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Management of term breech presentation
Management of term breech presentation Tracy A. Flanagan, M.D., Kristi M. Mulchahey, M.D., Carol C. Korenbrot, Ph.D., James R. Green, M.D., and Russell :K. Laros, Jr., M.D. San Francisco, California The management of 7J 6 cases of singleton breech presentation oci:urring at 37 or more weeks of gestational age is r!'Jviewed. Beginning in 1980 a trial of external version was offered if the breeeh was identified before active labor. Only 433 (61%) breeches were identified before active labor. Of these, 171 (44%) underwent an attempt at external version and 83 (48%) were successful. The 623 cases remaining as breech presentation were stratified into three groups: (1) cesarean section without labor (379), (2) trial of labor with cesarean section (69), and (3) tria( of labor with vaginal delivery (i 75). The criteria for allowing a trial of labor are detailed. Careful review of maternal and fetal variables indicates that a trial of labor in selected patients will result in vaginal delivery in 72% and that this can be achieved without ari increase in fetal or maternal mortality or morbidity. Furthermore, successful external version followed by a trial of labor in selected cases is highly cost-effective. (AM J 0BSTET GYNECOL 1987;156:1492-502.)
Key words: Obstetrics, breech presentation, delivery, external version Currently in the United States, approximately 80% of all term infants presenting as a breech are deiivered by cesarean section. This accounts for roughly 15% of all cesarean sections. Over the past 2 decades the percentage of breech infants delivered by cesarean section has increased from 10% to in excess of 80%. 1• 2 This change was in response to a number of uncontrolled studies, inany of which did not differentiate between preterm and term breech.'· • These studies showed an increase in neonatal inotbidity and mortality when delivery was vaginal. More recent studies on term deliveries with carefully selected patients have shown no difference in neonatal outcome. 5 ·' Protocols for selecting candidates for a trial of labor and vaginal delivery have consistently included constraints on estimated fetal weight, pelvic measurements, attitude of the fetai head, and course. of labor. Recently, external version has been suggested as an additiohal technique to reduce the number of cesarean sections done for breech presentation. External version of the fetus near term has been reported to convert varying proportions of breech into vertex presentations. 8- 10 Cesarean sections have increased risks of morbidity and mortality for the mother and under certain con-
ditions for the fetus. Surgical intervention is also associated with a substantial increased need for hospital and professional resources and therefore increased economic cost of birth._ Although this cost increase is warranted to prevent morbidity and mortality for the infant, it is important to continually examine under what conditions ce5arean sections can be avoided without increased harm to the infant. The Obstetrical Services of the University of California, San Francisco at Moffitt Hospital and San Francisco General Hospital have continued to advocate vaginal birth for term infants iri the breech position under selected circumstances. Since 1980, external version has been attempted at 37 to 39 weeks' gestation in an increasing. number of cases. If the version was unsuccessful, a trial of labor was routinely considered. It is our hypothesis that the attempt of external version for the term infant in the breech position followed by a trial of labor for patients meeting our selection criteria is preferable to a policy of routine cesarean section. We further hypothesize that this can be achieved without an increase in fetal morbidity or mortality. Finally, such an approach will lower the incidence of cesarean section and thus reduce the economic cost. Material and methods
From the Department of Obstetrics, Gynecology, and Reproductive Sciences and the Center for Reproductive Health Policy, University of California, San Francisco. Supported in part by National Institutes of Health Grant No. HD 13543. Presented at the Fifty-third Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Glenden Beach, Oregon, September 21-25, 1986. Reprint requests: Russell K. Laros, Jr., M.D., Professor and Vice Chairman, Department of Obstetrics, Gynecology and Reproductive Sciences, Room M -1489, University of California, San Francisco, CA 94143-0132.
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To evaluate the above hypothesis, we reviewed all cases of term infants in breech presentations occurring troin 1976 through 1984 at Moffitt Hospital and from 1980 through 1984 at San Francisco General Hospital. Three groups were compared with respect to demographic factors, maternal and fetal outcome, and charges: (1) patients delivered by cesarean section without labor, (~) patients allowed a trial of labor but subsequently delivered by cesarean section, and (3) patients
Management of term breech presentation
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with a trial of labor with subsequent vaginal delivery. Most data analyzed were collected prospectively and maintained in our computerized perinatal data base. Additional data were retrospectively abstracted from the medical and financial records. There were 716 cases of singleton breech presentation occurring at 37 or more weeks of gestational age. In five cases fetal anomalies known to be fatal had been diagnosed antenatally. These cases were excluded from the final data. There were five other cases in which fetal anomalies felt to be compatible with life were known; these cases were not excluded. Gestational age was calculated on the basis of the last menstrual period. Gestational age was confirmed by neonatal assessment in all cases. If a discrepancy of more than 2 weeks existed, the data were reviewed and a final gestational age was assigned. Patients were given standard prenatal care by residents, certified nurse midwives, and faculty physicians. Beginning in 1980, if a breech presentation was identified before the onset of labor, the patient was usually offered external version. Before 1980, the use of external version was uncommon. If the patient elected an attempt at external version, she was monitored for 10 to 20 minutes in a labor room to assure fetal well-being. An intravenous infusion of saline solution was begun, and a level 1 ultrasonic evaluation was performed to confirm fetal position and the location of the placenta and cord. A version was then attempted. In many cases a ~-mimetic was infused intravenously either before any attempt at version was made or after a first attempt had been unsuccessful. After either the successful or unsuccessful attempt, fetal heart rate was again monitored for a brief period of time. If the version was unsuccessful, the patient refused version, or the breech was first identified in early labor, the patient was given the option of an elective cesarean section or a trial oflabor. Our criteria for a trial oflabor were an estimated fetal weight of 3850 gm or less, radiologically defined pelvic measurements of at least 10 em between the ischial spines, an anteroposterior diameter at the pelvic inlet of at least 11 em, and a transverse, inlet diameter of 12 em or more, and a military or flexed attitude of the fetal head. Before 1981, the standard Colcher-Sussman technique of x-ray pelvimetry was used. More recently, all pelvimetry was obtained with computerized tomography.'' Peripartal women labored with an intravenous line in place. Oxytocin was used when necessary for either induction of labor in cases of premature rupture of the membranes or augmentation in cases of documented inadequate uterine forces. Epidural anesthesia was offered to most patients. Delivery was done by resident physicians with faculty supervision. Whenever possible, Piper forceps were applied to the aftercoming head.
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An anesthesiologist and pediatrician were present at the time of delivery. In approximately one third of cases, blood gases from the umbilical cord were obtained. This reflects a change in institutional policy from obtaining cord blood gases in only complicated deliveries to obtaining samples at all deliveries. Apgar scores were assigned at 1 and 5 minutes by the pediatrician present at the delivery who also examined the infant for trauma. Depending on clinical status, an infant was admitted to either the well baby or the intensive care nursery. If the status deteriorated during the neonatal course, the infant was transferred to the intensive care nursery and was considered an admission to the intensive care nursery. Perinatal death was defined as any death occurring from the thirtyseventh week of fetal life through discharge of the neonate from the hospital. Regarding postpartum complications, endometritis was defined clinically as uterine tenderness associated with maternal fever and was treated with intravenous antibiotics until the patient was afebrile. The patient then continued taking oral antibiotics for an additional 3 to 7 days. Wound infections, including episiotomy infections, were treated by drainage and local wound care. Antibiotics were usually not used. Financial data were obtained only for patients delivering at Moffitt Hospital during the years 1980 through 1984 in order that external version data could be included. Total hospital charge per patient was defined as the sum of all charges for services and procedures while an inpatient and included charges for external version. Maternal charges were aggregated from the thirty-seventh week of pregnancy until discharge after birth. Infant charges were those incurred from birth until the time of discharge. The hospital charges included a basic charge for room and care plus separate itemized charges for ancillary services, including laboratory and radiologic studies, use of the operating room, delivery room, intrapartum anesthesia, and transfusions, respiratory care, physical therapy, and inpatient drug treatment. 12 To adjust for increases in hospital rates during the study period, charges for room and care were adjusted by an 11% per year rate of increase as indicated by the Budget and Reimbursement Office. Thus all charges quoted represent 1985 dollar equivalents. Statistical analysis was performed with the SPSSx statistical package. 13 Analysis of variance was used for continuous variables and X2 analysis for categoric variables. Statistically significant differences required a P value of <0.05. Results
Of 716 breech presentations (Fig. 1), only 433 (61 %) were identified before the onset of labor. Of these, 171
1494 Flanagan et al.
June 1987 Am J Obstet Gynecol
GIIOUIP n
Elective Fetopelvic disproportion Prior cesarean section Medical c:ompllcadons
133 131 48 67
VAGINAL DELNERV N:175
GIIOUIP
IU
..__,
Coni,._ Felal distress
..
GROUII'
nnn
14 11
Fig. 1. Clinical course of 716 term infants in breech positions managed at the University of California, San Francisco.
Table I. Reasons for cesarean section without trial of labor Reason
N
Small pelvis Patient's choice Breech Previous cesarean section Large infant Footling Other Defiexed head Failed induction Toxemia High PP No films None stated Herpes IUGR Prior surgery Chorioamnionitis Fetal anomaly Pelvic tumor Total
108
PP = Presenting part; IUGR dation.
60 53 48 24 20 18 9 8 8
7 3 3 2 2 2 1 1 1
379
= intrauterine growth retar-
(44%) underwent an attempt at external version. Eighty-three (48%) versions were successful. Seventyfour of these women (89%) went on to have a vaginal delivery, whereas nine women (11 %) were delivered by
cesarean section for either fetal distress or abnormal labor. Eighty-eight of the versions (52%) were unsuccessful. In the 623 patients in whom version was unsuccessful or was not tried, 379 (61 %) were delivered by cesarean section without labor. X-ray film pelvimetry was performed in only 115 (19%) of these 623 patients. The reasons for electing cesarean section without labor are listed in Table I. The four reasons most frequently cited were "small pelvis," "patient's choice," "previous cesarean section," and "breech." The largest proportion of patients, however, had cesarean section for elective indications ("breech," "Patient's choice," "footling," or "complete breech"). There were various medical indications including chorioamnionitis, diabetes, toxemia, herpes, uterine myoma, previous uterine surgery, intrauterine growth retardation, known fetal anomalies, high presenting part, and an inability to obtain x-ray film pelvimetry. Two hundred forty-four women (39%) underwent a trial of labor. Sixty-nine of these women (28%) ultimately were delivered by cesarean section. The indications for surgery were abnormal labor in 44 patients (64%), fetal distress in 14 (20%), and cord prolapse in 11 (16%). The remaining 175 women (72%) were delivered of the infants vaginally. X-ray film pelvimetry
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Table II. Predelivery maternal and fetal variables Group
2
Variable
Nulliparous(%) Prepregnancy weight (kg)* Height (em) Footling or complete breech (%) Pelvimetry (em) Inletanteroposterior* Transverse* Midtransverse* Fetal weight (gm)* Estimated Station at delivery* Length of labor (hr)* First stage Abnormal labor (% )*
I
3
1 No trial of labor, cesarean section (n = 379)
Cesarean section (n = 69)
61.2 58.2 ± 13.2 159.9 ± 9.45 29.3
62.3 60.6 ± 14.4 169.5 ± 6.99 29.0
54.9 56.2 ± 8.7 159.9 ± 12.77 24.0
11.7 ± 1.74 12.5 ± 1.08 10.2 ± 1.13
12.6 ± 0.99 13.2 ± 1.12 10.9 ± 0.69
12.4 ± 0.98 13.0 ± 1.12 11.2 ± 0.97
3313 ± 462 -1.9 ± 1.78
3366 ± 367 -1.2 ± 1.98
3103 ± 414 +2.9 ± 0.71
9.3 ± 7.51 60.9
7.2 ± 5.14 14.3
Trial of labor
I
Vaginal delivery (n = 175)
*p ,;;;0.05.
Table III. Use of oxytocin in vaginal trial groups (groups 2 and 3)
Oxytocin induction Augmentation None Total
Table IV. Anesthetic techniques used for vaginal breech delivery (group 3)
No.
%
Technique
No.
%
33 10 201 244
13 4 0
Pudendal Epidural General None Total
116 42 5 12 175
66 24 3 _l 100
17
was performed in 119 of the 244 patients (49%) allowed a trial of labor. Of the 623 babies who remained breech, 20% were footling, 72% were frank, and 8% were complete. Data for these 623 patients and babies were stratified into three groups: group 1, cesarean section without labor, group 2, trial of labor with cesarean section, and group 3, trial of labor with vaginal delivery. Antepartum, intrapartum, and postpartum maternal variables and neonatal outcome variables such as Apgar scores, cord blood gases, birth trauma, admission to the intensive care nursery, and perinatal death were compared between the three study groups. Predelivery variables. Table II details variables that might influence the choice of method of delivery. Although not all included in the table, there was no difference in age, parity, gravidity, height, race, or type of breech. Comparing group 1 with groups 2 and 3 (the vaginal trial groups), the pelvic measurements are significantly smaller in group 1. The estimated total weight was also significantly larger in group 1. Undoubtedly, these factors influenced the decision to proceed with cesarean section without labor in women with small pelvic measurements or thought to be carrying a
large infant. Although there was also a significant difference in maternal weight (but not height), it is not likely that this influenced the choice of route of delivery. Labor and delivery. The method of delivery used in the 175 patients delivered vaginally was 32 spontaneous, 129 assisted or partial extraction, and 14 complete breech extractions. The significant differences in station at delivery is as expected. In both groups that labored (groups 2 and 3), there were significant differences in the length of the first stage and in the frequency of abnormal labors. Prolonged latent labor and arrest of the active phase were more common in group 2 and were the indications for cesarean section after a trial of labor. As shown in Table III, oxytocin was used in 43 (17%) of the 244 patients having a trial of labor. The indication was for induction of labor in 33 patients and augmentation in 10. The types of anesthesia used for patients in group 3 are listed in Table IV. The anesthetic technique used had no significant effects on any of the outcome variables. There was a slight but significant difference in the length of the second stage of labor. The mean lengths were 0.53, 0.43, 1.15, and 0.51 min-
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Table V. Neonatal outcome Group
2
Variable
I No trial of labor, cesarean section (n = 379)
Cesarean section (n = 69)
3297 ± 560
3395 ± 535
Fetal weight (gm)* Actual Apgar scores 1-min 0-3 (%)* 4-7 8-10
5-min 0-3 (%)* 4-7 8-10 Umbilical artery gases pH* Po2 (mm Hg) Pco2 (mm Hg) Base excess* Hospital stay (days) Newborn* Admission to intensive care nursery(%) Birth trauma(%)* Perinatal death(%)
7.24 14 53 -4.96
± ± ± ±
0.07 5.44 9.16 3.59
5.7 ± 3.49 7.2 1.1 1.1
Trial of labor
14.5 42.0 43.5 4.3 7.2 88.4
9.5 41.4 49.1 0.5 7.4 92.1
3
I
7.19 16 56 -6.42
± ± ± ±
1
Vaginal delivery (n = 175)
3054 ± 520 14.9 49.1 36.0 0.6 13.1 86.3
0.11 5.39 11.5 4.60
5.9 ± 3.17 13.8 4.8 1.4
7.19 ± 15 ± 54± -6.88 ±
0.08 6.19 8.07 3.72
3.8 ± 2.63 5.2 6.5 0
*p ~ 0.05.
Table VI. Neonatal trauma* Group I
Group 2
Group 3
None 354 Fracture 1 (Osteogenesis imperfecta) Bruise 1 Butt Iacer2 ation Nerve damage 0
60 0
158 0
2 I
9 I
Total
63
358
0 (In utero) I69
*No observation recorded in 37 cases.
utes, respectively, for patients receiving none, general, regional, and pudendal anesthesia (F = 5.29; p < 0.002). Neonatal outcome. As can be seen in Table V, there were significant differences between the three groups with respect to actual birth weight. The mean weight of babies in group 2, the failed vaginal trial group, was significantly heavier than the other groups. There were also differences between groups with respect to both I- and 5-minute Apgar scores. In each instance the group 2 babies fell between those in groups I and 3. These findings are placed in clinical perspective by examination of blood gas values of the cord. Although both the pH and base excess are significantly higher in those infants delivered by cesarean section without labor, the differences have little clinical significance. That
there are no significant differences between groups 2 and 3 suggests that labor rather than the route of delivery has some effect on blood gas values of umbilical cord. With respect to birth trauma, there was significantly more recorded in those infants delivered vaginally. As shown in Table VI, the difference was from an increased frequency of "bruising" in group 3 infants. There was one instance of a facial nerve palsy in group 3. This infant was noted to have facial asymmetry at birth that has persisted. The cause of the facial nerve paralysis was thought to be intrauterine pressure rather than any trauma at the time of vaginal delivery. The fracture occurred in an infant in group I diagnosed postnatally as having osteogenesis imperfecta. There were no significant differences in the incidence of admission to the intensive care nursery or perinatal mortality. There were five neonatal deaths, four in group I and one in group 2. The cause of each death was a congenital anomaly incompatible with life. None of these five anomalies had been diagnosed before delivery. Maternal outcome. As seen in Table VII, the estimated maternal blood loss was significantly greater in group 1, but there was no difference in either the frequency of transfusion or the hematocrit difference between groups. The incidence of endometritis was significantly greater in both groups delivered by cesarean section.
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Table VII. Maternal outcome Group 2 1 No trial of labor,
cesarean section Variable
Hospital stay (days) Maternal* Estimated blood loss (ml)* Transfusion(%) Maternal hematocrit difference Admission-discharge(%) Infections (%) Wound Endometritis* Footling or complete breech(%) Endometritis(%)
(n
= 379)
I
3
Trial of labor
Cesarean section (n ;, 69)
I
Vaginal delivery (n = 175)
5.4 ::!: 1.68 706 ::!: 298 7.7
5.9::!: 3.33 687 ::!: 320 4.3
3.0 ::!: 1.19 382::!: 189 6.3
....: 3.81 ::!: 3.71
-4.30::!: 4.02
-3.60 ::!: 3.81
1.3 }3.7 29.3 13.7
0 14.5 29.0 14.5
2.3 0.6 24.0 0.6
*p.;; 0.05.
Charges. The length of hospital stay for both mother and neonate was significantly longer if a cesarean section was performed. This lengthened stay had a significant effect on hospital charges. Fig. 2 displays the actual hospital charges. Clearly, attempted external version is cost"effective with an advantage of almost $1,600 per birth (1985 dollars) over a population in which no version is tried.
Comment The data compiled here reflects changing practice patterns over the 6 years observed. External version, previously not accepted as safe, has become routine. X-ray film pelvimetry, previously erratically obtained, is now required before a trial of labor and vaginal delivery are allowed. Despite these changes, vaginal delivery has always been offered as an option at our institution provided that the maternal pelvis was considered adequate and the baby was judged to be of average size. Whether the patient chose the vaginal route of delivery depended on the physician who expiained the options and her understanding of the relative risks involved. Approximately 35% opted for cesarean section simply because the infant was "a breech." Clearly, if one is to decrease the frequency Of cesarean section for term inf~nts in the breech position, the presentation must be identified before the active phase of labor. That only 61% of the breech presentations were identified before the onset of labor eliminated external version as an option for most of those patients. Furthermore, late diagnosis allows less time to evaluate pelvic and fetal size, explain options to the mother, and thus make a deliberate choice of route of delivery. It surprised us to find that our success rate at external cephalic version was lower than that published by other
authors. In older studies success rates as high as 90% were reported. For example, in 1975 Bradley-Watson 14 reported a success rate as high as 90% for version. His attempts at version, however, were begun as early as 28 weeks' gestational age. Some were performed with heavy sedation ot even general anesthesia. His lorigterm success rate (i.e., vertex presentation at delivery) was only 40%. 14 He also noted a worrisome 4.4% complication rate, which was mostly related to premature delivery. His experience has led others away from attempts at external cephalic version before 36 weeks. Although the initial success rate is higher, the longterm success rate is not higher than version delayed until term, with an increase in complications. In 1981 Van Dorsten et al. 10 reported on 51 version attempts from 37 to 39 weeks' gestational age with a 68% success rate. They excluded patients for many reasons, including maternal contraindicatioi:ts to J3-mimetic therapy. uteroplacental insufficiency, prior surgery, iabor, and rupture of membranes. They also had approximately equal numbers of multiparous and primiparous patients. Multiple other studies, including the present one, have confirmed the increased success rate of version among multiparous patients. Our success rate of 48% for version was lower than that previously reported. Closer examination of the data suggests possible explanations for this. Maternal weight and average gestational age were not different between the successful and unsuccessful groups in our study, nor did they vary significantly from otlJ.er current studies. Our patients, however, were not excluded from a trial of version because of rupture of membranes, labor, prior uterine surgery, or the presence of an anterior placenta. Although the success rate of versions in these subgroups was lower than that for the group
1498 Flanagan et al.
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Am J Obstet Gynecol
VAGINAL BIRTH $7,040±670 SUCCESSFUL< VERSION 7 20 9 $ ' 0±5 CESAREAN BIRTH $8,050±1,240
°
EXTERNAL / VERSION/ TRIED ~ $8,580±480
~
~~
UNSUCCESSFUL VERSION $ 9,650±700
VAGINALBIRTH $6,600±500 CESAREAN WITH LABOR $10,430±9.10 CESAREAN WITHOUT LABOR $10,870±1,430 VAGINAL BIRTH $7,360±890
NO EXTERNAL VERSION~
_
~ED ;-=------------------------~
$10,170±610
CESAREAN WITH LABOR $10,880±1,040
~ CESAREAN WITHOUT LABOR
-
$11,820±1,070
Fig. 2. Actual values of total hospital charges ( 1985 dollars) with and without external version. All data are for Moffitt Hospital and are expressed as mean ± standard error.
as a whole, the trials of version were accomplished without an increase in morbidity. Finally, we had a relatively high percentage of primiparous patients in our version population, which further lowered the success rate. It seems appropriate to us, however, to include these patients in version protocols. Although their chance of successful version is lower, the trial can be accomplished without any increase in morbidity, and success is of great benefit to the patient. With respect to predelivery variables, as one would expect, patients who were felt to be candidates for a vaginal trial had significantly larger pelvic measurements. Estimated fetal weight was also less in the vaginal trial group. This is corroborated by the observation that 34.7% of the reasons given for cesarean section without a trial of labor included "small pelvis" and "large estimated fetal weight." Actual birth weights, however, were comparable across groups, emphasizing the difficulty in accurately estimating fetal weight before delivery. There were many more labor abnormalities observed in group 2 compared with group 3. The presence of a labor abnormality coexistent with adequate uterine activity was a contraindication to a continued trial. The data confirm this. Looking at neonatal outcome, there were few statistically or clinically significant differences. The blood gas values of the cord indicated more acidemia in those patients laboring. The acidemia, however, was mild and not of clinical significance. The higher incidence of trauma observed in group 3 involves primarily bruising with no major intrapartum injury. All babies delivered by cesarean section, regardless of a trial of labor, stayed in the hospital significantly longer than those delivered
vaginally. This excess stay mirrors the mother's stay and reflects a policy of keeping mother and newborn together whenever possible. With respect to maternal outcome variables, although the estimated blood loss was significantly greater in those delivered by cesarean section, the differences between admission imd discharge hematocrit levels were essentially the saine for all three groups. There were no differences in the number of transfusions. The greatest differences were in the lengths of stay. Womeri delivered by cesarean section stayed in the hospital on the average 2 days longer than patients delivered vaginally. With respect to febrile morbidity, patients delivered by cesarean section had significantly more infectious morbidity. Clearly, cesarean section is more costly, reflecting the higher incidence of infectious morbidity, greater use of resources, and longer maternal and newborn hospital stay. Successful version of breech fetuses at term is highly cost-effective with an expected savings of$1,600 per term breech patient for hospital charges alone. These savings are 30 times the charges for the procedure. Finally, Fig. 3 illustrates the clinical course of ioo hypothetical cases of term breech presentation managed according to our protocol at the University of California, San Francisco. It uses percentages derived from retrospective data and assumes that all such cases are diagnosed before term and referred for an attempt at external version. This model achieves a cesarean section rate of 44% as contrasted with a presently observed nationwide rate in excess of 80%. In conclusion, we feel that identifying infants in the
Management of term breech presentation
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1499
UNSUCCESSFUL BREECH N=44
CESAREAN SECTION NO LABOR N 33
=
VAGINAL DELIVERY
N:56
Fig. 3. Theoretic distribution of 100 cases of term infants in the breech position managed with the University of California, San Francisco, protocol.
breech position early, offering external version, and allowing selected vaginal trials is a safe and costeffective obstetric approach to term infants in a breech presentation. REFERENCES 1. National Institutes of Health consensus development statement on cesarean childbirth. J Reprod Med 1980; 26:103. 2. Green JE, McLean F, Smith LP, et al. Has an increased cesarean section rate for term breech delivery reduced the incidence of birth asphyxia, trauma and death? AM J 0BSTET GYNECOL 1982;142:643. 3. Hall JE, Kohl SC. Breech presentation: a study of 1456 cases. AMJ 0BSTET GYNECOL 1956;72:977. 4. Morgan HS, Kane SH. Analysis of 16,327 breech births. JAMA 1964;187:262. 5. CoHee JV, Chein C, Quilligan EJ. The randomized management of term frank breech presentation: a study of 208 cases. AMJ 0BSTET GYNECOL 1980;137:235. 6. Gimovsky ML, Petrie RH, Todd WD. Neonatal performance of the selected term vaginal breech. Obstet Gynecol 1980;56:687. 7. Gimovsky ML, Wallace RL, Schifrin BS, eta!. Randomized management of the nonfrank breech presentation at term: a preliminary report. AM J 0BSTET GYNECOL 1983;146:34. 8. Fall 0, Nilsson BA. External cephalic version in breech presentation under tocolysis. Obstet Gynecol 1979;53: 713.
9. Hofmeyr GJ. Effect of external cephalic version in late pregnancy on .breech presentation and cesarean section rate: a controlled trial. Br J Obstet Gynaecol1983;90:392. 10. Van Dorsten JP, Schifrin BS, Wallace RL. Randomized controlled trial of external cephalic version with tocolysis in late pregnancy. AM j 0BSTET GYNECOL 1981; 141:417. 11. Federle MP, Cohen HA, Rosenwein MF, et a!. Pelvimetry by digital radiography: a low-dose examination. Radiology 1982;143:733. . 12. Korenbrot CC, Aalto LH, Laros RK. The costeffectiveness of stopping preterm labor with betaadrenergic treatment. N EnglJ Med 1984;310:691. 13. SPssx Users Guide. New York: McGraw-Hill Book Co, 1983. 14. Bradley-Watson PJ. The decreasing value of external cephalic version in modern obstetric practice. AM J 0BSTET GYNECOL 1975;123:237.
Discussion
DR. RALPH W. HALE, Honolulu, Hawaii. Dr. Laros et al. are to be congratulated on an excellent paper. Breech delivery is currently one of the most thoughtprovoking procedures iii our specialty. It generates much discussion not only at scientific meetings such as the Pacific Coast but also in the lay literature, peer review committees, and the hospital corridors. Unfortunately, the perception of most obstetriciansgynecologists today is that a breech presentation means
1500 Flanagan et al.
an automatic cesarean section. The major issue as Dr. Laros so accurately states is, how do you deliver the infant in the breech position; is there an option to cesarean section? In this report, Dr. Laros et al. have proposed two alternatives to consider for breech delivery. First, let the irifant in the breech position deliver vaginally, if appropriate criteria are met, and secondly turn the infant from breech position to a vertex position. In this latter procedure, we revert to an old procedure that has been considered inappropriate for many years. However, modern pharmacotechnology has obviously changed the ground rules. There were 716 breeches in this study, which extended from 1976 to 1984. Only those patients pre~ senting after 1980 were given the additional option of external version. This was offered to the patient unless she was in labor; then she did not have the option. I would question whether this is still the authors' protocol. In our smaller series, we have opted for attempting version in labor. One of oui: patients was a 26-yeari:>ld gravida 3 who was 6 em dilated at the time of version with a presenting part at - 2 station and we were successful. The key factor was the station of the presenting part. It would appear that S9% of the patients in this study may ha~e benefited from this option. The authors report that 244 (39%) of these patients underwent a trial of labor and 72% delivered vaginally whereas 28% had a cesarean section for obstetric causes. Have the authors compared this rate and the indications for cesarean section with those of vertex presentations 2 ? At their institutions, the authors used oxytocin in 43 (17%) patients and 33 of these were for induction of labor. I still hear reputable physicians indicate that oxytocin is contradicted in a breech presentation. Obviously, the authors disagree, as do I, with this contention. In relation to the higher incidence of endometritis in patients with cesarean section, were prophylactic antibiotics used at any time in the study? At the University of Hawaii, we have a]so used external version for breeches. Dr. Willcourt, in our maternal-fetal division, has a much smaller series, 20 patients, but reports similar results. We have had a 60% success rate in external version and a 50% vaginal delivery rate. Our protocol includes 5 mg of ritodine at 1 mg/min for 5 minutes before version. We use a careful preversion ultrasound scan to look for a nuchal cord and continuous uitrasound scanning during the procedure to evaluate fetal heart rate. All patients are maintained nothing by inouth, and the anesthesiologist and operating room team are prepared for immediate cesarean section. Wealso obtain cord gases on all deliveries by either cesarean section or vaginal delivery. We have experienced several problem areas, however. Technically, we find that when the presenting part is in the pelvis at - 1 station or deeper, it is very difficult to turn the fetus. We also find that a frank breech presentation is more difficult and would like to know if Dr. Laros has had the same experience. As with these authors, we have had a larger percentage of primi-
june 1987 Am j Obstet Gynecol
gravidas than multigravidas, and this may be a contributing factor, but our study size is too small to determine factors at this time. The other major problem that we have faced in advocating version has been the perception of the patients and physicians. Many patients are now convinced that ariy procedure other than cesarean section will result in a brain-damaged baby and many obstetriciansgynecologists have the same opinion. This will be a hard attitude to change. However, excellent research such as Dr. Laros et al. have performed will be a major step forward. I have four questions. ( 1) Do you now offer the option of external version in labor, ot is it still only for nonlabor patients? (2) Have you compared the indications and rate of cesarean section for your breech presentations with the vertex presentations in yout institution? (3) Were prophylactic antibiotics used in patients having a cesarean section? (4) Have you had more difficulty with version of frank breeches compared with others? What about the station of the presenting part? DR. RoBERT C. GooDLIN, Denver, Colorado. I just have four simple questions. Since we have been doing attempts of version, especially when the patient is in early labor, we have noticed that at least one fourth of the time, the cord comes down in front of the vertex. Do you ignore that? We have been going ahead with cesarean section. In our experience, when the placenta is anterior, the failure rate of version is much higher. We have had three cases of abruptio and an increased incidence of fetal-maternal hemorrhage. I suspect you do not consider the placenta as a relative contraindication. I recall tha,t the original paper by Hendricks and Brenner stated that the incidence of bruising was 10 to 15 tiines as high in a vaginal delivery as in an abdominal delivery. I see that your data goes along with that, and when we tell this figure to our patients, many of them say, "I want a cesarean section." Do you discuss bruising in your consent form? We started doing computerized tomographic pelvimetry as soon as Dr. Filly described it, and our incidence of abnormal pelves is only 2%. If I read your figures correctly, the incidence of c~ronic pulmonary disease is about 14%. Are you dealing with patients with vitamin D deficiency? Finally, an average cord pH of less than 7.20 in the umbilical artery is abnormal, and I would personally abandon a procedure in which the average or most newborns have acidosis at delivery. DR. WILLIAM K. GRAVES, San Francisco, California. If we are interested in reducing cesarean section rates generally and the incidence of cesareans in term infants in breech presentations in particular, there obviousiy are two approaches: to increase the number of women with breech presentations at term who are aliowed a trial of labor and to identify and attempt external version of breeches after 36 to 37 weeks of gestation. If we maintain or increase the incidence of vaginal breech deliveries, we have to move quickly before a generation of residents go into practice who have had essentially no training in vaginal breech delivery.
Volume 156 Number 6
In addition to the selection criteria and prerequisites for a trial of vaginal delivery described by Dr. Laros, I think we would agree that the "assisted breech" with spontaneous delivery to the baby's umbilicus ordinarily is the only safe and accepted method of management. Because of the frequent inhibition of maternal bearing down efforts, I am hesitant about the wisdom of epidural anesthesia in the primiparous patient. Finally, I think that we will soon have a patient education pamphlet from the American College to assist in obtaining informed consent for attempted external version, as well as a trial of vaginal breech delivery. DR. JosEPH HANSS, Phoenix, Arizona. Like all of us, I am board certified and a fellow of the American College, but have become known as one of the general practitioners of obstetrics and gynecology. I practice in a three-man group in Phoenix and have an anecdote of qne case, which alone is always bad. Two weeks ago I was asked by a resident staff member of one of our level 3 institutions to act as a supervisor for a primagravid patient who was a failed version and who was given the option of cesarean section and refused. Reluctant, the perinatologists refused to accept responsibility for that patient. Our group did. The residents successfully delivered that child with an Apgar score of 9 and without bruises after a relatively short labor. My contention is that we are beyond the point of resident staff members who are not trained; we have already trained a group of educators who are untrained. DR. JAMES C. CAILLOUETTE, Pasadena, California. I would like to speak on behalf of those who are in the obstetric trenches in private practice, as I and many of you are. I would like to speak to the academicians in the audience. When I finished my residency training at Los Angeles County-University of Southern California in 1959, the cesarean section rate was 3%. With the proliferation of academic programs over the past 25 years, you have done a magnificent job of convincing those in practice, the legal profession and the public that the correct way to deliver a breech presentation is by cesarean section. I submit to you that it will take another 25 years to turn that mind set around. It is very difficult to change the attitude of the public. It is not possible to change the attitudes of the general population as fast as academicians can produce papers with new concepts. DR. E. PAUL KIRK, Portland, Oregon. We followed a similar protocol at our institution and have run into almost identical difficulties with what I see as careless antepartum preparation of these patients. One of the details of that antepartum preparation is the question of extension of the head, or more properly, hyperextension of the head, which I saw was only a small factor in your series. I would like to ask specifically, when do you make that assessment? How do you make that assessment, and what is the definition of the difference between an extended head and a hyperextended head? DR. LAROS (Closing). Dr. Hale, with respect to- the questions you raised, we will continue to offer version to patients in active labor, but the success rate is going
Management of term breech presentation
1501
to be relatively low. We looked at our reasons for failure in great detail. Obesity, parity, presence of a frank breech, station, and the presence of an anterior placenta were important factors in failure of external version. When we did statistical analysis, only parity and the type of breech turned out to be statistically significant, which is probably a reflection of the relatively small number of cases. As everyone does more versions, they will have similar experiences. Our cesarean section rate over the time period in question was 17.5%. Thus the breech section rate was substantially higher. In 1968 Dr. George Morely at Michigan looked back at their data and proposed that in fact the section rate for breeches was too low and to achieve optimal fetal outcome, we should point to a section rate of some 33%. I suspect that is where our breech section rate will turn out to be. Dr. Hale, we use prophylactic antibiotics in patients who are in labor at the cesarean sections. It is generally given after cord clamping in a three-dose regimen. Patient preparation is very important, and the patients have to have a thorough understanding of what their choices are. Dr. Goodlin, we also see cords floating around, and do not pay much attention to them. We have not had an untoward incident with an external version to date. It is going to happen sooner or later, and I have no delusions about that. That is why we carry out version in the labor and delivery area. We have the patients come in with nothing by mouth, and we are prepared to deliver them if the need occurs. The other thing we have noticed is some fair bradycardias during the course of version; one needs to anticipate this. A great advantage of continually monitoring the patient with ultrasonography is the ability to immediately detect a severe bradycardia. The bruising issue continues to be troublesome. I am suspicious that pediatricians are a little biased against our use of vaginal breech delivery and record bruising more carefully in these cases. One thing that bothers me and those of you who have observed more recent graduates delivering these infants by cesarean sections is, if you do not know how to deliver a breech vaginally, you do not know how to do it by cesarean section either. If you cannot take down the legs vaginally, you probably cannot take them down through a uterine incision. We still need to teach these techniques. Dr. Goodlin, I really did not give you the data to know the percentage of small pelves. We gave the frequency of fetopelvic disproportion, which was sort of a Gestalt on the part of the physician who said how big the baby was, and what the pelvis size was. The actual pelvic measurements were statistically smaller, but actually only about 7% of the time was a small pelvis the sole reason for choosing an abdominal delivery. Finally, regarding the pH of 7.19 yes, I was surprised that the mean umbilical artery pH was that low, but those infants did quite well. In large part these pH values reflect a transient respiratory acidosis cause by compression. Dr. Graves, I am not sure exactly what rou asked
1502 Flanagan et al.
with respect to the parity issue. I have long believed and continue to believe that being a nulligravida carrying a term breech is not a contraindication to labor, and I think there are good data to support that. A very large study from New York indicated that neonatal morbidity and mortality rates were higher in multigravid breeches than in primigravid breeches. In a study published from Norway, they took advantage of universal military training and compared the intelligence quotient values of military inductees who had been breeches delivered by cesarean section with those breeches delivered vaginally. There was no difference. With respect to the use of conduction anesthesia, Dr. Crawford and others in the United Kingdom would be concerned by your feelings. Our bias with limited data is that the epidural technique is an ideal anesthesia for breech delivery. It allows a slow, controlled delivery. What is needed is the willingness to wait and not do breech extractions. If you do assisted breech delivery with an epidural, you have very nice results. Finally, we look forward to the American College of Obstetricians and Gynecologists pamphlet for patient education with regards to breech delivery.
June 1987 Am J Obstet Gynecol
Dr. Hanss, you are to be congratulated for helping your perinatologists. Our perinatologist fellows take call in-house as the senior consultant, and we tell them if they are concerned about doing a breech delivery, call one of us-we will come and help. I think it is imperative that those of you practicing in community hospitals offer to help your younger colleagues do breech deliveries. This offer must be good both day or night until they become confident. Dr. Caillouette, I understand what you are saying, and I appreciate the dilemma that we have created. It is unfortunate that somehow the message came across so "a breech deserves a section." That may be true for very small breeches, I am convinced that it is not true for the premature vertex. Academia must work to overcome this misinformation. Dr. Kirk, with regard to your protocol and experience, I am pleased to hear that you have the same good results and problems that we do. As I mentioned, we continue to do versions in selected patients in labor.
Key words: Obstetrics, breech presentation, delivery, external version Currently in the United States, approximately 80% of all term infants presenting as a breech are deiivered by cesarean section. This accounts for roughly 15% of all cesarean sections. Over the past 2 decades the percentage of breech infants delivered by cesarean section has increased from 10% to in excess of 80%. 1• 2 This change was in response to a number of uncontrolled studies, inany of which did not differentiate between preterm and term breech.'· • These studies showed an increase in neonatal inotbidity and mortality when delivery was vaginal. More recent studies on term deliveries with carefully selected patients have shown no difference in neonatal outcome. 5 ·' Protocols for selecting candidates for a trial of labor and vaginal delivery have consistently included constraints on estimated fetal weight, pelvic measurements, attitude of the fetai head, and course. of labor. Recently, external version has been suggested as an additiohal technique to reduce the number of cesarean sections done for breech presentation. External version of the fetus near term has been reported to convert varying proportions of breech into vertex presentations. 8- 10 Cesarean sections have increased risks of morbidity and mortality for the mother and under certain con-
ditions for the fetus. Surgical intervention is also associated with a substantial increased need for hospital and professional resources and therefore increased economic cost of birth._ Although this cost increase is warranted to prevent morbidity and mortality for the infant, it is important to continually examine under what conditions ce5arean sections can be avoided without increased harm to the infant. The Obstetrical Services of the University of California, San Francisco at Moffitt Hospital and San Francisco General Hospital have continued to advocate vaginal birth for term infants iri the breech position under selected circumstances. Since 1980, external version has been attempted at 37 to 39 weeks' gestation in an increasing. number of cases. If the version was unsuccessful, a trial of labor was routinely considered. It is our hypothesis that the attempt of external version for the term infant in the breech position followed by a trial of labor for patients meeting our selection criteria is preferable to a policy of routine cesarean section. We further hypothesize that this can be achieved without an increase in fetal morbidity or mortality. Finally, such an approach will lower the incidence of cesarean section and thus reduce the economic cost. Material and methods
From the Department of Obstetrics, Gynecology, and Reproductive Sciences and the Center for Reproductive Health Policy, University of California, San Francisco. Supported in part by National Institutes of Health Grant No. HD 13543. Presented at the Fifty-third Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Glenden Beach, Oregon, September 21-25, 1986. Reprint requests: Russell K. Laros, Jr., M.D., Professor and Vice Chairman, Department of Obstetrics, Gynecology and Reproductive Sciences, Room M -1489, University of California, San Francisco, CA 94143-0132.
1492
To evaluate the above hypothesis, we reviewed all cases of term infants in breech presentations occurring troin 1976 through 1984 at Moffitt Hospital and from 1980 through 1984 at San Francisco General Hospital. Three groups were compared with respect to demographic factors, maternal and fetal outcome, and charges: (1) patients delivered by cesarean section without labor, (~) patients allowed a trial of labor but subsequently delivered by cesarean section, and (3) patients
Management of term breech presentation
Volume 156 Number 6
with a trial of labor with subsequent vaginal delivery. Most data analyzed were collected prospectively and maintained in our computerized perinatal data base. Additional data were retrospectively abstracted from the medical and financial records. There were 716 cases of singleton breech presentation occurring at 37 or more weeks of gestational age. In five cases fetal anomalies known to be fatal had been diagnosed antenatally. These cases were excluded from the final data. There were five other cases in which fetal anomalies felt to be compatible with life were known; these cases were not excluded. Gestational age was calculated on the basis of the last menstrual period. Gestational age was confirmed by neonatal assessment in all cases. If a discrepancy of more than 2 weeks existed, the data were reviewed and a final gestational age was assigned. Patients were given standard prenatal care by residents, certified nurse midwives, and faculty physicians. Beginning in 1980, if a breech presentation was identified before the onset of labor, the patient was usually offered external version. Before 1980, the use of external version was uncommon. If the patient elected an attempt at external version, she was monitored for 10 to 20 minutes in a labor room to assure fetal well-being. An intravenous infusion of saline solution was begun, and a level 1 ultrasonic evaluation was performed to confirm fetal position and the location of the placenta and cord. A version was then attempted. In many cases a ~-mimetic was infused intravenously either before any attempt at version was made or after a first attempt had been unsuccessful. After either the successful or unsuccessful attempt, fetal heart rate was again monitored for a brief period of time. If the version was unsuccessful, the patient refused version, or the breech was first identified in early labor, the patient was given the option of an elective cesarean section or a trial oflabor. Our criteria for a trial oflabor were an estimated fetal weight of 3850 gm or less, radiologically defined pelvic measurements of at least 10 em between the ischial spines, an anteroposterior diameter at the pelvic inlet of at least 11 em, and a transverse, inlet diameter of 12 em or more, and a military or flexed attitude of the fetal head. Before 1981, the standard Colcher-Sussman technique of x-ray pelvimetry was used. More recently, all pelvimetry was obtained with computerized tomography.'' Peripartal women labored with an intravenous line in place. Oxytocin was used when necessary for either induction of labor in cases of premature rupture of the membranes or augmentation in cases of documented inadequate uterine forces. Epidural anesthesia was offered to most patients. Delivery was done by resident physicians with faculty supervision. Whenever possible, Piper forceps were applied to the aftercoming head.
1493
An anesthesiologist and pediatrician were present at the time of delivery. In approximately one third of cases, blood gases from the umbilical cord were obtained. This reflects a change in institutional policy from obtaining cord blood gases in only complicated deliveries to obtaining samples at all deliveries. Apgar scores were assigned at 1 and 5 minutes by the pediatrician present at the delivery who also examined the infant for trauma. Depending on clinical status, an infant was admitted to either the well baby or the intensive care nursery. If the status deteriorated during the neonatal course, the infant was transferred to the intensive care nursery and was considered an admission to the intensive care nursery. Perinatal death was defined as any death occurring from the thirtyseventh week of fetal life through discharge of the neonate from the hospital. Regarding postpartum complications, endometritis was defined clinically as uterine tenderness associated with maternal fever and was treated with intravenous antibiotics until the patient was afebrile. The patient then continued taking oral antibiotics for an additional 3 to 7 days. Wound infections, including episiotomy infections, were treated by drainage and local wound care. Antibiotics were usually not used. Financial data were obtained only for patients delivering at Moffitt Hospital during the years 1980 through 1984 in order that external version data could be included. Total hospital charge per patient was defined as the sum of all charges for services and procedures while an inpatient and included charges for external version. Maternal charges were aggregated from the thirty-seventh week of pregnancy until discharge after birth. Infant charges were those incurred from birth until the time of discharge. The hospital charges included a basic charge for room and care plus separate itemized charges for ancillary services, including laboratory and radiologic studies, use of the operating room, delivery room, intrapartum anesthesia, and transfusions, respiratory care, physical therapy, and inpatient drug treatment. 12 To adjust for increases in hospital rates during the study period, charges for room and care were adjusted by an 11% per year rate of increase as indicated by the Budget and Reimbursement Office. Thus all charges quoted represent 1985 dollar equivalents. Statistical analysis was performed with the SPSSx statistical package. 13 Analysis of variance was used for continuous variables and X2 analysis for categoric variables. Statistically significant differences required a P value of <0.05. Results
Of 716 breech presentations (Fig. 1), only 433 (61 %) were identified before the onset of labor. Of these, 171
1494 Flanagan et al.
June 1987 Am J Obstet Gynecol
GIIOUIP n
Elective Fetopelvic disproportion Prior cesarean section Medical c:ompllcadons
133 131 48 67
VAGINAL DELNERV N:175
GIIOUIP
IU
..__,
Coni,._ Felal distress
..
GROUII'
nnn
14 11
Fig. 1. Clinical course of 716 term infants in breech positions managed at the University of California, San Francisco.
Table I. Reasons for cesarean section without trial of labor Reason
N
Small pelvis Patient's choice Breech Previous cesarean section Large infant Footling Other Defiexed head Failed induction Toxemia High PP No films None stated Herpes IUGR Prior surgery Chorioamnionitis Fetal anomaly Pelvic tumor Total
108
PP = Presenting part; IUGR dation.
60 53 48 24 20 18 9 8 8
7 3 3 2 2 2 1 1 1
379
= intrauterine growth retar-
(44%) underwent an attempt at external version. Eighty-three (48%) versions were successful. Seventyfour of these women (89%) went on to have a vaginal delivery, whereas nine women (11 %) were delivered by
cesarean section for either fetal distress or abnormal labor. Eighty-eight of the versions (52%) were unsuccessful. In the 623 patients in whom version was unsuccessful or was not tried, 379 (61 %) were delivered by cesarean section without labor. X-ray film pelvimetry was performed in only 115 (19%) of these 623 patients. The reasons for electing cesarean section without labor are listed in Table I. The four reasons most frequently cited were "small pelvis," "patient's choice," "previous cesarean section," and "breech." The largest proportion of patients, however, had cesarean section for elective indications ("breech," "Patient's choice," "footling," or "complete breech"). There were various medical indications including chorioamnionitis, diabetes, toxemia, herpes, uterine myoma, previous uterine surgery, intrauterine growth retardation, known fetal anomalies, high presenting part, and an inability to obtain x-ray film pelvimetry. Two hundred forty-four women (39%) underwent a trial of labor. Sixty-nine of these women (28%) ultimately were delivered by cesarean section. The indications for surgery were abnormal labor in 44 patients (64%), fetal distress in 14 (20%), and cord prolapse in 11 (16%). The remaining 175 women (72%) were delivered of the infants vaginally. X-ray film pelvimetry
Management of term breech presentation
Volume 156 Number 6
1495
Table II. Predelivery maternal and fetal variables Group
2
Variable
Nulliparous(%) Prepregnancy weight (kg)* Height (em) Footling or complete breech (%) Pelvimetry (em) Inletanteroposterior* Transverse* Midtransverse* Fetal weight (gm)* Estimated Station at delivery* Length of labor (hr)* First stage Abnormal labor (% )*
I
3
1 No trial of labor, cesarean section (n = 379)
Cesarean section (n = 69)
61.2 58.2 ± 13.2 159.9 ± 9.45 29.3
62.3 60.6 ± 14.4 169.5 ± 6.99 29.0
54.9 56.2 ± 8.7 159.9 ± 12.77 24.0
11.7 ± 1.74 12.5 ± 1.08 10.2 ± 1.13
12.6 ± 0.99 13.2 ± 1.12 10.9 ± 0.69
12.4 ± 0.98 13.0 ± 1.12 11.2 ± 0.97
3313 ± 462 -1.9 ± 1.78
3366 ± 367 -1.2 ± 1.98
3103 ± 414 +2.9 ± 0.71
9.3 ± 7.51 60.9
7.2 ± 5.14 14.3
Trial of labor
I
Vaginal delivery (n = 175)
*p ,;;;0.05.
Table III. Use of oxytocin in vaginal trial groups (groups 2 and 3)
Oxytocin induction Augmentation None Total
Table IV. Anesthetic techniques used for vaginal breech delivery (group 3)
No.
%
Technique
No.
%
33 10 201 244
13 4 0
Pudendal Epidural General None Total
116 42 5 12 175
66 24 3 _l 100
17
was performed in 119 of the 244 patients (49%) allowed a trial of labor. Of the 623 babies who remained breech, 20% were footling, 72% were frank, and 8% were complete. Data for these 623 patients and babies were stratified into three groups: group 1, cesarean section without labor, group 2, trial of labor with cesarean section, and group 3, trial of labor with vaginal delivery. Antepartum, intrapartum, and postpartum maternal variables and neonatal outcome variables such as Apgar scores, cord blood gases, birth trauma, admission to the intensive care nursery, and perinatal death were compared between the three study groups. Predelivery variables. Table II details variables that might influence the choice of method of delivery. Although not all included in the table, there was no difference in age, parity, gravidity, height, race, or type of breech. Comparing group 1 with groups 2 and 3 (the vaginal trial groups), the pelvic measurements are significantly smaller in group 1. The estimated total weight was also significantly larger in group 1. Undoubtedly, these factors influenced the decision to proceed with cesarean section without labor in women with small pelvic measurements or thought to be carrying a
large infant. Although there was also a significant difference in maternal weight (but not height), it is not likely that this influenced the choice of route of delivery. Labor and delivery. The method of delivery used in the 175 patients delivered vaginally was 32 spontaneous, 129 assisted or partial extraction, and 14 complete breech extractions. The significant differences in station at delivery is as expected. In both groups that labored (groups 2 and 3), there were significant differences in the length of the first stage and in the frequency of abnormal labors. Prolonged latent labor and arrest of the active phase were more common in group 2 and were the indications for cesarean section after a trial of labor. As shown in Table III, oxytocin was used in 43 (17%) of the 244 patients having a trial of labor. The indication was for induction of labor in 33 patients and augmentation in 10. The types of anesthesia used for patients in group 3 are listed in Table IV. The anesthetic technique used had no significant effects on any of the outcome variables. There was a slight but significant difference in the length of the second stage of labor. The mean lengths were 0.53, 0.43, 1.15, and 0.51 min-
1496 Flanagan et al.
June 1987 Am J Obstet Gynecol
Table V. Neonatal outcome Group
2
Variable
I No trial of labor, cesarean section (n = 379)
Cesarean section (n = 69)
3297 ± 560
3395 ± 535
Fetal weight (gm)* Actual Apgar scores 1-min 0-3 (%)* 4-7 8-10
5-min 0-3 (%)* 4-7 8-10 Umbilical artery gases pH* Po2 (mm Hg) Pco2 (mm Hg) Base excess* Hospital stay (days) Newborn* Admission to intensive care nursery(%) Birth trauma(%)* Perinatal death(%)
7.24 14 53 -4.96
± ± ± ±
0.07 5.44 9.16 3.59
5.7 ± 3.49 7.2 1.1 1.1
Trial of labor
14.5 42.0 43.5 4.3 7.2 88.4
9.5 41.4 49.1 0.5 7.4 92.1
3
I
7.19 16 56 -6.42
± ± ± ±
1
Vaginal delivery (n = 175)
3054 ± 520 14.9 49.1 36.0 0.6 13.1 86.3
0.11 5.39 11.5 4.60
5.9 ± 3.17 13.8 4.8 1.4
7.19 ± 15 ± 54± -6.88 ±
0.08 6.19 8.07 3.72
3.8 ± 2.63 5.2 6.5 0
*p ~ 0.05.
Table VI. Neonatal trauma* Group I
Group 2
Group 3
None 354 Fracture 1 (Osteogenesis imperfecta) Bruise 1 Butt Iacer2 ation Nerve damage 0
60 0
158 0
2 I
9 I
Total
63
358
0 (In utero) I69
*No observation recorded in 37 cases.
utes, respectively, for patients receiving none, general, regional, and pudendal anesthesia (F = 5.29; p < 0.002). Neonatal outcome. As can be seen in Table V, there were significant differences between the three groups with respect to actual birth weight. The mean weight of babies in group 2, the failed vaginal trial group, was significantly heavier than the other groups. There were also differences between groups with respect to both I- and 5-minute Apgar scores. In each instance the group 2 babies fell between those in groups I and 3. These findings are placed in clinical perspective by examination of blood gas values of the cord. Although both the pH and base excess are significantly higher in those infants delivered by cesarean section without labor, the differences have little clinical significance. That
there are no significant differences between groups 2 and 3 suggests that labor rather than the route of delivery has some effect on blood gas values of umbilical cord. With respect to birth trauma, there was significantly more recorded in those infants delivered vaginally. As shown in Table VI, the difference was from an increased frequency of "bruising" in group 3 infants. There was one instance of a facial nerve palsy in group 3. This infant was noted to have facial asymmetry at birth that has persisted. The cause of the facial nerve paralysis was thought to be intrauterine pressure rather than any trauma at the time of vaginal delivery. The fracture occurred in an infant in group I diagnosed postnatally as having osteogenesis imperfecta. There were no significant differences in the incidence of admission to the intensive care nursery or perinatal mortality. There were five neonatal deaths, four in group I and one in group 2. The cause of each death was a congenital anomaly incompatible with life. None of these five anomalies had been diagnosed before delivery. Maternal outcome. As seen in Table VII, the estimated maternal blood loss was significantly greater in group 1, but there was no difference in either the frequency of transfusion or the hematocrit difference between groups. The incidence of endometritis was significantly greater in both groups delivered by cesarean section.
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Volume 156 Number 6
1497
Table VII. Maternal outcome Group 2 1 No trial of labor,
cesarean section Variable
Hospital stay (days) Maternal* Estimated blood loss (ml)* Transfusion(%) Maternal hematocrit difference Admission-discharge(%) Infections (%) Wound Endometritis* Footling or complete breech(%) Endometritis(%)
(n
= 379)
I
3
Trial of labor
Cesarean section (n ;, 69)
I
Vaginal delivery (n = 175)
5.4 ::!: 1.68 706 ::!: 298 7.7
5.9::!: 3.33 687 ::!: 320 4.3
3.0 ::!: 1.19 382::!: 189 6.3
....: 3.81 ::!: 3.71
-4.30::!: 4.02
-3.60 ::!: 3.81
1.3 }3.7 29.3 13.7
0 14.5 29.0 14.5
2.3 0.6 24.0 0.6
*p.;; 0.05.
Charges. The length of hospital stay for both mother and neonate was significantly longer if a cesarean section was performed. This lengthened stay had a significant effect on hospital charges. Fig. 2 displays the actual hospital charges. Clearly, attempted external version is cost"effective with an advantage of almost $1,600 per birth (1985 dollars) over a population in which no version is tried.
Comment The data compiled here reflects changing practice patterns over the 6 years observed. External version, previously not accepted as safe, has become routine. X-ray film pelvimetry, previously erratically obtained, is now required before a trial of labor and vaginal delivery are allowed. Despite these changes, vaginal delivery has always been offered as an option at our institution provided that the maternal pelvis was considered adequate and the baby was judged to be of average size. Whether the patient chose the vaginal route of delivery depended on the physician who expiained the options and her understanding of the relative risks involved. Approximately 35% opted for cesarean section simply because the infant was "a breech." Clearly, if one is to decrease the frequency Of cesarean section for term inf~nts in the breech position, the presentation must be identified before the active phase of labor. That only 61% of the breech presentations were identified before the onset of labor eliminated external version as an option for most of those patients. Furthermore, late diagnosis allows less time to evaluate pelvic and fetal size, explain options to the mother, and thus make a deliberate choice of route of delivery. It surprised us to find that our success rate at external cephalic version was lower than that published by other
authors. In older studies success rates as high as 90% were reported. For example, in 1975 Bradley-Watson 14 reported a success rate as high as 90% for version. His attempts at version, however, were begun as early as 28 weeks' gestational age. Some were performed with heavy sedation ot even general anesthesia. His lorigterm success rate (i.e., vertex presentation at delivery) was only 40%. 14 He also noted a worrisome 4.4% complication rate, which was mostly related to premature delivery. His experience has led others away from attempts at external cephalic version before 36 weeks. Although the initial success rate is higher, the longterm success rate is not higher than version delayed until term, with an increase in complications. In 1981 Van Dorsten et al. 10 reported on 51 version attempts from 37 to 39 weeks' gestational age with a 68% success rate. They excluded patients for many reasons, including maternal contraindicatioi:ts to J3-mimetic therapy. uteroplacental insufficiency, prior surgery, iabor, and rupture of membranes. They also had approximately equal numbers of multiparous and primiparous patients. Multiple other studies, including the present one, have confirmed the increased success rate of version among multiparous patients. Our success rate of 48% for version was lower than that previously reported. Closer examination of the data suggests possible explanations for this. Maternal weight and average gestational age were not different between the successful and unsuccessful groups in our study, nor did they vary significantly from otlJ.er current studies. Our patients, however, were not excluded from a trial of version because of rupture of membranes, labor, prior uterine surgery, or the presence of an anterior placenta. Although the success rate of versions in these subgroups was lower than that for the group
1498 Flanagan et al.
June 1987
Am J Obstet Gynecol
VAGINAL BIRTH $7,040±670 SUCCESSFUL< VERSION 7 20 9 $ ' 0±5 CESAREAN BIRTH $8,050±1,240
°
EXTERNAL / VERSION/ TRIED ~ $8,580±480
~
~~
UNSUCCESSFUL VERSION $ 9,650±700
VAGINALBIRTH $6,600±500 CESAREAN WITH LABOR $10,430±9.10 CESAREAN WITHOUT LABOR $10,870±1,430 VAGINAL BIRTH $7,360±890
NO EXTERNAL VERSION~
_
~ED ;-=------------------------~
$10,170±610
CESAREAN WITH LABOR $10,880±1,040
~ CESAREAN WITHOUT LABOR
-
$11,820±1,070
Fig. 2. Actual values of total hospital charges ( 1985 dollars) with and without external version. All data are for Moffitt Hospital and are expressed as mean ± standard error.
as a whole, the trials of version were accomplished without an increase in morbidity. Finally, we had a relatively high percentage of primiparous patients in our version population, which further lowered the success rate. It seems appropriate to us, however, to include these patients in version protocols. Although their chance of successful version is lower, the trial can be accomplished without any increase in morbidity, and success is of great benefit to the patient. With respect to predelivery variables, as one would expect, patients who were felt to be candidates for a vaginal trial had significantly larger pelvic measurements. Estimated fetal weight was also less in the vaginal trial group. This is corroborated by the observation that 34.7% of the reasons given for cesarean section without a trial of labor included "small pelvis" and "large estimated fetal weight." Actual birth weights, however, were comparable across groups, emphasizing the difficulty in accurately estimating fetal weight before delivery. There were many more labor abnormalities observed in group 2 compared with group 3. The presence of a labor abnormality coexistent with adequate uterine activity was a contraindication to a continued trial. The data confirm this. Looking at neonatal outcome, there were few statistically or clinically significant differences. The blood gas values of the cord indicated more acidemia in those patients laboring. The acidemia, however, was mild and not of clinical significance. The higher incidence of trauma observed in group 3 involves primarily bruising with no major intrapartum injury. All babies delivered by cesarean section, regardless of a trial of labor, stayed in the hospital significantly longer than those delivered
vaginally. This excess stay mirrors the mother's stay and reflects a policy of keeping mother and newborn together whenever possible. With respect to maternal outcome variables, although the estimated blood loss was significantly greater in those delivered by cesarean section, the differences between admission imd discharge hematocrit levels were essentially the saine for all three groups. There were no differences in the number of transfusions. The greatest differences were in the lengths of stay. Womeri delivered by cesarean section stayed in the hospital on the average 2 days longer than patients delivered vaginally. With respect to febrile morbidity, patients delivered by cesarean section had significantly more infectious morbidity. Clearly, cesarean section is more costly, reflecting the higher incidence of infectious morbidity, greater use of resources, and longer maternal and newborn hospital stay. Successful version of breech fetuses at term is highly cost-effective with an expected savings of$1,600 per term breech patient for hospital charges alone. These savings are 30 times the charges for the procedure. Finally, Fig. 3 illustrates the clinical course of ioo hypothetical cases of term breech presentation managed according to our protocol at the University of California, San Francisco. It uses percentages derived from retrospective data and assumes that all such cases are diagnosed before term and referred for an attempt at external version. This model achieves a cesarean section rate of 44% as contrasted with a presently observed nationwide rate in excess of 80%. In conclusion, we feel that identifying infants in the
Management of term breech presentation
Volume 156 Number 6
1499
UNSUCCESSFUL BREECH N=44
CESAREAN SECTION NO LABOR N 33
=
VAGINAL DELIVERY
N:56
Fig. 3. Theoretic distribution of 100 cases of term infants in the breech position managed with the University of California, San Francisco, protocol.
breech position early, offering external version, and allowing selected vaginal trials is a safe and costeffective obstetric approach to term infants in a breech presentation. REFERENCES 1. National Institutes of Health consensus development statement on cesarean childbirth. J Reprod Med 1980; 26:103. 2. Green JE, McLean F, Smith LP, et al. Has an increased cesarean section rate for term breech delivery reduced the incidence of birth asphyxia, trauma and death? AM J 0BSTET GYNECOL 1982;142:643. 3. Hall JE, Kohl SC. Breech presentation: a study of 1456 cases. AMJ 0BSTET GYNECOL 1956;72:977. 4. Morgan HS, Kane SH. Analysis of 16,327 breech births. JAMA 1964;187:262. 5. CoHee JV, Chein C, Quilligan EJ. The randomized management of term frank breech presentation: a study of 208 cases. AMJ 0BSTET GYNECOL 1980;137:235. 6. Gimovsky ML, Petrie RH, Todd WD. Neonatal performance of the selected term vaginal breech. Obstet Gynecol 1980;56:687. 7. Gimovsky ML, Wallace RL, Schifrin BS, eta!. Randomized management of the nonfrank breech presentation at term: a preliminary report. AM J 0BSTET GYNECOL 1983;146:34. 8. Fall 0, Nilsson BA. External cephalic version in breech presentation under tocolysis. Obstet Gynecol 1979;53: 713.
9. Hofmeyr GJ. Effect of external cephalic version in late pregnancy on .breech presentation and cesarean section rate: a controlled trial. Br J Obstet Gynaecol1983;90:392. 10. Van Dorsten JP, Schifrin BS, Wallace RL. Randomized controlled trial of external cephalic version with tocolysis in late pregnancy. AM j 0BSTET GYNECOL 1981; 141:417. 11. Federle MP, Cohen HA, Rosenwein MF, et a!. Pelvimetry by digital radiography: a low-dose examination. Radiology 1982;143:733. . 12. Korenbrot CC, Aalto LH, Laros RK. The costeffectiveness of stopping preterm labor with betaadrenergic treatment. N EnglJ Med 1984;310:691. 13. SPssx Users Guide. New York: McGraw-Hill Book Co, 1983. 14. Bradley-Watson PJ. The decreasing value of external cephalic version in modern obstetric practice. AM J 0BSTET GYNECOL 1975;123:237.
Discussion
DR. RALPH W. HALE, Honolulu, Hawaii. Dr. Laros et al. are to be congratulated on an excellent paper. Breech delivery is currently one of the most thoughtprovoking procedures iii our specialty. It generates much discussion not only at scientific meetings such as the Pacific Coast but also in the lay literature, peer review committees, and the hospital corridors. Unfortunately, the perception of most obstetriciansgynecologists today is that a breech presentation means
1500 Flanagan et al.
an automatic cesarean section. The major issue as Dr. Laros so accurately states is, how do you deliver the infant in the breech position; is there an option to cesarean section? In this report, Dr. Laros et al. have proposed two alternatives to consider for breech delivery. First, let the irifant in the breech position deliver vaginally, if appropriate criteria are met, and secondly turn the infant from breech position to a vertex position. In this latter procedure, we revert to an old procedure that has been considered inappropriate for many years. However, modern pharmacotechnology has obviously changed the ground rules. There were 716 breeches in this study, which extended from 1976 to 1984. Only those patients pre~ senting after 1980 were given the additional option of external version. This was offered to the patient unless she was in labor; then she did not have the option. I would question whether this is still the authors' protocol. In our smaller series, we have opted for attempting version in labor. One of oui: patients was a 26-yeari:>ld gravida 3 who was 6 em dilated at the time of version with a presenting part at - 2 station and we were successful. The key factor was the station of the presenting part. It would appear that S9% of the patients in this study may ha~e benefited from this option. The authors report that 244 (39%) of these patients underwent a trial of labor and 72% delivered vaginally whereas 28% had a cesarean section for obstetric causes. Have the authors compared this rate and the indications for cesarean section with those of vertex presentations 2 ? At their institutions, the authors used oxytocin in 43 (17%) patients and 33 of these were for induction of labor. I still hear reputable physicians indicate that oxytocin is contradicted in a breech presentation. Obviously, the authors disagree, as do I, with this contention. In relation to the higher incidence of endometritis in patients with cesarean section, were prophylactic antibiotics used at any time in the study? At the University of Hawaii, we have a]so used external version for breeches. Dr. Willcourt, in our maternal-fetal division, has a much smaller series, 20 patients, but reports similar results. We have had a 60% success rate in external version and a 50% vaginal delivery rate. Our protocol includes 5 mg of ritodine at 1 mg/min for 5 minutes before version. We use a careful preversion ultrasound scan to look for a nuchal cord and continuous uitrasound scanning during the procedure to evaluate fetal heart rate. All patients are maintained nothing by inouth, and the anesthesiologist and operating room team are prepared for immediate cesarean section. Wealso obtain cord gases on all deliveries by either cesarean section or vaginal delivery. We have experienced several problem areas, however. Technically, we find that when the presenting part is in the pelvis at - 1 station or deeper, it is very difficult to turn the fetus. We also find that a frank breech presentation is more difficult and would like to know if Dr. Laros has had the same experience. As with these authors, we have had a larger percentage of primi-
june 1987 Am j Obstet Gynecol
gravidas than multigravidas, and this may be a contributing factor, but our study size is too small to determine factors at this time. The other major problem that we have faced in advocating version has been the perception of the patients and physicians. Many patients are now convinced that ariy procedure other than cesarean section will result in a brain-damaged baby and many obstetriciansgynecologists have the same opinion. This will be a hard attitude to change. However, excellent research such as Dr. Laros et al. have performed will be a major step forward. I have four questions. ( 1) Do you now offer the option of external version in labor, ot is it still only for nonlabor patients? (2) Have you compared the indications and rate of cesarean section for your breech presentations with the vertex presentations in yout institution? (3) Were prophylactic antibiotics used in patients having a cesarean section? (4) Have you had more difficulty with version of frank breeches compared with others? What about the station of the presenting part? DR. RoBERT C. GooDLIN, Denver, Colorado. I just have four simple questions. Since we have been doing attempts of version, especially when the patient is in early labor, we have noticed that at least one fourth of the time, the cord comes down in front of the vertex. Do you ignore that? We have been going ahead with cesarean section. In our experience, when the placenta is anterior, the failure rate of version is much higher. We have had three cases of abruptio and an increased incidence of fetal-maternal hemorrhage. I suspect you do not consider the placenta as a relative contraindication. I recall tha,t the original paper by Hendricks and Brenner stated that the incidence of bruising was 10 to 15 tiines as high in a vaginal delivery as in an abdominal delivery. I see that your data goes along with that, and when we tell this figure to our patients, many of them say, "I want a cesarean section." Do you discuss bruising in your consent form? We started doing computerized tomographic pelvimetry as soon as Dr. Filly described it, and our incidence of abnormal pelves is only 2%. If I read your figures correctly, the incidence of c~ronic pulmonary disease is about 14%. Are you dealing with patients with vitamin D deficiency? Finally, an average cord pH of less than 7.20 in the umbilical artery is abnormal, and I would personally abandon a procedure in which the average or most newborns have acidosis at delivery. DR. WILLIAM K. GRAVES, San Francisco, California. If we are interested in reducing cesarean section rates generally and the incidence of cesareans in term infants in breech presentations in particular, there obviousiy are two approaches: to increase the number of women with breech presentations at term who are aliowed a trial of labor and to identify and attempt external version of breeches after 36 to 37 weeks of gestation. If we maintain or increase the incidence of vaginal breech deliveries, we have to move quickly before a generation of residents go into practice who have had essentially no training in vaginal breech delivery.
Volume 156 Number 6
In addition to the selection criteria and prerequisites for a trial of vaginal delivery described by Dr. Laros, I think we would agree that the "assisted breech" with spontaneous delivery to the baby's umbilicus ordinarily is the only safe and accepted method of management. Because of the frequent inhibition of maternal bearing down efforts, I am hesitant about the wisdom of epidural anesthesia in the primiparous patient. Finally, I think that we will soon have a patient education pamphlet from the American College to assist in obtaining informed consent for attempted external version, as well as a trial of vaginal breech delivery. DR. JosEPH HANSS, Phoenix, Arizona. Like all of us, I am board certified and a fellow of the American College, but have become known as one of the general practitioners of obstetrics and gynecology. I practice in a three-man group in Phoenix and have an anecdote of qne case, which alone is always bad. Two weeks ago I was asked by a resident staff member of one of our level 3 institutions to act as a supervisor for a primagravid patient who was a failed version and who was given the option of cesarean section and refused. Reluctant, the perinatologists refused to accept responsibility for that patient. Our group did. The residents successfully delivered that child with an Apgar score of 9 and without bruises after a relatively short labor. My contention is that we are beyond the point of resident staff members who are not trained; we have already trained a group of educators who are untrained. DR. JAMES C. CAILLOUETTE, Pasadena, California. I would like to speak on behalf of those who are in the obstetric trenches in private practice, as I and many of you are. I would like to speak to the academicians in the audience. When I finished my residency training at Los Angeles County-University of Southern California in 1959, the cesarean section rate was 3%. With the proliferation of academic programs over the past 25 years, you have done a magnificent job of convincing those in practice, the legal profession and the public that the correct way to deliver a breech presentation is by cesarean section. I submit to you that it will take another 25 years to turn that mind set around. It is very difficult to change the attitude of the public. It is not possible to change the attitudes of the general population as fast as academicians can produce papers with new concepts. DR. E. PAUL KIRK, Portland, Oregon. We followed a similar protocol at our institution and have run into almost identical difficulties with what I see as careless antepartum preparation of these patients. One of the details of that antepartum preparation is the question of extension of the head, or more properly, hyperextension of the head, which I saw was only a small factor in your series. I would like to ask specifically, when do you make that assessment? How do you make that assessment, and what is the definition of the difference between an extended head and a hyperextended head? DR. LAROS (Closing). Dr. Hale, with respect to- the questions you raised, we will continue to offer version to patients in active labor, but the success rate is going
Management of term breech presentation
1501
to be relatively low. We looked at our reasons for failure in great detail. Obesity, parity, presence of a frank breech, station, and the presence of an anterior placenta were important factors in failure of external version. When we did statistical analysis, only parity and the type of breech turned out to be statistically significant, which is probably a reflection of the relatively small number of cases. As everyone does more versions, they will have similar experiences. Our cesarean section rate over the time period in question was 17.5%. Thus the breech section rate was substantially higher. In 1968 Dr. George Morely at Michigan looked back at their data and proposed that in fact the section rate for breeches was too low and to achieve optimal fetal outcome, we should point to a section rate of some 33%. I suspect that is where our breech section rate will turn out to be. Dr. Hale, we use prophylactic antibiotics in patients who are in labor at the cesarean sections. It is generally given after cord clamping in a three-dose regimen. Patient preparation is very important, and the patients have to have a thorough understanding of what their choices are. Dr. Goodlin, we also see cords floating around, and do not pay much attention to them. We have not had an untoward incident with an external version to date. It is going to happen sooner or later, and I have no delusions about that. That is why we carry out version in the labor and delivery area. We have the patients come in with nothing by mouth, and we are prepared to deliver them if the need occurs. The other thing we have noticed is some fair bradycardias during the course of version; one needs to anticipate this. A great advantage of continually monitoring the patient with ultrasonography is the ability to immediately detect a severe bradycardia. The bruising issue continues to be troublesome. I am suspicious that pediatricians are a little biased against our use of vaginal breech delivery and record bruising more carefully in these cases. One thing that bothers me and those of you who have observed more recent graduates delivering these infants by cesarean sections is, if you do not know how to deliver a breech vaginally, you do not know how to do it by cesarean section either. If you cannot take down the legs vaginally, you probably cannot take them down through a uterine incision. We still need to teach these techniques. Dr. Goodlin, I really did not give you the data to know the percentage of small pelves. We gave the frequency of fetopelvic disproportion, which was sort of a Gestalt on the part of the physician who said how big the baby was, and what the pelvis size was. The actual pelvic measurements were statistically smaller, but actually only about 7% of the time was a small pelvis the sole reason for choosing an abdominal delivery. Finally, regarding the pH of 7.19 yes, I was surprised that the mean umbilical artery pH was that low, but those infants did quite well. In large part these pH values reflect a transient respiratory acidosis cause by compression. Dr. Graves, I am not sure exactly what rou asked
1502 Flanagan et al.
with respect to the parity issue. I have long believed and continue to believe that being a nulligravida carrying a term breech is not a contraindication to labor, and I think there are good data to support that. A very large study from New York indicated that neonatal morbidity and mortality rates were higher in multigravid breeches than in primigravid breeches. In a study published from Norway, they took advantage of universal military training and compared the intelligence quotient values of military inductees who had been breeches delivered by cesarean section with those breeches delivered vaginally. There was no difference. With respect to the use of conduction anesthesia, Dr. Crawford and others in the United Kingdom would be concerned by your feelings. Our bias with limited data is that the epidural technique is an ideal anesthesia for breech delivery. It allows a slow, controlled delivery. What is needed is the willingness to wait and not do breech extractions. If you do assisted breech delivery with an epidural, you have very nice results. Finally, we look forward to the American College of Obstetricians and Gynecologists pamphlet for patient education with regards to breech delivery.
June 1987 Am J Obstet Gynecol
Dr. Hanss, you are to be congratulated for helping your perinatologists. Our perinatologist fellows take call in-house as the senior consultant, and we tell them if they are concerned about doing a breech delivery, call one of us-we will come and help. I think it is imperative that those of you practicing in community hospitals offer to help your younger colleagues do breech deliveries. This offer must be good both day or night until they become confident. Dr. Caillouette, I understand what you are saying, and I appreciate the dilemma that we have created. It is unfortunate that somehow the message came across so "a breech deserves a section." That may be true for very small breeches, I am convinced that it is not true for the premature vertex. Academia must work to overcome this misinformation. Dr. Kirk, with regard to your protocol and experience, I am pleased to hear that you have the same good results and problems that we do. As I mentioned, we continue to do versions in selected patients in labor.