Papp, Breech deliveries and cesarean section J. Perinat. Med. 31 (2003) 415–419 415 Breech deliveries and cesarean section Zoltán Papp I. Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary 1 Introduction Three to four percent of singleton pregnancies at term are complicated by breech presentation. Complications occur in about 60% of breech deliveries. Fetuses with breech presentation are at increased risk of birth injuries and hypoxia during vaginal delivery. The management of breech presentation is in a state of flux at the present time. Use of cesarean section is increasing. External version – even with the use of tocolytic agents for relaxation – is dangerous because of its possible complications. Cesarean sections in large hospitals in developing countries have a case mortality rate of 0.6–1.1%. It may be much higher in smaller hospitals. Although most mortality is related to the indication of cesarean section, in some patients the operation itself may be the cause of maternal death. Cesarean section for breech presentation should, therefore, be prevented as much as possible in hospitals with limited resources in developing countries. In these countries the attending personnel need to be trained to perform breech deliveries to safely deliver these fetuses [18]. Breech presentation is the most common malpresentation, with about 3–4% of singleton fetuses presenting breech at delivery. Management of breech presentation has been a contentious issue with a lowering threshold for cesarean section in recent years. The recent publication of the term breech trial by Hannah et al [6] is likely to place vaginal breech delivery in the pages of history in the developed world. However, the technique of trauma free breech delivery is important, as there will be situations where vaginal breech delivery will be unavoidable. In addition, it is important to remember the technique of vaginal breech deliv- ery as the same principles apply to delivery of the breech through a uterine incision. The incidence of breech presentation depends on the gestational age. Nearly 25–30% of all fetuses will present as breech before 28 weeks, but by 34 weeks the majority will have converted to cephalic presentation. About 3–4% of all pregnancies at term will be in breech presentation. 2 Types of breech presentation There are three types of breech presentation. 1. Frank or extended breech. The lower extremities are fully flexed at the hip and fully extended at the knee. The presenting part tends to fit snugly into the lower segment and therefore the incidence of cord prolapse is low. This is the most common type, occurring in 60–70% of cases. It is also seen more frequently in the primigravida as term approaches. 2. Complete or flexed breech. The hips and knees of the fetus are flexed, with buttocks and feet at the same level. The presenting part is more irregular and therefore early engagement is less likely and prolapse of the cord is slightly more common. This is the least common type, occurring in 10% of pre-term and term breeches. 3. Incomplete breech/footling breech. This is most common in pre-term singleton breeches and occurs in 20–25% of infants weighing more than 2500 g. Presentation of one or both feet is more common than knee presentation. Apart from a high risk of cord prolapse, delivery of the fetus up to the thorax with entrapment of the fetal head may occur through an incompletely dilated cervix. © 2003 by Walter de Gruyter GmbH & Co. KG Berlin · New York Brought to you by | University of Michigan Authenticated Download Date | 6/18/15 10:25 PM 416 3 Papp, Breech deliveries and cesarean section Potential fetal complications Perinatal mortality and morbidity are estimated to be three times that of comparable infants with vertex presentation [11]. Breech presentation is commonly associated with certain adverse maternal and fetal factors which inherently give rise to increased perinatal morbidity and mortality. Trauma and hypoxia are the two principal factors contributing to increased perinatal morbidity and mortality, and their effects depend on the gestational age. Nevertheless, the incidence of respiratory problems in the newborn in a large study was 0.4% among those delivered by elective cesarean section, almost five-fold higher than those delivered vaginally [12]. Maternal mortality after cesarean section is three to seven times higher than after vaginal birth [10, 19]. 3.1 Term breech Neurological injuries may result from traumatic delivery and in this context hyperextension of the fetal head may be important. In breech deliveries conducted vaginally, hyperextension of the fetal head has been associated with intracerebral bleeding, tentorial tears, subdural hematomas and cervical cord laceration. Breech presentation is a sign of potential handicap, and elective planned cesarean section has been suggested to reduce the effects of trauma and hypoxia [2, 8]. 4 Management 4.1 External cephalic version Complications of external cephalic version include transient bradycardia, abruption of the placenta, cord complications, feto-maternal hemorrhage with possible sensitization, pre-labor rupture of membranes and failure of the procedure. Success rates increase with non-frank breech presentation, normal amniotic fluid volume and multiparity. An appropriately trained person should perform external cephalic version. In most units external cephalic version is becoming a routine for uncomplicated breech presentation. More research is needed to evaluate women’s views on external cephalic version [20]. 4.2 Pre-term breech Cerebellar damage and ataxic cerebral palsy are important sequelae of hypoxic insult. The effect of trauma can range from widespread bruises of limbs and body to damage to the internal organs, transection of the spinal cord, nerve palsies and fracture of long bones. Therefore, hypoxia and trauma, along with prematurity, increase the risk of poor outcome. 3.2 tation. Because the majority of breech presentations spontaneously convert to vertex as pregnancy progresses, and because of potential complications, many dislike this procedure [9]. With the publication of the term breech trial, external cephalic version remains the only means of reducing cesarean section rate for breech presen- Cesarean section versus vaginal breech delivery Pre-term breech. Cesarean section will probably reduce the trauma, but is unlikely to eliminate it [4]. The outcome is mostly gestational-age-dependent. At present, most obstetricians favor cesarean delivery for uncomplicated pre-term breech. Controlled prospective studies have shown that the outcome of breech fetuses weighing more than 1500 g is not dependent on the mode of delivery [1, 16, 17]. A more recent review from the Cochrane database by Grant does not justify a policy of elective cesarean section for preterm breech [5]. In the absence of good evidence that a pre-term breech baby needs to be delivered by cesarean section, a decision about mode of delivery should be made after discussion with the woman, her partner and the pediatrician. Term breech. A critical review of literature in 1993 [2] set the stage for a Canadian multicenter term breech trial [6]. At 121 centers in 26 countries, 2188 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned cesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up until six weeks postpartum. The primary outcomes were perinatal mortality, neonatal mortality or serious neonatal morbidity, and maternal mortality or serious maternal morbidity. Data were received for J. Perinat. Med. 31 (2003) Brought to you by | University of Michigan Authenticated Download Date | 6/18/15 10:25 PM Papp, Breech deliveries and cesarean section 417 2083 women. Of the 1041 women assigned planned cesarean section, 941 (90.4%) were delivered by cesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned cesarean section group than for the planned vaginal birth group (17 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19–0.56]; p < 0.0001).There were no differences between the groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79–1.95]; p = 0.35). The conclusion of this study is that planned cesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups [6]. The trial had to be stopped on April 21st, 2000, as the difference in the rate of primary outcome (perinatal mortality and morbidity) between the two groups was significant. Perinatal mortality, neonatal mortality or serious neonatal morbidity was significantly lower for the planned cesarean section group than for the planned vaginal birth group (l.5 versus 5.0%, relative risk 0.33, 95% CL 0.19–0.56; P < 0.0001). As many as 39 cesarean sections may be necessary to avoid one dead or severely compromised baby in developing countries whereas the number of additional sections in developed countries may be as low as seven. In a multiethnic population 70.7 % of candidates selected for attempted vaginal breech delivery at term were successful. The remaining 29.3 % underwent cesarean delivery for labor disorders or non-reassuring fetal heart rate patterns [3]. Planned cesarean delivery for pregnancies with breech presentation at term may result in a lower risk of incontinence and is not associated with an increased risk of other problems for women at three months postpartum, although the effect on longer-term outcomes is uncertain [7]. These findings, however, have been criticized for methodological reasons [13, 14, 21]. Prevention of cesarean section for breech presentation could be the most effective way to reduce the complication rate. As preterm labor is the most common cause of breech presentation, prevention of preterm labor will give many fetuses time to turn to cephalic presentations. After 36 weeks, external cephalic version might be done. In this regard it is essential to have an antenatal visit scheduled at 36 weeks’ gestation to determine the position of the fetus by palpation. Ultrasound may be helpful to confirm breech presentation, but it is not essential as ultrasound is not always easily accessible in developing countries. In cases of breech presentation elective cesarean section should be considered if external version fails. Vaginal delivery should not be allowed and elective cesarean section is indicated in the following cases: • Estimated fetal weight over 3,500 g • Small pelvis • Additional complications (e.g. diabetes mellitus) • Previous baby with birth injuries • Previous difficult vaginal delivery. A high presenting part at full dilatation of cervix is a warning that the pelvis may be smaller or that the fetus may be larger than originally assessed. Therefore one should not attempt to pull the presenting part down, but consider cesarean section. Indications for emergency cesarean delivery: • Footling presentation • Poor flexion of head • Estimated fetal body weight under 1,500 g or more than 3,500 g • Poor progress • High presenting part at full dilatation of the cervix • Fetal distress • Cord prolapse. At cesarean section for breech delivery, good exposure and, therefore, an abdominal wound and uterine incision of sufficient size are essential. Cesarean section is sometimes done in patients long before term or where the fetus is severely growth retarded. Under these circumstances the lower segment may be poorly formed and narrow. It is then better to do a vertical incision as it may be easily elongated cephalically, should difficulty in the delivery of the head be encountered. If patients are carefully selected and the guidelines for vaginal breech delivery are strictly adhered to, the fetus will be delivered safely and un- J. Perinat. Med. 31 (2003) Brought to you by | University of Michigan Authenticated Download Date | 6/18/15 10:25 PM 418 Papp, Breech deliveries and cesarean section necessary cesarean section, which would cause maternal harm, will be avoided. After exclusion of obvious contraindications to vaginal birth such as macrosomia, placenta praevia, hydrocephalus or previous difficult vaginal delivery, a cesarean delivery is only done when there is abnormal progress of labor or when the fetal heart rate is not completely normal. Adequate training by experienced clinicians and a physiologic approach to labor in this normal fetal presentation will also lead to relatively low cesarean delivery rates [7]. In our practice, vaginal delivery is preferred if the following criteria are met: frank breech only, estimated fetal weight of 2500–3500 g, adequate pelvimetry without hyperextended head, normal progression of labor, no evidence of fetal hypoxia with continuous fetal monitoring, and maternal weight under 90 kg. Vaginal delivery of frank breech at term may be just as safe as cesarean section when careful selection criteria are used. If these criteria are not fulfilled, or the fetal monitoring cannot be performed, cesarean section is advisable. The increasing rate of cesarean section has significantly lowered the perinatal morbidity and mortality in developed countries in the past decades. There will be circumstances when vaginal delivery will be unavoidable. The following situations are important [15]: • Women may choose to deliver vaginally. • Cesarean section is planned but labor occurs too quickly. Nearly 10% of women for whom cesarean section was planned in the term breech trial delivered vaginally. • Labor and delivery may occur at a site where facilities for cesarean section may not be available. • Incorrect diagnosis of presenting part – frank breech may be mistaken for cephalic presentation until second stage. • Delivery of the second twin breech presentation. In addition to these situations it is important to be adept with the skills of vaginal breech delivery as the same atraumatic principles of assisted breech delivery are necessary to deliver the breech through the uterine incision at cesarean section. Abstract Breech presentation is the most common malpresentation, with about 3–4% of singleton fetuses presenting breech at delivery. Management of breech presentation has been a contentious issue with a lowering threshold for cesarean section in recent years. Perinatal mortality and morbidity are estimated to be three times that of comparable infants with vertex presentation. Breech presentation is commonly associated with certain adverse maternal and fetal factors which inherently give rise to increased perinatal morbidity and mortality. At present, most obstetricians favor cesarean delivery for uncomplicated pre-term breech. Controlled prospective studies have shown that the outcome of breech fe- tuses weighing more than 1500 g was not dependent on the mode of delivery. A more recent review from the Cochrane database by Grant does not justify a policy of elective cesarean section for pre-term breech. Vaginal delivery is preferred if the following criteria are met: frank breech only, estimated fetal weight of 2500–3500 g, adequate pelvimetry without hyperextended head, normal progression of labor, no evidence of fetal hypoxia under continuous fetal monitoring, and maternal weight under 90 kg. Vaginal delivery of frank breech at term may be just as safe as cesarean section when careful selection criteria are used. If these criteria are not fulfilled, or fetal monitoring cannot be performed, cesarean section is advisable. Keywords: Breech presentation, cesarean delivery. References [1] Brown L, T Karrison, M Cibilis: Mode of delivery and perinatal results in breech presentation. Am J Obstet Gynecol 171 (1994) 28 [2] Cheng M, M Hannah: Breech delivery at term: a critical review of literature. Obstet Gynecol 82 (1993) 605 [3] Diro M, A Puangsricharern, L Royer, MJ O’Sullivan, G Burkett: Singleton term breech deliveries in nulliparous and multiparous women: A 5-year experience at The University of Miami/Jackson Memorial Hospital. Am J Obstet Gynecol 181 (1999) 247 J. Perinat. Med. 31 (2003) Brought to you by | University of Michigan Authenticated Download Date | 6/18/15 10:25 PM Papp, Breech deliveries and cesarean section 419 [4] Görbe É, S Chasen, Á Harmath, P Patkós, Z Papp: Very-low-birthweight breech infants: Short-term outcome by method of delivery. J Matern Fetal Med 6 (1997) 155 [5] Grant A: Elective vs selective caesarean for delivery of the small baby. Cochrane Databases systematic review 2000, Issue 4 [6] Hannah ME, WJ Hannah, SA Hewson, ED Hodnett, S Saigal, AR Willan for the Term Breech Trial Collaborative Group: Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 356 (2000) 1375 [7] Hannah ME, WJ Hannah, ED Hodnett, B Chalmers, R Kung, A Willan, K Amankwah, M Cheng, M Helewa, S Hewson, S Saigal, H Whyte, A Gafni: Outcomes at 3 months after planned Caesarean vs planned vaginal delivery for breech presentation at term. JAMA 287 (2002) 1822 [8] Herbst A, K Thorngren-Jerneck: Mode of delivery in breech presentation at term: increased neonatal morbidity with vaginal delivery. Acta Obstet Gynecol Scand 80 (2001) 731 [9] Hofmeyer GJ: External cephalic version for breech presentation at term. Cochrane database systematic review 2000, Issue 4 [10] Jolly J, J Walker, K Bhabra: Subsequent obstetric performance related to primary mode of delivery. Br J Obstet Gynaecol 106 (1999) 227 [11] Kuppila O: The perinatal mortality in breech delivery and observation on affecting factors. A retrospective study of 2227 cases. Acta Obstet Gynecol Scand 39 (1975) 1 [12] Levine EM, V Gai, JJ Barton, CM Strom: Mode of delivery and risk of respiratory diseases in newborns. Obstet Gynecol 97 (2001) 439 [13] Lumley J: Any room left for disagreement about assisting breech births at term? Lancet 356 (2000) 1368 [14] Lydon-Rochelle M, VL Holt, DP Martin, TR Easterling: Association between method of delivery and maternal rehospitalization. JAMA 283 (2000) 2411 [15] Mukhopadhyay S, S Arulkumaran: Breech delivery. Best Pract Res Clin Obstet Gynaecol 16 (2002) 31 [16] Nisell H, P Bistoletti, C Palms: Preterm breech delivery. Early and late complications. Acta Obstet Gynecol Scand 60 (1981) 363 [17] Penn ZJ, PH Steer, A Grant: A multicentre randomised controlled trial to compare elective versus selective caesarean section for the delivery of the preterm breech infant. Br J Obstet Gynaecol 103 (1996) 684 [18] Pereira C, A Bugalho, S Bergström, F Vaz, M Cotiro: A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique. Br J Obstet Gynaecol 103 (1996) 508 [19] Schuitemaker N, J van Roosmalen, G Dekker, P van Dongen, H van Geijn, GJ Bennebroek: Maternal mortality after caesarean section in The Netherlands. Acta Obstet Gynecol Scand 75 (1997) 332 [20] Shennan A, S Bewley: How to manage term breech deliveries. Avoid vaginal breech deliveries but offer external cephalic version. BMJ 323 (2001) 244 [21] van Roosmalen J, F Rosendaal: There is still room for disagreement about vaginal delivery of breech infants at term. Br J Obstet Gynaecol 109 (2002) 967 Zoltán Papp MD, PhD, DSc H-1088 Budapest Baross u. 27 Hungary J. Perinat. Med. 31 (2003) Brought to you by | University of Michigan Authenticated Download Date | 6/18/15 10:25 PM
