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The preterm breech delivery in Zaria, Northern Nigeria
Int J Gynecol Obstet, 1992, 38: 287-291 International Federation of Gynecology and Obstetrics
287
The preterm breech delivery in Zaria, Northern
Nigeria
J. Emembolu Department of Obstetrics and Gynaecology, A. B. U. Teaching Hospital, Zaria, Kaduna State (Nigeria)
(Received August 28th, 1991) (Revised and accepted December 20th, 1991)
Abstract The preterm breech occurred in 31.21% of singleton breech presentations in a prospective study at Ahmadu Bell0 University Teaching Hospital (ABUTH), Zaria, Nigeria. The uncorrectedperinatal mortality of 670.5 per 1000 deliveries was 1.7 times that for term breech presentations. Failure to book for antenatal care (50.94%), admission of cases in the second stage of labor (21.84OA) and intrauterine fetal death on admission (38.64%) were associatedfactors of the high perinatal mortality. The mortality was extremely high in the very low birthweigh t fetus ( < 1500 g) delivered vaginally. Moreover, the cesarean section rate was associated with a 2.4 times higher perinatal morbidity and mortality rates than vaginal delivery.
Keywords: Preterm breech; Harmful sociocultural factors; High perinatal mortality; Vaginal delivery. Introduction The medical literature is inconclusive on the best approach to the delivery of preterm breech infants, and numerous authors have advocated cesarean section for the low birthweight breech fetus [ 1,2]. More recently, however, other investigations have questioned the use of cesarean section for such presenta0020-7292/92/%05.00 0 1992 International
Federation of Gynecology and Obstetrics Printed and Published in Ireland
tions [ 3,4]. Kitchen et al. [ 51 supported by others [ 61 reported that despite the high incidence of significant handicaps associated with breech deliveries, the mode of delivery (vaginal or abdominal) did not play a significant role. Abudu [ 71 in Lagos, Nigeria observed that low birthweight complicated singleton deliveries in 5.2% with a corrected perinatal mortality of 339 per 1000 deliveries. Furthermore, it was observed that infants weighing <2500 g accounted for 61.6% of breech perinatal deaths [ 81. In spite of these high perinatal mortality figures, three factors have significantly influenced the preference for the vaginal rather than the abdominal route in the management of the preterm breech delivery in this environment. Firstly, our patients intensely dislike abdominal delivery which they believe is a failure of their womanhood. They would therefore persist with attempted vaginal delivery in subsequent pregnancies. Secondly, most cases are unbooked, live in remote villages and hence are unlikely to seek early medical attention when labor supervenes in the subsequent pregnancies. Finally, many patients who had had perinatal deaths following cesarean deliveries develop a negative attitude to hospital confinement and would therefore resist future hospital supervision in pregnancy and labor. As a result therefore, it became necessary to evaluate the effect of this delivery policy on preterm breech presentation in this environment. Article
288
Emembolu
Materiak and methods In a prospective study of all singleton breech deliveries conducted at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria from January 1987 to December 1989, 88 of 282 breech presentations were preterm with a birthweight of ~2500 g. These were analyzed together with 48 preterm infants of 311 vertex presentations documented as controls over the same period. These controls were the next singleton vertex deliveries admitted after the indexed patients. The vaginal deliveries were conducted by or under the close supervision of the Senior resident or Consultant. The after-coming head was delivered by the Maureceau-Smillie-Veit method or by application of the Wrigley’s Forceps. The data collected were analyzed to determine the factors associated with mortality in these infants. The term early perinatal mortality in this study refers to all stillbirths and neonatal deaths in the first 7 days of extrauterine life. The early perinatal mortality is used in this study because of failure of compliance at follow-up clinics which made subsequent statistical data analysis inaccurate. The statistical analysis using the x2-test was performed where applicable. ReMlltS The frequency
of preterm
deliveries
in
breech presentation in this study was 31.21% (Table 1) which was double the 15.43% for the vertex deliveries. Intrauterine fetal death (IUFD) on admission was observed in 38.64% of breech and 14.06% of vertex presentations. When these were excluded, the perinatal mortality rates dropped from 670.5/1000 to 471.6/1000 for live breech and 416.7/1000 to 66.7/1000 for live vertex presentations. The preterm breech carried a significantly worse prognosis than the term breech presentation (P < 0.05) and this was readily shown when the very low birthweight (I 1.499 kg) were compared to the low birthweight breech infants (0.05 < P < 0.01). Most cases of the preterm deliveries were unbooked (Table 2) but there were no significant differences between their frequencies in breech (50.94%) and vertex (56.67%) presentations. Nonetheless, whether unbooked or booked at other health centres, the perinatal mortality in preterm breech was significantly higher (2.5 times) than among those booked at Ahmadu Bello University Teaching Hospital, Zaria (P < 0.05). The mode of delivery in the live preterm breech is illustrated in Table 3. The frequency of cesarean section was 18.18% but this was associated with a high incidence of neonatal asphyxia and an early neonatal death rate (for infants weighting between 1500 and 2499 g) 2.4 times that for vaginal delivery. The overall mortality in the low birthweight breech infants delivered by cesarean section was
Table 1. Comparison of outcome in breech and vertex presentations by birthweight. IUFD on admission
Breech
Vertex
Breech
Vertex
Breech
Vertex
Breech
Vertex
S 1.49 1.50-2.49 r 2.50
37 (13.12)’ 51 (18.09) 191 (67.73)
7 (2.25) 41 (13.17) 261 (83.92)
22 (59.46) 12 (23.53) 54 (28.27)
5 (71.43) 38 (31.71) 16 (6.13)
15 (40.54) 38 (74.51) 138 (72.25)
I (28.57) 28 (17.37) 245 (93.87)
12 (80.00) 13 (34.21) 20 (14.49)
-
Unbooked
3 (100)
2 (0.64)
282 (100)
311 (100)
Total
BPercentages given in parentheses.
Int J Gynecol Obstet 38
2 90 (31.92)
1 35 (11.25)
Live fetus on admission
Perinatal mortality (live fetus)
Total admissions
Birthweight (kg)
1 192 (68.09)
1 276 (88.75)
1 45 (23.44)
2 (7.14) 7 (2.86) 1 10 (3.62)
Preterm breech delivery in Northern Nigeria
Table 2.
289
Booking status in live breech and vertex low birthweight babies.
Booking status
Total Breech
Vertex
Early neonatal death
Perinatal death
Breech
Breech
Vertex
Vertex
Booked at
ABUTHZa Other health centres Not booked Total
18 (34.OO)b 8 (15.09)
7 (23.33) 6 (20.00)
3 (16.67) 1 (12.50)
-
5 (27.78) 5 (62.50)
27 (50.94)
17 (56.67)
12 (44.44)
I (5.88)
15 (55.56)
2 (11.76)
53 (100)
30 (100)
16 (30.19)
1 (3.33)
25 (47.17)
2 (6.67)
-
DABUTHZ - Ahmadu Be110University Teaching Hospital, Zaria. bPercentages given in parentheses.
53.33% compared with 43.73% when delivered vaginally. These figures were not statistically significant because of the small numbers involved. Furthermore, Table 4 shows that the indications for cesarean section in the live preterm pregnancies were mainly placenta previa, abruptio placenta and pre-eclampsia/ eclampsia. Such indications which were associated with placental insufficiency were responsible for 62.5% of the perinatal deaths (5 of 8 cases) in cesarean deliveries. Head entrapment was less common in the preterm breech infants and occured in 5.68% (5 of 88 cases) compared with 14.95% (20 of 104 cases) for term breech presentations. Ten perinatal deaths (52.63%) were observed in 19 patients with preterm breech who were admitted in the second stage of labor. Major fetal anomalies incompatible with life occured in four instances (4.55%) and when these were excluded, resulted in a corrected perinatal mortality of 420.0/1000 in live preterm breech deliveries. Table 3.
Discussion This study shows that there is a high overall perinatal mortality for the preterm breech and vertex deliveries which agrees with the report of Abudu [ 71, and also that the breech carried a 1.7 times worse prognosis than the preterm vertex presentation. This high fetal wastage in low birthweight breech presentation may be ascribed to such associated factors as lack of antenatal care, lack of female education, and delayed referral [ 9,101 for more expert management, all of which are associated with a high incidence of intrauterine fetal death on admission. The effect of prematurity is illustrated by the 1.8 times perinatal mortality for the preterm compared with the term breech delivery which confirms the report by Adeleye [ 81. Head entrapment and major fetal anomaly did not contribute significantly to the perinatal mortality in this study. On the other hand, admission of cases in the second stage of labor was associated with a high perinatal mortality and probably
Comparison of live low birthweight breech presentation by mode of delivery.
Birthweight (kg)
Live fetus on admission Vaginal
Cesarean
s1.49 1.50-2.49
13 (34.21)’ 25 (65.79)
2 (13.33) 13 (86.67)
Total
38 (100)
15 (100)
APGAR score ~7 at 5 min
Early neonatal death
Vaginal
Vaginal
Cesarean
Cesarean
6 (46.15) 9 (36.00)
1 (50.00) 9 (69.23)
5 (38.46) 4 (16.00)
2 (100) 5 (38.46)
15 (39.47)
10 (66.67)
9 (23.68)
7 (46.67)
BPercentages given in parentheses. Article
290 Emembolu Table 4.
Indications and outcome of cesarean section in five low birthweight breech and vertex presentations.
Placenta previa Abruptio placenta PET/Eclampsia Previous C/section Previous WF Recurrent abortions
Breech
Vertex
No. of Deaths cases
No. of Deaths cases
4 3 2 3 2 1
2 2 1
5 2
1 1
-
I -
1
-
-
1 -
reflects the delay in referral due to transportation difficulties, male dominance in decisionmaking prior to patient presentation to the hospital and also the negative influence of the traditional birth attendants who did not release their patients until serious difficulties supervened. The major controversy involves the best management of preterm breech presentation. The perinatal mortality rate was reportedly worse for the very low birthweight fetuses (< 1500 g) compared with those weighing 1500 g and above [ 1,3,4,6]. It was suggested [ 1] that cesarean delivery was preferable to vaginal delivery in these very low birthweight breech infants though this was later refuted [ 3,111. The poorly formed lower uterine segment in such cases is associated with an increased frequency of classical cesarean section [ 111 an important morbidity consideration in this environment. However, local consideration such as failure to book for antenatal care, the socio-cultural preference for home deliveries and distaste for abdominal deliveries in collaboration with the generally high perinatal mortality in low birthweight infants in our neonatal units militate against cesarean section in uncomplicated preterm breech deliveries. In conclusion, therefore, this study agrees with others [ 12,131 that cesarean section should not be used in all cases of preterm breech presentation. In this environment, Int J Gynecol Obstet 38
therefore, cesarean section is advocated in preterm breech for obstetric indications. The emphasis should be on training of the obstetric resident in the art of breech management and proper neonatal resuscitative technique irrespective of the mode of delivery of the breech fetus. In the long term, improved female education, a concerted drive towards hospital/clinic antenatal attendance and early referral of cases should reduce the incidence of prematurity and intrauterine fetal death prior to admission, and consequently the high perinatal mortality in pretemr breech presentation. Acknowledgement I wish to express my gratitude to other consultants whose patients were also involved in the study and to all the staff of the department. References Bowes WA, Taylor ES, O’Brien M and Bowes C: Breech delivery: Evaluation of the method of delivery on perinatal results and maternal morbidity. Am J Obstet Gynecol 135: 695, 1979. Kauppila 0, Gronroos M, Aro P, Aittoniemi P and Kuopala M: Management of low birthweight breech delivery: Should caesarean section be routine? Obstet Gynecol57: 289, 1981. Cox C, Kendall AC and Hommers M: Changed prognosis of breech presenting low birthweight infants. Br J Obstet Gynaecol 89: 881, 1982. Tatun RK, Orr JW, Soongs S and Huddleston JF: Vaginal breech delivery of selected infants weighing more than 2000 g. Am J Obstet Gynecol 152: 145, 1985. Kitchen WH, Yu VYH, Orgill AA, Ford G, Rickards A, Astbury J, Ryan MM et al.: Infants born before 27 weeks gestation: Survival and morbidity at 2 years of age. Br J Obstet Gynaecol 89: 887, 1982. Westgren LMR, Songster G and Paul RH: Preterm breech delivery: Another retrospective study. Obstet Gynecol66: 481, 1985. Abudu 0: Low birthweight and perinatal mortality in Lagos. J Obstet Gynecol EastXentr Afr 7: 68, 1988. Adeleye JA: A two-year assessment of some aspects of breech delivery; caesarean section in breech presentation and perinatal mortality at the University College Hospital, Ibadan, Nigeria. Trop J Obstet Gynecol 5: 31, 1985.
Preterm breech delivery in Northern Nigeria 9
Harrison KA: Child-bearing, Health and Social Priorities: A survey of 22 774 consecutive hospital births in Zaria, Northern Nigeria. Br J Obstet Gynaecol92(5): 22, 1985. 10 Ekwempu CC: The influence of antenatal care on pregnancy outcome. Trop J Obstet Gynecol8(2): 45, 1990. 11 Annon PJ: Management of singleton breech presentation. Trop Doctr 14: 167, 1984.
291
Address for reprinta: J.O. Emembolu Dept. of Obetrks & Gynaecology Altmadu Bell0 University Teaching Hospital Zaria, K&ma State Nigeria
Article
287
The preterm breech delivery in Zaria, Northern
Nigeria
J. Emembolu Department of Obstetrics and Gynaecology, A. B. U. Teaching Hospital, Zaria, Kaduna State (Nigeria)
(Received August 28th, 1991) (Revised and accepted December 20th, 1991)
Abstract The preterm breech occurred in 31.21% of singleton breech presentations in a prospective study at Ahmadu Bell0 University Teaching Hospital (ABUTH), Zaria, Nigeria. The uncorrectedperinatal mortality of 670.5 per 1000 deliveries was 1.7 times that for term breech presentations. Failure to book for antenatal care (50.94%), admission of cases in the second stage of labor (21.84OA) and intrauterine fetal death on admission (38.64%) were associatedfactors of the high perinatal mortality. The mortality was extremely high in the very low birthweigh t fetus ( < 1500 g) delivered vaginally. Moreover, the cesarean section rate was associated with a 2.4 times higher perinatal morbidity and mortality rates than vaginal delivery.
Keywords: Preterm breech; Harmful sociocultural factors; High perinatal mortality; Vaginal delivery. Introduction The medical literature is inconclusive on the best approach to the delivery of preterm breech infants, and numerous authors have advocated cesarean section for the low birthweight breech fetus [ 1,2]. More recently, however, other investigations have questioned the use of cesarean section for such presenta0020-7292/92/%05.00 0 1992 International
Federation of Gynecology and Obstetrics Printed and Published in Ireland
tions [ 3,4]. Kitchen et al. [ 51 supported by others [ 61 reported that despite the high incidence of significant handicaps associated with breech deliveries, the mode of delivery (vaginal or abdominal) did not play a significant role. Abudu [ 71 in Lagos, Nigeria observed that low birthweight complicated singleton deliveries in 5.2% with a corrected perinatal mortality of 339 per 1000 deliveries. Furthermore, it was observed that infants weighing <2500 g accounted for 61.6% of breech perinatal deaths [ 81. In spite of these high perinatal mortality figures, three factors have significantly influenced the preference for the vaginal rather than the abdominal route in the management of the preterm breech delivery in this environment. Firstly, our patients intensely dislike abdominal delivery which they believe is a failure of their womanhood. They would therefore persist with attempted vaginal delivery in subsequent pregnancies. Secondly, most cases are unbooked, live in remote villages and hence are unlikely to seek early medical attention when labor supervenes in the subsequent pregnancies. Finally, many patients who had had perinatal deaths following cesarean deliveries develop a negative attitude to hospital confinement and would therefore resist future hospital supervision in pregnancy and labor. As a result therefore, it became necessary to evaluate the effect of this delivery policy on preterm breech presentation in this environment. Article
288
Emembolu
Materiak and methods In a prospective study of all singleton breech deliveries conducted at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria from January 1987 to December 1989, 88 of 282 breech presentations were preterm with a birthweight of ~2500 g. These were analyzed together with 48 preterm infants of 311 vertex presentations documented as controls over the same period. These controls were the next singleton vertex deliveries admitted after the indexed patients. The vaginal deliveries were conducted by or under the close supervision of the Senior resident or Consultant. The after-coming head was delivered by the Maureceau-Smillie-Veit method or by application of the Wrigley’s Forceps. The data collected were analyzed to determine the factors associated with mortality in these infants. The term early perinatal mortality in this study refers to all stillbirths and neonatal deaths in the first 7 days of extrauterine life. The early perinatal mortality is used in this study because of failure of compliance at follow-up clinics which made subsequent statistical data analysis inaccurate. The statistical analysis using the x2-test was performed where applicable. ReMlltS The frequency
of preterm
deliveries
in
breech presentation in this study was 31.21% (Table 1) which was double the 15.43% for the vertex deliveries. Intrauterine fetal death (IUFD) on admission was observed in 38.64% of breech and 14.06% of vertex presentations. When these were excluded, the perinatal mortality rates dropped from 670.5/1000 to 471.6/1000 for live breech and 416.7/1000 to 66.7/1000 for live vertex presentations. The preterm breech carried a significantly worse prognosis than the term breech presentation (P < 0.05) and this was readily shown when the very low birthweight (I 1.499 kg) were compared to the low birthweight breech infants (0.05 < P < 0.01). Most cases of the preterm deliveries were unbooked (Table 2) but there were no significant differences between their frequencies in breech (50.94%) and vertex (56.67%) presentations. Nonetheless, whether unbooked or booked at other health centres, the perinatal mortality in preterm breech was significantly higher (2.5 times) than among those booked at Ahmadu Bello University Teaching Hospital, Zaria (P < 0.05). The mode of delivery in the live preterm breech is illustrated in Table 3. The frequency of cesarean section was 18.18% but this was associated with a high incidence of neonatal asphyxia and an early neonatal death rate (for infants weighting between 1500 and 2499 g) 2.4 times that for vaginal delivery. The overall mortality in the low birthweight breech infants delivered by cesarean section was
Table 1. Comparison of outcome in breech and vertex presentations by birthweight. IUFD on admission
Breech
Vertex
Breech
Vertex
Breech
Vertex
Breech
Vertex
S 1.49 1.50-2.49 r 2.50
37 (13.12)’ 51 (18.09) 191 (67.73)
7 (2.25) 41 (13.17) 261 (83.92)
22 (59.46) 12 (23.53) 54 (28.27)
5 (71.43) 38 (31.71) 16 (6.13)
15 (40.54) 38 (74.51) 138 (72.25)
I (28.57) 28 (17.37) 245 (93.87)
12 (80.00) 13 (34.21) 20 (14.49)
-
Unbooked
3 (100)
2 (0.64)
282 (100)
311 (100)
Total
BPercentages given in parentheses.
Int J Gynecol Obstet 38
2 90 (31.92)
1 35 (11.25)
Live fetus on admission
Perinatal mortality (live fetus)
Total admissions
Birthweight (kg)
1 192 (68.09)
1 276 (88.75)
1 45 (23.44)
2 (7.14) 7 (2.86) 1 10 (3.62)
Preterm breech delivery in Northern Nigeria
Table 2.
289
Booking status in live breech and vertex low birthweight babies.
Booking status
Total Breech
Vertex
Early neonatal death
Perinatal death
Breech
Breech
Vertex
Vertex
Booked at
ABUTHZa Other health centres Not booked Total
18 (34.OO)b 8 (15.09)
7 (23.33) 6 (20.00)
3 (16.67) 1 (12.50)
-
5 (27.78) 5 (62.50)
27 (50.94)
17 (56.67)
12 (44.44)
I (5.88)
15 (55.56)
2 (11.76)
53 (100)
30 (100)
16 (30.19)
1 (3.33)
25 (47.17)
2 (6.67)
-
DABUTHZ - Ahmadu Be110University Teaching Hospital, Zaria. bPercentages given in parentheses.
53.33% compared with 43.73% when delivered vaginally. These figures were not statistically significant because of the small numbers involved. Furthermore, Table 4 shows that the indications for cesarean section in the live preterm pregnancies were mainly placenta previa, abruptio placenta and pre-eclampsia/ eclampsia. Such indications which were associated with placental insufficiency were responsible for 62.5% of the perinatal deaths (5 of 8 cases) in cesarean deliveries. Head entrapment was less common in the preterm breech infants and occured in 5.68% (5 of 88 cases) compared with 14.95% (20 of 104 cases) for term breech presentations. Ten perinatal deaths (52.63%) were observed in 19 patients with preterm breech who were admitted in the second stage of labor. Major fetal anomalies incompatible with life occured in four instances (4.55%) and when these were excluded, resulted in a corrected perinatal mortality of 420.0/1000 in live preterm breech deliveries. Table 3.
Discussion This study shows that there is a high overall perinatal mortality for the preterm breech and vertex deliveries which agrees with the report of Abudu [ 71, and also that the breech carried a 1.7 times worse prognosis than the preterm vertex presentation. This high fetal wastage in low birthweight breech presentation may be ascribed to such associated factors as lack of antenatal care, lack of female education, and delayed referral [ 9,101 for more expert management, all of which are associated with a high incidence of intrauterine fetal death on admission. The effect of prematurity is illustrated by the 1.8 times perinatal mortality for the preterm compared with the term breech delivery which confirms the report by Adeleye [ 81. Head entrapment and major fetal anomaly did not contribute significantly to the perinatal mortality in this study. On the other hand, admission of cases in the second stage of labor was associated with a high perinatal mortality and probably
Comparison of live low birthweight breech presentation by mode of delivery.
Birthweight (kg)
Live fetus on admission Vaginal
Cesarean
s1.49 1.50-2.49
13 (34.21)’ 25 (65.79)
2 (13.33) 13 (86.67)
Total
38 (100)
15 (100)
APGAR score ~7 at 5 min
Early neonatal death
Vaginal
Vaginal
Cesarean
Cesarean
6 (46.15) 9 (36.00)
1 (50.00) 9 (69.23)
5 (38.46) 4 (16.00)
2 (100) 5 (38.46)
15 (39.47)
10 (66.67)
9 (23.68)
7 (46.67)
BPercentages given in parentheses. Article
290 Emembolu Table 4.
Indications and outcome of cesarean section in five low birthweight breech and vertex presentations.
Placenta previa Abruptio placenta PET/Eclampsia Previous C/section Previous WF Recurrent abortions
Breech
Vertex
No. of Deaths cases
No. of Deaths cases
4 3 2 3 2 1
2 2 1
5 2
1 1
-
I -
1
-
-
1 -
reflects the delay in referral due to transportation difficulties, male dominance in decisionmaking prior to patient presentation to the hospital and also the negative influence of the traditional birth attendants who did not release their patients until serious difficulties supervened. The major controversy involves the best management of preterm breech presentation. The perinatal mortality rate was reportedly worse for the very low birthweight fetuses (< 1500 g) compared with those weighing 1500 g and above [ 1,3,4,6]. It was suggested [ 1] that cesarean delivery was preferable to vaginal delivery in these very low birthweight breech infants though this was later refuted [ 3,111. The poorly formed lower uterine segment in such cases is associated with an increased frequency of classical cesarean section [ 111 an important morbidity consideration in this environment. However, local consideration such as failure to book for antenatal care, the socio-cultural preference for home deliveries and distaste for abdominal deliveries in collaboration with the generally high perinatal mortality in low birthweight infants in our neonatal units militate against cesarean section in uncomplicated preterm breech deliveries. In conclusion, therefore, this study agrees with others [ 12,131 that cesarean section should not be used in all cases of preterm breech presentation. In this environment, Int J Gynecol Obstet 38
therefore, cesarean section is advocated in preterm breech for obstetric indications. The emphasis should be on training of the obstetric resident in the art of breech management and proper neonatal resuscitative technique irrespective of the mode of delivery of the breech fetus. In the long term, improved female education, a concerted drive towards hospital/clinic antenatal attendance and early referral of cases should reduce the incidence of prematurity and intrauterine fetal death prior to admission, and consequently the high perinatal mortality in pretemr breech presentation. Acknowledgement I wish to express my gratitude to other consultants whose patients were also involved in the study and to all the staff of the department. References Bowes WA, Taylor ES, O’Brien M and Bowes C: Breech delivery: Evaluation of the method of delivery on perinatal results and maternal morbidity. Am J Obstet Gynecol 135: 695, 1979. Kauppila 0, Gronroos M, Aro P, Aittoniemi P and Kuopala M: Management of low birthweight breech delivery: Should caesarean section be routine? Obstet Gynecol57: 289, 1981. Cox C, Kendall AC and Hommers M: Changed prognosis of breech presenting low birthweight infants. Br J Obstet Gynaecol 89: 881, 1982. Tatun RK, Orr JW, Soongs S and Huddleston JF: Vaginal breech delivery of selected infants weighing more than 2000 g. Am J Obstet Gynecol 152: 145, 1985. Kitchen WH, Yu VYH, Orgill AA, Ford G, Rickards A, Astbury J, Ryan MM et al.: Infants born before 27 weeks gestation: Survival and morbidity at 2 years of age. Br J Obstet Gynaecol 89: 887, 1982. Westgren LMR, Songster G and Paul RH: Preterm breech delivery: Another retrospective study. Obstet Gynecol66: 481, 1985. Abudu 0: Low birthweight and perinatal mortality in Lagos. J Obstet Gynecol EastXentr Afr 7: 68, 1988. Adeleye JA: A two-year assessment of some aspects of breech delivery; caesarean section in breech presentation and perinatal mortality at the University College Hospital, Ibadan, Nigeria. Trop J Obstet Gynecol 5: 31, 1985.
Preterm breech delivery in Northern Nigeria 9
Harrison KA: Child-bearing, Health and Social Priorities: A survey of 22 774 consecutive hospital births in Zaria, Northern Nigeria. Br J Obstet Gynaecol92(5): 22, 1985. 10 Ekwempu CC: The influence of antenatal care on pregnancy outcome. Trop J Obstet Gynecol8(2): 45, 1990. 11 Annon PJ: Management of singleton breech presentation. Trop Doctr 14: 167, 1984.
291
Address for reprinta: J.O. Emembolu Dept. of Obetrks & Gynaecology Altmadu Bell0 University Teaching Hospital Zaria, K&ma State Nigeria
Article