VAGINAL BREECH DELIVERY IS THIS THE LAST WE HEARD

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Vaginal Breech Delivery: Is this the last we heard of it

VAGINAL BREECH DELIVERY: IS THIS THE LAST WE HEARD OF IT?

Raul Artal, M.D.

Professor and Chairman

Saint Louis University

Department of Obstetrics, Gynecology and Women’s Health

The management of breech presentation and its route of delivery have always been controversial and considered a challenge for obstetricians.

Prior to 1960 less than 10% of patients with breech presentation underwent Cesarean sections. During the past three decades, particularly in the USA, it has been reported a steady decline in singleton vaginal breech deliveries. In year 2000 the National Center for Health Statistics reported that 84.2% of pregnancies with breech presentation in the USA were delivered by Cesarean section.

Several factors have led to this dramatic change in the standard of practice. Foremost the strive to continuously lower maternal and perinatal morbidity and mortality and the prevailing consensus that planned Cesarean sections have consistently better outcome. With the decline in vaginal deliveries fewer and fewer individuals were either trained or gained expertise in vaginal breech deliveries. Another significant factor influencing the obstetrician’s current choice of practice has also been the progressive impact of legal liability.

Prior to 1960 the reported incidence of significant fetal morbidity and mortality in many institutions was 10-25%. After 1960 the reported fetal mortality was still significant 1-3%, while the maternal morbidity associated with these deliveries was as high as 50%. (2) Several studies and reviews over the past decade have reached the inescapable conclusion that even the most skilful obstetricians experienced/reported significant morbidity while performing vaginal breech deliveries. By year 2000 many reports and institutions have instituted the policy that planned Cesarean delivery for term breech presentation is significantly safer than vaginal delivery. (Table I, II)

Table I

Effect of Vaginal Delivery for Term Breech

Presentation Neonatal Morbidity

No. injured/no of deliveries

Vaginal Cesarean Odds Ratio 85% CI

Anderman et al 8/108 2/117 3.80 1.107-13.49

Barlov & Larsson 7/125 1/100 3.80 0.92-15.88

Bistoletti et al 22/313 0.53 3.46 1.102-11.75

Collea et al 2/115 0.93 6.16 0.38-99.99

Flanagan et al 14/232 3/357 6.36 2.37-17.05

Gimovsky & Petrie 6/204 2/463 8.28 1.83-37.87

Kaupilla 53/790 0/222 3.86 1.98-7.53

Ohlsen 16/288 0/52 3.44 0.85-18.84

Songane et al 19/599 1/255 3.37 1.28-8.87

Typical odds ratio 3.96 2.76-5.67

Table II

Effect of Vaginal Delivery for Term Breech

Presentation on Corrected Perinatal Mortality

No. of deaths/No. of deliveries

Vaginal Cesarean Odds Ratio 95% CI

Bistoletti et al 0/309 0/52 1.00 1.00-1.00

Collea et al 0/114 0/93 1.00 1.00-1.00

Flanagan et al 0/244 0/375 1.00 1.00-1.00

Gimovsky & Petrie 0/204 1/463 5.50 0.47-64.35

Kauppila 22/1383 0/287 3.40 1.11-10.36

Ohlsen 5/288 0/52 3.30 0.29-38.26

Roumen & Luyben 2/234 0/13 2.89 0.01-.99

Songane et al 6/602 0/255 4.19 0.72-4.22

Thorpe-Beeston et al 8/1990 1/1457 3.60 0.96-18.52

Woodward & Callahan 2/95 0/5 2.90 0.00-99.99

Typical odds ratio 3.86 2/22-6.69

Between 1965-1975 emphasis was placed on carefully planned vaginal deliveries by “skilled obstetricians” who included in their management scheme pelvimetry, limited fetal weight to below 3500 gm, anesthesia and closely assessed labor progress. With this approach the perinatal morbidity and mortality was lowered in some centers, however it still exceeded the one reported for planned Cesarean sections.

Roman et al (15) reported on 15,818-singleton term breech vaginal deliveries conducted in Sweden between 1987-1993. The authors of this large study indicated that most obstetricians in Sweden followed the recommendation that breech vaginal delivery should be attempted only if the following conditions are met: gestational age is more than 34 completed weeks, estimated fetal weight (by ultrasound) is more than 2000 grams but less than 4000 grams and pelvic size considered adequate after pelvimetry. Nevertheless this very large retrospective cohort study conclusions were that vaginal delivery of term breech presenting infants is associated with higher risk of neonatal mortality and morbidity compared with delivery by elective cesarean section, and that term singleton infants in the breech presentation would benefit from an elective cesarean section.

In 1998 Kwang-Sun Lee et al (16) reported on the U.S.A. experience between 1989-1991, which included a total of 371,692 singleton live births with breech presentation. In this very large study singleton live births with breech presentation delivered by cesarean section had a lower birth weight- specific neonatal mortality as compared with vaginal births 3.2 vs. 5.3.

And ultimately a pivotal study was published in 2000 by Hannah et al (18). The study strengths were in its design and the large number of subjects. Conducted in 121 centers, 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned to planned cesarean section or planned vaginal birth.

The study clearly defined the eligibility criteria (term, breech singletons etc.) and clearly defined exclusion criteria (fetopelvic disproportion, fetal anomalies and other). Management of labor and delivery were clearly stated and carried out: elective cesarean section at 38 weeks after documented mature fetal lung profile. Cesarean section was also done for footling breech, fetal heart rate abnormalities or dysfunctional labor. The deliveries were conducted by “experienced” obstetricians. The randomization was properly conducted by parity with a block size of two. The treatment groups were clearly defined and a follow-up was conducted at 6 weeks postpartum. The study also included appropriate primary and secondary maternal and neonatal outcomes.

The statistical analysis was appropriate. The researchers collected and recorded all appropriate outcome data. The primary outcome included perinatal and neonatal morbidity (such as neurological sequelae, Apgar scores less than 4 at 5 minutes, cord blood base deficit greater than 15, intubation within 24 hours of delivery).

The secondary outcome included maternal mortality or significant morbidity (postpartum hemorrhage, hysterectomy, cervical lacerations and other).

The statistical analysis was a multiple logistic regression, which tested between baseline characteristics and a multitude of outcomes.

The sample size of the Hannah et al study was calculated to yield an 80% power to detect a reduction in perinatal and neonatal mortality or significant morbidity from 0.8% to 0.1% after elective cesarean section.

The results of the Hannah et al study were compelling in that planned cesarean section for term singleton breech presentation would save one infant from death or significant morbidity for every seven cesareans.

The Hannah et al study had limitations. There was poorer compliance for women allocated to planned vaginal vs. cesarean delivery (56.7% vs. 90.4%).

The information on physician skill for delivering breech infants was limited.

There was a possible detection bias from under-reporting significant neonatal morbidity (0.4% in planned c/section vs. 5.1% in the planned vaginal delivery group) for countries with high perinatal rates.

However, despite all the above pitfalls, a thorough analysis under evidence-based guidelines is conclusive and difficult to argue with. This is a first rate clinical trial without limitations.

The treatment effect had a significant relative risk reduction (RRR). Based on the study design and results the evidence-based clinical practice recommendation and grading is a 1A.

In 2001 the Cochrane registry has observed that 550 of 1227 (45%) women with term breech presentations assigned to vaginal delivery protocols were delivered by cesarean section and that planned cesarean delivery was associated with greatly reduced risks of corrected perinatal and neonatal death (OR 0.29, 95% CI O. l0,086). (17)

Low risk patients that had delivered vaginally experience a more than X3 fold increase in infant mortality.

In 2001 the Royal College of Obstetricians and Gynecologists (Guide line No. 20) recommended that: “The Best method of delivering a term frank or complete breech singleton is by planned cesarean section.”

Currently there is insufficient evidence to support routine cesarean section for the delivery of term breech and to support cesarean section for the delivery of the first or second twin.

Later in 2001 ACOG, as a result of findings of the study (Hannah et al), recommended that planned vaginal delivery of a singleton term breech may no longer be appropriate. In those instances in which breech vaginal deliveries are pursued, great caution should be exercised. Patients with persistent breech presentation at term in singleton gestation should undergo a planned cesarean section.

In view of these recommendations and other realities in the U.S., several practice guidelines prevail:

The recommended method of delivery for a term breech is elective C/section.
Occasional inevitable vaginal breech deliveries will still occur.
Vaginal breech deliveries will be taught in residency programs.
External cephalic versions will be increasingly used.
Individual patients will be delivered vaginally at request only (with informed consent).
Will the pendulum swing back? Difficult to say, but probably not. It appears the skill to conduct a vaginal breech delivery will slowly disappear.

References

ACOG Committee Opinion No. 265: Mode of Term Singleton Breech Delivery Obstet Gynecol 2001;98:1189-90
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
Anderman S, Ellenbogen A, Jaschevatzky OE, Grunstein S. Is term breech presentation in primigravida an absolute indication for cesarean section? Eur J Obstet Gynecol Reprod Biol 1984;18:11-16.
Bistoletti P, Nesell H, Palme C, Lagercrantz H. Term breech delivery: Early and late complications. Acta Obstet Gynecol Scand 1981;60:165-71.
Barlov K, Larsson G. Results of a five-year prospective study using a feto-pelvic scoring system for term singleton breech delivery after uncomplicated pregnancy. Act Obstet Gynecol Scan 1986;65:315-19.
Flanagan TA, Mulchahey KM, Korenbrot CC, Green R, Laros RK. Management of term breech presentation. Am J Obst Gynecol 1987;156:1492-1502
Gimovsky ML, Petrie RH. The intrapartum management of the breech presentation. Clin Perinatol 1989;16:976-86.
Kaupilla O. The perinatal mortality in breech deliveries and observations on affecting factors: A retrospective study on 2,227 cases. Acta Obstet Gynecol Scand Suppl 1975;39:1-79.
Ohlsen H. Outcome of term breech delivery in primigravidae. A feto-pelvic breech index. Acta Obstet Gynecol Scand. 1975;54:141-51.
Songane FF, Thobani S, Malik H, Bingham P, Lilford RJ. Balancing the risks of planned elective cesarean section and trial of vaginal delivery for the mature, selected singleton breech.
Roumen FJME, Luyben AG. Safety of term vaginal breech. Eur J Obstet Gynecol Reprod Biol. 1991;40:171-77.
Thorpe Beeston JG, Bonfield PJ, Saunders NJ. Outcome of breech delivery at term. Br Med J. 1992;305:746-47.
Woodward RW, Callahan WE. Breech labor and delivery in the primigravida. Obstet Gynecol 1969;34:260-65.
Cheng M, Hannah M. Breech delivery at term: A critical review of the literature. Obstet Gynecol 1993;82:605-18.
Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by mode of delivery among term breech births: Swedish experience 1987-1993. Obstet Gynecol 1998;92:945-50.
Kwang-Sun Lee, Khoshnood B. Siriam S. Hsieh HL, Singh J and Mittdendorf R. Relationship of cesarean delivery to lower birth weight-specific neonatal mortality in singleton breech infants in the United States. Obstet Gynecol 1998;92:769-74.
Cochrane Database Syst Rev 2001;1:CD00166
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, et al. Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Lancet 2000;356:1375-83.
Royal College of Obstetricians and Gynecologists: Guideline No. 20, 2001

ENDOMETRIAL PATOLOJILERIN DEĞERLENDIRILMESINDE TRANSVAGINAL ULTRASONOGRAFI SALINE INFUSION SONOHISTEROGRAFI VE
MEDICAL DIRECTIVE TITLE ASSESSMENT AND TREATMENT OF VAGINAL YEAST
NISTAT NISTATINA COMPRIMIDOS RECUBIERTOS – COMPRIMIDOS VAGINALES SUSPENSIÓN

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