Breech presentation at term and associated obstetric risks factors-a nationwide population based cohort study

The association of assisted reproductive technology with fetal malpresentation: a systematic review and meta-analysis

BACKGROUND

Since its introduction, assisted reproductive technology (ART) has developed into a common clinical practice around the world; yet it still raises a lot of questions. Throughout time, many researchers have investigated its association with several obstetric incidences and its consequences on perinatal outcomes. The aim of the current meta-analysis was to estimate the correlation between ART procedures and malpresentation of the fetus in singleton pregnancies.

METHODS

The study was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) guidelines and prospectively registered under the PROSPERO database (CRD42023458084). Five databases (Embase, MEDLINE®, APA PsycInfo, Global Health, Health Management Information Consortium (HMIC)) and two additional sources were searched from inception to 31 May 2023. Quality of the included studies was assessed using the ROBINS-1 scale, whilst quality of evidence by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. Summative and subgroup data as well as heterogeneity were generated by the Cochrane platform RevMan Web.

RESULTS

Overall, 11 studies were included in the study with a total of 3,360,134 deliveries. Results indicate a higher risk of malpresentation at delivery in fetuses conceived through ART than those conceived naturally (RR: 1.50, (95% confidence interval (CI):1.30, 1.73)). This risk decreased when adjustments for potential confounders were applied (RR = 1.12, 95% CI 1.02, 1.23).

CONCLUSIONS

Based on observational studies, this meta-analysis indicated that singleton pregnancies conceived through ART are associated with higher risk of malpresentation than those conceived naturally, albeit the difference was lower when potential confounders were examined. Thus, future large studies are required to better understand possible reversible and irreversible factors of this relationship.

Malpresentation and autism spectrum disorder in the study to explore early development

BACKGROUND

An infant's presentation at delivery may be an early indicator of developmental differences. Non-vertex presentation (malpresentation) complicates delivery and often leads to caesarean section, which has been associated with neurodevelopmental delays, including autism spectrum disorder (ASD). However, malpresentation could be an early sign of an existing developmental problem that is also an upstream factor from caesarean delivery. Little research has been done to investigate the association between malpresentation and ASD.

OBJECTIVES

We examine the association between malpresentation at delivery and ASD and whether this association differs by gestational age.

METHODS

We used data from the Study to Explore Early Development (SEED), a multi-site, case-control study of children with ASD compared to population controls. The foetal presentation was determined using medical records, birth records and maternal interviews. We defined malpresentation as a non-vertex presentation at delivery, then further categorised into breech and other malpresentation. We used multivariable logistic regression to estimate the adjusted odds ratio (aOR) for the association between malpresentation and ASD.

RESULTS

We included 4047 SEED participants, 1873 children with ASD and 2174 controls. At delivery, most infants presented vertex (n = 3760, 92.9%). Malpresentation was associated with higher odds of ASD (aOR 1.31, 95% confidence interval [CI] 1.02, 1.68) after adjustment for maternal age, poverty level, hypertensive disorder and smoking. The association was similar for breech and other types of malpresentation (aOR 1.28, 95% CI 0.97, 1.70 and aOR 1.40, 95% CI 0.87, 2.26, respectively) and did not differ markedly by gestational age.

CONCLUSIONS

Malpresentation at delivery was modestly associated with ASD. Early monitoring of the neurodevelopment of children born with malpresentation could identify children with ASD sooner and enhance opportunities to provide support to optimise developmental outcomes.

Corrected evaluation of the breech presentation outcome based on etiology of this presentation in congenitally malformed uterus

Background

Breech presentation (BP) results from at random filling of the intrauterine cavity, with an equal probability for a BP or cephalic presentation (CP). Each fetus in BP has its "pair" in CP randomly assumed CP. Direct comparison of BP and CP makes bias to less expressed differences between these two groups. It is therefore necessary to subtract the number of fetuses/newborns from the CP set that are identical to the number of fetuses/newborns in the BP set, with identical characteristics, and add this group to the BP set before comparing them to the rest of the CP fetuses/newborns in the matching process.

Methods

The procedure encompasses nine variables in pregnancies with a congenitally malformed uterus (CMU) identified at the Department of Obstetrics (1985-2014): gestational age, birth mass, birth length, head circumference, shoulders circumference, umbilical length, placental weight, newborn mass/newborn length ratio, and newborn mass/placental mass ratio. Firstly, the probability of BP was determined and its relation to gestational age, physical characteristics, and previous presentations. Then direct comparison as well as case-control matching of the CP and BP were performed. Case-control matching was based on either a single specific variable (M1) or all combined variables (M2).

Findings

462 deliveries were identified with CMU. In 81 cases of multiparity, a fetal presentation was found to be an independent event regardless of the previous presentation, gestational age, and newborn physical characteristics. In four types of CMU with 337 deliveries (Bicornuate, Didelphys, Unicornuate, Arcuate), 9 variables with 36 instances of comparison were observed. M1 in 10 instances and M2 in 6 instances showed a statistically significant lower value of breech/random presentation compared with CP. CP have lower value in 2 instances in M1 and 1 in M2. Statistically significant differences were absent without the matching process.

Interpretations

The study confirms the maximum probability for the BP is 50%. The case-control matching procedure shows that it is able to detect the difference between the breech/random presentation and CP, while the classic method of direct comparison was unable to detect any differences. The outcome of the breech/random presentation in CMU should be evaluated with the described case-control matching procedure.

Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study

BACKGROUND

Accurate knowledge of fetal presentation at term is vital for optimal antenatal and intrapartum care. The primary objective was to compare the impact of routine third trimester ultrasound or point-of-care ultrasound (POCUS) with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes.

METHODS AND FINDINGS

This was a retrospective multicentre cohort study where we included data from St. George's (SGH) and Norfolk and Norwich University Hospitals (NNUH). Pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH). Women with multiple pregnancy, preterm birth prior to 37 weeks, congenital abnormality, and those undergoing planned cesarean section for breech presentation were excluded. Undiagnosed breech presentation was defined as follows: (a) women presenting in labour or with ruptured membranes at term subsequently discovered to have a breech presentation; and (b) women attending for induction of labour at term found to have a breech presentation before induction. The primary outcome was the proportion of all term breech presentations that were undiagnosed. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE), and perinatal mortality (including stillbirths and early neonatal deaths). We employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood). The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models. All analyses were conducted using R for Statistical Software (v.4.2.0). Before and after the implementation of routine third trimester scan or POCUS, there were 16,777 and 7,351 births in SGH and 5,119 and 4,575 in NNUH, respectively. The rate of breech presentation in labour was consistent across all groups (3% to 4%). In the SGH cohort, the percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before (years 2016 to 2020) and 2.8% (7/251) after (year 2020 to 2021) the implementation of universal screening (p < 0.001). Similarly, in the NNUH cohort, the percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before (year 2015) and 3.5% (5/142) after (year 2020 to 2021) the implementation of universal POCUS screening (p < 0.001). Bayesian regression analysis with informative priors showed that the rate of undiagnosed breech was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9%. Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9%. There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). We do not have reliable data on number of facility-based ultrasound scans via the standard antenatal referral pathway or external cephalic versions (ECVs) performed during the study period.

CONCLUSIONS

In our study, we observed that both a policy of routine facility-based third trimester ultrasound or POCUS are associated with a reduction in the proportion of term breech presentations that were undiagnosed, with an improvement in neonatal outcomes. The findings from our study support the policy of third trimester ultrasound scan for fetal presentation. Future studies should focus on exploring the cost-effectiveness of POCUS for fetal presentation.

What to do when it is breech? A state-of-the-art review on management of breech presentation

Any non-cephalic presentation in a fetus is regarded as malpresentation. The most common malpresentation, breech, contributes to 3%-5% of term pregnancies and is a leading indication for cesarean delivery. Identification of risk factors and a proper physical examination are beneficial; however, ultrasound is the gold standard for the diagnosis of malpresentations. External cephalic version (ECV) refers to a procedure aimed to convert a non-cephalic presenting fetus to cephalic presentation. This procedure is performed manually through the mother’s abdomen by a trained health care provider, to reduce the likelihood of a cesarean section. Studies have reported a version success rate of above 50% by ECV. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus. The focus is to elaborate all clinical scenarios of breech and to provide an evidence-based clinical approach for them. After discussing breech prevalence, risk factors, diagnosis, and management, an updated review of ECV is presented. Moreover, ECV indications/contraindications, alternatives, clinical techniques on how to perform ECV and breech vaginal delivery, and obstetrical considerations for the delivery of malpresentations are thoroughly discussed.

[Perinatal risk factors for the occurrence of singleton apparently stillborn infants]

OBJECTIVES

To identify the perinatal risk factors for the occurrence of singleton apparently stillborn infants.

METHODS

This was a case-control study. A total of 154 singleton neonates with gestational age ≥28 weeks and Apgar score of 0-1 who were subsequently successfully resuscitated in the Obstetrics and Gynecology Hospital of Fudan University from January 2006 to December 2015 were enrolled as the case group (apparently stillborn group). A total of 616 singleton infants born from January 2006 to December 2015 (1-minute Apgar score >1) were randomly selected in a 1:4 ratio as the control group. Univariate analysis and multivariate logistic regression were used to analyze the perinatal risk factors for the occurrence of apparently stillborn infants.

RESULTS

The gestational age and birth weight in the apparently stillborn group were significantly lower than those in the control group (P<0.05). The incidences of fetal hydrops, cord prolapse, grade III meconium-stained amniotic fluid, placental abruption, breech presentation, severe pre-eclampsia, maternal general anesthesia at delivery, abnormal antenatal fetal heart monitoring and decreased fetal movement were significantly higher in the apparently stillborn group than those in the control group (P<0.05). The multivariate logistic analysis showed that the mother had general anesthesia at delivery (OR=34.520), decreased antenatal fetal movement (OR=28.168),placental abruption (OR=15.641), grade III meconium-stained amniotic fluid (OR=6.365), abnormal antenatal fetal heart monitoring (OR=5.739), and breech presentation (OR=2.614) were risk factors for the occurrence of apparently stillborn infants (P<0.05), while higher gestational age was a protective factor (OR=0.686, P<0.05).

CONCLUSIONS

Attention needs to be paid to mothers with abnormal prenatal fetal heart monitoring, decreased fetal movement, preterm labor, placental abruption, breech presentation, grade III meconium-stained amniotic fluid, and general anesthesia. Preparations for resuscitation should be done to rescue apparently stillborn infants.

Depression, anxiety and stress in women with breech pregnancy compared to women with cephalic presentation-a cross-sectional study

PURPOSE

This study aims to evaluate the level of psychological distress for women with breech compared to cephalic presentation. We hypothesized, that women with breech presentation have higher levels of depression, stress and anxiety. Secondary objectives were to analyze potential demographic risk factors and comorbidity of psychological distress in breech pregnancy.

METHODS

The breech study group was formed by 379 women with breech presentation. A sample of 128 women with cephalic presentation was recruited during routine clinical care. Depression, anxiety and stress symptoms were ascertained by means of the Depression-Anxiety-Stress-Score (DASS)-21 questionnaire. Categorial data was analyzed with Chi-square or exact test, continuous data with unpaired t test or Mann-Whitney U test. Demographic risk factors were identified using a binary logistic regression model.

RESULTS

Prevalence of psychological distress among women with breech was not higher compared to those of other pregnant women. Symptomatic depression, anxiety and stress affected 5.8%, 14.5% and 11.9% of women with breech, respectively. Decreasing age was identified as a risk factor for anxiety (p = 0.006). Multiparity increased risk for depression (p = 0.001), for anxiety (p = 0.026) and for perinatal stress (p = 0.010). More than 80% of women with depressive symptoms had comorbidities of psychological distress.

CONCLUSIONS

Breech presentation compared to cephalic presentation was not associated with higher levels of psychological distress. However, breech pregnancies are affected by symptoms of potential mental disorder. Multiparous women and younger women may need additional support and would benefit from a standardized screening tool for the assessment of perinatal psychological distress.

CLINICAL TRIAL REGISTRATION

Ethical approval (EA2/241/18) was granted by the Ethics Commission of the Charité University Hospital on the 23.01.2019 (ClinicalTrials.gov Identifier: NCT03827226).

Use of external cephalic version for breech presentation at term: A national survey of Norwegian birth units

INTRODUCTION

International guidelines recommend that external cephalic version (ECV) be offered to all women with single fetuses in breech presentation at term. In Norway, ECV is not offered routinely; the national clinical guidelines advice that birth units capable of offering ECV for breech pregnancies make their own practice decisions. This study was performed to determine the extent to which Norwegian birth units offer ECV to pregnant women with fetuses in breech presentations at term, and to identify factors that might influence the use of ECV.

MATERIAL AND METHODS

A survey of all 39 obstetric birth units providing ECV in Norway was conducted using a self-reporting questionnaire about ECV availability, attitudes, clinical procedures, perceived competence, and outcome expectations.

RESULTS

Chief obstetricians from all birth units responded. Twenty-six (67%) respondents reported that their units offered ECV for breech presentation at term to a large degree. Thirty-one (80%) respondents reported a large degree of competence in performing ECV. Thirty-three (85%) units followed local ECV procedures. Nineteen (49%) units provided standardized information about the procedure to pregnant women. The respondents had different views about who should be offered ECV, and varying knowledge about ECV outcomes.

CONCLUSIONS

The majority of Norwegian birth units offer ECV to pregnant women with fetuses in breech position to a large extent. However, the survey results reveal challenges related to ECV information provision to pregnant women, determination of women's eligibility for ECV attempts, and familiarity and agreement with the knowledge base regarding ECV.

Factors Associated with the Chance of Carrying out a Primary Cesarean in a University Hospital

OBJECTIVE

 The present study seeks to identify the associated factors that increased primary cesarean delivery rates.

METHODS

 This was a cross-sectional study that evaluated the number of primary cesarean sections performed in the years 2006 and 2018 at the Hospital de Clínicas de Porto Alegre (HCPA, in the Portuguese acronym), through the collection of data from the medical records of the patients.

RESULTS

 Advanced maternal age, twin pregnancy, and higher body mass index (BMI) became more frequent in 2018 in comparison with 2006. To mitigate the impact of confounding in comparisons among groups, we made an adjustment by propensity scores and detected significant differences when comparing both age groups on twin pregnancy rates, gestational diabetes mellitus, and thyroid disease.

CONCLUSION

 Data from the present study can be used to prevent and improve the management of morbidities, impacting on better outcomes in obstetrical practice.

Neonatal outcome in vaginal breech labor at 32 + 0-36 + 0 weeks of gestation: a nationwide, population-based record linkage study

Background

In many countries, vaginal breech labor at term is an option in selected cases. However, the safety of vaginal breech labor in preterm is still unclear. Therefore our study aimed to evaluate the safety of vaginal breech labor in late preterm deliveries.

Design

A retrospective register-based study.

Setting

Maternity hospitals in Finland, 2004–2017.

Participants

The study population included 762 preterm breech deliveries at 32 + 0—36 + 6 gestational weeks according to the mode of delivery, 535 (70.2%) of them were born vaginally in breech presentation, and 227 (29.8%) were delivered by non-urgent cesarean section.

Methods

The study compared short-term neonatal adverse outcomes of singleton vaginal breech deliveries with non-urgent cesarean deliveries at 32 + 0 to 36 + 6 weeks of gestation. An odd ratio with 95% confidence intervals was calculated to estimate the relative risk of adverse outcomes.

Outcome measures

Neonatal death, an arterial umbilical pH below seven, a five-minute Apgar score below four and seven, admission to neonatal intensive care unit, neonatal intubation, neonatal antibiotic therapy, neonatal birth trauma, respiratory distress syndrome, neonatal convulsions, cerebral ischemia, hypoxic-ischemic encephalopathy, congenital hypotonia, and a composite of severe adverse outcomes.

Results

A five-minute Apgar scores below seven were increased in vaginal breech labor at 32 + 0 to 36 + 6 weeks of gestation compared to non-urgent cesarean sections (aOR 2.48, 95% CI 1.08–5.59). Neonatal antibiotic therapy, the admission to neonatal intensive care unit, and neonatal respiratory distress syndrome were decreased after vaginal breech labor compared to the outcomes of non-urgent cesarean section (neonatal antibiotic therapy aOR 0.60, 95% CI 0.40–0.89; neonatal NICU admission aOR 0.47, 95% CI 0.33–0.68; respiratory distress syndrome aOR 0.30, 95% CI 0.19–0.48).

Conclusion

Vaginal breech labor at 32 + 0—36 + 6 gestational weeks does not increase severe neonatal short-term morbidity or mortality compared to cesarean section.

Women’s experiences of breech birth decision making: An integrated review

INTRODUCTION

Currently, caesarean section is the primary mode of birth for a breech presenting fetus, leading to a deskilling of clinicians and limitation of birth choices for women. The aim of this review is to present a synthesized summary of existing literature related to women’s experiences of breech birth mode decision-making.

METHODS

A systematic search of the literature was conducted in April 2021, utilizing five databases to identify and obtain peer-reviewed articles meeting the predetermined selection criteria.

RESULTS

Four major categories were synthesized from the integrated review: 1) Women who desire a vaginal birth may experience a range of negative emotions such as feelings of disempowerment, loss, uncertainty and a sense of isolation; 2) Women who experience a breech presentation at term experience significant pressures to conform to expectations of medical professionals and their families due to perceptions of risk related to breech birth; 3) Breech birth decision-making in a limiting system; and 4) Overall satisfaction with the decision to plan a vaginal breech birth.

CONCLUSION

Women with a breech presenting fetus at term experience a complex range of emotions and internal and external pressures due to perceptions of risk around breech birth. Midwives were seen as helpful throughout the breech experience. The reduced caesarean section rate for breech, observed in studies exploring specialized care pathways or dedicated services, could reduce the incidence of Severe Acute Maternal Morbidity.

[Impact of a service protocol on the practice of vaginal delivery of breech presentations at term]

OBJECTIVES

The delivery of breech presentations remains controversial. Our study analysed the impact of a service protocol on the proportion of planned vaginal delivery and its success. Immediate neonatal morbidity and factors that may influence the success of vaginal delivery were studied.

METHODS

Retrospective study, between 2009 and 2020 at the CHRU of Limoges, type 3 maternity hospital, on patients with a breech foetus at term. The proportion of planned vaginal delivery and the rate of effective vaginal delivery were compared before/after 2015. Neonatal morbidity was compared for planned vaginal delivery and planned cesarean delivery groups.

RESULTS

We included 923 patients. The rate of planned vaginal delivery was significantly higher after 2015 from 5.2% to 19% (P<0.001), with a success rate increasing from 60% to 82.1% (P=0.06). The rate of vaginal breech deliveries significantly increased from 3.8% to 17% (P<0.001). We found significantly more newborns with moderate acidosis when a vaginal delivery was attempted (P<0.001). The success of vaginal delivery was correlated to the Magnin index (P=0.044), to gestational age (P=0.037), and to multiparity (OR 3.78 95% CI [1.42-10.03] P=0.006).

CONCLUSION

Our study demonstrates the benefits of setting up a service protocol for the practice of breech vaginal delivery.

Congenital anomalies in breech presentation: A nationwide record linkage study

Our study aimed to determine if congenital anomalies are associated with breech presentation at delivery. We conducted a nationwide, retrospective population-based record linkage study and analyzed all singleton births in Finland from 1996 to 2016 using the mandatory health register data collected by the Finnish Institute for Health and Welfare. We compared all major congenital anomalies detected during pregnancy, birth, or the first year of life according to the fetus's presentation at the time of delivery using X² -square statistic and Student's t test. We adjusted the results for known risk factors for congenital anomalies to estimate adjusted odds ratios and 95% confidence intervals. Fetuses in breech presentation at delivery had an increased risk for congenital anomalies (6.5%) compared with fetuses in cephalic presentation (3.6%), P < .001. Breech presentation was associated with nearly all types of examined congenital anomalies. The strongest associations were observed with congenital deformities of the hip, the central nervous system, the respiratory system, and the musculoskeletal system. Our study supports the theory that breech presentation is, in many cases, a symptom of a fundamental problem in fetal morphogenesis or function. Neonates born in the breech presentation have a higher risk of congenital anomalies and should undergo a postnatal screening.

Effects of external cephalic version for breech presentation at or near term in high-resource settings: A systematic review of randomized and non-randomized studies

INTRODUCTION

External cephalic version (ECV) for breech presentation involves manual manipulation of the fetus from breech to cephalic presentation at or near term, in an attempt to avoid breech birth. This systematic review summarizes the literature on the effects of ECV at or near term on pregnancy outcomes in high-resource settings.

METHODS

The MEDLINE, Embase, CINAHL, Cochrane Library, MIDIRS, and SweMED+ databases were searched for relevant articles published through April 2019, with no limitation on publication date. Clinical trials comparing the effects of ECV at ≥36 weeks, with or without tocolysis, with that of no ECV, conducted in northern, western, and central Europe, the USA, Canada, Australia, and New Zealand were eligible for inclusion.

RESULTS

Nine articles reporting on 184704 breech pregnancies were included. Pooled data showed that ECV attempts reduced the failure to achieve vaginal cephalic birth (risk ratio, RR=0.56; 95% CI: 0.45–0.71), caesarean section performance (RR=0.57; 95% CI: 0.50–0.64), and non-cephalic presentation at birth (RR=0.45; 95% CI: 0.29–0.68) compared with no ECV. ECV attempts also increased the incidence of Apgar score <7 at 5 minutes (RR=1.29; 95% CI: 1.10–1.52).

CONCLUSIONS

Women for whom ECV is attempted at or near term are at reduced risk of caesarean section, non-cephalic presentation at term, and failure to achieve vaginal cephalic birth. Compared with no ECV, attempted ECV was also associated with a slightly increased risk of a low Apgar score at 5 minutes. The evidence is limited by the scarcity of high-quality research and the presence of risks of bias.

Is Vaginal Breech Delivery Still a Safe Option?

OBJECTIVE

 To determine whether there was any difference in neonatal and maternal outcomes between breech vaginal delivery and cephalic vaginal delivery.

METHODS

 A retrospective, case-control study was conducted between January 2015 and December 2017 in a Portuguese hospital. A total of 26 cases of breech vaginal delivery were considered eligible and 52 pregnant women formed the control group.

RESULTS

 Induced labor was more frequent in the breech vaginal delivery group (46% versus 21%, p = 0.022). Episiotomy was more common in the breech vaginal delivery group (80% versus 52%, p = 0.014), and one woman had a 3rd degree perineal laceration. Newborns in the study group had a lower birthweight (2,805 g versus 3,177 g, p < 0.001). There was no significant difference in the neonatal outcomes.

CONCLUSION

 The present study showed that breech vaginal delivery at term compared with cephalic presentation was not associated with significant differences in neonatal and maternal morbidity. It also suggests that breech vaginal delivery remains a safe option under strict selection criteria and in the presence of an experienced obstetrician.

'Dr. Google, is caesarean section good for me?' - the global Internet searches associated with mode of birth methods: Retrospective analysis of Google trends data

OBJECTIVE

We investigated Google queries in the years 2004-2019 as related to mode of birth methods in scope of global and local popularity, secular trends, and associations with real-world data.

DESIGN

We retrieved data from Google Trends (GT) over time and regional interest in (n = 9) topics related to birth. We calculated the interest of all the topics in proportion to the Relative Search Volume (RSV) of 'Caesarean section'"(CS). We retrieved WHO data on the CS rate and the World Bank data on the fertility rate. We analysed secular trends.

FINDINGS

Globally, the highest popularity was observed for these topics: 'Childbirth' (6.93 [times higher than CS]), 'Caesarean section' (1.00), and 'Preterm birth' (0.59). The regional RSV of 'Caesarean section' was associated with the real CS rate (r = 0.29; p = 0.016) and the interest in 'Childbirth' was associated with the regional fertility rate (r = 0.48; p < 0.001). Globally, the most dynamic rate of increase of interest was observed for 'Vaginal delivery' (+4.96 RSV/year) and 'Caesarean section' (+4.88 RSV/year), while a decrease was noted only for 'Home birth' (-3.04 RSV/year) and 'Water birth' (-1.84 RSV/year).

CONCLUSIONS

The interest of Google users in most of the birth-related topics increased over time and is associated with real-world data. Using GT may provide insight into the interest of Google users regarding different birth-related matters.

IMPLICATION FOR PRACTICE

Health professionals should be active in e-discourse to provide reliable information and recommend trustworthy websites to women and those who support them.

Term cesarean breech delivery in the first pregnancy is associated with an increased risk for maternal and neonatal morbidity in the subsequent delivery: a national cohort study

Purpose

To determine whether there is an association between term cesarean breech delivery in the first pregnancy and maternal and neonatal morbidities in the subsequent pregnancy and delivery.

Methods

We conducted a retrospective, nationwide Finnish population-based cohort study, including all deliveries from January 2000 to December 2017. We included all women with the first two consecutive singleton deliveries of which the first one was a breech delivery regardless of mode of delivery (n = 11,953), and constructed a data set in which the first two deliveries for these women were connected. The outcomes of the second delivery of the women with a first pregnancy that resulted in cesarean breech delivery at term were compared with women whose first pregnancy resulted in a vaginal breech delivery at term. P-value, odds ratio, and adjusted odds ratio were calculated.

Results

Neonates of a subsequent delivery after cesarean breech delivery had an increased risk for arterial umbilical cord pH below seven, a higher rate of a 5 min APGAR score < 7 and a higher rate of neonatal intensive care unit admission. The women with a history of cesarean section with the fetus in breech presentation were more often in need of a blood transfusion and suffered more often a uterus rupture. In this group, the second delivery was more often a planned cesarean section, an emergency cesarean section, or an instrumental vaginal delivery.

Conclusions

Primary cesarean breech section in the first pregnancy is associated with adverse neonatal and maternal outcomes in the subsequent delivery.

Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies

Background

The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies.

Main body

In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed.

Conclusion

The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study

PURPOSE

To determine if the common risks for breech presentation at term labor are also eligible in preterm labor.

METHODS

A Finnish cross-sectional study included 737,788 singleton births (24-42 gestational weeks) during 2004-2014. A multivariable logistic regression analysis was used to calculate the risks of breech presentation.

RESULTS

The incidence of breech presentation at delivery decreased from 23.5% in pregnancy weeks 24-27 to 2.5% in term pregnancies. In gestational weeks 24-27, preterm premature rupture of membranes was associated with breech presentation. In 28-31 gestational weeks, breech presentation was associated with maternal pre-eclampsia/hypertension, preterm premature rupture of membranes, and fetal birth weight below the tenth percentile. In gestational weeks 32-36, the risks were advanced maternal age, nulliparity, previous cesarean section, preterm premature rupture of membranes, oligohydramnios, birth weight below the tenth percentile, female sex, and congenital anomaly. In term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, premature rupture of membranes, oligohydramnios, congenital anomaly, female sex, and birth weight below the tenth percentile.

CONCLUSION

Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in extremely preterm deliveries has, with the exception of preterm premature rupture of membranes, similar clinical risk profiles as in cephalic presentation.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]

OBJECTIVES

To study the frequency, the risk factors and the mode of delivery of breech presentation. To analyze the perinatal morbidity and mortality associated with breech presentation in comparison to cephalic presentation from all mode of delivery.

METHODS

MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019.

RESULTS

Three modes of breech presentation exist according to fetal lower limbs position: frank in 2/3 of cases, complete in 1/3 of cases or, more rarely, incomplete (LE3). About 5% of women gave birth in breech presentation in France (LE3). As the frequency of breech presentation decreases with increasing gestational age, this incidence is lower after 37 WG and represents only 3% of term deliveries (LE3). Congenital uterine malformation (LE3) and fibroma (LE3), prematurity (LE3), oligoamnios (LE3), some fetal congenital malformations (LE3) and low birthweight for gestational age (LE3) are the main risk factors with breech presentation. In France, one-third of women with a term fetus in breech presentation attempt a vaginal delivery (LE3), which is successful in 70% of cases (LE3). Neonatal outcome is not associated with type of breech presentation (frank or complete) in case of vaginal delivery attempt after 37 WG (LE3). Overall, perinatal morbidity and mortality after 37 WG of breech presentation appear to be greater than in cephalic presentation from all mode of delivery (LE3). The risk of traumatic injury in breech delivery is estimated under 1% (LE3). The most common injuries are collarbone fractures, hematomas or contusions, and brachial plexus injury (LE3). Breech presentation is associated with an increased risk of hip dysplasia (LE3) and cesarean delivery does not seem to be a protective factor (LE3). Breech presentation does not appear to be associated with an increased risk of cerebral palsy compared to cephalic presentation after exclusion of fetuses with congenital malformations (LE3).

CONCLUSION

Worldwide, mode of delivery of breech presentation has undergone profound changes since the publication of the TBT (Term Breech Trial). There are intrinsic factors associated with breech presentation, which should not be overlooked when interpreting the increased perinatal morbidity and mortality observed in case of breech presentation.

Preterm Birth, Low Gestational Age, Low Birth Weight, Parity, and Other Determinants of Breech Presentation: Results from a Large Retrospective Population-Based Study

Aim of this study is to analyze determinants of breech presentation using information from two regional databases of Lombardy (Italy) including data on consecutive singleton breech and vertex deliveries occurred in the Region, between January 2010 and December 2015. Breech presentation occurred in 3.8% of all single deliveries. Main determinants of breech presentation at birth were: gestational age and birth weight (the lower, the higher the incidence of breech presentation), maternal age (the older the mother, the higher the risk of breech presentation), parity (the frequency of breech decreased with increasing parity) and previous cesarean section. Breech presentation resulted more frequent after assisted reproduction procedures.

Outcome of small for gestational age-fetuses in breech presentation at term according to mode of delivery: a nationwide, population-based record linkage study

PURPOSE

To evaluate whether a trial of planned vaginal labor is associated with adverse perinatal outcome in singleton, small for gestational agefetuses in breech presentation at term.

METHODS

This is a Finnish nationwide, population-based record linkage study. The studied population included all small for gestational age breech labors from January 1, 2004 to December 31, 2014. "Small for gestational age" was defined as birth weight below the 10th percentile according to gestational age. An odds ratio with 95% confidence intervals was used to estimate the relative risk for perinatal mortality and morbidity in a trial of vaginal labor. The reference group included all small for gestational age infants born in breech presentation by planned cesarean section.

RESULTS

During the study period of eleven years, 1841 small for gestational age infants were delivered in breech position at term. A trial of vaginal breech labor is associated with a higher rate of neonates with an umbilical pH below seven [odds ratio 7.82 (1-61.21)], a lower 5-min Apgar score < 7 [adjusted odds ratio 6.39 (1.43-28.46)] and < 4 [adjusted odds ratio 6.39 (1.43-28.46)], a higher rate of postpartum neonatal intubations [adjusted odds ratio 6.52 (1.93-22)], an increased rate of neonatal antibiotic therapy [adjusted odds ratio 3.31 (1.85-5.93)], and with a higher rate of combined severe adverse perinatal outcome [adjusted odds ratio 4.24 (1.43-12.61)].

CONCLUSION

A trial of vaginal breech labor in SGA fetuses is associated with adverse perinatal outcome and should be avoided.

Increased rate of acute caesarean sections in women with epilepsy: results from the Oppland Perinatal Database in Norway

Background and purpose

Studies in women with epilepsy (WWE) regarding pregnancy and labour complications have disclosed contradictory results. Our purpose was to investigate whether WWE have a higher risk of acute caesarean section (CS) or pregnancy complications than women without epilepsy or women with other chronic diseases and, if we found a higher risk, to explore potential explanations.

Methods

The study used prospectively registered obstetric data from the Oppland Perinatal Database in the period 2001–2011, containing information on 18 244 births, including 110 singleton pregnancies in mothers with validated epilepsy. Data regarding epilepsy were collected retrospectively from medical records.

Results

Epilepsy was a significant risk factor for acute CS, breech presentation and low birth weight in offspring [odds ratio (OR), 1.93, 95% confidence interval (CI), 1.2–3.1; OR, 2.29, 95% CI, 1.2–4.6 and OR, 2.10, 95% CI, 1.0–4.2, respectively]. In multivariate logistic regression analysis, antiepileptic drug exposure was an independent risk factor for acute CS (OR, 2.00; 95% CI, 1.06–3.77) and polytherapy was a significant risk factor for breech presentation (OR, 5.37; 95% CI, 1.13–25.57). Seizure frequency during pregnancy had no influence on the complication rate.

Conclusions

We found that WWE using antiepileptic drugs during pregnancy had increased rates of acute CS, breech presentation and low birth weight, and that seizure frequency during pregnancy did not influence the complication rate.

Regulation of amniotic fluid volume: insights derived from amniotic fluid volume function curves

Recent advances in understanding the regulation of amniotic fluid volume (AFV) include that AFV is determined primarily by the rate of intramembranous absorption (IMA) of amniotic fluid across the amnion and into fetal blood. In turn, IMA rate is dependent on the concentrations of yet-to-be identified stimulator(s) and inhibitor(s) that are present in amniotic fluid. To put these concepts in perspective, this review 1) discusses the evolution of discoveries that form the current basis for understanding the regulation of AFV, 2) reviews the contribution of IMA to this regulation, and 3) interprets experimentally induced shifts in AFV function curves and amnioinfusion function curves in terms of the activity of the amniotic fluid stimulator and inhibitor of IMA. In the early 1980s, it was not known whether AFV was regulated. However, by the late 1980s, IMA was discovered to be a "missing link" in understanding the regulation of AFV. Over the next 25 years the concept of IMA evolved from being a passive process to being an active, unidirectional transport of amniotic fluid water and solutes by vesicles within the amnion. In the 2010s, it was demonstrated that a renally derived stimulator and a fetal membrane-derived inhibitor are present in amniotic fluid that regulate IMA rate and hence are the primary determinants of AFV. Furthermore, AFV function curves and amnioinfusion function curves provide new insights into the relative efficacy of the stimulator and inhibitor of IMA.

The complex aetiology of cerebral palsy

Cerebral palsy (CP) is the most prevalent, severe and costly motor disability of childhood. Consequently, CP is a public health priority for prevention, but its aetiology has proved complex. In this Review, we summarize the evidence for a decline in the birth prevalence of CP in some high-income nations, describe the epidemiological evidence for risk factors, such as preterm delivery and fetal growth restriction, genetics, pregnancy infection and other exposures, and discuss the success achieved so far in prevention through the use of magnesium sulfate in preterm labour and therapeutic hypothermia for birth-asphyxiated infants. We also consider the complexities of disentangling prenatal and perinatal influences, and of establishing subtypes of the disorder, with a view to accelerating the translation of evidence into the development of strategies for the prevention of CP.

Neurodevelopmental outcome at the age of 4 years according to the planned mode of delivery in term breech presentation: a nationwide, population-based record linkage study

PURPOSE

To evaluate whether a trial of planned vaginal breech labor affects neurologic development in children.

METHODS

This is a nationwide, Finnish, population-based record linkage study. An odds ratio with 95% confidence intervals was used to estimate the relative risk that a child delivered by planned vaginal breech labor would be diagnosed with adverse neurodevelopmental outcome (cerebral palsy, epilepsy, intellectual disability, sensor neural developmental outcome, hyperactivity, speech and language problems) at the age of 4 years. The reference group were children born by planned cesarean section.

RESULTS

During a study period of 7 years, 8374 infants were delivered in breech position. Among them, 3907 (46.7%) had an attempted labor and 4467 (53.3%) infants were delivered by planned cesarean section. There were no differences in the neurodevelopmental outcome. In the planned vaginal labor group, 133 (3.4%) children had an abnormal neurodevelopmental outcome at the age of 4 years compared to 142 (3.2%) in the planned cesarean section group.

CONCLUSION

The absolute risk of abnormal neurological outcome in breech deliveries at term was low, regardless of planned mode of birth. Planned vaginal breech labor did not increase the risk for abnormal neurological outcome compared to planned cesarean section.

Risk factors associated with adverse perinatal outcome in planned vaginal breech labors at term: a retrospective population-based case-control study

BACKGROUND

Vaginal breech delivery is associated with adverse perinatal outcome. The aim of this study was to identify factors associated with adverse perinatal outcome in term breech pregnancies, and to provide clinicians an aid in selecting women for a trial of vaginal labor with the fetus in breech position.

METHODS

We conducted a retrospective, nationwide, Finnish population-based case-control study. All planned singleton vaginal deliveries at term with the fetus in breech position between the years 2005 and 2014 were analyzed. The study's end point was a composite set of adverse perinatal outcomes. All infants with an adverse outcome were compared to the infants with normal outcomes. A multivariate logistic regression model was used to analyze the data.

RESULTS

An adverse perinatal outcome was recorded for 73 (1.5%) infants. According to the study results fetal growth restriction (adjusted odds ratio, 2.94; 95% CI, 1.30-6.67), oligohydramnios (adjusted odds ratio, 2.94; 95% CI, 1.15-7.18), a history of cesarean section (adjusted odds ratio, 2.94; 95% CI, 1.28-6.77, gestational diabetes (adjusted odds ratio, 2.89; 95% CI, 1.54-5.40), epidural anesthesia (adjusted odds ratio, 2.20; 95% CI, 1.29-3.75) and nulliparity (adjusted odds ratio, 1.84; 95% CI, 1.10-3.08) were associated with adverse perinatal outcome.

CONCLUSIONS

Adverse perinatal outcome in planned vaginal breech labor at term is associated with fetal growth restriction, oligohydramnios, previous cesarean delivery, gestational diabetes, nulliparity and epidural anesthesia.