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The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20

Influence of mode of delivery on outcomes inpreterm breech infants presenting in labor

Claire O’Reilly, Mark P. Hehir & Rhona Mahony

To cite this article: Claire O’Reilly, Mark P. Hehir & Rhona Mahony (2018): Influence of mode ofdelivery on outcomes in preterm breech infants presenting in labor, The Journal of Maternal-Fetal &Neonatal Medicine, DOI: 10.1080/14767058.2018.1500542

To link to this article: https://doi.org/10.1080/14767058.2018.1500542

Accepted author version posted online: 12Jul 2018.

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INFLUENCE OF MODE OF DELIVERY ON OUTCOMES IN

PRETERM BREECH INFANTS PRESENTING IN LABOR

Claire O’REILLY1 MB BCh, Mark P HEHIR1 MD MBA, Rhona MAHONY1 MD

FRCOG

Institutions:

1National Maternity Hospital,

Holles St,

Dublin 2.

Author for correspondence:

Dr Mark P Hehir MD MBA BSc MRCPI MRCOG

E-mail: markhehir23@gmail.com

Tel +353 1 6373100

FINANCIAL DISCLOSURE: The authors report no conflict of interest.

Word Count: Abstract = 191

Text = 2499

Funding: No funding was received for this work.

Short Title: Delivery and outcomes of preterm breech infants

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Precis: Vaginal delivery of preterm breech infants decreases after 27 weeks gestation,

however it remains an important aspect of contemporary practice and a necessary skill for

clinicians.

Abstract

Objective: Rates of vaginal breech delivery at term have fallen significantly. We sought to

examine rates of preterm vaginal breech delivery and outcomes associated with delivery

route.

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Methods:This retrospective cohort study was carried out at a large tertiary referral centre

serving an urban population, from 2001-2011. The primary objective was to compare

outcomes of breech presenting preterm infants according to mode of delivery. The

incidence of preterm breech delivery was examined as well as maternal and neonatal

outcomes associated with vaginal and abdominal delivery of preterm breech infants.

Results:A total of 15% (413/2759) of breech presenting infants delivered prior to 37 weeks

gestation. In extreme prematurity (<28 weeks) the majority (88%; 37/42) of those who

presented in labor delivered vaginally, this rate fell to 47% (63/134) after 28 weeks. Infants

delivered vaginally after 28 weeks were more likely to have an Apgar <7 at 5mins, than

those who had a cesarean delivery (22.5% [16/71] vs. 9% [25/278], p=0.002; NNT=4).

Maternal blood loss >500ml was more likely in those patients delivered by cesarean section

(24.2% [74/305] vs. 3.7% [4/108]; p<0.0001; NNT=2).

Conclusion:These results demonstrate that vaginal delivery of a preterm breech –

presenting infant is a necessary skill for all birth attendants in contemporary practice,

particularly prior to 28 weeks gestation.

INTRODUCTION

Breech presentation occurs in 3-4% of all deliveries1 and is associated with an increased

risk of neonatal morbidity and mortality compared with the overall obstetric population.2

The appropriate mode of delivery of a breech presentation was investigated by the Term

Breech Trial (TBT), which recommended elective cesarean delivery of breech infants

at term.3 Published data from our institution has shown that cesarean delivery of breech

infants has become standard practice in contemporary obstetrics, with vaginal breech

delivery now a relatively rare event.4 This practice carries the potential to cost practicing

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clinicians experience in vaginal breech delivery. The TBT concluded that there is a decrease

in perinatal mortality and early neonatal morbidity associated with cesarean delivery in

nulliparous parturients, additional studies have shown that cesarean delivery can confer risk

to both mother and baby in both current and future pregnancies.5-7 Data has also suggested

that the majority of patients, given the choice would favour a vaginal delivery8,9 and that in

an appropriately selected patient population vaginal breech delivery is still a safe option.10

The optimal mode of delivery of preterm breech infants is also a contentious issue.11 The

RCOG guideline on “Management of Breech Presentation” advises that routine cesarean

section of preterm breeches is not advised.12 Preterm infants were not included in the TBT,

thus evidence relating to their ideal mode of delivery is lacking. Despite this the trial has

had a profound impact on clinicians attitudes to vaginal breech delivery and the preferred

mode of delivery has been shown to be cesarean section.13,14 A randomized controlled trial

to determine the most beneficial mode of delivery in preterm breech presenting infants, has

been attempted and abandoned due to insufficient enrolment.15 Furthermore observational

data relating to maternal and neonatal morbidity associated with vaginal breech delivery of

a preterm infant is not widely reported in the literature. We set out to examine the mode of

delivery of breech infants at gestations prior to 37 weeks, as well as markers of maternal

and neonatal morbidity in those women who had a vaginal breech delivery versus those

delivered by cesarean section.

MATERIALS AND METHODS

This is a retrospective cohort study carried out at the National Maternity Hospital, Holles

St., in Dublin Ireland. The hospital is a large tertiary referral maternity unit, which delivers

approximately 9,000 infants per year. The hospital, located in central Dublin, serves an

urban population. The study included all singleton preterm breech deliveries (<37 weeks

gestation) over an 11-year period from January 1st 2001 to December 31st 2011. Stillbirths

and lethal congenital anomalies were excluded from the study cohort. There was no

change in institutional policy to preterm breech delivery over the course of the study. The

data was gathered as part of continuous hospital wide audit of practice and was hence

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deemed exempt from ethical committee approval by the National Maternity Hospital ethics

committee.

The hospital’s policy regarding breech – presenting infants is that any patient with a breech

presentation at 37-38 weeks’ gestation is counselled and offered external cephalic version

or elective cesarean section at 39 weeks’ gestation. Management of preterm breeches is

judged on an individual case – by – case basis. If a patient arrives to hospital in labor, is

making satisfactory progress with normal fetal monitoring then a vaginal breech delivery

may be attempted provided the patient is counselled regarding potential complications.

Patients are also informed about the possibility for a difficult cesarean delivery due to

descent of the breech into the pelvis in advanced labor.

The primary objective was to compare outcomes of breech presenting preterm infants

according to mode of delivery. We examined the mode of delivery and associated

complications for preterm breech infants at three gestational periods. The gestational

periods investigated were classified as extreme prematurity (24+0 – 27+6 weeks of

gestation), moderate prematurity (28+0 – 31+6 weeks) and finally mild prematurity (32+0 –

36+6 weeks). Gestational age was determined by last menstrual period (LMP), in the event

of patients being unaware of LMP or having an irregular menstrual cycle ultrasonography

was used to determine gestational age.

Labor and delivery characteristics that were analysed included duration of labor (measured

from time of admission to the delivery ward to time of delivery) and method of vaginal

breech delivery i.e. spontaneous, assisted with Mauriceau–Smellie–Veit (MSV), or assisted

via instrumental delivery. Markers of neonatal morbidity for the group of patients delivered

vaginally were compared with those in the group delivered by cesarean section in each

gestational period. Neonatal morbidity was assessed by examining rates of perinatal death

associated with traumatic breech delivery as well as rates of cord pH <7.0, Apgar < 7 at 5

minutes and admission to the neonatal intensive care unit. Maternal morbidity was assessed

by examining the incidence of post–partum hemorrhage (blood loss >500ml and >1000ml)

as well as episiotomy and anal sphincter injury rates.

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Statistical analysis was performed using the χ2 test and Fisher exact test, Odds ratios and

95% confidence intervals were also included. Numbers needed to treat (NNT) to prevent

harm were also calculated. Comparison of means was accomplished with a student’s t –

test. The SPSS software package (version 20.0; SPSS, Chicago, IL) was used; and a 2-tailed

probability value of <0.05 was considered significant.

RESULTS

During the 11 – year study there were 85,785 deliveries, this included 2759 (3.2%)

breech deliveries. A total of 15% (413/2759) of breech infants were <37 weeks gestation.

Approximately 40% (163/413) had a medically indicated pre-labour caesarean delivery

while the remaining 60% (250/413) presented in preterm labour.

The rate of cesarean delivery of all preterm breech infants in labour was 57% (142/250).

A graph of the rate of cesarean delivery among preterm breech presenting infants for each

completed week of gestation from 24+0 to 36+6 can be seen in figure 1. From 24 to 26

weeks gestation the rate of vaginal delivery of breech infants was 85% (23/27). The rate of

cesarean delivery increases from 26+0 and reaches a plateau of approximately 80% at 27

completed weeks gestation where it remains until the end of the 37th week.

Extreme Prematurity (24 – 28 weeks gestation)

A total of 64 breech infants were delivered between 24–28 weeks gestation. The rate of

cesarean delivery was 42.2% (27/64). The majority of those delivered by cesarean section

were not in labour (81.4% [22/27]). A total of 65.6% (42/64) of patients presented in labor

and the rate of vaginal delivery of those in this group was 88.1% (37/42). Of the 37 infants

who delivered vaginally 11 (29%) required the MSV manoeuvre to assist with delivery, no

infant required an operative vaginal delivery. Prior to 26 weeks the rate of vaginal delivery

of those patients who present in labor was 100% (22/22), the perinatal mortality rate was

9.1% (2/22).

The mean duration of labor of those who presented in spontaneous labor and subsequently

delivered vaginally was 91.2 ± 75 mins (range 5 – 414mins). The rate of nulliparity was

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similar among patients delivered vaginally and abdominally (45.9% [20/37] vs. 40.7%

[11/27]; p=0.79). The mean birthweight of the cohort delivered prior to 28 weeks gestation

was 869.6 ± 208.7g. Infants delivered by cesarean section however were found to be

larger than those delivered vaginally (934.2 ± 244.3g vs. 822.5 ± 166.6g; p=0.02). Infants

delivered vaginally were not at increased risk of an Apgar score <7 at 5 mins versus those

who had a cesarean delivery (55.5% [15/27] vs. 45.9% [17/37]; p=0.6). Similarly there was

no difference in the incidence of a cord pH < 7.0 between both groups (9% [2/22] vs. 11.7%

[2/17]; p = 1.0). The rate of perinatal mortality in this gestational cohort was 7.8% (5/64).

Four of the 5 fetal losses took place in women who had a vaginal breech delivery. Three of

the four fetal deaths delivered vaginally were associated with extreme prematurity with two

delivering at 24 weeks and one at 25 weeks gestation. The fourth was delivered at 27 weeks

however the patient had had ruptured membranes since 19 weeks gestation. The baby died

at 2 hours of age. The fetal loss delivered by cesarean section was associated with placental

abruption at 27 weeks and 6 days.

Women who had a cesarean delivery were more likely to have a blood loss greater than

500ml (26% [7/27] vs. 5.4% [2/37]; p=0.02; NNT=2). The incidence of blood loss greater

than 1000ml between the two groups appeared to be greater although it did not reach

statistical significance (11.1% [3/27] vs. 0% [0/37]; p=0.07). The rate of episiotomy in

those patients delivered vaginally was 13.5% (5/37), no patient suffered anal sphincter

injury. A summary of outcomes found in breech deliveries of infants between 24 and 28

weeks gestation can be seen in table 1.

Moderate Prematurity (28 – 32 weeks gestation)

The rate of cesarean delivery increased between 28-32 weeks gestation to 81.9% (86/105).

Similar to the previous gestational epoch the majority of those delivered by cesarean

section were not in labor (80.2% [69/86]). The rate of cesarean delivery of those in labor

was 47.2% (17/36), this was increased when compared with the rate of cesarean delivery

in the previous gestational period (47.2% vs. 11.9%; p=0.0002). Of the 19 infants who

had a vaginal breech delivery between 28 and 32 weeks gestation, 9 (47%) required the

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MSV manoeuvre to assist delivery. No infants required an instrumental delivery. The rate

of nulliparity was similar among patients delivered vaginally and abdominally (52.6%

[10/19] vs. 55.9% [48/86]; p=0.8). There was no difference found in the birthweight of

infants delivered by cesarean section or those delivered vaginally (1367 ± 398g vs. 1415

± 239g; p=0.6). The mean duration of labor of those who delivered vaginally was 48.2 ±

64 mins (Range 2 -237 mins). Infants delivered vaginally were found to have an increased

rate of having an Apgar score of < 7 at 5mins over those who had a cesarean delivery

(31.6% [6/19] vs. 11.6% [10/86]; p=0.03; NNT=3). Infants delivered vaginally were not

however more likely to have a pH < 7.0 (9.1% [1/11] vs. 6.2% [3/48]; p=0.5; NNT=26).

The perinatal mortality rate was 1.9% (2/105), one of these infants was delivered vaginally.

When maternal morbidity was examined women who had a cesarean delivery were more

likely to have a blood loss greater than 500ml (30.2% [23/86] vs. 0% [0/19]; p=0.01;

NNT=2). They were not more likely to have a blood loss of >1000ml (3.5% (3/86) vs. 0%

(0/19); p=1.0). The rate of episiotomy in those patients delivered vaginally was 26.3%

(5/19), no patient suffered anal sphincter injury. A summary of outcomes found in breech

deliveries of infants between 28-32 weeks gestation can be seen in table 2.

Mild Prematurity (32 – 37 weeks gestation)

The cesarean delivery rate between 32-37 weeks gestation was 78.6% (192/244). The rate

of cesarean delivery in labor similar to the previous gestational period was 47% (46/98),

there was no difference when compared with the rate of cesarean delivery in the previous

gestational epoch from 28-32 weeks (47.2% vs. 47%; p=0.97). Of the 52 infants who had

a vaginal breech delivery between 32-37 weeks gestation, 30 (58%) required the MSV

manoeuvre to assist delivery, while 3 (6%) had a forceps assisted – delivery of the after-

coming head. A comparison of rates of vaginal breech delivery of preterm infants for

individual gestational epochs can be seen in table 3. Patients requiring a cesarean delivery

were more likely to be nulliparous than those who had a vaginal delivery (64.6%[124/192]

vs. 40.3%[21/52]; p=0.002). There was no difference in birthweight of infants delivered

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by cesarean section or those delivered vaginally (2388±618g vs. 2420±495g; p=0.72).

The mean duration of labor of those infants who had a vaginal breech delivery was 114.3

± 132 mins. Infants delivered vaginally had an increased risk of having an Apgar score

of <7 at 5mins over those who had a cesarean delivery (19.2%[10/52] vs. 7.8%[15/192];

p=0.03; NNT=5). Infants delivered vaginally were not more likely to have a pH<7.0

(10.2% [4/39] vs. 3.9% [4/104]; p=0.2). The perinatal mortality rate was 0.8% (2/244)

with one of these two infants having a vaginal breech delivery. Those who had a cesarean

delivery were more likely to have a blood loss greater than 500ml (23% [44/192] vs.

3.8% [2/52]; p=0.001; NNT=2), they were not however more likely to have a blood loss

of >1000ml (5.2%[10/192] vs. 1.9%[1/52]; p=0.46). The rate of episiotomy in patients

delivered vaginally was 53.8% (28/52), there were no cases of sphincter injury. A summary

of outcomes found in breech deliveries of infants between 32 and 37 weeks gestation can be

seen in table 4.

DISCUSSION

We have previously published trends in management of breech deliveries at term4

however this study represents a contemporary analysis of management of preterm breech

presentation between 24-37 weeks gestation. From 26 weeks gestation the rate of cesarean

delivery rapidly increased reaching a plateau of circa 80%, which was maintained until 37

weeks gestation.

In the severe prematurity group it was found that the majority of patients who present

in labor prior to 28 weeks gestation deliver vaginally (88%). Between 28 and 37 weeks

gestation the rate of vaginal breech delivery in labor was 47%.

We found that infants between the gestational ages of 28 and 37 weeks who had a vaginal

breech delivery were more likely to have an Apgar score of < 7 at 5 mins, they were not

however more likely to have a low cord pH (<7.0).

Studies have suggested an increased risk of neonatal mortality in vaginal breech deliveries

when compared with cesarean delivery.11,16 This however has been disputed by subsequent

publications.17 The risk of increased rates of neonatal mortality are difficult to quantify as

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while a traumatic vaginal breech delivery, may contribute to an increased risk of neonatal

mortality, sequelae of prematurity in this cohort also play a significant role in neonatal

outcomes.

Over the study there was no change in institutional policy on the management preterm

breech, a limitation that must be considered however is the publication of the term breech

trial in 2001. This may have had an impact on the attitudes of individual clinicians and it is

impossible to quantify this effect.

In our previously published data we have discussed the potential lack of training of

obstetric residents and the possibility of experienced clinicians losing their skills in the

management of vaginal breech delivery. This study demonstrates that vaginal breech

delivery is a frequent challenge in contemporary obstetrics and that it is a necessary

skill that all residents need to develop. Appropriate selection of patients suitable for

trial of vaginal breech delivery must be carried swiftly on their arrival to the delivery

ward and this is best accomplished by involving senior staff in the assessment. Use of

simulation models has potential in the education of residents and the maintenance of skills

in more experienced clinicians. One study has demonstrated that residents were more

knowledgeable and safer in their management of vaginal breech delivery after just one

exposure to a model simulating vaginal breech delivery.18

Vaginal breech delivery of both term and preterm infants remains a necessary skill that

clinicians must endeavour to remain familiar with as these results suggest this is a task they

will be required to carry out many times over their career.

REFERENCES

1 Hickok DE, Gordon DC, Milberg JA, Williams MA, Daling JR. The frequency of

breech presentation by gestational age at birth: a large population-based study. Am J

Obstet Gynecol 1992:166:851-2.

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2 Albrechtson S, Rasmussen S, Irgens LM. Secular trends in peri- and neonatal

mortality in breech presentation Norway 1967-1994. Acta Obstet Gynecol Scand

2000;79:508-12.

3 Hannah ME, Hannah WJ, Hewson SA, Hod- nett ED, Saigal S, Willan AR. Planned

caesarean section versus planned vaginal birth for breech presentation at term:

a randomised multicentre trial: Term Breech Trial Collaborative Group. Lancet

2000;356:1375-83.

4 Hehir MP, O’Connor HD, Kent EM, Fitzpatrick C, Boylan PC, Coulter-Smith S,

Geary MP, Malone FD. Changes in vaginal breech delivery rates in a single large

metropolitan area. Am J Obstet Gynecol 2012;206:498.e1-4.

5 Hemminki E, Merilainen J. Long-term effects of cesarean sections: ectopic

pregnancies and placental problems. Am J Obstet Gynecol 1996;174:1569-74.

6 Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported

postpartum general health status among primiparous women. Paediatr Perinat

Epidemiol 2001;15: 232-40.

7 Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode

of delivery at term: influence of timing of elective caesarean section. BJOG

1995;102:101-6.

8 Chong ES, Mongelli M. Attitudes of Singapore women toward cesarean and vaginal

deliveries. Int J Gynaecol Obstet 2003;80:189-94.

9 Yogev Y, Horowitz E, Ben-Haroush A, Chen R, Kaplan B. Changing attitudes toward

mode of delivery and external cephalic version in breech presentations. Int J

Gynaecol Obstet 2002;79:221-4.

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10 Alarab M, Regan C, O’Connell MP, Keane DP, O’Herlihy C, Foley ME.

Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol

2004;103:407-12.

11 Reddy Um, Zhang J, Sun L, Chen Z, Raju TNK, Laughon K. Neonatal mortality

by attempted route of delivery in early preterm birth. Am J Obstet Gynecol 2012;

207:117.e1-8.

12 Hofmeyr GJ, Impey LWM. RCOG green top guideline No. 20b: Management breech

presentation. 2006. www.rcog.org.uk/guidelines

13 Sullivan EA, Moran K, Chapman M. Term breech singletons and caesarean

section: a population study, Australia 1991-2005. Aust N Z J Obstet Gynaecol.

2009;49:456-60.

14 Hartnack Tharin JE, Rasmussen S, Krebs L. Consequences of the Term Breech Trial

in Denmark. Acta Obstet Gynecol Scand 2011;90: 767-71.

15 Penn ZJ, Steer PJ, Grant A. A multicenter randomized controlled trial comparing

elective and selective cesarean section for the delivery of the preterm breech infant.

BJOG 1996;103:684-9.

16 Grravenhorst JB, Schreuder AM, Veen S, Brand R, Verloove-Vanhorick SP, Verwiej

RA, van Zeben-van der Aa DM, Ens-Dokkum MH. Breech delivery in very preterm

and very low birthweight infants in The Netherlands. Br J Obstet Gynaecol 1993

May;100(5):411-5.

17 Kayem G, Baumann R, Goffinet F, El Abiad S, Vile Y, Cabrol D, Haddad B. Early

preterm breech delivery: is a policy of planned vaginal delivery associated with

increased risk of neonatal death? Am J Obstet Gynecol 2008 Mar;198(3):289.e1-6.

Epub 2008 Feb 1.

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18 Deering S, Brown J, Hodor J, Satin AJ. Simulation training and resident

performance of singleton vaginal breech delivery. Obstet Gynecol. 2006

Jan;107(1):86-9.

FIGURE LEGEND

Figure 1 shows the rate of cesarean delivery of preterm breech presenting infants.

Increasing gestational age is shown on the X-axis in increments of completed

gestational weeks.

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Table 1. Outcomes associated with delivery of a

breech – presenting infant between 24+0 and 27+6

Characteristic VaginalDelivery (N=37)

LSCS(N=27)

P – Value

Gestational Age (Days) 186.1 ± 7 178.5 ± 6.9 < 0.0001

Birthweight 934.2 ± 244.3g 822.5 ± 166.6g 0.02

Nulliparity 45.9% [20/37] 40.7 [11/27] NS

Apgar < 4 @ 5mins 19.4% [6/37] 28.6% [6/27] NS

Apgar < 7 @ 5 mins 45.9% [17/37] 55.5% [15/27] NS

pH < 7.0 9% [2/22] 11.7% [2/17] NS

Maternal BloodLoss >500ml

5.4% [2/37] 26% [7/27] 0.02

Maternal BloodLoss >1000ml

0% [0/37] 11.1% [3/27] 0.07

Legend

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Table 2. Outcomes associated with delivery of a

breech – presenting infant between 28+0 and 31+6

Characteristic VaginalDelivery (N=19)

LSCS(N=86)

P – Value

Gestational Age (Days) 211.2 ± 7.8 209.8 ± 8.6 NS

Birthweight 1415 ± 239g 1367 ± 398g NS

Nulliparity 52.6% [10/19] 55.9% [48/86] NS

Apgar < 4 @ 5mins 10.5% [2/19] 3.5% [3/86] NS

Apgar < 7 @ 5 mins 31.6% [6/19] 11.6% [10/86] 0.03

pH < 7.0 9.1% [1/11] 6.2% [3/48] NS

Maternal BloodLoss >500ml

0% [0/19] 30.2% [23/86] 0.01

Maternal BloodLoss >1000ml

0% (0/19) 3.5% (3/86) NS

Legend

NS = Non – significant; p > 0.05

Table 3. Rates of vaginal breech delivery of preterm infants in spontaneous laboraccording to gestational period

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Comparison with previousgestational epoch

GestationalPeriod

Vaginal Delivery P- Value Odds Ratio;95% CI

ExtremePrematurity

(24+0 – 27+6)

88.1% (37/42) NA NA

ModeratePrematurity(28+0-31+6)

47.2% (17/36) 0.0002 8.2; 2.6 – 25.8

Mild Prematurity(32+0 – 36+6)

47% (46/98) 0.97 1.01; 0.47 – 2.2

LegendCI = Confidence IntervalNA= Not available

Table 4. Outcomes associated with delivery of a

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Characteristic VaginalDelivery (N=52)

LSCS(N=192)

P – Value

Birthweight 2388 ± 618g 2420 ± 495g NS

Nulliparity 40.3% [21/52] 64.6% [124/192] 0.002

Apgar < 4 @ 5 mins 5.8% [3/52] 1.0% [2/192] NS

Apgar < 7 @ 5 mins 19.2% [10/52] 7.8% [15/192] 0.03

pH < 7.0 10.2% [4/39] 3.9% [4/104] NS

Maternal BloodLoss >500ml

3.8% [2/52] 23% [44/192] 0.001

Maternal BloodLoss >1000ml

1.9% [1/52] 5.2% [10/192] NS

Legend

NS = Non – significant; p > 0.05

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