Should a preterm breech go for vaginal delivery or caesarean section.HS Warke, RM Saraogi, SM Sanjanwalla
Dr. R.N. Cooper Hospital, Vile Parle, Mumbai, India., India
This study correlates the mode of breech delivery to the immediate neonatal outcome in preterm breeches. We had 9816 deliveries in the period between 1st January 1994 to 31st August 1996. The incidence of breech deliveries was 3.95% and the incidence of preterm breech deliveries was 1.9%. Totally 112 (69%) patients delivered vaginally and 50 (31%) underwent caesarean section. Between 30-36.6 weeks gestation the incidence of birth asphyxia was higher in the vaginal group. In this group the take home baby rate after vaginal delivery was 81% as compared to 86% in caesarean group. Head entrapment, cord prolapse, respiratory distress syndrome and intraventricular haemorrhage were the various complications seen with vaginal breech delivery.
Keywords: Breech Presentation, Cesarean Section, Delivery, Obstetric, Female, Gestational Age, Human, Infant, Newborn, Infant, Premature, Pregnancy, Pregnancy Complications, Pregnancy Outcome,
In the present era, where caesarean section has become much safer and with good neonatal care, obstetricians all over the world find themselves in a dilemma regarding the management of a preterm breech in labour. At present many obstetricians have come to view preterm breech delivery as a high-risk situation, best treated by primary caesarean section. The usual reasons for this attitude are fear of entrapment of relatively large aftercoming head, cord prolapse, in-coordinate labour, intrapartum hypoxia, aspiration pneumonia and traumatic injuries. However a negative issue is the recognized high incidence of major congenital anomalies in breech presenting foetuses. The complications of vaginal breech delivery such as difficulty with the aftercoming head or breech extraction claim a significant number of lives especially when the infant weight less than 2500 grams or greater than 4000 grams. The current survival figures in infants weighing 750, 1000, 1500 and 2000 grams or more at delivery are 18%, 80%, 88% and 99% respectively.
Empericism should have a statistical base and hence we looked at the conduct of breech deliveries at our institute in a retrospective manner.
The aim of this study was to correlate the mode of delivery to the immediate neonatal outcome in preterm breeches.
We had 9816 deliveries in the period between 1st January 1994 to 31st August 1996. The incidence of breech deliveries was 3.95% (388 patients). The incidence of preterm breech deliveries (up to 36.6 weeks gestation) was 1.9% (162 patients).
All the patients with intrauterine fetal death and lethal congenital malformation were excluded. In cases of multiple pregnancies only those with first foetus in breech presentation were included. Steroids were administered when indicated and whenever possible. Tocolytics were tried wherever possible. All the vaginal breech deliveries were conducted or supervised by an experienced obstetrician.
The patients were divided into four categories according to the gestational age [Table - 1]
The incidence of caesarean section increased as the gestational age increased. Totally, 69% (112) patients delivered vaginally and did not have any medical or obstetric complications. 31% (50) underwent caesarean section [Table - 1]. The indications for which caesarean section was performed were divided into 2 categories [Table - 2]
Where there was on additional foeto-maternal high risk factor along with breech presentation and
Where there was no other high risk factor and caesarean section was done for breech per se.
As expected in the group of below 30 weeks gestation caesarean sections were performed basically for maternal indications. In the group between 30-33.6 weeks only 20% of the patients underwent caesarean section for breech per say whereas 80% patients who underwent caesarean section had additional high risk factor. In the last group between 34-36.6 weeks 60% of patients underwent caesarean section for breech per se. Of the patients who delivered vaginally 73.2% were multigravidas and of the patients who delivered by caesarean section 92% were primigravidas.
The mode of delivery was correlated to the 5 minutes Apgar score. Though no conclusions could be drawn in the group below 30 weeks due to small sample size, a significant difference was found above 30 weeks.
As the grey zone of controversy would center on the group from 30-36.6 weeks this study focused on this group particularly. In this group the incidence of severe asphyxia was much high in the vaginal delivery group [Table - 3].
4 babies in the vaginal group died intrapartum of which in 2 cases cord prolapse occurred and 13 babies died in the neonatal period. 2 babies had Erbs palsy and 3 had convulsions in the vaginal group. Thus morbidity was higher after vaginal deliveries.
3 babies in the vaginal group none in caesarean group had head entrapment. 6 babies in the vaginal group and 3 in caesarean group died due to respiratory distress syndrome. 2 babies in vaginal group and none in caesarean group had intraventricular haemorrhage. 2 babies in vaginal group and 1 in caesarean group died due to sepsis. Necrotising enterocolitis was seen in 2 babies with vaginal delivery.
Among the babies delivered by caesarean section, six babies died in the neonatal period. In three of these babies, caesarean section was done for breech per se and in the other three babies caesarean section was done for an associated foeto-maternal indication.
In the group of 30-36.6 weeks, 47 patients underwent caesarean section of which in only 22 patients caesarean section was done for breech per se. A comparison was done between breech delivery per vaginum having no obstetric or medical complications with caesarean section done only for breech per se. The take home baby rate was analysed.
In the group of 30-36.6 weeks the take home baby rate after vaginal delivery was 81% compared to 86% in the caesarean section group where caesarean section was done for breech per se. The deaths due to cord prolapse were excluded while calculating take home baby rate for vaginal delivery group, cord prolapse being an indication for caesarean section.
Ingemarsson et al who studied the long term follow up of these babies those delivered vaginally and those delivered by caesarean section. The incidence of birth asphyxia and CSF bleed was three times higher in the vaginal group and the incidence of neurological abnormalities was 10 times higher in the vaginal group. Lyon and Papsin et al in their studies have shown similar results. De Crespingny et al has proposed the routine use of caesarean section in cases of preterm breech so as to reduce intrapartum hypoxia and birth trauma.
As the spectrum of while light has various colours with different wavelengths, the literature on this subject shows varied conflicting reports. On one side we have a report saying no increase in morbidity and mortality after vaginal delivery by Laurence et al and on the other hand we have a report by Lyon et al stating that the method of choice for delivering these patients would be caesarean section.
It is important to exclude extreme prematurity and congenital malformations, which are 3 to 5 time commoner especially before caesarean section.
Gimovsky et al has put forth an individualized approach thus to strike the best balance between neonatal and maternal mortality and morbidity.
It is seen that majority of the infants weighing less than 1500 grams presented as footling braches with higher incidence of cord prolapse. Premature footling breech foetuses specially those weighing between 1000 grams and 1500 grams are best managed by caesarean section.
In conclusions this study would make us think in order to review our policies regarding preterm breech deliveries. Caesarean section would be a preferable mode of delivery for preterm breech associated with other complications, especially for premature foetuses presenting as footling breeches and lower weight ranges. Patients with complete and frank breech presentations however can be permitted to undergo labour, while caesarean section is being reserved for associated indications such as abnormal pelvis, failure of labour to progress, hyperextension of fetal head etc. The safety of labour in this group of breech patients might be increased by the use of electronic fetal heart rate monitoring and blood sampling for pH as has been recommended by Hill et al. The mortality and morbidity in vaginal group can be reduced by managing cord prolapse by an emergency caesarean section and the vaginal breech deliveries being conducted by an experienced obstetrician. The preterm breech should be delivered with great care and safety.
Thanks to our Medical Superintendent, Dr. Wadiwalla for granting us permission to publish hospital data.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]