 0 0 0 0 0 0
1
0
31
0
Table VI. Cause of death Premature Anoxia Atelectasis Infection Subarachnoid
( No.
hemorrhage
Hyaline membrane
disease
of cases 4 4 7 3
1
Term
Subdural hemorrhage Anoxia Nonconclusive Total
i 3 26
was 14 per cent. The mortality for term infants was 6 per cent and for prematures, 29 per cent. In the entire corrected series there were 7 term deaths, with autopsies performed on 6 (Table VI). Subdural hemorrhage apparently due to trauma of delivery was found in 2 and generalized anoxia caused the death of 2 others. The cause of death was not clearly
408
Patterson,
Mulliniks,
and
June 1, 1967 Am. J. Obst. & Gynec.
Schreier
Table VII Perinatal Method
of
delivery
Spontaneous assisted Breech extraction Cesarean section
Premature (%) 29 67 0
mortality Term (%I 6 20 0
determined in 3 infants, but was most likely anoxia. There were 19 stillbirths and neonatal deaths in the corrected premature group, and autopsies were performed on 16 of these. Their causes of death are listed in Table VI. Comment This report confirms an increased perinatal mortality for primiparous breech deliveries. The perinatal death rate for the corrected group of spontaneous and assisted vaginal breech deliveries was 14 per cent, 29 per cent for premature and 6 per cent for term infants (Table VII). Cesarean section was performed in 31 cases with no fetal or neonatal loss. Although the number of breech extractions was small, the mortality for these was high, 67 per cent for premature and 20 per cent for term infants. One can see from these figures that breech extraction is associated with a prohibitively high perinatal wastage. Therefore, when there is an indication for immediate delivery, and fetal size is thought sufficient for good survival, cesarean section is the treatment of choice rather than breech extraction. As previously stated the use of intravenous
oxytocin with breech labors has been markedly curtailed at this institution since 1959. In fact, it was used in only 10 cases in the present series, or only one-third as frequently as in the previously reported group. There were no deaths associated with oxytocin in this series. X-ray pelvimetry is obtained routinely at this institution for all primiparous breech labors; and when clinical or x-ray findings suggest fetopelvic disproportion, oxytocin stimulation is not used and cesarean section is the management of choice. There are several obstetricians on our staff who believe oxytocin is contraindicated in all breech labors. Cesarean section in this series was associated with 100 per cent survival. It is our opinion that breech labors complicated by uterine dysfunction or unsatisfactory progress should be delivered by the abdominal route. Breech labors must show steady progress as evidenced by continuous descent and cervical dilatation; otherwise, cesarean section is indicated. Although this series is small, we believe that 100 per cent survival with cesarean section as compared to survival with vaginal deliveries warrants liberalization of cesarean section in the management of breech deliveries when dealing with a previously untested pelvis. Again, we are reminded of Ralph Wright’s advocation of routine cesarean section for all term breech deliveries. One could speculate as to whether cesarean section in the 106 term breech deliveries managed vaginally would have salvaged the 7 term infants who died, since all term deaths occurred with vaginal delivery.
REFERENCES
5. 6.
Morgan, H. S., and Kane, S. H.: J. A. M. A. 187: 262, 1964. Todd, W. D., and Steer, C. M.: Obst. & Gynec. 22: 583, 1963. Hall, J. E.: and Kohl, S. G.: AM. J. OBST. & GYNEC. 72: 977, 1956. Eastman, N. J., and Hellman, L. M.: Williams Obstetrics, ed. 13, New York, 1966, Appleton-Century-Crofts, Inc., p. 846. & Gynec. 14: 758, Wright, R. C.: Obst. 1959. Churchill, J. A.: Electroenceph. & Clin. Neurophysiol. 11: 1, 1959.
7.
Steer, C. M., and Bonney, W.: AM. J. OBST. & GYNEC. 83: 526, 1962. 8. Fuldner, R. V.: AM. J. OBST. & GYNEC. 74: 159, 1957. J. A.: Tr. Am. Neurological So9. Churchill, ciety, 1957, p. 134. W. D.: Arvr. J. OBST. & GYNEC. 84: 10. Varner, 876, 1962. 11. Jackson, R. L.: AM. J. OBST. & GYNEC. 81: 653, 1961. 894 Madison Avenue Memphis, Tennessee
38103
Volume
98
Number
3
Discussion J. L. WULFF, JR., St. Louis, Missouri. The authors have presented very clearly a problem which needs to be emphasized frequently in our specialty, namely, the management of breech presentation. For years we have talked of this presentation as though it were one of the two usual ways for an infant to be born. One might have a rare condition, such as a face presentation or a transverse lie, but, excluding these, then all babies either came as cephalic or as breech presentations. We have used these two as though they were equally important. Only a moment’s reflection, however, should make us realize that an incidence of 3.0 to 3.5 per cent does not allow breech presentations to occur very frequently in our own private practices. Perhaps, then, we should consider breech presentation as an uncommon complication of labor. Dr. Patterson further narrows his discussion by considering breech presentation only in the primigravida. These patients represented an incidence of 0.45 per cent in his series of over 46,000 deliveries. In our latest report from St. Louis Maternity Hospital,1 the incidence of gravida i breech presentations was 1.2 per cent, and Neimand and Rosenthal2 recently reported a similar incidence of 1.2 per cent at the Long Island Jewish Hospital. We are reminded of the hazards of this presentation by the authors’ statement that breech mortality is five times higher than that for cephalic presentations. Dr. Harold Morgan3 of Lincoln, Nebraska, put these percentages into more startling figures with this statement, “. . . in 1962, 3,500 full-term infants were included in the nation-wide breech perinatal loss rate. If these babies were subjected to the loss rate for all other full-term babies, 2,400 of these infants would be alive today.” As was pointed out by Dr. Patterson, there is sublethal damage which must also be considered in these deliveries where the unmolded head is rapidly compressed and decompressed in its hasty passage through the pelvis. Cerebral palsy, epilepsy, hemiplegia, and mental retardation all have been reported as occurring with greater frequency following breech vaginal deliveries.4 We must realize that our responsibility is to lower these rates by whatever means are available. The mortality and morbidity can be reduced significantly merely by changing the breech presentation to a cephalic one in the mother. As DR.
GEORGE
Breech
presentation
409
the first method of lowering these rates, then, external version of the fetus should be attempted in all patients with breech presentations, after the thirty-fourth week of gestation. Although there is admittedly some danger to the fetus by this maneuver, it is certainly far less than the hazards of breech delivery itself. Second, x-ray pelvimetry and confirmation of fetal attitude are “musts” in all primigravida breech presentations, since contractions of the bony pelvis will prove hazardous to the unmolded after-coming head. Third, we must reappraise our attitude toward cesarean section in breech presentation. The current authors report 31 cesarean sections without a fetal death, and these patients represented 15.6 per cent of their breech cases. Dr. Richard Bryant and the discussants of his paper on cesarean section, given here 2 days ago, emphasized first the rising importance of breech presentation as an indication for cesarean section, and second the decreased perinatal mortality and morbidity associated with this operation. Dr. Patterson mentioned the work of Dr. Ralph Wright, who shocked many of our colleagues in 1959 when he advocated routine elective cesarean sections for all breeches. Many of our esteemed leaders at that time said that by doing this routinely we would be losing the “art of obstetrics,” relegating ourselves to the role of either “midwife or surgeon.” However, the “art of obstetrics” is far less important than saving lives, and all statistical reports show that vaginal delivery of breeches carries much too high a mortality. We seem to feel that doing a cesarean section in these cases is too radical, but it is interesting to estimate what such an approach would mean in our practices. It has been shown by Dr. Robert Ross of this organization and others that only the very busiest obstetricians will deliver 200 babies annually over any long period of years, say 15 or 20. Generously allowing such a man to deliver 4,000 babies during the active years of his practice, he may then deliver a maximum total of 1.2 per cent or 48 primigravida breech deliveries during his lifetime. Are we radical then in suggesting that these babies be delivered not only alive but also free from sublethal brain damage by performing elective cesarean sections? Actually, this is the conservative approach and must be advocated more freely if we are to lower the mortality rate in breech presentations-infrequent and hazardous as they are.
410
Patterson,
Mulliniks,
and
June 1, 1967 Am. J. Obst. & Gynec.
Schreier
REFERENCES
1.
Wulff, George J. L., Jr., Trueblood, A. C., Jr., and Holland, Robert A.: Obst. & Gynec. 16: 288, 1960. 2. Neimand, Karl M., and Rosenthal, Alexander H.: AM. J. OBST. & GYNEC. 93: 230, 1965. 3. Morgan, Harold S., and Kane, Sydney: J. A. M. A. 187: 262, 1964. 4. Eastman, N. J., Kohl, S. G., Maisel, J. E., and Kavaler. F.: Obst. & Gvnec. Surv. 17: 459, 1962. ’ 5. Wright, Ralph C.: Obst. & Gynec. 14: 758, 1959. DR. J. VIVIAN GIBBS, Knoxville, Tennessee. A report similar to the one we have just heard was given to us in Knoxville and has made us reevaluate our policy on breech delivery. We have a four-man group and are all Board-certified specialists. Two of us scrub for all breech deliveries and one of us stays at the hospital all the time that the patient is in labor. We have lost only one breech infant because of trauma at delivery. This resulted from pressure on the fundus at the time of delivery, causing the baby’s neck to be broken. There is a place for a trial of labor in breech presentation and intravenous oxytocin stimulation, if necessary. If, after an adequate test of labor and pudendal block, spontaneous delivery to the navel of baby does not occur, we prefer cesarean section to breaking up the breech. DR. WILLIAM B. GODDARD, Denver, Colorado. Most breech studies suffer from two serious defects. The first of these is that when you compare breech and vertex groups, unless you are very careful with your weight correction, each weight group will be weighted by the lower weight groups. Unless you have a paired series for weight variation, you will not be dealing with similar groups. The second defect which most breech studies suffer from is a lumping of the various types of breech presentations into a unit. The essayists’ comments about the prolapsed cord are excellent illustrations of this. They had no prolapsed cord in the frank breech. Prolapse occurs in the single footling and double footling breech deliveries. Stimulation of the flagging labor in breech presentations may produce a lethal combination. Breech extraction is, I believe, the modern remnant of accouchement force. These two measures should be avoided by cesarean section and not by attempts at delivery from below. Let me ask one question of the audience: When you do a cesarean section, who is present-an experienced obstetrician, a scrub as-
’
sistant, one or more scrub nurses, circulating nurses, and an experienced anesthesiologist at the head of the table? Now, if you do a major obstetric manipulation, such as delivery of the breech, whom do you have present? Does everybody in this group have in their delivery room a scrub assistant, a circulating nurse, and an experienced anesthesiologist at the head of the table? I submit that I do not and I submit also that most of you do not. Delivery of the infant in breech presentation is a major obstetric manipulation and it should have the same safeguards as those provided cesarean section. DR. PATTERSON (Closing). We are often told, when discussing breech presentations, “My babies go to the nursery well. The last hundred breech deliveries did not present a problem.” I submit to these obstetricians that those mothers who have a retarded child or one with a flaccid arm or leg do not return to them but change doctors. Some physicians will also say, “I am going to take a chance with this delivery, managing it Now, I would like to ask, “Who from below.” is taking the chance, the doctor or the infant?” The frequency of the use of intravenous oxytocin, at least in our series, has been reduced a great deal. Others have reported a similar decrease recently but have stated that oxytocin does have a place in the management of vaginal delivery of the infant in breech presentation. In other series, just as in ours, there has been an increased cesarean section rate, usually double what it has been in the past. One can see that they have liberalized the indications for cesarean sections and have given careful consideration before resorting to intravenous oxytocin and vaginal delivery of the infant in breech presentation. We did not mean to imply that we would agree with Dr. Wright altogether in connection with routine cesarean section for all breech deliveries, but I believe we should consider cesarean section at any time when the breech labor is not moving along smoothly. Dr. Goddard mentioned the weight grouping of infants as being very important, and, of course, it certainly is. At the Second Scientific Session of the Collaborative Project in Washington last year, it was reported that those infants who weighed near 1,000 grams had a very high death rate or brain damage rate at one year of age and that it was not until a birth weight of near 2,000 grams that there was good survival of normal infants at one year.
P.
PATTERSON,
ROBERT PHIL Memphis,
C. C.
M.D.
MULLINIKS,
SCHREIER,
in the primigrawida
JR.,
M.D.
M.D.
Tennessee
Breech presentation continues to seriously concern obstetricians, particularly since various neurological abnormalities have been found in these children years after birth. This clinical study concerns 208 primigravidas with single breech presentation. The corrected perinatal mortality was 13 per cent compared with an over-all perinatal mortality of 3.3 per cent. Cerebral trauma and anoxia are implicated as serious hazards associated with delivery of the aftercoming head. Breech extraction was associated with a prohibitively high perinatal wastage. Intravenous oxytocin was employed to augment labor of a very small and very select group of patients with no associated perinatal loss. A IO0 per cent fetal salvage following cesarean section compared with the perinatal loss associated with vaginal delivery, even in a small series such as this, warrants liberalization of cesarean section in the management of breech presentation in the primigravida.
B R E E c H presentation continues to be a challenge to the obstetrician, even with what might be considered improved obstetric techniques and more scientific knowledge of medicine in general. Journals of this discipline regularly contain articles dealing with breech presentation and the problems associated with its management. The increased perinatal wastage attributable to breech presentation is well documented in the literature. Less well documented, however, is morbidity in terms of major and minor neurological abnormalities in these children discovered months or years later. Loss of or damage to an infant as a result of labor and delivery remains among the most distressing circumstances in obstetrics. The importance of this problem is recognized when one recalls that the perinatal mortality associated with breech presentation From the Department of Obstetrics and Gynecology, The University of Tennessee College of Medicine, and The City of Memphis Hospitals. Presented at the Thirty-fourth Annual Meeting of the Central As.rociation of Obstetricians and Gynecologists, Biloxi, Mississippi, Oct. 20-22, 1966.
is reported to be five times that of all perinatal deaths in genera1.l If corrected for prematurity, the permatal loss for term breech infants is three to four times as high as the perinatal mortality for all term infants.lv * Hall and Kohl3 reported a corrected premature breech delivery perinatal mortality rate of 26.9 per cent and a corrected term breech delivery mortality rate of 4.7 per cent. Breech presentation has associated with it certain problems that by and large are not associated with cephalic presentation. The largest part of the infant is delivered last, so that a trial of labor with the largest part is not possible as it is with cephalic presentation. In addition, when there are borderline relationships between the fetal head and the pelvis, there is no time for gradual molding of the head. Another difference is the rapidity with which this unmolded head traverses the pelvis, particularly when the delivery is “hurried along” by the obstetrician or when fetal distress occurs and extraction is performed. Also, further complicating the breech presentation is an associated increased incidence of prolapse of the umbilical cord.3q 4
Volume Number
98 3
Version and extraction have been practically discarded from obstetric practice, and high and midforceps deliveries have been virtually abandoned for good reason and rightly so. Therefore, vaginal delivery of an infant in breech presentation is the main “technique” left in the so-called “art of obstetrics.” For this reason, many have been reluctant to perform cesarean section for breech presentation and have continued to practice and advocate vaginal delivery if at all feasible. Ralph C. Wright, in 1959, was first to advocate routine cesarean section for all gravidas with breech presentation after 35 weeks’ gestation provided that the fetus is living and there is no maternal disease contraindicating abdominal delivery.5 He points out that various reports indicate at least two thirds of term infants lost with breech delivery could be saved by cesarean section, since mortality figures are two-thirds less for term breech deliveries carried out abdominally. In addition, he cites known cases of minor brain damage, mental retardation, and cerebral palsy that are not recognized in the perinatal period and not reflected in most statistics. He refers to Churchill’s report of 92 cases of epilepsy in which 19.6 per cent were breech deliveries-over five times the normal 3.5 per cent incidence of breech delivery.6 Other similar reports include that of Steer and Bonney’ who note that, of 317 cerebral palsy cases, 9 per cent were delivered in breech presentation. Fuldners reports 7.1 to 16.6 per cent of athetoid and spastic hemiplegic patients were delivered in breech presentation. In another article, Churchill reports that of 297 patients with cerebral palsy, epilepsy, and mental retardation, 10 per cent were delivered in breech presentation. When reviewing these statistics, however, one must recall that prematurity was a factor in these series and may indeed have been the major factor. Although breech presentation in general has been the topic of many studies, breech presentation in the primigravida seems to be the major challenge. Varner,lO in 1962, re-
Breech
presentation
405
ported a ninefold increase in perinatal mortality for term breech deliveries in primigravidas delivered vaginally as compared with all term vaginal deliveries. Records of breech deliveries in primigravidas from the Department of Obstetrics and Gynecology of The City of Memphis Hospitals were reported in 1961.11 For the years 1953 through 1958 there were 189 single breech deliveries in primigravidas with a corrected perinatal mortality of 11 per cent. Perinatal mortality for the premature infants was 28 per cent and for the term group 6.3 per cent.The possible influence of intravenous oxytocin stimulation was also reported. Thirty labors were augmented with intravenous oxytocin because of uterine dysfunction. The perinatal mortality for this group was 20 per cent. The mortality for the non-oxytocintreated group was 9.5 per cent. Thus, there was a twofold increase in perinatal mortality when intravenous oxytocin was used to augment labor when uterine dysfunction complicated breech presentation in the primigravida. The incidence of cesarean section was 8.7 per cent with the indications being elderly primigravidas, prolapsed cords, and prolonged labors. It was concluded that uterine dysfunction with breech presentation will respond to intravenous oxytocin but with an almost prohibitively high fetal mortality. In this department since 1959 there has been marked liberalization of the indications for cesarean section for the management of breech deliveries. At the same time there has been a marked reduction in the use of intravenous oxytocin to augment or complete the breech delivery. Material
The material for this study was obtained from the records of 208 primigravidas with single breech presentations. These patients were delivered on the Obstetric Service of The City of Memphis Hospitals and The University of Tennessee from Jan, 1, 1959, through Dec. 31, 1965. During this 7 year period there were 46,420 deliveries at this institution. Not included in this study were multiple pregnancies or infants weighing less
406
Patterson,
Mulliniks,
and
June 1, 1967 Am. J. Obst. & Gym.
Schreier
with pulmonary stenosis, and 4 infants exhibiting multiple anomalies. The corrected figures contain those infants whose deaths were more probably associated with labor and delivery. The corrected group contains 198 infants with an over-all perinatal mortality of 13 per cent (Table II) . This compares to a 3.3 per cent perinatal mortality for all infants (not shown in this table) weighing 1,000 grams or more delivered at this institution during the same period, a fourfold increase. The mortality for the premature breech deliveries in this series was 31 per cent and for the term breech deliveries, 5.1 per cent. The types of breech presentation were recorded in 145 of the cases in this study. As in the previous report from this institution the most common type was frank breech, and the second most frequent was double
than 1,000 grams. All gravidas were service patients and approximately 98 per cent were Negro.
Results The uncorrected group contains 208 single breech deliveries of primigravidas resulting in infants weighing 1,000 grams or more (Table I). One hundred and forty infants were mature (2,500 grams or more) and 68 were premature (1,000 to 2,499 grams). Stillbirths and neonatal deaths are reported including deaths through the first 28 days of life providing death occurred in this hospital. Excluded from this series are severely macerated stillbirths showing evidence of longstanding intrauterine death and congenital anomalies incompatible with life. The congenital anomalies excluded were hydrocephalus, hypoplastic right heart syndrome
Table I. Perinatal Uncorrected
mortality
(uncorrected)
(208)
Discharged Stillborn Neonatal
(2,500
deaths
Total
Table II. Perinatal
mortality
Term grams
Premature (l,OOO-2,499 grams)
+)
130 6 4
42 9 17
140
68
(198)
Discharged Stillborn Neonatal
No. of cases
137
Breech
extraction
cord second
Term Prolapsed cord Prolonged second Fetal distress
stage
stage
Total
No. of cases
%
%
42
5.1
69.0
No. of cases
%
172
87.0
26
13.0
198
100.0
145------31.0 61
(8 cases) 1 No.
Indication Premature Prolapsed Prolonged
17.0%
Premature
94.9
3 4-----------,
Total
Table III.
1
130 death
loss
(corrected) Term
Corrected
Perinatal
of cases
Outcome
2 1
1 neonatal 1 neonatal
3 1 1
1 stillborn Good Good
Cause
I death death
Meningitis Torn tentorium
Anoxia
of
death
cerebelli
due to trapped
head
Volume Number
98 3
footling. Single footling and complete breech presentations occurred least often. Prolapse of the umbilical cord occurred in 12 cases, an over-all incidence of 5.7 per cent. All prolapses occurred with footling or full breech presentations. In this series no cord prolapse occurred with frank breech presentation. The corrected perinatal loss associated with cord prolapse was 27 per cent. For prematures, it was 33 per cent and for term 25 per cent. In the corrected group, breech extraction was performed in 8 cases, 3 for premature and 5 for term infants (Table III). Indications for extraction were prolapsed cord, prolonged second stage, and fetal distress. Two of the 3 premature extracted infants died neonatally, one from meningitis and one from cerebral hemorrhage due to a torn tentorium cerebelli, giving a perinatal mortality of 67 per cent. One of the 5 term infants extracted was stillborn as a result of anoxia due to a trapped head, giving a perinatal mortality of 20 per cent. Intravenous oxytocin was used for stimulation of labor in 9 uery select cases and for induction in one (Table IV). Indications for oxytocin augmentation were uterine dysfunction in 8 cases and fetal distress in one case. Induction of labor was employed in one case for severe pre-eclampsia. There was no perinatal mortality in the corrected group. Cesarean section was employed for delivery of 31 infants in the corrected group for a section rate of 15.6 per cent (Table V). Twenty-eight of these infants were term and 3 weighed less than 2,500 grams, the smallest weighing 2,183 grams. There were no stillbirths or neonatal deaths in the corrected cesarean section group. One infant in the uncorrected group died neonatally with congestive heart failure due to hypoplastic heart syndrome with pulmonary stenosis. Indications for cesarean section were primarily uterine dysfunction, failure of continuous progress and/or descent, fetopelvic disproportion, prolapsed cord, and fetal distress. There were 159 spontaneous and assisted vaginal breech deliveries in the corrected group. The over-all perinatal mortality rate
Breech
Table IV. Oxytocin
presentation
stimulation
407
(10 cases)
No. of cases
Outcome
Uterine dysfunction Fetal distress
3 1
Good Good
Term Uterine dysfunction Severe pre-eclampsia (induction j
5 1
GOOd Good
Indication Premature
Table V. Cesarean
section
No. of cases
Indication Uterine
(corrected) Mortality
dysfunction
Without- oxytocin With oxytocin Failure to descend Fetopelvic disproportion Prolapsed cord Fetal distress Abruptio placentae, partial Toxemia Prolonged ruptured bag of water Total
8 1 8 3 ,i 1 1
0 0 0 0 0 0 0 0
1
0
31
0
Table VI. Cause of death Premature Anoxia Atelectasis Infection Subarachnoid
( No.
hemorrhage
Hyaline membrane
disease
of cases 4 4 7 3
1
Term
Subdural hemorrhage Anoxia Nonconclusive Total
i 3 26
was 14 per cent. The mortality for term infants was 6 per cent and for prematures, 29 per cent. In the entire corrected series there were 7 term deaths, with autopsies performed on 6 (Table VI). Subdural hemorrhage apparently due to trauma of delivery was found in 2 and generalized anoxia caused the death of 2 others. The cause of death was not clearly
408
Patterson,
Mulliniks,
and
June 1, 1967 Am. J. Obst. & Gynec.
Schreier
Table VII Perinatal Method
of
delivery
Spontaneous assisted Breech extraction Cesarean section
Premature (%) 29 67 0
mortality Term (%I 6 20 0
determined in 3 infants, but was most likely anoxia. There were 19 stillbirths and neonatal deaths in the corrected premature group, and autopsies were performed on 16 of these. Their causes of death are listed in Table VI. Comment This report confirms an increased perinatal mortality for primiparous breech deliveries. The perinatal death rate for the corrected group of spontaneous and assisted vaginal breech deliveries was 14 per cent, 29 per cent for premature and 6 per cent for term infants (Table VII). Cesarean section was performed in 31 cases with no fetal or neonatal loss. Although the number of breech extractions was small, the mortality for these was high, 67 per cent for premature and 20 per cent for term infants. One can see from these figures that breech extraction is associated with a prohibitively high perinatal wastage. Therefore, when there is an indication for immediate delivery, and fetal size is thought sufficient for good survival, cesarean section is the treatment of choice rather than breech extraction. As previously stated the use of intravenous
oxytocin with breech labors has been markedly curtailed at this institution since 1959. In fact, it was used in only 10 cases in the present series, or only one-third as frequently as in the previously reported group. There were no deaths associated with oxytocin in this series. X-ray pelvimetry is obtained routinely at this institution for all primiparous breech labors; and when clinical or x-ray findings suggest fetopelvic disproportion, oxytocin stimulation is not used and cesarean section is the management of choice. There are several obstetricians on our staff who believe oxytocin is contraindicated in all breech labors. Cesarean section in this series was associated with 100 per cent survival. It is our opinion that breech labors complicated by uterine dysfunction or unsatisfactory progress should be delivered by the abdominal route. Breech labors must show steady progress as evidenced by continuous descent and cervical dilatation; otherwise, cesarean section is indicated. Although this series is small, we believe that 100 per cent survival with cesarean section as compared to survival with vaginal deliveries warrants liberalization of cesarean section in the management of breech deliveries when dealing with a previously untested pelvis. Again, we are reminded of Ralph Wright’s advocation of routine cesarean section for all term breech deliveries. One could speculate as to whether cesarean section in the 106 term breech deliveries managed vaginally would have salvaged the 7 term infants who died, since all term deaths occurred with vaginal delivery.
REFERENCES
5. 6.
Morgan, H. S., and Kane, S. H.: J. A. M. A. 187: 262, 1964. Todd, W. D., and Steer, C. M.: Obst. & Gynec. 22: 583, 1963. Hall, J. E.: and Kohl, S. G.: AM. J. OBST. & GYNEC. 72: 977, 1956. Eastman, N. J., and Hellman, L. M.: Williams Obstetrics, ed. 13, New York, 1966, Appleton-Century-Crofts, Inc., p. 846. & Gynec. 14: 758, Wright, R. C.: Obst. 1959. Churchill, J. A.: Electroenceph. & Clin. Neurophysiol. 11: 1, 1959.
7.
Steer, C. M., and Bonney, W.: AM. J. OBST. & GYNEC. 83: 526, 1962. 8. Fuldner, R. V.: AM. J. OBST. & GYNEC. 74: 159, 1957. J. A.: Tr. Am. Neurological So9. Churchill, ciety, 1957, p. 134. W. D.: Arvr. J. OBST. & GYNEC. 84: 10. Varner, 876, 1962. 11. Jackson, R. L.: AM. J. OBST. & GYNEC. 81: 653, 1961. 894 Madison Avenue Memphis, Tennessee
38103
Volume
98
Number
3
Discussion J. L. WULFF, JR., St. Louis, Missouri. The authors have presented very clearly a problem which needs to be emphasized frequently in our specialty, namely, the management of breech presentation. For years we have talked of this presentation as though it were one of the two usual ways for an infant to be born. One might have a rare condition, such as a face presentation or a transverse lie, but, excluding these, then all babies either came as cephalic or as breech presentations. We have used these two as though they were equally important. Only a moment’s reflection, however, should make us realize that an incidence of 3.0 to 3.5 per cent does not allow breech presentations to occur very frequently in our own private practices. Perhaps, then, we should consider breech presentation as an uncommon complication of labor. Dr. Patterson further narrows his discussion by considering breech presentation only in the primigravida. These patients represented an incidence of 0.45 per cent in his series of over 46,000 deliveries. In our latest report from St. Louis Maternity Hospital,1 the incidence of gravida i breech presentations was 1.2 per cent, and Neimand and Rosenthal2 recently reported a similar incidence of 1.2 per cent at the Long Island Jewish Hospital. We are reminded of the hazards of this presentation by the authors’ statement that breech mortality is five times higher than that for cephalic presentations. Dr. Harold Morgan3 of Lincoln, Nebraska, put these percentages into more startling figures with this statement, “. . . in 1962, 3,500 full-term infants were included in the nation-wide breech perinatal loss rate. If these babies were subjected to the loss rate for all other full-term babies, 2,400 of these infants would be alive today.” As was pointed out by Dr. Patterson, there is sublethal damage which must also be considered in these deliveries where the unmolded head is rapidly compressed and decompressed in its hasty passage through the pelvis. Cerebral palsy, epilepsy, hemiplegia, and mental retardation all have been reported as occurring with greater frequency following breech vaginal deliveries.4 We must realize that our responsibility is to lower these rates by whatever means are available. The mortality and morbidity can be reduced significantly merely by changing the breech presentation to a cephalic one in the mother. As DR.
GEORGE
Breech
presentation
409
the first method of lowering these rates, then, external version of the fetus should be attempted in all patients with breech presentations, after the thirty-fourth week of gestation. Although there is admittedly some danger to the fetus by this maneuver, it is certainly far less than the hazards of breech delivery itself. Second, x-ray pelvimetry and confirmation of fetal attitude are “musts” in all primigravida breech presentations, since contractions of the bony pelvis will prove hazardous to the unmolded after-coming head. Third, we must reappraise our attitude toward cesarean section in breech presentation. The current authors report 31 cesarean sections without a fetal death, and these patients represented 15.6 per cent of their breech cases. Dr. Richard Bryant and the discussants of his paper on cesarean section, given here 2 days ago, emphasized first the rising importance of breech presentation as an indication for cesarean section, and second the decreased perinatal mortality and morbidity associated with this operation. Dr. Patterson mentioned the work of Dr. Ralph Wright, who shocked many of our colleagues in 1959 when he advocated routine elective cesarean sections for all breeches. Many of our esteemed leaders at that time said that by doing this routinely we would be losing the “art of obstetrics,” relegating ourselves to the role of either “midwife or surgeon.” However, the “art of obstetrics” is far less important than saving lives, and all statistical reports show that vaginal delivery of breeches carries much too high a mortality. We seem to feel that doing a cesarean section in these cases is too radical, but it is interesting to estimate what such an approach would mean in our practices. It has been shown by Dr. Robert Ross of this organization and others that only the very busiest obstetricians will deliver 200 babies annually over any long period of years, say 15 or 20. Generously allowing such a man to deliver 4,000 babies during the active years of his practice, he may then deliver a maximum total of 1.2 per cent or 48 primigravida breech deliveries during his lifetime. Are we radical then in suggesting that these babies be delivered not only alive but also free from sublethal brain damage by performing elective cesarean sections? Actually, this is the conservative approach and must be advocated more freely if we are to lower the mortality rate in breech presentations-infrequent and hazardous as they are.
410
Patterson,
Mulliniks,
and
June 1, 1967 Am. J. Obst. & Gynec.
Schreier
REFERENCES
1.
Wulff, George J. L., Jr., Trueblood, A. C., Jr., and Holland, Robert A.: Obst. & Gynec. 16: 288, 1960. 2. Neimand, Karl M., and Rosenthal, Alexander H.: AM. J. OBST. & GYNEC. 93: 230, 1965. 3. Morgan, Harold S., and Kane, Sydney: J. A. M. A. 187: 262, 1964. 4. Eastman, N. J., Kohl, S. G., Maisel, J. E., and Kavaler. F.: Obst. & Gvnec. Surv. 17: 459, 1962. ’ 5. Wright, Ralph C.: Obst. & Gynec. 14: 758, 1959. DR. J. VIVIAN GIBBS, Knoxville, Tennessee. A report similar to the one we have just heard was given to us in Knoxville and has made us reevaluate our policy on breech delivery. We have a four-man group and are all Board-certified specialists. Two of us scrub for all breech deliveries and one of us stays at the hospital all the time that the patient is in labor. We have lost only one breech infant because of trauma at delivery. This resulted from pressure on the fundus at the time of delivery, causing the baby’s neck to be broken. There is a place for a trial of labor in breech presentation and intravenous oxytocin stimulation, if necessary. If, after an adequate test of labor and pudendal block, spontaneous delivery to the navel of baby does not occur, we prefer cesarean section to breaking up the breech. DR. WILLIAM B. GODDARD, Denver, Colorado. Most breech studies suffer from two serious defects. The first of these is that when you compare breech and vertex groups, unless you are very careful with your weight correction, each weight group will be weighted by the lower weight groups. Unless you have a paired series for weight variation, you will not be dealing with similar groups. The second defect which most breech studies suffer from is a lumping of the various types of breech presentations into a unit. The essayists’ comments about the prolapsed cord are excellent illustrations of this. They had no prolapsed cord in the frank breech. Prolapse occurs in the single footling and double footling breech deliveries. Stimulation of the flagging labor in breech presentations may produce a lethal combination. Breech extraction is, I believe, the modern remnant of accouchement force. These two measures should be avoided by cesarean section and not by attempts at delivery from below. Let me ask one question of the audience: When you do a cesarean section, who is present-an experienced obstetrician, a scrub as-
’
sistant, one or more scrub nurses, circulating nurses, and an experienced anesthesiologist at the head of the table? Now, if you do a major obstetric manipulation, such as delivery of the breech, whom do you have present? Does everybody in this group have in their delivery room a scrub assistant, a circulating nurse, and an experienced anesthesiologist at the head of the table? I submit that I do not and I submit also that most of you do not. Delivery of the infant in breech presentation is a major obstetric manipulation and it should have the same safeguards as those provided cesarean section. DR. PATTERSON (Closing). We are often told, when discussing breech presentations, “My babies go to the nursery well. The last hundred breech deliveries did not present a problem.” I submit to these obstetricians that those mothers who have a retarded child or one with a flaccid arm or leg do not return to them but change doctors. Some physicians will also say, “I am going to take a chance with this delivery, managing it Now, I would like to ask, “Who from below.” is taking the chance, the doctor or the infant?” The frequency of the use of intravenous oxytocin, at least in our series, has been reduced a great deal. Others have reported a similar decrease recently but have stated that oxytocin does have a place in the management of vaginal delivery of the infant in breech presentation. In other series, just as in ours, there has been an increased cesarean section rate, usually double what it has been in the past. One can see that they have liberalized the indications for cesarean sections and have given careful consideration before resorting to intravenous oxytocin and vaginal delivery of the infant in breech presentation. We did not mean to imply that we would agree with Dr. Wright altogether in connection with routine cesarean section for all breech deliveries, but I believe we should consider cesarean section at any time when the breech labor is not moving along smoothly. Dr. Goddard mentioned the weight grouping of infants as being very important, and, of course, it certainly is. At the Second Scientific Session of the Collaborative Project in Washington last year, it was reported that those infants who weighed near 1,000 grams had a very high death rate or brain damage rate at one year of age and that it was not until a birth weight of near 2,000 grams that there was good survival of normal infants at one year.