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Route of breech delivery and maternal and neonatal outcomes
International Journal of Gynecology & Obstetrics 73 Ž2001. 7᎐14
Article
Route of breech delivery and maternal and neonatal outcomes L. Sanchez-RamosU , T.L. Wells, C.D. Adair, G. Arcelin, A.M. Kaunitz, D.S. Wells Department of Obstetrics and Gynecology, Uni¨ ersity of Florida Health Sciences Center, Jackson¨ ille, FL, USA Received 16 June 2000; received in revised form 17 November 2000; accepted 21 November 2000
Abstract Objecti¨ e: To compare maternal and neonatal outcomes in elective cesarean vs. attempted vaginal delivery for breech presentation at or near term. Methods: We reviewed the maternal and neonatal charts of all singleton breech deliveries of at least 35 weeks’ gestation or 2000 g delivered between 1986 and 1997 at our institution. Patients delivered by elective cesarean were compared to those attempting a vaginal delivery. The neonatal outcomes analyzed were: corrected mortality; Apgar scores less than 7 at 5 min; abnormal umbilical cord blood gases; birth trauma; and admissions to the intensive care nursery. Maternal morbidity was also assessed and compared. Results: Of 848 women meeting criteria for evaluation, 576 were delivered by elective cesarean while 272 attempted a vaginal delivery. Of 272 women undergoing a trial of labor, 203 Ž74.6%. were delivered vaginally, while 69 Ž25.4%. failed an attempt at vaginal delivery and underwent a cesarean. When comparing patients delivered by elective cesarean with those attempting a vaginal delivery, no significant differences were noted in neonatal outcomes. However, maternal morbidity was higher among women delivered by cesarean, regardless of the indications for the procedure. Similar neonatal and maternal results were noted when nulliparous patients were analyzed separately. Conclusions: Cesarean delivery of selected near-term infants presenting as breech is associated with increased maternal morbidity without corresponding improvement in neonatal outcomes. 䊚 2001 International Federation of Gynecology and Obstetrics. All rights reserved. Keywords: Breech delivery; Maternal; Neonatal
U
Corresponding author. Department of Obstetrics and Gynecology, 653-1 West 8th st., Jacksonville, Fl 32209, USA. Tel.: q1-904-244-3116; fax: q1-904-244-3124. E-mail address: [email protected] ŽL. Sanchez-Ramos.. 0020-7292r01r$20.00 䊚 2001 International Federation of Gynecology and Obstetrics. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 0 . 0 0 3 8 4 - 2
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L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
1. Introduction Breech presentation is known to be associated with higher perinatal morbidity and mortality than cephalic presentation, perhaps due to the mode of delivery and the higher incidence of congenital anomalies w1,2x. In 1959, Wright recommended that all breech-presenting fetuses be delivered by cesarean in order to improve perinatal outcomes w3x. During the past 40 years other retrospective studies cited improved perinatal outcomes for elective cesarean delivery, leading to very high cesarean rates for this abnormal presentation w4᎐6x. In fact, the cesarean delivery rate for breech presentation among US parturients has increased from 12% in 1970 to greater than 80% in 1985 w7,8x. However, during the same time interval, a number of authors suggested that properly selected vaginal breech deliveries in term patients were associated with outcomes similar to those achieved with elective cesarean birth w9᎐12x. Accordingly, management of breech delivery remains a controversial issue w13x. Policies regarding the management of breech presentation for term patients have been hindered by a lack of large, well-designed clinical trials that address the safety of vaginal delivery and define specific criteria for a trial of vaginal delivery w14x. Nonetheless, at the University of Florida Health Sciences Center in Jacksonville, we have continued to practice selective vaginal birth for term fetuses with breech presentations. The aim of this study is to report our experience, comparing specific maternal and neonatal morbidity markers for patients who underwent a trial of labor with those delivered by elective cesarean.
2. Materials and methods The medical records of all patients having a singleton breech delivery at University Medical Center, Jacksonville, FL between January 1986 and June 1997 were reviewed. This institution serves as the tertiary referral center for predominantly indigent, inner-city populations of northeast Florida. All patients were managed and de-
livered by resident physicians in obstetrics and gynecology under faculty supervision. The senior author was directly and actively involved in supervising intrapartum management during the entire study period. During the study period, 49 096 patients were delivered at this hospital. Of those patients, 1473 Ž3%. represented singleton breech presentations and 848 Ž1.7%. weighed 2000 g or more and were at least 35 weeks’ gestation. Gestational age was calculated based on menstrual dates or by sonographic examination carried out during either of the first two trimesters of pregnancy. The maternal and neonatal charts were reviewed to extract the relevant clinical information, which was entered into a computer’s database for analysis. The information included demographic characteristics, route of delivery, indications for cesarean delivery, pelvimetry, need for oxytocin infusion and maternal-neonatal outcomes. During the study period, patients with breech presentation were offered a trial of labor if the following criteria were met: Ž1. singleton frank or complete breech; Ž2. estimated fetal weight between 2000 and 4000 g; Ž3. adequate pelvis based clinically or by computerized axial tomography ŽCT. pelvimetry; and Ž4. non-extended fetal head as assessed by sonography or CT pelvimetry. Pelvic measurements were considered adequate if the distance of the ischial spines was at least 10 cm, the antero-posterior diameter of the pelvic inlet measured at least 11 cm and the transverse inlet diameter was at least 12 cm. The eventual route of delivery was decided by the attending physician managing each case. With regard to maternal and perinatal outcomes, patients delivered by an elective cesarean were compared with those attempting vaginal delivery, irrespective of the eventual route of delivery. Sub-group analyses of nulliparous patients were also performed. Patients meeting criteria for vaginal breech delivery who accepted a trial of labor received an intravenous infusion of a balanced salt solution through which oxytocin was used to augment uterine contractility in cases of hypotonic uterine dysfunction or for induction of labor where indi-
L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
cated. Pain control was afforded through intravenous narcotic analgesia or epidural anesthesia, which were offered and accepted by most patients. Assisted breech delivery was the method of choice, although occasionally Piper forceps were applied to the aftercoming head. A senior resident with direct faculty assistance performed the cesarean and vaginal deliveries. Neonatologists were present at all deliveries and examined the infant for condition at birth, trauma and necessity for admission to the neonatal intensive care unit. Newborns with congenital malformations Ž n s 6. were excluded from the analysis. Maternal morbidity was evaluated by the length of hospital stay and post delivery complications: endometritis; wound infection; blood transfusions; or anesthesia-related problems. Endometritis was defined as an oral temperature of at least 38⬚C on at least two occasions 6 h apart occurring 24 h after delivery and associated with uterine tenderness and need for antibiotic therapy. Statistical analysis was performed with the Statview 4.0 statistical package ŽAbacus Concepts Inc., Berkeley, CA.. Continuous variables were analyzed with two-tailed Student t- or Mann᎐Whitney U-tests. Categorical variables were analyzed by X 2 or Fisher exact test. At all times a P value of - 0.05 was considered statistically significant.
3. Results Eight hundred and forty-eight women, identified prior to or in early labor met study criteria
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and were included in this analysis. Of these 848 patients, 576 Ž67.9%. were delivered by elective cesarean without attempting a trial of labor, 69 Ž8.1%. were delivered by cesarean after attempting a vaginal delivery and 203 Ž23.9%. attempted a trial of labor and delivered vaginally. An algorithm of the eventual mode of delivery for all analyzed patients is shown in Fig. 1. Overall, 203 of 848 Ž23.9%. subjects had a vaginal breech delivery. However, of 272 subjects who met protocol criteria and attempted vaginal delivery, 203 Ž74.6%. were delivered vaginally. Of 272 subjects whom otherwise met criteria for vaginal delivery, 106 Ž39%. did not undergo CAT scan pelvimetry. The reasons for this were: perception of insufficient time prior to estimated delivery; adequate clinical pelvimetry; and physician preference. Maternal and fetal demographic characteristics are depicted in Table 1. No significant differences were noted between the groups for maternal age, gravidity and parity, nulliparity, or estimated fetal weight. The proportion of patients with a history of cesarean birth was significantly greater for those not attempting a vaginal delivery. The indications for elective cesarean delivery are noted in Table 2. The most common indication for not attempting a trial of labor was patient choice Ž40.8%.. Dystocia was the indication in 55 of 69 Ž79.7%. patients who underwent a cesarean after a failed attempt at vaginal delivery. Without regard to the eventual mode of delivery, patients who attempted a vaginal delivery had a shorter length of hospital stay and febrile morbidity. No differences were noted with regard to blood
Table 1 Maternal and fetal characteristics a Characteristics
Elective cesarean Ž N s 576.
Attempted vaginal delivery Ž N s 272.
P value
Age Žyears. Gestational age Žweeks. Estimated fetal weight Žg. Nulliparity Oxytocin Previous cesarean
24.0" 5.9 38.3" 2.4 3096 " 687 265 Ž46. 4 Ž0.7. 92 Ž16.
24.2" 5.7 38.7" 1.9 3028 " 552 122 Ž44.8. 106 Ž39. 16 Ž5.9.
0.62 0.03 0.26 0.81 0.0001 0.0003
a
Data are presented as mean " S.D. or N Ž%..
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L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
Fig. 1. Flow chart and mode of delivery for 848 singleton breech deliveries.
transfusions or anesthesia complications ŽTable 3.. The birth weight of newborns whose mothers attempted to deliver vaginally was significantly decreased when compared to those delivered by elective cesarean. No differences were noted in the proportion of newborns with acidemia Žumbilical artery pH values - 7.00.. No difference was noted in birth trauma or perinatal mortality ŽTable 4.. A near-term Ž35 weeks’. newborn delivered by cesarean was noted to have an intraventricular hemorrhage grade III. The neonate died on the 25th day of life. Two neonatal deaths were noted in the attempted vaginal delivery group: a fullterm neonate developed early neonatal pneumonia and died on day 12 of life; and a second newborn developed neonatal sepsis and died within a week of birth.
Of 122 nulliparous women attempting a vaginal breech delivery, 92 Ž75.4%. delivered vaginally. Nulliparous women who delivered vaginally had Table 2 Indications for elective cesarean delivery Indication
No. of patients
Percent Ž%.
Patient choice Incomplete breech Abnormal pelvimetrya Macrosomia Hyperextension Non-reassuring fetal testing Other
235 144 58 28 19 22 70
40.8 25.0 10.1 4.9 3.3 3.8 12.1
a
Abnormal pelvimetry by computerized axial tomography or roentgenology.
L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
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Table 3 Maternal outcomes a
Length of stay Ždays. Febrile morbidity Transfusion Anesthesia complications No morbidity a
Elective cesarean Ž N s 576.
Attempted vaginal delivery Ž N s 272.
P value
4 Ž4, 4. 79 Ž13.7. 7 Ž1.2. 6 Ž1.0. 476 Ž82.6.
2 Ž2, 3. 23 Ž8.4. 3 Ž1.1. 3 Ž1.1. 241 Ž88.6.
0.001 0.03 1.00 1.00 0.02
Data are presented as N Ž%. or median Žinterquartile range..
newborns with significantly smaller birth weights. No differences were noted for the remaining neonatal outcomes ŽTable 5.. When compared to those delivered by cesarean, neonates delivered vaginally of nulliparous women weighed less and appeared to have a higher incidence of abnormal cord pH values ŽTable 6..
4. Discussion Despite the increasing cesarean rate for this indication, breech presentation continues to be associated with a higher perinatal morbidity and mortality than cephalic presentation w8x. Cheng and Hannah w15x reviewed 24 studies of singleton
Table 4 Neonatal outcomes a
Birth weight Žg. Apgar- 7 Žat 5 min. Cord pH- 7.16 Cord pH F 7.00 NICUb admissions Birth trauma Perinatal deathsc
Elective cesarean Ž N s 576.
Attempted vaginal delivery Ž N s 272.
P value
3136 " 617 19 Ž3.3. 55 Ž9.6. 7 Ž1.2. 38 Ž6.6. 9 Ž1.6. 1 Ž0.2.
3053 " 487 13 Ž4.8. 53 Ž19.5. 3 Ž1.1. 20 Ž7.3. 6 Ž2.2. 2 Ž0.7.
0.05 0.34 0.004 1.00 0.66 0.58 0.24
a
Data are presented as mean " S.D. or N Ž%.. NICUs neonatal intensive care unit. c Corrected perinatal mortality Ž6 congenital malformations excluded: holoprosencephaly; omphalocele; Down’s syndrome; meningocele; cleft liprpalate; and multiple anomalies.. b
Table 5 Selected outcome variables of neonates delivered vaginally in nulliparous vs. muliparous womena Characteristics
Nulliparous patients Ž N s 92.
Multiparous patients Ž N s 111.
P value
Birth weight Žg. Apgar score - 7 Žat 5 min. Cord arterial pH- 7.00 Cord arterial pH of F 7.16 NICUb admissions
2944 " 440 6 Ž6.5. 2 Ž2.2. 9 Ž9.8. 7 Ž7.6.
3049 " 467 4 Ž3.6. 2 Ž1.8. 15 Ž13.5. 7 Ž6.3.
0.10 0.52 0.59 0.51 0.78
a b
Data are presented as mean q S.D. or N Ž%.. NICUs neonatal intensive care unit.
L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
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Table 6 Selected outcome variables of neonates delivered of nulliparous womena Characteristics
Cesarean Ž N s 265.
Vaginal delivery Ž N s 92.
P value
Birth weight Žg. Apgar score - 7 Žat 5 min. Cord arterial pH- 7.00 Cord arterial pH of F 7.16 NICUb admissions
3102 " 565 6 Ž2.3. 4 Ž1.5. 10 Ž3.8. 21 Ž7.9.
2944 " 440 6 Ž6.5. 2 Ž2.2. 9 Ž9.8. 7 Ž7.6.
0.01 0.09 0.07 0.05 0.99
a b
Data are presented as mean q S.D. or N Ž%.. NICUs neonatal intensive care unit.
term breeches that presented results according to the intended mode of delivery. Their review suggested that an attempt at vaginal delivery may be associated with higher perinatal mortality and morbidity rates than planned cesarean delivery. In another meta-analysis, Gifford et al. w14x reviewed nine studies which used strict selection criteria and demonstrated a potential increased risk of neonatal morbidity after an attempted vaginal delivery in fetuses presenting as breech. Although the authors found a higher risk of neonatal morbidity after an attempt at vaginal delivery, the risk difference for overall morbidity and death was relatively small. In addition, while performing the meta-analysis, the authors encountered several methodologic problems, which limited the validity of their conclusions. In our study of 848 women with breech presentations, 203 Ž74.6%. of 272 women who agreed to a trial of labor, delivered vaginally. These results compare to similar studies in the literature. Irion w16x reported that of 385 women attempting vaginal delivery, 269 Ž70%. delivered vaginally. Daniel et al. w17x studied a cohort of 496 women with singleton breech presentations at term. Two hundred and twenty-six Ž80%. of 283 patients attempting a trial of labor delivered vaginally. More recently, Diro et al. w18x reported their experience with 1021 women with singleton term fetuses in breech presentation. Of 191 patients considered candidates for vaginal delivery, 135 Ž70.7%. were successful. Similarly, Erkaya et al. w19x evaluated 1040 consecutive breech deliveries in Turkey and concluded in favor of a selective approach for mode of delivery in patients with breech presen-
tation in order to balance the fetal morbidity associated with vaginal delivery and maternal morbidity and cost associated with cesarean delivery. Our results support the concept that for patients meeting specific criteria, a trial of labor is associated with a high rate of vaginal delivery. In appropriately selected patients, an attempt at vaginal breech delivery does not appear to increase perinatal morbidity or mortality while maternal morbidity is significantly decreased. This approach has advantages of not only reducing morbidity but also substantially reducing hospital costs. The fact that 12 fetuses with incomplete breech underwent attempted vaginal delivery might suggest to some the occurrence of protocol violations. More likely, however, these occurrences reflected spontaneous conversion from complete breech. Oxytocin was used for at least one-third of patients attempting a vaginal delivery. Our reassuring results regarding maternal and perinatal safety underscores that prudent use of uterotonic agents for induction andror labor augmentation is appropriate in selected patients. An increased incidence of abnormal umbilical artery pH- 7.16 was noted in those attempting vaginal delivery, regardless of the eventual route of delivery. Similar findings were noted for nulliparous patients who delivered vaginally. However, no difference was noted for fetal acidemia Žumbilical artery pH- 7.00.. We did not find a statistically different risk of other neonatal complications Žabnormal Apgar scores, NICU admissions,
L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
birth trauma, or corrected perinatal mortality. between the infants born after a trial of vaginal delivery and those born by an elective cesarean. Nulliparity, in patients with breech-presenting fetuses, is often considered an indication for an elective cesarean delivery w20x. In this study, 92 Ž75.4%. of 122 nulliparous women who met our protocol criteria, delivered vaginally. No significant differences were noted in neonatal complications or perinatal mortality for those delivered vaginally compared to those delivered by cesarean. The high percentage of vaginal delivery among patients not having CT pelvimetry ŽFig. 1. may reflect that this group of patients had rapidly progressive labor. Patients attempting a vaginal delivery had a significantly lower risk of maternal complications. Two hundred forty one Ž88.6%. of 272 women attempting vaginal delivery had no evidence of morbidity Ž Ps 0.02.. These results are consistent with those of other studies w16,19x. A similar reduction in maternal morbidity was also noted in Cheng and Hannah’s meta-analysis w15x. The length of hospital stay was nearly twice as long for those delivered by cesarean Ž2.8q 1.7 vs. 4.3q 1.8 days.. This reduction in hospitalization has important economical implications. While this large series supports the concept of vaginal breech delivery in selected cases, it has shortcomings characteristic of observational studies. Recently, large population-based studies from the United States w21x and from Sweden w22x concluded that term singleton infants presenting in breech would benefit from cesarean delivery. However, although these studies were based on the results of nearly 40 000 infants, they too were observational. A potential limitation of our, as well as other observational studies, relates to the heterogeneity of the study population. For example, we cannot systematically exclude the possibility that lower risk parturients may have been preferentially encouraged to attempt a trial of labor. If this type of differential management indeed occurred, our results could have been biased in favor of the trial of labor group. Two randomized clinical trials have been reported and both were hampered by small sample
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size and methods of data analysis w23,24x Until a large randomized clinical trial is conducted, the debate will continue. While this debate rages, the skills required for safe vaginal breech delivery may be lost. References w1x Croughan-Minihane MS, Petitti DB, Gords L, Golditch I. Morbidity among breech infants according to method of delivery. Obstet Gynecol 1990;75:821᎐825. w2x Graves WK. Breech delivery in 20 years of practice. Am J Obstet Gynecol 1980;137:229᎐234. w3x Wright RC. Reduction of perinatal mortality and morbidity in breech delivery through routine use of cesarean section. Obstet Gynecol 1959;14:758᎐763. w4x Hall JE, Kohl S. Breech presentation: a study of 1456 cases. Am J Obstet Gynecol 1956;72:977᎐990. w5x Watson WJ, Benson WL. Vaginal delivery for the selected frank breech infant at term. Obstet Gynecol 1984;64:638᎐640. w6x Harris JM, Nessim JA. To do or not to do a cesarean section. J Am Med Assoc 1959;169:570᎐576. w7x Stafford RS. Recent trends in cesarean section use in California. West J Med 1990;153:511᎐514. w8x Eller DP, Van Dorsten JP. Route of delivery for the breech presentation: a conondrum. Am J Obstet Gynecol 1995;173:393᎐398. w9x Schutte MF, Van Hemel OJS, Van De Berg C, Van De Pol A. Perinatal mortality in breech presentations as compared to vertex presentations in singleton pregnancies: an analysis based upon 57,819 computer-registered pregnancies in the Netherlands. Eur J Obstet Gynecol Reprod Bio 1985;19:391᎐400. w10x Tatum RK, Orr JW, Soong SJ, Huddleston JF. Vaginal breech delivery of selected infants weighing more than 2000 grams. Am J Obstet Gynecol 1985;152:145᎐155. w11x Myers SA, Gliecher N. Breech delivery: why the dilemma? Am J Obstet Gynecol 1986;155:6᎐10. w12x Rosen MG, Chik L. The effect of delivery route on outcome in breech presentation. Am J Obstet Gynecol 1984;148:909᎐914. w13x Russell JK. Breech: vaginal delivery or cesarean section. Br Med J 1982;285:830᎐831. w14x Gifford DS, Morton SC, Fiske M, Kahn K. A meta-analysis of infant outcomes after breech delivery. Obstet Gynecol 1995;85:1047᎐1054. w15x Cheng M, Hannah M. Breech delivery at term: a critical review of the literature. Obstet Gynecol 1993; 82:605᎐618. w16x Irion O, Almagbaly PH, Morabia A. Planned vaginal delivery vs. elective cesarean section: a study of 705 singleton term breech presentations. Br J Obstet Gynaecol 1998;105:710᎐717.
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w17x Daniel Y, Fait G, Lessing JB, Jaffa A, David MP, Kupferminc MJ. Outcome of 496 term singleton breech deliveries in a tertiary center. Am J Perinatol 1998;15:97᎐101. w18x Diro M, Puangsricharern A, Royer L, O’Sullivan MJ, Burkett G. Singleton term breech deliveries in nulliparous and multiparous women: a 5-year experience at the University of MiamirJackson Memorial hospital. Am J Obstet Gynecol 1999;181:247᎐252. w19x Erkaya S, Tuncer RA, Kutlar I, Onat N, Ercakmak S. Outcome of 1040 consecutive breech deliveries: clinical experience of a maternity hospital in Turkey. Int J Gynecol Obstet 1997;59:115᎐118. w20x Minogue M. Vaginal breech delivery in multiparae: a review of perinatal mortality National Maternity Hospital, 1967᎐1971. J Ir Med Assoc 1974;67:117᎐119.
w21x Lee KS, Khoshnood B, Sriram S, Hsieh HL, Singh J, Mittendorf R. Relationship of cesarean delivery to lower birth weight-specific neonatal mortality in singleton breech infants in the United States. Obstet Gynecol 1998;92:769᎐774. w22x Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by mode of delivery among term breech births: Swedish experience 1987᎐1993. Obstet Gynecol 1998;92:945᎐950. w23x Collea JV, Chein C, Quilligan EJ. The randomized management of term frank breech presentation: a study of 208 cases. Am J Obstet Gynecol 1980;137:235᎐244. w24x Gimovsky ML, Wallace RL, Schiffin BS, Paul RH. Randomized management of the non-frank breech presentation at term: a preliminary report. Am J Obstet Gynecol 1983;146:34᎐40.
Article
Route of breech delivery and maternal and neonatal outcomes L. Sanchez-RamosU , T.L. Wells, C.D. Adair, G. Arcelin, A.M. Kaunitz, D.S. Wells Department of Obstetrics and Gynecology, Uni¨ ersity of Florida Health Sciences Center, Jackson¨ ille, FL, USA Received 16 June 2000; received in revised form 17 November 2000; accepted 21 November 2000
Abstract Objecti¨ e: To compare maternal and neonatal outcomes in elective cesarean vs. attempted vaginal delivery for breech presentation at or near term. Methods: We reviewed the maternal and neonatal charts of all singleton breech deliveries of at least 35 weeks’ gestation or 2000 g delivered between 1986 and 1997 at our institution. Patients delivered by elective cesarean were compared to those attempting a vaginal delivery. The neonatal outcomes analyzed were: corrected mortality; Apgar scores less than 7 at 5 min; abnormal umbilical cord blood gases; birth trauma; and admissions to the intensive care nursery. Maternal morbidity was also assessed and compared. Results: Of 848 women meeting criteria for evaluation, 576 were delivered by elective cesarean while 272 attempted a vaginal delivery. Of 272 women undergoing a trial of labor, 203 Ž74.6%. were delivered vaginally, while 69 Ž25.4%. failed an attempt at vaginal delivery and underwent a cesarean. When comparing patients delivered by elective cesarean with those attempting a vaginal delivery, no significant differences were noted in neonatal outcomes. However, maternal morbidity was higher among women delivered by cesarean, regardless of the indications for the procedure. Similar neonatal and maternal results were noted when nulliparous patients were analyzed separately. Conclusions: Cesarean delivery of selected near-term infants presenting as breech is associated with increased maternal morbidity without corresponding improvement in neonatal outcomes. 䊚 2001 International Federation of Gynecology and Obstetrics. All rights reserved. Keywords: Breech delivery; Maternal; Neonatal
U
Corresponding author. Department of Obstetrics and Gynecology, 653-1 West 8th st., Jacksonville, Fl 32209, USA. Tel.: q1-904-244-3116; fax: q1-904-244-3124. E-mail address: [email protected] ŽL. Sanchez-Ramos.. 0020-7292r01r$20.00 䊚 2001 International Federation of Gynecology and Obstetrics. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 0 . 0 0 3 8 4 - 2
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L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
1. Introduction Breech presentation is known to be associated with higher perinatal morbidity and mortality than cephalic presentation, perhaps due to the mode of delivery and the higher incidence of congenital anomalies w1,2x. In 1959, Wright recommended that all breech-presenting fetuses be delivered by cesarean in order to improve perinatal outcomes w3x. During the past 40 years other retrospective studies cited improved perinatal outcomes for elective cesarean delivery, leading to very high cesarean rates for this abnormal presentation w4᎐6x. In fact, the cesarean delivery rate for breech presentation among US parturients has increased from 12% in 1970 to greater than 80% in 1985 w7,8x. However, during the same time interval, a number of authors suggested that properly selected vaginal breech deliveries in term patients were associated with outcomes similar to those achieved with elective cesarean birth w9᎐12x. Accordingly, management of breech delivery remains a controversial issue w13x. Policies regarding the management of breech presentation for term patients have been hindered by a lack of large, well-designed clinical trials that address the safety of vaginal delivery and define specific criteria for a trial of vaginal delivery w14x. Nonetheless, at the University of Florida Health Sciences Center in Jacksonville, we have continued to practice selective vaginal birth for term fetuses with breech presentations. The aim of this study is to report our experience, comparing specific maternal and neonatal morbidity markers for patients who underwent a trial of labor with those delivered by elective cesarean.
2. Materials and methods The medical records of all patients having a singleton breech delivery at University Medical Center, Jacksonville, FL between January 1986 and June 1997 were reviewed. This institution serves as the tertiary referral center for predominantly indigent, inner-city populations of northeast Florida. All patients were managed and de-
livered by resident physicians in obstetrics and gynecology under faculty supervision. The senior author was directly and actively involved in supervising intrapartum management during the entire study period. During the study period, 49 096 patients were delivered at this hospital. Of those patients, 1473 Ž3%. represented singleton breech presentations and 848 Ž1.7%. weighed 2000 g or more and were at least 35 weeks’ gestation. Gestational age was calculated based on menstrual dates or by sonographic examination carried out during either of the first two trimesters of pregnancy. The maternal and neonatal charts were reviewed to extract the relevant clinical information, which was entered into a computer’s database for analysis. The information included demographic characteristics, route of delivery, indications for cesarean delivery, pelvimetry, need for oxytocin infusion and maternal-neonatal outcomes. During the study period, patients with breech presentation were offered a trial of labor if the following criteria were met: Ž1. singleton frank or complete breech; Ž2. estimated fetal weight between 2000 and 4000 g; Ž3. adequate pelvis based clinically or by computerized axial tomography ŽCT. pelvimetry; and Ž4. non-extended fetal head as assessed by sonography or CT pelvimetry. Pelvic measurements were considered adequate if the distance of the ischial spines was at least 10 cm, the antero-posterior diameter of the pelvic inlet measured at least 11 cm and the transverse inlet diameter was at least 12 cm. The eventual route of delivery was decided by the attending physician managing each case. With regard to maternal and perinatal outcomes, patients delivered by an elective cesarean were compared with those attempting vaginal delivery, irrespective of the eventual route of delivery. Sub-group analyses of nulliparous patients were also performed. Patients meeting criteria for vaginal breech delivery who accepted a trial of labor received an intravenous infusion of a balanced salt solution through which oxytocin was used to augment uterine contractility in cases of hypotonic uterine dysfunction or for induction of labor where indi-
L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
cated. Pain control was afforded through intravenous narcotic analgesia or epidural anesthesia, which were offered and accepted by most patients. Assisted breech delivery was the method of choice, although occasionally Piper forceps were applied to the aftercoming head. A senior resident with direct faculty assistance performed the cesarean and vaginal deliveries. Neonatologists were present at all deliveries and examined the infant for condition at birth, trauma and necessity for admission to the neonatal intensive care unit. Newborns with congenital malformations Ž n s 6. were excluded from the analysis. Maternal morbidity was evaluated by the length of hospital stay and post delivery complications: endometritis; wound infection; blood transfusions; or anesthesia-related problems. Endometritis was defined as an oral temperature of at least 38⬚C on at least two occasions 6 h apart occurring 24 h after delivery and associated with uterine tenderness and need for antibiotic therapy. Statistical analysis was performed with the Statview 4.0 statistical package ŽAbacus Concepts Inc., Berkeley, CA.. Continuous variables were analyzed with two-tailed Student t- or Mann᎐Whitney U-tests. Categorical variables were analyzed by X 2 or Fisher exact test. At all times a P value of - 0.05 was considered statistically significant.
3. Results Eight hundred and forty-eight women, identified prior to or in early labor met study criteria
9
and were included in this analysis. Of these 848 patients, 576 Ž67.9%. were delivered by elective cesarean without attempting a trial of labor, 69 Ž8.1%. were delivered by cesarean after attempting a vaginal delivery and 203 Ž23.9%. attempted a trial of labor and delivered vaginally. An algorithm of the eventual mode of delivery for all analyzed patients is shown in Fig. 1. Overall, 203 of 848 Ž23.9%. subjects had a vaginal breech delivery. However, of 272 subjects who met protocol criteria and attempted vaginal delivery, 203 Ž74.6%. were delivered vaginally. Of 272 subjects whom otherwise met criteria for vaginal delivery, 106 Ž39%. did not undergo CAT scan pelvimetry. The reasons for this were: perception of insufficient time prior to estimated delivery; adequate clinical pelvimetry; and physician preference. Maternal and fetal demographic characteristics are depicted in Table 1. No significant differences were noted between the groups for maternal age, gravidity and parity, nulliparity, or estimated fetal weight. The proportion of patients with a history of cesarean birth was significantly greater for those not attempting a vaginal delivery. The indications for elective cesarean delivery are noted in Table 2. The most common indication for not attempting a trial of labor was patient choice Ž40.8%.. Dystocia was the indication in 55 of 69 Ž79.7%. patients who underwent a cesarean after a failed attempt at vaginal delivery. Without regard to the eventual mode of delivery, patients who attempted a vaginal delivery had a shorter length of hospital stay and febrile morbidity. No differences were noted with regard to blood
Table 1 Maternal and fetal characteristics a Characteristics
Elective cesarean Ž N s 576.
Attempted vaginal delivery Ž N s 272.
P value
Age Žyears. Gestational age Žweeks. Estimated fetal weight Žg. Nulliparity Oxytocin Previous cesarean
24.0" 5.9 38.3" 2.4 3096 " 687 265 Ž46. 4 Ž0.7. 92 Ž16.
24.2" 5.7 38.7" 1.9 3028 " 552 122 Ž44.8. 106 Ž39. 16 Ž5.9.
0.62 0.03 0.26 0.81 0.0001 0.0003
a
Data are presented as mean " S.D. or N Ž%..
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L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
Fig. 1. Flow chart and mode of delivery for 848 singleton breech deliveries.
transfusions or anesthesia complications ŽTable 3.. The birth weight of newborns whose mothers attempted to deliver vaginally was significantly decreased when compared to those delivered by elective cesarean. No differences were noted in the proportion of newborns with acidemia Žumbilical artery pH values - 7.00.. No difference was noted in birth trauma or perinatal mortality ŽTable 4.. A near-term Ž35 weeks’. newborn delivered by cesarean was noted to have an intraventricular hemorrhage grade III. The neonate died on the 25th day of life. Two neonatal deaths were noted in the attempted vaginal delivery group: a fullterm neonate developed early neonatal pneumonia and died on day 12 of life; and a second newborn developed neonatal sepsis and died within a week of birth.
Of 122 nulliparous women attempting a vaginal breech delivery, 92 Ž75.4%. delivered vaginally. Nulliparous women who delivered vaginally had Table 2 Indications for elective cesarean delivery Indication
No. of patients
Percent Ž%.
Patient choice Incomplete breech Abnormal pelvimetrya Macrosomia Hyperextension Non-reassuring fetal testing Other
235 144 58 28 19 22 70
40.8 25.0 10.1 4.9 3.3 3.8 12.1
a
Abnormal pelvimetry by computerized axial tomography or roentgenology.
L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
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Table 3 Maternal outcomes a
Length of stay Ždays. Febrile morbidity Transfusion Anesthesia complications No morbidity a
Elective cesarean Ž N s 576.
Attempted vaginal delivery Ž N s 272.
P value
4 Ž4, 4. 79 Ž13.7. 7 Ž1.2. 6 Ž1.0. 476 Ž82.6.
2 Ž2, 3. 23 Ž8.4. 3 Ž1.1. 3 Ž1.1. 241 Ž88.6.
0.001 0.03 1.00 1.00 0.02
Data are presented as N Ž%. or median Žinterquartile range..
newborns with significantly smaller birth weights. No differences were noted for the remaining neonatal outcomes ŽTable 5.. When compared to those delivered by cesarean, neonates delivered vaginally of nulliparous women weighed less and appeared to have a higher incidence of abnormal cord pH values ŽTable 6..
4. Discussion Despite the increasing cesarean rate for this indication, breech presentation continues to be associated with a higher perinatal morbidity and mortality than cephalic presentation w8x. Cheng and Hannah w15x reviewed 24 studies of singleton
Table 4 Neonatal outcomes a
Birth weight Žg. Apgar- 7 Žat 5 min. Cord pH- 7.16 Cord pH F 7.00 NICUb admissions Birth trauma Perinatal deathsc
Elective cesarean Ž N s 576.
Attempted vaginal delivery Ž N s 272.
P value
3136 " 617 19 Ž3.3. 55 Ž9.6. 7 Ž1.2. 38 Ž6.6. 9 Ž1.6. 1 Ž0.2.
3053 " 487 13 Ž4.8. 53 Ž19.5. 3 Ž1.1. 20 Ž7.3. 6 Ž2.2. 2 Ž0.7.
0.05 0.34 0.004 1.00 0.66 0.58 0.24
a
Data are presented as mean " S.D. or N Ž%.. NICUs neonatal intensive care unit. c Corrected perinatal mortality Ž6 congenital malformations excluded: holoprosencephaly; omphalocele; Down’s syndrome; meningocele; cleft liprpalate; and multiple anomalies.. b
Table 5 Selected outcome variables of neonates delivered vaginally in nulliparous vs. muliparous womena Characteristics
Nulliparous patients Ž N s 92.
Multiparous patients Ž N s 111.
P value
Birth weight Žg. Apgar score - 7 Žat 5 min. Cord arterial pH- 7.00 Cord arterial pH of F 7.16 NICUb admissions
2944 " 440 6 Ž6.5. 2 Ž2.2. 9 Ž9.8. 7 Ž7.6.
3049 " 467 4 Ž3.6. 2 Ž1.8. 15 Ž13.5. 7 Ž6.3.
0.10 0.52 0.59 0.51 0.78
a b
Data are presented as mean q S.D. or N Ž%.. NICUs neonatal intensive care unit.
L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
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Table 6 Selected outcome variables of neonates delivered of nulliparous womena Characteristics
Cesarean Ž N s 265.
Vaginal delivery Ž N s 92.
P value
Birth weight Žg. Apgar score - 7 Žat 5 min. Cord arterial pH- 7.00 Cord arterial pH of F 7.16 NICUb admissions
3102 " 565 6 Ž2.3. 4 Ž1.5. 10 Ž3.8. 21 Ž7.9.
2944 " 440 6 Ž6.5. 2 Ž2.2. 9 Ž9.8. 7 Ž7.6.
0.01 0.09 0.07 0.05 0.99
a b
Data are presented as mean q S.D. or N Ž%.. NICUs neonatal intensive care unit.
term breeches that presented results according to the intended mode of delivery. Their review suggested that an attempt at vaginal delivery may be associated with higher perinatal mortality and morbidity rates than planned cesarean delivery. In another meta-analysis, Gifford et al. w14x reviewed nine studies which used strict selection criteria and demonstrated a potential increased risk of neonatal morbidity after an attempted vaginal delivery in fetuses presenting as breech. Although the authors found a higher risk of neonatal morbidity after an attempt at vaginal delivery, the risk difference for overall morbidity and death was relatively small. In addition, while performing the meta-analysis, the authors encountered several methodologic problems, which limited the validity of their conclusions. In our study of 848 women with breech presentations, 203 Ž74.6%. of 272 women who agreed to a trial of labor, delivered vaginally. These results compare to similar studies in the literature. Irion w16x reported that of 385 women attempting vaginal delivery, 269 Ž70%. delivered vaginally. Daniel et al. w17x studied a cohort of 496 women with singleton breech presentations at term. Two hundred and twenty-six Ž80%. of 283 patients attempting a trial of labor delivered vaginally. More recently, Diro et al. w18x reported their experience with 1021 women with singleton term fetuses in breech presentation. Of 191 patients considered candidates for vaginal delivery, 135 Ž70.7%. were successful. Similarly, Erkaya et al. w19x evaluated 1040 consecutive breech deliveries in Turkey and concluded in favor of a selective approach for mode of delivery in patients with breech presen-
tation in order to balance the fetal morbidity associated with vaginal delivery and maternal morbidity and cost associated with cesarean delivery. Our results support the concept that for patients meeting specific criteria, a trial of labor is associated with a high rate of vaginal delivery. In appropriately selected patients, an attempt at vaginal breech delivery does not appear to increase perinatal morbidity or mortality while maternal morbidity is significantly decreased. This approach has advantages of not only reducing morbidity but also substantially reducing hospital costs. The fact that 12 fetuses with incomplete breech underwent attempted vaginal delivery might suggest to some the occurrence of protocol violations. More likely, however, these occurrences reflected spontaneous conversion from complete breech. Oxytocin was used for at least one-third of patients attempting a vaginal delivery. Our reassuring results regarding maternal and perinatal safety underscores that prudent use of uterotonic agents for induction andror labor augmentation is appropriate in selected patients. An increased incidence of abnormal umbilical artery pH- 7.16 was noted in those attempting vaginal delivery, regardless of the eventual route of delivery. Similar findings were noted for nulliparous patients who delivered vaginally. However, no difference was noted for fetal acidemia Žumbilical artery pH- 7.00.. We did not find a statistically different risk of other neonatal complications Žabnormal Apgar scores, NICU admissions,
L. Sanchez-Ramos et al. r International Journal of Gynecology & Obstetrics 73 (2001) 7᎐14
birth trauma, or corrected perinatal mortality. between the infants born after a trial of vaginal delivery and those born by an elective cesarean. Nulliparity, in patients with breech-presenting fetuses, is often considered an indication for an elective cesarean delivery w20x. In this study, 92 Ž75.4%. of 122 nulliparous women who met our protocol criteria, delivered vaginally. No significant differences were noted in neonatal complications or perinatal mortality for those delivered vaginally compared to those delivered by cesarean. The high percentage of vaginal delivery among patients not having CT pelvimetry ŽFig. 1. may reflect that this group of patients had rapidly progressive labor. Patients attempting a vaginal delivery had a significantly lower risk of maternal complications. Two hundred forty one Ž88.6%. of 272 women attempting vaginal delivery had no evidence of morbidity Ž Ps 0.02.. These results are consistent with those of other studies w16,19x. A similar reduction in maternal morbidity was also noted in Cheng and Hannah’s meta-analysis w15x. The length of hospital stay was nearly twice as long for those delivered by cesarean Ž2.8q 1.7 vs. 4.3q 1.8 days.. This reduction in hospitalization has important economical implications. While this large series supports the concept of vaginal breech delivery in selected cases, it has shortcomings characteristic of observational studies. Recently, large population-based studies from the United States w21x and from Sweden w22x concluded that term singleton infants presenting in breech would benefit from cesarean delivery. However, although these studies were based on the results of nearly 40 000 infants, they too were observational. A potential limitation of our, as well as other observational studies, relates to the heterogeneity of the study population. For example, we cannot systematically exclude the possibility that lower risk parturients may have been preferentially encouraged to attempt a trial of labor. If this type of differential management indeed occurred, our results could have been biased in favor of the trial of labor group. Two randomized clinical trials have been reported and both were hampered by small sample
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size and methods of data analysis w23,24x Until a large randomized clinical trial is conducted, the debate will continue. While this debate rages, the skills required for safe vaginal breech delivery may be lost. References w1x Croughan-Minihane MS, Petitti DB, Gords L, Golditch I. Morbidity among breech infants according to method of delivery. Obstet Gynecol 1990;75:821᎐825. w2x Graves WK. Breech delivery in 20 years of practice. Am J Obstet Gynecol 1980;137:229᎐234. w3x Wright RC. Reduction of perinatal mortality and morbidity in breech delivery through routine use of cesarean section. Obstet Gynecol 1959;14:758᎐763. w4x Hall JE, Kohl S. Breech presentation: a study of 1456 cases. Am J Obstet Gynecol 1956;72:977᎐990. w5x Watson WJ, Benson WL. Vaginal delivery for the selected frank breech infant at term. Obstet Gynecol 1984;64:638᎐640. w6x Harris JM, Nessim JA. To do or not to do a cesarean section. J Am Med Assoc 1959;169:570᎐576. w7x Stafford RS. Recent trends in cesarean section use in California. West J Med 1990;153:511᎐514. w8x Eller DP, Van Dorsten JP. Route of delivery for the breech presentation: a conondrum. Am J Obstet Gynecol 1995;173:393᎐398. w9x Schutte MF, Van Hemel OJS, Van De Berg C, Van De Pol A. Perinatal mortality in breech presentations as compared to vertex presentations in singleton pregnancies: an analysis based upon 57,819 computer-registered pregnancies in the Netherlands. Eur J Obstet Gynecol Reprod Bio 1985;19:391᎐400. w10x Tatum RK, Orr JW, Soong SJ, Huddleston JF. Vaginal breech delivery of selected infants weighing more than 2000 grams. Am J Obstet Gynecol 1985;152:145᎐155. w11x Myers SA, Gliecher N. Breech delivery: why the dilemma? Am J Obstet Gynecol 1986;155:6᎐10. w12x Rosen MG, Chik L. The effect of delivery route on outcome in breech presentation. Am J Obstet Gynecol 1984;148:909᎐914. w13x Russell JK. Breech: vaginal delivery or cesarean section. Br Med J 1982;285:830᎐831. w14x Gifford DS, Morton SC, Fiske M, Kahn K. A meta-analysis of infant outcomes after breech delivery. Obstet Gynecol 1995;85:1047᎐1054. w15x Cheng M, Hannah M. Breech delivery at term: a critical review of the literature. Obstet Gynecol 1993; 82:605᎐618. w16x Irion O, Almagbaly PH, Morabia A. Planned vaginal delivery vs. elective cesarean section: a study of 705 singleton term breech presentations. Br J Obstet Gynaecol 1998;105:710᎐717.
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w17x Daniel Y, Fait G, Lessing JB, Jaffa A, David MP, Kupferminc MJ. Outcome of 496 term singleton breech deliveries in a tertiary center. Am J Perinatol 1998;15:97᎐101. w18x Diro M, Puangsricharern A, Royer L, O’Sullivan MJ, Burkett G. Singleton term breech deliveries in nulliparous and multiparous women: a 5-year experience at the University of MiamirJackson Memorial hospital. Am J Obstet Gynecol 1999;181:247᎐252. w19x Erkaya S, Tuncer RA, Kutlar I, Onat N, Ercakmak S. Outcome of 1040 consecutive breech deliveries: clinical experience of a maternity hospital in Turkey. Int J Gynecol Obstet 1997;59:115᎐118. w20x Minogue M. Vaginal breech delivery in multiparae: a review of perinatal mortality National Maternity Hospital, 1967᎐1971. J Ir Med Assoc 1974;67:117᎐119.
w21x Lee KS, Khoshnood B, Sriram S, Hsieh HL, Singh J, Mittendorf R. Relationship of cesarean delivery to lower birth weight-specific neonatal mortality in singleton breech infants in the United States. Obstet Gynecol 1998;92:769᎐774. w22x Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by mode of delivery among term breech births: Swedish experience 1987᎐1993. Obstet Gynecol 1998;92:945᎐950. w23x Collea JV, Chein C, Quilligan EJ. The randomized management of term frank breech presentation: a study of 208 cases. Am J Obstet Gynecol 1980;137:235᎐244. w24x Gimovsky ML, Wallace RL, Schiffin BS, Paul RH. Randomized management of the non-frank breech presentation at term: a preliminary report. Am J Obstet Gynecol 1983;146:34᎐40.