Australian and New Zealand Journal of Obstetrics and Gynaecology 2014
DOI: 10.1111/ajo.12208
Original Article
Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study Ailsa BORBOLLA FOSTER,1 Annalise BAGUST,2 Andrew BISITS,2,3 Matthew HOLLAND1 and Alec WELSH2,3,4 1
Department of Obstetrics and Gynaecology, John Hunter Hospital, New Lambton, 2Faculty of Medicine, University of New South Wales, 3Department of Obstetrics & Gynaecology, Royal Hospital for Women, Randwick, and 4Australian Centre for Perinatal Science, University of New South Wales, Sydney, New South Wales, Australia
Background: The 2000 publication of the Term Breech Trial significantly impacted obstetric practice in Australia with a rapid increase in delivery of term breech singletons by caesarean section. More reassuring data from European centres who continued to offer vaginal breech deliveries to carefully selected women have led to a softening of international guidelines which now support an individualised approach to management. The application of this principle to an Australian population, particularly in the wake of such a major change in obstetric practice, has not previously been demonstrated. Aim: To compare short-term neonatal and maternal morbidity for infants with a singleton breech presentation born after 37 weeks, according to planned mode of delivery. Materials and Methods: Eleven-year single-centre retrospective study with intention-to-treat analysis based on intended mode of delivery. Results: Two hundred and forty-three of 766 (31.7%) eligible women elected for planned vaginal breech delivery. The overall success rate in this group was 58%. Morbidity rates were low and compare favourably with similar international studies. However, there was a nonsignificant trend towards higher rates of short-term serious neonatal and maternal morbidity in the planned vaginal delivery group (1.6 vs 0.4%, P = 0.08 and 8.2 vs 4.8%, P = 0.06, respectively). Conclusions: Attempted vaginal delivery for breech presentation remains an option in carefully selected women under strict obstetric protocols. Key words: breech, caesarean section, fetal presentation, obstetric delivery, term.
Introduction The optimal mode of delivery for the term breech fetus has long been a contentious issue in obstetrics and was brought into focus with the 2000 publication of the term breech trial which concluded that ‘planned caesarean section is better than planned vaginal birth’ largely due to a reported 4-fold reduction in perinatal death (0.3 vs 1.3%).1 Although its publication profoundly altered obstetric practice in Australia with an increase in the term breech caesarean rate from 76.7 to 96.3% between 1991 and 2005,2 its application to modern obstetric practice has continued to be a matter of ongoing debate. The main arguments against its conclusions centre on trial standards
Correspondence: Dr Andrew Bisits, Royal Hospital for Women, Barker st, Randwick, NSW 2031, Australia. Email: [email protected] Received 19 November 2013; accepted 8 March 2014.
of care, violations of inclusion criteria, erroneous attribution of adverse outcomes to mode of delivery3–5 and lack of difference in two year outcomes for infants.6 In addition, a number of international obstetric units with strong traditions in vaginal breech delivery (VBD) have demonstrated acceptable safety using term breech trial comparable outcomes, where stringent selection criteria and management are maintained.7–14 Despite international and Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) guidelines acknowledging that VBD may be safe for select populations,15,16 overall numbers remain low possibly reflecting medico-legal concerns in the wake of the term breech trial, which in turn has led to a paucity of experience and training over the last 10 years.2 This study was based in a large metropolitan teaching hospital in New South Wales (NSW) with over 4500 births per year that has continued to offer a breech service allowing choice surrounding mode of delivery at term. NSW delivers the largest number of babies in breech presentation within Australia,17 and this centre accounted
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
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for the largest number of VBD in this state over much of the study period.18–20 No contemporary literature has examined optimal mode of breech delivery in Australia and the purpose of this study therefore was to provide an overview of the safety and efficacy of this service through the evaluation of maternal and neonatal outcomes.
Materials and Methods Study design This was a single centre, 11-year retrospective cohort study conducted at a tertiary referral unit in New South Wales, Australia, between October 1999 and December 2010, the start date coinciding with departmental implementation of a formalised written care pathway for the management of term breech presentation. Inclusion criteria were all women who delivered a singleton pregnancy in any breech presentation (including footling breech) at ≥37-weeks gestation. Exclusion criteria included breech diagnosis at >5 cm cervical dilatation or during elective CS, private patients, fetal congenital abnormalities and other serious contraindications to labour and/or VBD (including severe maternal disease, placental abnormalities, oligohydramnios, cord presentation, intrauterine growth restriction, macrosomia, 2 or more prior lower segment caesareans, complicated uterine scars and deflexed fetal head). All women with a breech presentation identified prior to the onset of labour were referred to a nominated senior obstetrician with more than 10 years experience in VBD and fully counselled regarding delivery options. Where no contraindications were present, external cephalic version (ECV) was offered. The majority of women had a formal ultrasound assessment of fetal weight and growth, while a minority had a bedside scan assessing the same parameters. Computerised tomographic pelvimetry was performed as standard until 2004 when, with minimal evidence to support its utility, the practice was ceased and greater focus placed on progress of labour. Essential patient characteristics allowing consideration of VBD were adopted in line with current Australian and British college guidelines.15,16 Women who did not meet these criteria were counselled for elective caesarean delivery and in order to limit bias between study groups, were excluded from analysis. Women who planned an elective lower segment caesarean section (LSCS) were delivered after 39 weeks gestation unless prior onset of labour necessitated earlier delivery. Women electing for vaginal delivery followed strict obstetric protocols outlined in current RANZCOG and Royal College of Obstetrics and Gynaecology (RCOG) guidelines.15,16 Eligible deliveries were identified using the NSW computerised maternity care system Obstetrix and data regarding baseline characteristics, labour details and perinatal outcomes were obtained from individual maternal and neonatal medical records. 2
Ethical approval for the research was obtained from the Hunter New England Human Research Ethics Committee (Ref No. 12/07/18/5.06).
Outcomes and analysis Primary outcome was a composite index of neonatal mortality and serious neonatal morbidity within 28 days of delivery as used in the term breech trial. Measures of serious neonatal morbidity comprised: birth trauma, including subdural haematoma, intracerebral or intraventricular haemorrhage, spinal-cord injury, basal skull fracture, peripheral-nerve injury present at discharge from hospital or clinically significant genital injury; seizures occurring at less than 24 h of age or requiring two or more drugs to control them; Apgar score of less than 4 at 5 min; hypotonia for at least 2 h; stupor, decreased response to pain or coma; intubation and ventilation for at least 24 h; tube-feeding for four days or more; or admission to the neonatal intensive care unit for longer than four days. Cord blood results were omitted from this composite due to poor and uneven collection between groups. Secondary outcome was a composite index of maternal mortality and serious morbidity also as used in the term breech trial. Measures of serious morbidity comprised: postpartum haemorrhage of more than 1500 mL or need for blood transfusion; dilatation and curettage for bleeding or retained placental tissue; hysterectomy; cervical laceration involving the lower uterine segment (in the case of a vaginal delivery); vertical uterine incision or serious extension to a transverse uterine incision (in the case of caesarean section); vulvar or perineal haematoma requiring evacuation; deep-vein thrombophlebitis or pulmonary embolism requiring anticoagulant therapy; pneumonia; adult respiratorydistress syndrome; wound infection requiring prolonged hospital stay, as an inpatient or outpatient, or readmission to hospital; wound dehiscence or breakdown; maternal fever of at least 38.5°C on two occasions at least 24 h apart, not including the first 24 h; bladder, ureter or bowel injury requiring repair; genital-tract fistula; bowel obstruction; or other serious maternal morbidity. Results were analysed on an intention-to-treat basis with group allocation determined by planned mode of delivery prior to the onset of labour or the first plan made after onset where no documented prior plan existed or where presentation was diagnosed intrapartum (at ≤5 cm dilatation). Women who planned a VBD but did not establish in labour necessitating a LSCS remained allocated to the VBD group. Analysis was performed using SPSS version 2021 and STATA version 12.22 Results and baseline characteristics were compared using Fischer’s exact test for categorical data, Wilcoxon rank-sum test for non-normally distributed continuous variables and Independent t-test for normally distributed continuous variables. All statistical relationships were assessed by chiSquare test for categorical data and t-test for continuous data.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Breech presentation at term: A retrospective study
Results During the inclusion period, 1016 live, term, singleton breeches were delivered comprising 2.5% of total births. Two hundred and fifty cases (24.6%) were excluded from analysis as shown in Figure 1 with intrapartum presentation as the commonest reason for exclusion. Five hundred and twenty-three (68.3%) were delivered by elective LSCS and of the remaining 243 (31.7%), 141 (58.0%) successfully delivered vaginally (Fig. 1). Baseline characteristics are shown in Table 1. In this cohort of women, who all went on to deliver a fetus in the in the breech position, ECV attempt rates are also shown in Table 1 with the attempt proving unsuccessful in 165 of the VBD group and 201 of the LSCS group. Where ECV was not attempted, the commonest reasons were insufficient time between diagnosis and labour (56.7% VBD group vs 24.1% LSCS group), unfavourable fetal
position (21.2% VBD group vs 7.2% LSCS group) or the procedure was declined by the woman (14.9% VBD group vs 62.2% LSCS group). Intrapartum LSCS was most commonly due to a failure of adequate progress (55.9%), followed by footling presentation (23.5%) and fetal distress (12.7%). Other indications were postdates pregnancy with failure to establish labour spontaneously, maternal request, chorioamnionitis and cord presentation. Of the 523 planned LSCS, maternal request was the only indication in 71.3% of cases. Less common indications included footling presentation, maternal disease, fetal indication, postdates and uterine scar. Five (1.0%) women allocated to this group had rapid labours and delivered vaginally prior to emergency LSCS. No maternal or infant deaths occurred during the inclusion period, and there was no significant difference in
Women with live singleton fetus in the breech position at term (≥37 weeks) Oct. 1999 – Dec. 2010 n = 1016 Caesarean deliveries excluded (n = 201) • • • • • • • • • • • • • • •
Diagnosis >5 cm = 58 Private patient = 41 Placental abnormalities = 11 Fetal anomaly/congenital abnormality = 9 Oligohydramnios = 7 Maternal disease precluding vaginal delivery = 2 Intrauterine growth restriction = 16 Cord presentation = 7 Multiple previous caesareans = 23 >4 kg estimated fetal weight = 14 Large fetal head (but not >4 kg) = 1 Inadequate pelvimetry = 6 Previous classical caesarean = 1 Previous myomectomy = 1 Patient record unavailable = 4
Vaginal breech deliveries excluded (n = 49) • • • • • •
Cases for analysis n = 766
Intention to treat vaginal breech deliveries n = 243 (31.7%) Delivered vaginally n = 141 (58.0%)
Diagnosis >5 cm = 37 Private patient = 3 Fetal anomaly/congenital abnormality = 5 Cord presentation = 1 Born before arrival = 2 Patient record unavailable = 1
Delivered via intrapartum caesarean section n = 102 (42.0%)
Intention to treat caesarean deliveries n = 523 (68.3%) Delivered vaginally n = 5 (1.0%)
Delivered via elective caesarean section n = 518 (99.0%)
Figure 1 Flow of participants. © 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
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Table 1 Baseline and labour characteristics
Characteristic Actual mode of delivery Vaginal (n, %) LSCS (n, %) Maternal age (years) Mean (SD) Maternal body mass index (median, IQ range) Type of breech Footling (n, %) Frank/Complete (n, %) Time of breech diagnosis Intrapartum (n, %) Antenatal (n, %) External cephalic version attempted (n, %) Parity Nulliparous (n, %) Multiparous (n, %) Previous 1 LSCS (n, %) Gestation (median, IQ range) Neonatal details Birthweight (g)—mean (SD) Head circumference (cm) (median, IQ range)
Planned vaginal birth (n = 243)
Planned caesarean birth (n = 523)
P value
141 (58.0) 102 (42.0)
5 (1.0) 518 (99.0)
DOI: 10.1111/ajo.12208
Original Article
Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study Ailsa BORBOLLA FOSTER,1 Annalise BAGUST,2 Andrew BISITS,2,3 Matthew HOLLAND1 and Alec WELSH2,3,4 1
Department of Obstetrics and Gynaecology, John Hunter Hospital, New Lambton, 2Faculty of Medicine, University of New South Wales, 3Department of Obstetrics & Gynaecology, Royal Hospital for Women, Randwick, and 4Australian Centre for Perinatal Science, University of New South Wales, Sydney, New South Wales, Australia
Background: The 2000 publication of the Term Breech Trial significantly impacted obstetric practice in Australia with a rapid increase in delivery of term breech singletons by caesarean section. More reassuring data from European centres who continued to offer vaginal breech deliveries to carefully selected women have led to a softening of international guidelines which now support an individualised approach to management. The application of this principle to an Australian population, particularly in the wake of such a major change in obstetric practice, has not previously been demonstrated. Aim: To compare short-term neonatal and maternal morbidity for infants with a singleton breech presentation born after 37 weeks, according to planned mode of delivery. Materials and Methods: Eleven-year single-centre retrospective study with intention-to-treat analysis based on intended mode of delivery. Results: Two hundred and forty-three of 766 (31.7%) eligible women elected for planned vaginal breech delivery. The overall success rate in this group was 58%. Morbidity rates were low and compare favourably with similar international studies. However, there was a nonsignificant trend towards higher rates of short-term serious neonatal and maternal morbidity in the planned vaginal delivery group (1.6 vs 0.4%, P = 0.08 and 8.2 vs 4.8%, P = 0.06, respectively). Conclusions: Attempted vaginal delivery for breech presentation remains an option in carefully selected women under strict obstetric protocols. Key words: breech, caesarean section, fetal presentation, obstetric delivery, term.
Introduction The optimal mode of delivery for the term breech fetus has long been a contentious issue in obstetrics and was brought into focus with the 2000 publication of the term breech trial which concluded that ‘planned caesarean section is better than planned vaginal birth’ largely due to a reported 4-fold reduction in perinatal death (0.3 vs 1.3%).1 Although its publication profoundly altered obstetric practice in Australia with an increase in the term breech caesarean rate from 76.7 to 96.3% between 1991 and 2005,2 its application to modern obstetric practice has continued to be a matter of ongoing debate. The main arguments against its conclusions centre on trial standards
Correspondence: Dr Andrew Bisits, Royal Hospital for Women, Barker st, Randwick, NSW 2031, Australia. Email: [email protected] Received 19 November 2013; accepted 8 March 2014.
of care, violations of inclusion criteria, erroneous attribution of adverse outcomes to mode of delivery3–5 and lack of difference in two year outcomes for infants.6 In addition, a number of international obstetric units with strong traditions in vaginal breech delivery (VBD) have demonstrated acceptable safety using term breech trial comparable outcomes, where stringent selection criteria and management are maintained.7–14 Despite international and Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) guidelines acknowledging that VBD may be safe for select populations,15,16 overall numbers remain low possibly reflecting medico-legal concerns in the wake of the term breech trial, which in turn has led to a paucity of experience and training over the last 10 years.2 This study was based in a large metropolitan teaching hospital in New South Wales (NSW) with over 4500 births per year that has continued to offer a breech service allowing choice surrounding mode of delivery at term. NSW delivers the largest number of babies in breech presentation within Australia,17 and this centre accounted
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
1
A. Borbolla Foster et al.
for the largest number of VBD in this state over much of the study period.18–20 No contemporary literature has examined optimal mode of breech delivery in Australia and the purpose of this study therefore was to provide an overview of the safety and efficacy of this service through the evaluation of maternal and neonatal outcomes.
Materials and Methods Study design This was a single centre, 11-year retrospective cohort study conducted at a tertiary referral unit in New South Wales, Australia, between October 1999 and December 2010, the start date coinciding with departmental implementation of a formalised written care pathway for the management of term breech presentation. Inclusion criteria were all women who delivered a singleton pregnancy in any breech presentation (including footling breech) at ≥37-weeks gestation. Exclusion criteria included breech diagnosis at >5 cm cervical dilatation or during elective CS, private patients, fetal congenital abnormalities and other serious contraindications to labour and/or VBD (including severe maternal disease, placental abnormalities, oligohydramnios, cord presentation, intrauterine growth restriction, macrosomia, 2 or more prior lower segment caesareans, complicated uterine scars and deflexed fetal head). All women with a breech presentation identified prior to the onset of labour were referred to a nominated senior obstetrician with more than 10 years experience in VBD and fully counselled regarding delivery options. Where no contraindications were present, external cephalic version (ECV) was offered. The majority of women had a formal ultrasound assessment of fetal weight and growth, while a minority had a bedside scan assessing the same parameters. Computerised tomographic pelvimetry was performed as standard until 2004 when, with minimal evidence to support its utility, the practice was ceased and greater focus placed on progress of labour. Essential patient characteristics allowing consideration of VBD were adopted in line with current Australian and British college guidelines.15,16 Women who did not meet these criteria were counselled for elective caesarean delivery and in order to limit bias between study groups, were excluded from analysis. Women who planned an elective lower segment caesarean section (LSCS) were delivered after 39 weeks gestation unless prior onset of labour necessitated earlier delivery. Women electing for vaginal delivery followed strict obstetric protocols outlined in current RANZCOG and Royal College of Obstetrics and Gynaecology (RCOG) guidelines.15,16 Eligible deliveries were identified using the NSW computerised maternity care system Obstetrix and data regarding baseline characteristics, labour details and perinatal outcomes were obtained from individual maternal and neonatal medical records. 2
Ethical approval for the research was obtained from the Hunter New England Human Research Ethics Committee (Ref No. 12/07/18/5.06).
Outcomes and analysis Primary outcome was a composite index of neonatal mortality and serious neonatal morbidity within 28 days of delivery as used in the term breech trial. Measures of serious neonatal morbidity comprised: birth trauma, including subdural haematoma, intracerebral or intraventricular haemorrhage, spinal-cord injury, basal skull fracture, peripheral-nerve injury present at discharge from hospital or clinically significant genital injury; seizures occurring at less than 24 h of age or requiring two or more drugs to control them; Apgar score of less than 4 at 5 min; hypotonia for at least 2 h; stupor, decreased response to pain or coma; intubation and ventilation for at least 24 h; tube-feeding for four days or more; or admission to the neonatal intensive care unit for longer than four days. Cord blood results were omitted from this composite due to poor and uneven collection between groups. Secondary outcome was a composite index of maternal mortality and serious morbidity also as used in the term breech trial. Measures of serious morbidity comprised: postpartum haemorrhage of more than 1500 mL or need for blood transfusion; dilatation and curettage for bleeding or retained placental tissue; hysterectomy; cervical laceration involving the lower uterine segment (in the case of a vaginal delivery); vertical uterine incision or serious extension to a transverse uterine incision (in the case of caesarean section); vulvar or perineal haematoma requiring evacuation; deep-vein thrombophlebitis or pulmonary embolism requiring anticoagulant therapy; pneumonia; adult respiratorydistress syndrome; wound infection requiring prolonged hospital stay, as an inpatient or outpatient, or readmission to hospital; wound dehiscence or breakdown; maternal fever of at least 38.5°C on two occasions at least 24 h apart, not including the first 24 h; bladder, ureter or bowel injury requiring repair; genital-tract fistula; bowel obstruction; or other serious maternal morbidity. Results were analysed on an intention-to-treat basis with group allocation determined by planned mode of delivery prior to the onset of labour or the first plan made after onset where no documented prior plan existed or where presentation was diagnosed intrapartum (at ≤5 cm dilatation). Women who planned a VBD but did not establish in labour necessitating a LSCS remained allocated to the VBD group. Analysis was performed using SPSS version 2021 and STATA version 12.22 Results and baseline characteristics were compared using Fischer’s exact test for categorical data, Wilcoxon rank-sum test for non-normally distributed continuous variables and Independent t-test for normally distributed continuous variables. All statistical relationships were assessed by chiSquare test for categorical data and t-test for continuous data.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Breech presentation at term: A retrospective study
Results During the inclusion period, 1016 live, term, singleton breeches were delivered comprising 2.5% of total births. Two hundred and fifty cases (24.6%) were excluded from analysis as shown in Figure 1 with intrapartum presentation as the commonest reason for exclusion. Five hundred and twenty-three (68.3%) were delivered by elective LSCS and of the remaining 243 (31.7%), 141 (58.0%) successfully delivered vaginally (Fig. 1). Baseline characteristics are shown in Table 1. In this cohort of women, who all went on to deliver a fetus in the in the breech position, ECV attempt rates are also shown in Table 1 with the attempt proving unsuccessful in 165 of the VBD group and 201 of the LSCS group. Where ECV was not attempted, the commonest reasons were insufficient time between diagnosis and labour (56.7% VBD group vs 24.1% LSCS group), unfavourable fetal
position (21.2% VBD group vs 7.2% LSCS group) or the procedure was declined by the woman (14.9% VBD group vs 62.2% LSCS group). Intrapartum LSCS was most commonly due to a failure of adequate progress (55.9%), followed by footling presentation (23.5%) and fetal distress (12.7%). Other indications were postdates pregnancy with failure to establish labour spontaneously, maternal request, chorioamnionitis and cord presentation. Of the 523 planned LSCS, maternal request was the only indication in 71.3% of cases. Less common indications included footling presentation, maternal disease, fetal indication, postdates and uterine scar. Five (1.0%) women allocated to this group had rapid labours and delivered vaginally prior to emergency LSCS. No maternal or infant deaths occurred during the inclusion period, and there was no significant difference in
Women with live singleton fetus in the breech position at term (≥37 weeks) Oct. 1999 – Dec. 2010 n = 1016 Caesarean deliveries excluded (n = 201) • • • • • • • • • • • • • • •
Diagnosis >5 cm = 58 Private patient = 41 Placental abnormalities = 11 Fetal anomaly/congenital abnormality = 9 Oligohydramnios = 7 Maternal disease precluding vaginal delivery = 2 Intrauterine growth restriction = 16 Cord presentation = 7 Multiple previous caesareans = 23 >4 kg estimated fetal weight = 14 Large fetal head (but not >4 kg) = 1 Inadequate pelvimetry = 6 Previous classical caesarean = 1 Previous myomectomy = 1 Patient record unavailable = 4
Vaginal breech deliveries excluded (n = 49) • • • • • •
Cases for analysis n = 766
Intention to treat vaginal breech deliveries n = 243 (31.7%) Delivered vaginally n = 141 (58.0%)
Diagnosis >5 cm = 37 Private patient = 3 Fetal anomaly/congenital abnormality = 5 Cord presentation = 1 Born before arrival = 2 Patient record unavailable = 1
Delivered via intrapartum caesarean section n = 102 (42.0%)
Intention to treat caesarean deliveries n = 523 (68.3%) Delivered vaginally n = 5 (1.0%)
Delivered via elective caesarean section n = 518 (99.0%)
Figure 1 Flow of participants. © 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
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Table 1 Baseline and labour characteristics
Characteristic Actual mode of delivery Vaginal (n, %) LSCS (n, %) Maternal age (years) Mean (SD) Maternal body mass index (median, IQ range) Type of breech Footling (n, %) Frank/Complete (n, %) Time of breech diagnosis Intrapartum (n, %) Antenatal (n, %) External cephalic version attempted (n, %) Parity Nulliparous (n, %) Multiparous (n, %) Previous 1 LSCS (n, %) Gestation (median, IQ range) Neonatal details Birthweight (g)—mean (SD) Head circumference (cm) (median, IQ range)
Planned vaginal birth (n = 243)
Planned caesarean birth (n = 523)
P value
141 (58.0) 102 (42.0)
5 (1.0) 518 (99.0)
