Maternal and neonatal outcome after vaginal breech delivery of nulliparous versus multiparous women of singletons at term-A prospective evaluation of the Frankfurt breech at term cohort (FRABAT)

The influence of epidural anesthesia in pregnancies with scheduled vaginal breech delivery at term: a hospital-based retrospective analysis

INTRODUCTION

Epidural anesthesia is a well-established procedure in obstetrics for pain relief in labor and has been well researched as it comes to cephalic presentation. However, in vaginal intended breech delivery less research has addressed the influence of epidural anesthesia. The Greentop guideline on breech delivery states that there's little evidence and recommends further evaluation.

OBJECTIVE

The aim of this study was to compare maternal and neonatal outcomes in vaginally intended breech deliveries at term with and without an epidural anesthesia.

DESIGN

This study was a retrospective cohort study.

SAMPLE

This study included 2122 women at term with a singleton breech pregnancy from 37 + 0 weeks of pregnancy on and a birth weight of at least 2500 g at the obstetric department of University hospital Frankfurt from January 2007 to December 2018.

METHODS

Neonatal and maternal outcome was analyzed and compared between women receiving "walking" epidural anesthesia and women without an epidural anesthesia.

RESULTS

Fetal morbidity, measured with a modified PREMODA score, showed no significant difference between deliveries with (2.96%) or without (1.79%; p = 0.168) an epidural anesthesia. Cesarean delivery rates were significantly higher in deliveries with an epidural (35 vs. 26.2%, p = 0.0003), but after exclusion of multiparous women, cesarean delivery rates were not significantly different (40.2% cesarean deliveries with an epidural vs. 41.5%, p = 0.717). As compared to no epidurals, epidural anesthesia in vaginal delivery was associated with a significantly higher rate of manual assistance (33.8 versus 52.1%) and a longer duration of birth (223.7 ± 194 versus 516.2 ± 310 min) (both p < 0.0001)".

CONCLUSION

Epidural anesthesia can be offered as a safe option for pain relief without increasing neonatal or maternal morbidity and mortality. Nevertheless, it is associated with a longer birth duration and manually assisted delivery.

Does overweight and obesity have an impact on delivery mode and peripartum outcome in breech presentation? A FRABAT cohort study

PURPOSE

Obesity is a worldwide and growing issue affecting women in childbearing age, complicating surgical procedures as well as pregnancy. Through a reduction of not necessarily required cesarean deliveries-for instance in pregnancies with breech presentation-obesity mediated and surgery-associated morbidity might be contained. Date on the impact of maternal BMI in vaginally attempted breech delivery is not existing. To give insight into whether an elevated BMI leads to an increased perinatal morbidity in vaginally intended deliveries out of breech presentation, we analyzed delivery outcome of laboring women with a singleton baby in breech presentation with overweight and obesity (BMI ≥ 25 kg/m2) in comparison to women with a BMI of below 25 kg/m2.

METHODS

Based on data from January 2004 to December 2020, a cohort study was performed on 1641 women presenting with breech presentation at term (> 37 weeks). The influence of maternal BMI on perinatal outcome was analyzed with Chi2 testing for group differences and logistic regression analysis. Patients with a hyperglycemic metabolism were excluded from the study.

RESULTS

Fetal morbidity was not different when patients with a BMI of ≥ 25 kg/m2 (PREMODA morbidity score 2.16%) were compared to patients with a BMI of below 25 kg/m2 (1.97%, p = 0.821). Cesarean delivery rates were significantly higher in overweight and obese women with 43.9% compared to 29.3% (p < 0.0001). BMI and cesarean delivery were significantly associated in a logistic regression analysis (Chi2 coefficient 18.05, p < 0.0001). In successful vaginal deliveries out of breech presentation, maternal perineal injury rates (vaginal birth in normal-BMI women 48.4%; vaginal birth in overweight and obese women: 44.2%; p = 0.273) and rates of manually assisted delivery (vaginal birth in normal-BMI women: 44.4%; vaginal birth in obese and overweight women: 44.2%; p = 0.958) were not different between BMI groups.

CONCLUSIONS

Obesity and overweight are not associated with peripartum maternal or newborn morbidity in vaginally attempted breech delivery, if the patient cohort is thoroughly selected and vaginal breech delivery is in an upright maternal position. Reduction of cesarean delivery rates, especially in overweight and obese women might, have an important positive impact on maternal and newborn morbidity.

Sonographic examination at the beginning of the second stage of labor predicts birth outcome in vaginally intended breech deliveries: a blinded prospective study

PURPOSE

In order to spread competence in vaginal breech deliveries, it is necessary to develop new and easily applicable tools for birth progression and safety evaluation. Ultrasound is a useful and ubiquitously available tool with already documented value for birth progression observation. In deliveries out of breech presentation, an established ultrasound examination is missing. We determined the descent of the fetal buttocks in relation to the maternal pelvic inlet using intrapartum ultrasound. We evaluated these results in comparison to the clinical vaginal examination with the aim to establish an easily applicable method for birth outcome prediction. Therefore, we analyzed the predictive value of our examinations on birth outcome parameters, such as cesarean section rate, as well as fetal and maternal outcome parameters.

METHODS

We performed a prospective blinded study on 106 mothers with vaginally intended breech delivery. At beginning of stage two in labor, the descent of the fetal buttocks into the mother's pelvic inlet was detected with transabdominal ultrasound and vaginal examination by different observers.

PRIMARY OUTCOME VARIABLE

Cesarean section rate. Secondary outcome variables: rate of manual assistance in vaginal deliveries, birth duration, 5' APGAR score, umbilical arterial pH, maternal blood loss, and perineal injury. For non-parametric values, Wilcoxon's χ2 test was performed. In order to analyze the predictive value of our examination, lack-of-fit analysis was conducted. Reliability evaluation of the sonographic examination was done with a matched-pair analysis.

RESULTS

Women with positive intrapartum ultrasound breech engagement sign (+ IPUBES) had a significantly lower rate of cesarean section in comparison with those with negative IPUBES (5/67; 7.5% vs. 18/39; 46.2%; p < 0.0001). The area under the ROC curve for the prediction of CS for negative IPUBES was 0.765 with a sensitivity of 78.3% and a specificity of 74.7%. Sonographic examination showed an excellent reliability in a matched-pair analysis comparing vaginal and sonographic examinations with a mean difference of 0.012 (SD ± 0.027, 95% CI - 0.014 to 0.065). Mean birth duration was significantly longer in deliveries with negative IPUBES (533 min vs. 440 min; p = 0.0011). Fetal and maternal outcome parameters were not significantly different between deliveries with positive and negative IPUBES.

CONCLUSIONS

Sonographic evaluation of the fetal descent in relation to the mother's pelvic inlet screens reliably for emergency cesarean section. This newly presented method for birth progression observation might be a powerful tool for distribution of expertise in vaginal breech delivery and is able to give reference for clinical vaginal examination by obstetricians in training.

TRAIL REGISTRY

Clinical trial. Date of registration: 13.03.2019; Date of initial participant enrollment: 20.03.2019; DRKS00016885; https://www.drks.de ; German clinical trials register.

Mechanics of vaginal breech birth: Factors influencing obstetric maneuver rate, duration of active second stage of labor, and neonatal outcome

BACKGROUND

We investigated possible parameters that could predict the need for obstetric maneuvers, the duration of the active second stage of labor (i.e., the duration of active pushing), and short-term neonatal outcome in vaginal breech births.

MATERIALS AND METHODS

We performed a retrospective analysis of 268 successful singleton vaginal breech births in women without previous vaginal births from January 2015 to August 2022. Multivariable regression was used to investigate associations between maternal and fetal characteristics (including antepartum magnetic resonance (MR) pelvimetry) with obstetric maneuvers, the duration of active second stage of labor, pH values, and admission to the neonatal unit. Models for the prediction of obstetric maneuvers were built and internally validated.

RESULTS

Obstetric maneuvers were performed in a total of 130 women (48.5%). A total of 32 neonates (11.9%) had to be admitted to the neonatal unit. The intertuberous distance (ITD) (p < 0.001), epidural analgesia (p < 0.001), and birthweight (p = 0.026) were associated with the duration of active second stage of labor. ITD (p = 0.028) and birthweight (p = 0.011) were also independently associated with admission to the neonatal unit, while pH values below 7.10 dropped significantly (p = 0.0034) if ITD was ≥13 cm. Furthermore, ITD (p < 0.001) and biparietal diameter (p = 0.002) were independent predictors for obstetric maneuvers.

CONCLUSIONS

ITD is independently associated with the duration of active second stage of labor. Thus, it can predict suboptimal birth mechanics in the last stage of birth, which may lead to the need for obstetric maneuvers, lower arterial pH values, and admission to the neonatal unit. Consequently, MR pelvimetry gives additional information for practitioners and birthing people preferring a vaginal breech birth.

Neonatal admission rate after vaginal breech delivery

OBJECTIVES

The safest mode of delivery for fetuses in breech presentations is still an ongoing debate. The aim of this study was to analyze neonatal admission rates after vaginal breech delivery and compare it to other modes of delivery in order to counsel pregnant women with breech presentation adequately.

METHODS

We performed a retrospective monocentric analysis of all deliveries with singleton pregnancies in breech presentation > 36.0 weeks of gestation between 01/2018-12/2019. Short-term neonatal morbidity data was collected for vaginal delivery and primary as well as secondary cesarean sections from breech presentations.

RESULTS

A total of n=41/482 (8.5%) neonates had to be admitted to NICU: vaginal breech delivery n=18/153 (11.8%), primary cesarean section n=9/101 (8.9%, OR 0.73; CI 0.32-1.70; p=0.47), secondary cesarean section n=10/76 (13.2%, OR 1.14; CI 0.50-2.60, p=0.76) and vaginal vertex delivery n=4/152 (2.6%, OR 0.20; CI 0.06-0.51; p=0.005). There was no significant difference in transfer to NICU between all breech position delivery modes. Despite significantly lower pH and 5' APGAR values after vaginal delivery, neonates delivered by primary cesarean section and NICU admission had to be treated there significantly longer (mean 80.9 vs. 174.0 h). No significant difference in terms of ventilation parameters and infections were found between the vaginal delivery, primary and secondary cesarean section from breech presentation.

CONCLUSIONS

Vaginal breech delivery does not result in a higher neonatal admission rate in comparison to primary and secondary section. In contrast, there is a shorter NICU duration in case of neonatal admission after vaginal delivery.

Combined Assessment of the Obstetrical Conjugate and Fetal Birth Weight Predicts Birth Mode Outcome in Vaginally Intended Breech Deliveries of Primiparous Women-A Frabat Study

(1) Background: Guidelines on vaginal breech delivery require birth weight restrictions and neglect the impact of pelvic measurements despite contradicting evidence. There is a great need for more evidence on delivery outcome predicting factors for patients counselling. (2) Methods: We performed a prospective cohort study on 748 primiparous women intending vaginal breech birth and analyzed combined influence of fetal birth weight (BW) and the obstetric conjugate (conjugate vera obstetrica, CVO) on delivery outcome. (3) Results: We generated a BW/CVO ratio and devided our study cohort at median (257.8 g/cm) into a low ratio group (LR, with low birth weight and wide obstetric conjugate) and a high ratio group (HR, high birth weight and narrow obstetric conjugate). Cesarean section (CS) rate was significantly higher in HR (50.3%) as compared to LR (28.3%, p < 0.0001). Fetal morbidity was not different. In vaginally completed deliveries duration of birth was significantly longer in vHR (557 min) as in vLR (414 min, p < 0.001). Manual assistance to deliver the arms (‘Louwen maneuver’) positively correlated with birth weight (r2 = 0.215; p = 0.005) and the BW/CVO ratio (r2 = 0.0147; p = 0.02). (4) Conclusions: A high fetal birth weight combined with a tiny CVO predicts higher cesarean section probability, longer birth duration and the necessity to perform arm delivery assistance. Birth weight and pelvic measurements should be topics of great importance in patients counselling.

Term breech presentation-Intended cesarean section versus intended vaginal delivery-A systematic review and meta-analysis

INTRODUCTION

Three per cent of all infants are born in breech presentation, still the preferred way to deliver them remains controversial. The objective of this systematic review was to assess the safety for the mother and child depending on intended mode of delivery when the baby is in breech position at term.

MATERIAL AND METHODS

The population (P) was pregnant women with a child in breech presentation, from gestational week 34⁺⁰ . The intervention (I) was the intention to deliver by cesarean section, the comparison (C) was the intention to deliver vaginally. Outcomes (O) were perinatal mortality, perinatal morbidity, maternal mortality, maternal morbidity, conversion of delivery mode, and the mother's experience. Systematic literature searches were performed. We included randomized trials, cohort studies with more than 500 women/group and case series for more than 15 000 women published between 1990 and October 2021, written in English or the Nordic languages. The certainty of evidence was assessed using the GRADE approach and data were pooled in meta-analyses. PROSPERO registration number: CRD42020209546.

RESULTS

Thirty-two articles were included (with 530 604 women). The certainty of evidence was moderate or low because the study designs were mostly retrospective cohort studies. The only randomized trial showed reduced risk of perinatal mortality for planned cesarean section, risk ratio (RR) 0.27 (95% confidence interval [CI] 0.08-0.97, 2078 women, low certainty of evidence), stillbirths excluded. A meta-analysis of cohort studies resulted in a similar estimate, RR 0.36 (95% CI 0.25-0.51, 21 studies, 388 714 women, low certainty of evidence). We also found reduced risk for outcomes representing perinatal morbidity 0-28 days: 5-min Apgar score less than 7 in one randomized controlled trial: RR 0.27 (95% CI 0.12-0.58, 2033 women, moderate certainty of evidence), and in a meta-analysis: RR 0.1 (95% CI 0.14-0.26, 18 studies, 217 024 women, moderate certainty of evidence); APGAR score less than 4 at 5 min: RR 0.39 (95% CI 0.19-0.81, five studies, 44 498 women, low certainty of evidence); and pH less than 7.0: RR 0.23 (95% CI 0.12-0.43, four studies, 13 440 women, low certainty of evidence). Outcomes for the mother were similar in the groups except for reduced risk for experience of urinary incontinence in the group of planned cesarean section: RR 0.62 (95% CI 0.41-0.93, one study, 1940 women, low certainty of evidence). The conversion rate from planned vaginal delivery to emergency cesarean section ranged from 16% to 51% (median 41.8%, 10 studies, 50 763 women, moderate certainty of evidence).

CONCLUSIONS

Intended cesarean section may reduce the risk of perinatal mortality and perinatal as well as some maternal morbidity compared with intended vaginal delivery. It is uncertain whether there is any difference in maternal mortality. The conversion rate from intended vaginal delivery to emergency cesarean section is high.

Learning Breech Birth in an Upright Position Is Influenced by Preexisting Experience-A FRABAT Prospective Cohort Study

BACKGROUND

Vaginal breech delivery is becoming an extinct art although national guidelines underline its safety and vaginal breech delivery in an upright position has been shown to be a safe birth mode option. In order to spread clinical knowledge and be able to implement vaginal breech delivery into obstetricians' daily practice, we need to gather knowledge from facilities who teach specialized obstetrical management.

METHODS

We performed a prospective cohort study on 140 vaginal deliveries out of breech presentation solely-managed by seven newly-trained physicians and compared fetal outcome as well as rates of manual assistance in respect to preexisting experience.

RESULTS

Fetal morbidity rate measured with a modified PREMODA score was not significantly different in three sub-cohorts sorted by preexisting expertise levels of managing obstetricians (experience groups EG, EG0: 2, 5%; EG1: 3, 7.5%; EG2: 1, 1.7%; p = 0.357). Manual assistance rate was significantly higher in EG1 (low experience level in breech delivery and only in dorsal position) compared to EG0 and EG2 (EG1 28, 70%; EG0: 14, 25%; EG2: 21, 35%; p = 0.0008).

CONCLUSIONS

Our study shows that vaginal breech delivery with newly-trained obstetricians is a safe option whether or not they have advanced preexisting expertise in breech delivery. These data should encourage implementing vaginal breech delivery in clinical routine.