Singleton term breech deliveries in nulliparous and multiparous women: A 5-year experience at The University of Miami/Jackson Memorial Hospital

Makbib Diro, MD, Apithan Puangsricharern, MD, Luis Royer, MD, Mary Jo OSullivan, MD, and Gene Burkett, MD Miami, Florida
OBJECTIVE: The purpose of this retrospective study was to evaluate the feasibility of planned vaginal delivery, the maternal morbidity and mortality, and the short-term perinatal outcome in selected multiethnic women at term with singleton breech presentations. STUDY DESIGN: Singleton breech deliveries were identified from the delivery database between January 1, 1989, and December 31, 1993. A retrospective chart review identified 310 nulliparous and 711 multiparous women at term (37-42 weeks) for a total of 1021. Parameters studied included the success rate of planned vaginal deliveries and the incidences of maternal morbidity, perinatal morbidity, and mortality as a whole stratified by parity and mode of delivery. The Student t test, 2 test, and Fisher exact test were used for statistical analysis. RESULTS: Among 1021 women with singleton fetuses in a breech position at term, 191 were candidates for vaginal delivery, and 135 (70.7%) of these deliveries were successful. By parity, 12.3% of 310 nulliparous women and 21.5% of 711 multiparous women were candidates for vaginal delivery; 50% of the former and 75.8% of the latter underwent vaginal delivery. Maternal morbidity was more commonly associated with multiparity and cesarean delivery. Newborn intensive care admissions were equally distributed by parity, and significantly more were for vaginal than cesarean deliveries (17.4% vs 10.8%, P = .036 ). Premature rupture of the membranes complicated deliveries in 23.9% of the nulliparous women and only 6.5% of the multiparous women (P = .000). CONCLUSION: In this multiethnic population 70.7% of candidates selected for attempted vaginal breech delivery at term were successful. The remaining 29.3% underwent cesarean delivery for labor disorders or nonreassuring fetal heart rate patterns. (Am J Obstet Gynecol 1999;181:247-52.)

Key words: Breech delivery, perinatal mortality and morbidity, birth injury, cesarean delivery, management of term breeches

Vaginal breech delivery has been associated with higher fetal morbidity and mortality rates compared with elective cesarean birth.1-6 A liberal elective cesarean policy may reduce the risk of adverse perinatal outcome in term breech deliveries,5 but it increases maternal morbidity and cost of care. Controversy exists regarding management of the term breech presentation, with medicolegal issues contributing to the controversy. Most women with fetuses in a breech presentation are not candidates for a trial of vaginal delivery. Hydrocephalus, macrosomia, and placenta previa are obvious contraindications;
From the Division of Perinatology, Department of Obstetrics and Gynecology, University of Miami/Jackson Memorial Hospital. Presented at the Sixty-First Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists, White Sulfur Springs, West Virginia, January 23-26, 1999. Reprint requests: Makbib Diro, MD, University of Miami School of Medicine, Department of Obstetrics and Gynecology (R-136), PO Box 016960, Miami, FL 33101. Copyright 1999 by Mosby, Inc. 0002-9378/99 $8.00 + 0 6/6/99913

however, other factors may be relative contraindications and should be evaluated on a case-by-case basis. To narrow the possibility of failed trial of vaginal delivery, a few publications have presented criteria to aid in selection of pregnancies with breech presentation for vaginal delivery,6, 7 including the use of computed tomographic pelvimetry.8 The purpose of our study was to evaluate our institutional experience over 5 years measured by the success rate of vaginal delivery in selected candidates, maternal and short-term neonatal morbidity and mortality, and differences, if any, of these parameters between the primiparous and multiparous women. We also sought to determine whether our experience calls for modification of the guidelines and our practice patterns. Material and methods This institutional review boardapproved study was conducted at the University of Miami/Jackson Memorial Hospital during the 5 years from January 1, 1989, 247

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Table I. Guidelines for management of breech at term at University of Miami/Jackson Memorial Hospital
Candidates for vaginal delivery 1. Frank breech 2. Flexed fetal head 3. No nuchal arm 4. Fetal weight between 1500 and 3750 g 5. Clinically adequate pelvis Contraindication to vaginal delivery 1. Macrosomia 2. Hydrocephalus 3. Placenta previa 4. Abruptio placentae remote from delivery Relative contraindications (flexibility exists) 1. Nulliparity 2. Previous uterine scar 3. Primigravida aged >35 y 4. Conception after infertility 5. Significant medical or obstetric complication 6. Prior difficult vaginal delivery 7. Premature rupture of membranes

Table II. Demographic characteristics and immediate fetal outcome by parity

Nulliparous women Maternal age (y)* Gestational age (wk)* Birth weight (g)* 5-min Apgar score* Ethnicity Black (n = 221) Haitian (n = 56) Hispanic (n = 425) White non-Hispanic (n = 291) Other (n = 28) *Mean SD. 23.68 6.16 39.44 1.48 3281.39 477.51 8.30 1.53 60 11 127 105 7 Multiparous women 28.75 6.14 39.34 1.47 3366.95 542.81 8.39 2.69 161 45 298 186 21

through December 31, 1993. Maternal and neonatal charts of all term (37-42 weeks gestation) singleton breech deliveries identified from the labor and delivery database were retrospectively reviewed. The existing institutional guidelines for vaginal breech delivery during the study period were a clinically adequate pelvis and frank breech of <3750 g with a flexed head and no nuchal arms. Absolute contraindications to vaginal delivery were similar to those of cephalic presentation (ie, placenta previa, hydrocephalus, macrosomia, and abruptio placentae remote from delivery). Relative contraindications were related to the judgment of the attending physician in charge and discussion with the patient (Table I). Whenever possible, elective planned cesarean deliveries were performed if absolute contraindications to vaginal delivery existed. Ultrasonography was used to estimate the fetal weight and to evaluate the type of breech and the attitude of the head. Potential candidates for vaginal delivery were further evaluated on admission for labor and delivery to determine whether any exclusion criteria existed. Once the attending physician determined that the patient was a candidate, the possibility was presented to the patient. If she elected to attempt vaginal delivery, progress of labor was carefully monitored with Friedmans curve, and oxytocin was used as indicated in a manner similar to that for vertex presentation. Epidurals were encouraged for labor analgesia and initiated at about 4 cm of cervical dilatation with bupivacaine (0.25% 10 mL bolus initially and 3-4 mL every 1.5-2 hours for maintenance as necessary) at the time of this study. These were also used for surgical anesthesia (lidocaine 2% with epinephrine in a 1:200,000 concentration) in case cesarean delivery became necessary. Management and delivery were carried out by the third- and fourth-year residents and supervised

by fellows and attending physicians. The latter, a pediatrician, and an anesthesiologist were in attendance for all vaginal breech deliveries. The outcomes measured were vaginal delivery, maternal morbidity and mortality, neonatal morbidity and mortality including 5-minute Apgar scores of <6, and neonatal intensive care unit (NICU) admissions. Comparisons of these outcome data were done between primiparous and multiparous women. An unplanned vaginal delivery was considered a positive outcome, and an unplanned cesarean delivery was considered a negative outcome, whereas the rest were planned and expected. Statistical analysis was performed by SPSS (SPSSPC, Chicago, Ill). Two-tailed t tests, 2 tests, and the Fisher exact test were used as appropriate. Results During the 5-year study period the incidence of breech presentation was 4.6% (2670 of 58,531 total deliveries) for the institution. There were a total of 1021 singleton term breech deliveries (310 primiparas and 711 multiparas), which composed the study population. The demographic characteristics are shown in Table II. Table III illustrates the planned route of delivery at admission and the actual delivery outcome by parity. The cesarean delivery rate was 85.6% in the total study population; however, in selected candidates for vaginal delivery there was a 70.7% success rate. Candidates for vaginal delivery were 12.3% of the primiparas and 21.5% of the multiparas. The success rate was 50% in the former and 75.8% in the latter groups. Moreover, 12 patients (2.2%) in the multiparous group with planned cesarean deliveries actually were delivered vaginally. The percentages of candidates eligible for vaginal delivery and the success rates analyzed by ethnicity appear similar (Table IV). There were no maternal deaths or life-threatening morbidities. Easily treatable morbidities included fever, endomyometritis, and wound and urinary tract infec-

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Table III. Planned delivery type and actual delivery outcome by parity
Nulliparous women Vaginal delivery Planned vaginal delivery Planned cesarean delivery
TOTAL

Multiparous women Vaginal delivery 116 12 128 116/153 (75.8%) Cesarean delivery 37 546 583

Cesarean delivery 19 272 291

Successful vaginal delivery

19 0 19 19/38 (50%)

tions, the incidence of which varied according to parity and type of delivery and which were more frequent in multiparas (55% vs 40%, P = .000) and in women undergoing cesarean delivery (50.5% vs 37.4%, P = .003). Of the 3 cesarean hysterectomies, 2 were for uncontrollable postpartum bleeding (one of which was caused by partial placenta accreta) and the third was for multiple large myomas in a patient who had requested sterilization. Of significance is the association between premature rupture of the membranes and nulliparity (23.9% compared with only 6.5% in the multiparas, P = .000). Two neonatal deaths occurred within a few hours of birth, one in a patient without prenatal care who was admitted with full cervical dilatation and was delivered soon thereafter of an infant with Apgar scores of 2 and 2 at 1 and 5 minutes, respectively. The other infant had multiple anomalies, and an attempt at vaginal delivery failed. The infant had Apgar scores of 3 and 5 at 1 and 5 minutes, respectively. An additional 4 neonates with significant multiple anomalies died within several days to weeks after birth. Of 15 stillbirths, 14 were intrauterine deaths before the onset of labor, and 1 was an intrapartum death. Five were in primiparas and were associated with anencephaly (n = 1), tight nuchal cord (n = 2), and abruptio placentae (n = 1); 1 was without explanation. The 9 intrauterine fetal deaths in the multiparas were associated with anencephaly (n = 2), trisomy 18 (n = 2), macrosomia (n = 2), total abruptio placentae (n = 1), and tight nuchal cord (n = 1); again 1 was without explanation. The only intrapartum death occurred in a fetus with arrest of descent after delivering to the umbilicus, which led to an emergency cesarean; the neonate could not be resuscitated. Twenty-nine (2.9%) neonates had Apgar scores of <6 at 5 minutes; 13 (44.8%) of them were admitted to the NICU, and 16 (55.2%) went to the nursery. Of the 118 total NICU admissions, 105 (89%) had Apgar scores of >6, whereas the 13 (11%) were the only ones with scores of <6 at 5 minutes. There was no difference in the rates of NICU admission between the neonates of primiparas and the neonates of multiparas (11.1% vs 12.1%, respectively), but significantly more vaginally delivered neonates were admitted to the NICU compared with cesarean deliveries (17.4% vs 10.8%, respectively; P = .036). Neonatal morbidities (eg, bruises, hip dislocation, hyper-

Table IV. Percentage of candidates for vaginal delivery and success by ethnicity
Total No. of patients Black Haitian Hispanic White Others
TOTAL

Vaginal delivery candidates (No.) 37 (16.7%) 15 (26.8%) 87 (20.5%) 46 (15.8%) 6 (21.4%) 191 (18.7%)

Success (No.) 26 (70.3%) 12 (80%) 61 (70%) 32 (69.6%) 4 (66.7%) 135 (70.9%)

221 56 425 291 28 1021

bilirubinemia, fracture of bones, intracranial hemorrhages, and neonatal depression) as a whole were significantly more frequent in the primiparas compared with the multiparas (57.7% vs 17.4%, P = .000). If hyperbilirubinemia were to be eliminated, the overall rate would be decreased to 25.5%. There was no difference by delivery type (32% vaginal delivery vs 29.3% cesarean). Fetal anomalies were equally prevalent by parity (3.5% for primiparas vs 2.7% for multiparas) but were more common in the vaginally delivered group (6.8% vaginal vs 2.3% cesarean, P = .003). Neonatal depression was reported in 19.7% of the primiparas and 12.1% of the multiparas (P = .002), which was equally distributed between cesarean section and vaginal deliveries. Likewise, hip dislocation was similarly distributed between the cesarean and vaginal deliveries (8.8% vs 9.5%) but more prevalent in primiparas (13.5% vs 6.9%, P = .001). One intracranial hemorrhage occurred in a vaginally delivered infant of a multiparous woman, and fractures of the clavicle were noted in 1 infant of a primipara delivered by cesarean section and in 2 infants of multiparas delivered vaginally. Comment As previously reported,1-6 our study demonstrates increased perinatal risks of vaginal breech deliveries. In terms of long-term outcome, a few follow-up reports are available. One 2-year follow-up study could not demonstrate any long-term neurologic morbidity.9 Another 4year study showed increased neurodevelopmental handicaps only in a subgroup of infants delivered vaginally who had hyperextension of the head.10 A large randomized study has been suggested to establish short- and long-

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term outcomes to substantiate whether routine cesarean section should be recommended for the management of breech presentations at term,11 but such a study has not happened because of difficulties that would be encountered from the ethical and medicolegal perspective. The clinical diagnosis of neonatal depression was higher in our study than in a comparable report with a similar protocol that dealt with a homogeneous population7 in contrast to our multiethnic population. The use of computed tomographic pelvimetry8 as opposed to clinical evaluation of the pelvis, as was the case in all of our patients, can be debated. Our population that was clinically eligible for vaginal delivery had a success rate of 75% in the multiparous group, which is comparable with the 81% reported in the computed tomographic study. The risks of vaginal breech deliveries are real and have been discussed in detail in 3 reviews.3, 4, 12 Reports have originated from different parts of the world, namely, Canada,3 Scandinavia,5, 7 England,2, 12 and Hong Kong.13 One Swedish report suggested elective cesarean delivery in term breech presentations,5 a move with significant implications in a homogeneous population known for its low cesarean rate. The primary concern in a vaginal breech delivery at term seems to be the risk for adverse perinatal outcome, even though medicolegal issues are added factors in the United States. The earlier reported intrapartum fetal death is a case in point, demonstrating the importance of patient selection and adherence to strict management guidelines. When retrospectively reviewed, those parameters were not followed in this case. Elective cesarean delivery would theoretically reduce neonatal morbidity and mortality, but morbidities such as fracture of the clavicle, hip dislocation, and bruises may not be eliminated, as shown by others and by us. Whether performing the breech delivery abdominally or vaginally, physicians should be familiar with all maneuvers that may be necessary for a successful delivery of this abnormal presentation. External cephalic version is successful in 50% to 70% of selected cases,13, 14 but many patients remain unsuitable candidates. Despite successful version to a cephalic presentation, the rate of cesarean delivery is increased 2.25 times over those with initial cephalic presentation.13 Among candidates for vaginal breech delivery at Jackson Memorial Hospital, the cesarean rates were 50% in the primiparas and 25% in the multiparas, which is higher than the concurrent institutional rate, confirming the notion that breech presentation predisposes to cesarean delivery even in the best of circumstances. In summary, our experience supports the concept that for the baby a vaginal breech delivery is associated with an increased risk over elective cesarean delivery, but at the same time it can be achieved in 50% to 75% of carefully selected candidates for vaginal delivery without a major adverse perinatal outcome. To dismiss this fact

would subject many women to unnecessary cesarean delivery with all its consequences. From our study we conclude that in properly selected and managed cases the risk to the fetus is minimal, and vaginal delivery deserves consideration. Selection of appropriate candidates requires establishment of and adherence to strict guidelines and good clinical judgment. We thank Lunthita Duthely for her commitment to data management.
REFERENCES

1. Kiely JL. Mode of delivery and neonatal death in 17587 infants presenting by the breech. Br J Obstet Gynaecol 1991;98:898904. 2. Thorpe-Beeston JG, Banfield PJ, Saunders NJ. Outcome of breech delivery at term. BMJ 1992;305:746-7. 3. Cheng M, Hannah M. Breech delivery at term: a critical review of the literature. Obstet Gynecol 1993;82:605-18. 4. Gifford DS, Morton SC, Fiske M, Kahn K. A meta-analysis of infant outcomes after breech delivery. Obstet Gynecol 1995;85:1047-54. 5. Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by mode of delivery among term breech births: Swedish experience 19871993. Obstet Gynecol 1998;92:945-50. 6. Erkkola R. Controversies: selective vaginal delivery for breech presentation. J Perinat Med 1996;24:553-61. 7. Albrechtsen S, Rasmussen S, Reigstad H, Markestad T, Irgens LM, Dalaker K. Evaluation of a protocol for selecting fetuses in breech presentation for vaginal delivery or cesarean section. Am J Obstet Gynecol 1997;177:586-92. 8. Christian SS, Brady K, Read JA, Kopelman JN. Vaginal breech delivery: a five-year prospective evaluation of a protocol using computed tomographic pelvimetry. Am J Obstet Gynecol 1990;163:848-55. 9. Rosen MG, Debanne S, Thompson K, Bilenker RM. Long-term neurological morbidity in breech and vertex births. Am J Obstet Gynecol 1985;151:718-20. 10. Svenningsen NW, Westgren M, Ingemarsson I. Modem strategy for the term breech deliverya study with a 4-year follow-up of the infants. J Perinat Med 1985;13:117-26. 11. Schiff E, Friedman SA, Mashiach S, Hart O, Barkai G, Sibai BM. Maternal and neonatal outcome of 846 term singleton breech deliveries: seven-year experience at a single center. Am J Obstet Gynecol 1996;175:18-23. 12. Bingham P, Lilford RJ. Management of the selected term breech presentation: assessment of the risks of selected vaginal delivery versus cesarean section for all cases. Obstet Gynecol 1987;69:965-78. 13. Lau TK, Lo KWK, Rogers M. Pregnancy outcome after successful external cephalic version for breech presentation at term. Am J Obstet Gynecol 1997;176:218-23. 14. Flanagan TA, Mulchahey KM, Korenbrot CC, Green JR, Laros RK. Management of term breech presentation. Am J Obstet Gynecol 1987;156:1492-502.

Discussion DR EDGAR O. HORGER III, Columbia, South Carolina. Dr Diro has presented a retrospective chart review of 1021 singleton term breech deliveries over a 5-year period. His departmental guidelines have made relative contraindications to vaginal delivery rather broad and leave much of the decision making to the judgment and philosophy of the attending physician. Having spent the last 30 years as an attending physician, I emphatically support this plan, but perhaps some additional information is needed. I will assume that Dr Diros internal re-

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view of his data provides absolute numbers regarding breech delivery recommendations of the various faculty physicians involved during the 5 years under review. How much of a role did the philosophy of the individual attending physician play in allowing labor? I am a believer in vaginal breech delivery, and I look forward to the development of a foolproof method for selecting appropriate candidates. We do advocate vaginal breech delivery at Palmetto Richland Memorial Hospital, as shown by the 26.8% rate (124/462) in the same 5-year period under study. I do have several questions and concerns regarding the presentation. Patients with contraindications for vaginal delivery are said to have undergone elective planned cesarean delivery whenever possible. How many of the cesarean deliveries were done before the onset of labor? A further need for the numbers of scheduled cesarean deliveries arises when one looks at NICU admissions and neonatal morbidity rates in infants delivered vaginally and those delivered by means of cesarean. One would expect very few NICU admissions and minimal neonatal morbidity in those delivered by scheduled cesarean before labor begins. If one estimates that one fifth of the planned cesarean deliveries were done before labor, one lowers the denominator of intrapartum cesarean deliveries significantly. Consequently, for those infants delivered by means of cesarean during labor, the NICU admission rate may rise above 14%, and the neonatal morbidity rate will be near 39%. If this morbidity rate is compared with the 32% found in vaginal delivery cases, perhaps the worst scenario would be planned vaginal delivery that ultimately requires intrapartum cesarean. The information regarding stillbirths is very unclear. Two intrauterine deaths are said to have been caused by macrosomia, which is hard for me to understand as a cause of antepartum death. One would hope that all fetuses that die antepartum would be delivered vaginally. However, an earlier draft of Dr Diros manuscript stated that 6 of the 14 were delivered by cesarean. What led to these 6 cesarean deliveries? Where in the outcome data do we find those stillbirths with vaginal delivery? Were these not included in the planned and successful vaginal deliveries? Abnormal fetuses were 3 times more likely to be delivered vaginally. Were any of these fetuses written off as not expected to live, and did the abnormal fetuses contribute to the 32% neonatal morbidity rate in those delivered vaginally? Unfortunately, I am confused about the take-home message. Only 12% of the nulliparous women were judged to be eligible for vaginal delivery, and only 50% of these achieved vaginal delivery. The ultimate successful vaginal delivery rate in nulliparous women was only 6.1% (19/310). Even more important, the neonatal morbidity rate for the infants of nulliparous women was 57.7%. These figures suggest an unacceptable risk/benefit ratio in nulliparous women. Perhaps all nulliparous women with fetuses in a breech presentation should have ce-

sarean delivery without any trial of labor. The neonatal morbidity rate of 17.4% in the infants of multigravidas was significantly lower, but this is certainly not a negligible rate. One of the stated purposes of Dr Diros study was to determine whether the 5-year experience at Jackson Memorial Hospital called for any modification of the departmental guidelines for term breech delivery. This prompts my final question. Has your study led to any changes in your manner of selection for vaginal delivery? DR DIRO (Closing). We appreciate the time and effort put into Dr Horgers critical review of the manuscript. He has raised several legitimate issues, some of which we may not be able to answer because of the nature of a retrospective study. During the study period there were 8 perinatal attending physicians at any given time. All agreed with the eligibility and the contraindications. Flexibility occurred in the area of relative contraindications, where some would allow labor more readily than others, but the overall eligibility rate ranged between 10% and 18%. Cesarean deliveries before labor occurred in 198 patients. One would expect that elective cesarean deliveries would have the fewest NICU admissions, and the worst scenario would be cesarean delivery during labor. This may be true in general, but the indications for the cesarean must be considered, such as fetal distress versus arrest of labor. Distribution of NICU admissions in the 3 groups was as follows: 13.7% of neonates delivered vaginally contributed 20.3% of the NICU admissions, 19.7% of the group delivered by cesarean before labor contributed 13.6% of the NICU admissions, and 66.6% of neonates delivered by cesarean during labor contributed 66.1% of the NICU admissions. At least from this analysis, although cesarean deliveries before labor had the least proportion of NICU admissions, there was not a disproportionate increase in NICU admissions in the group delivered by cesarean during labor. One should understand that our NICU admissions were not necessarily for serious problems; in fact, most cases were because of blood gas determinations or for observation according to nursery protocols before transfer to regular newborn nurseries. Stillbirth data have been revised in the text to clarify the questions raised by Dr Horger. Vaginal delivery was planned for all fetal deaths. When serious malformations were detected, patients were counseled about the prognosis and mode of delivery. The fact that most were vaginal deliveries meant that they qualified for vaginal delivery unrelated to the anomaly. The neonatal morbidity rate was not corrected for malformations. Dr Horger has also raised the issue of the ultimate low successful vaginal delivery rate in the nulliparous women. It could be assumed that by increasing the eligibility rate for vaginal delivery the success rate might be increased to more than the 6.1% of all nulliparous women undergoing vaginal delivery. However, this can only be presumed and remains to be proved. In reference to the morbidity rate in the nulliparous

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women, I want to emphasize that these morbid conditions were mainly minor, such as hyperbilirubinemia (42.6% in nulliparous deliveries vs 36.4% in multiparous deliveries). In our study, looking at short-term morbidities potentially associated with breeches, most were neonatal depression (19.7% in nulliparas and 12.1% in multiparas), hip dislocations (13.5% vs 6.9%), and minor bruises (3.2% vs 2.3%). Cesarean delivery of all nulli-

paras with breech presentations may not eliminate some of the inherent problems in breech per se, such as hip dislocations and depression. Thus it remains that serious morbidities are indeed low, and vaginal delivery should be attempted in well-selected cases in both nulliparas and multiparas. Our selection criteria remain the same, and we continue to encourage those who are candidates to attempt a trial of vaginal delivery.

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