Abstract
Vaginal delivery of a breech baby is a necessary obstetrical skill since approximately 4% of babies at term are in breech presentation. Yet, on most delivery wards, the expertise required to deliver breech babies vaginally has virtually disappeared. Patients and obstetricians should be aware that there is no convincing evidence that cesarean section is better for the breech baby than assisted vaginal delivery, provided that certain strict criteria are met, and that cesarean section is associated with a higher risk of morbidity and mortality for the parturient than vaginal delivery. In addition, repeated cesarean sections carry additional substantial health risks for parturients. A trial of external cephalic version should be offered to all parturients who do not have contraindications for this procedure. Supraregional centers that specialize in breech delivery should be organized and basic simulator training for residents should be provided. In addition, a system of suprainstitutional standby teams of experienced obstetricians should be established to provide expertise in planned vaginal delivery.
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Release date: 1 March 2012; Expiration date: 1 March 2013
Learning objectives
Upon completion of this activity, participants will be able to:
• Assess risk factors for breech presentation
• Distinguish characteristics of breech pregnancies
• Compare risks associated with vaginal vs cesarean delivery for breech presentation
• Analyze how to improve rates of vaginal delivery for breech presentation
Financial & competing interests disclosure
EDITOR
Elisa Manzotti,Publisher, Future Science Group, London, UK.
Disclosure: E Manzotti has disclosed no relevant financial relationships.
CME AUTHOR
Charles P Vega, MD,Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine, CA, USA.
Disclosure: Charles P Vega, MD, has disclosed no relevant financial relationships.
AUTHOR AND CREDENTIALS
Marek Glezerman, MD,The Emma Neiman Professor of Obstetrics and Gynecology, Sackler Faculty of Medicine, Tel Aviv University; Hospital for Women, Rabin Medical Center, Petah Tikva, Israel.
Disclosure: Marek Glezerman, MD, has disclosed no relevant financial relationships.
Approximately 95% of fetuses have stabilized at delivery with vertex presentation and approximately 3–4% with breech presentation. The etiology for this malpresentation remains largely elusive, although in approximately 20% of cases contributing factors may be found. These include primiparity, multiple pregnancy, oligo- or poly-hydramnios, placental pathology, and certain fetal malformations. The incidence of breech presentation is inversely related to the length of gestation and may be as high as 25% before the 28th gestational week Citation[1]. Therefore, before term, breech presentation is usually regarded as a transient event, at least before week 35. After that, fewer than 10% of breech presentations will spontaneously revert to vertex. It makes sense, therefore, to make the diagnosis of breech presentation after the 35th week of pregnancy. There is consensus now that efforts should be made to try and turn a breech baby into vertex presentation and external cephalic version in experienced hands is successful in 50–60% of cases. Nonconventional methods such as acupuncture, moxibustion, knee–elbow position and others have yielded positive results, but evidence-based data on these methods are scarce. Eventually, a woman admitted to the delivery ward with her fetus in breech presentation will expect that a skillful obstetrician will deliver her safely. Regrettably, most residents are currently not adequately trained in planned vaginal breech delivery (VBD). This is the crux of the matter: how skillful are modern obstetricians in VBD and is the parturient being given a fair chance to choose between vaginal and abdominal delivery, if one of these two options is actually not available owing to lack of obstetric skills? There are, and always will be, situations when a parturient arrives with breech presentation at the delivery ward and a cesarean section (CS) is not an option due to medical reasons, availability of facilities, very advanced labor or patients’ refusal to have surgery, or the attending obstetrician has not been sufficiently trained in assisted VBD. Of course, an individual should not perform a procedure for which he/she is not sufficiently trained, but there are circumstances where a physician may have no other choice than to deliver a breech baby vaginally. Thus, how safe is such a procedure for mother and infant?
The problem
Breech presentation is the most common form of malpresentation, and the etiology and management has been the topic of professional discussions for centuries. Until a decade ago, the delivery of a breech baby was an integral part of obstetric training, although many obstetricians preferred CS over vaginal delivery. There is no doubt that breech presentation has always been a challenge for obstetricians, because of the skills required to deliver a breech. Moreover, the immediate perinatal outcome, in terms of APGAR scores and acid–base status of breech babies, is often reported to be inferior when delivered vaginally. This is probably a misconception. Luterkort and Marsál have examined this issue and compared the outcome for breech babies, not only within groups of mode of delivery, but also between groups of fetal presentation Citation[2]. Indeed, when looking at breech babies delivered vaginally versus those delivered abdominally, pH levels were lower and base excess was higher in the vaginal group. However, when stratifying by presentation, the same difference was also true for vertex babies. Thus, babies born by the vaginal route have lower pH and higher base excess regardless of their presentation but as a result of the mode of delivery. Unfortunately, many obstetricians are not aware of this situation. Enter the medico–legal environment, which has affected medical practice profoundly during the past decades. Rarely, if at all, is an obstetrician sued for performing a CS in a parturient with breech presentation, but very often so if the outcome of a VBD is short of optimal. In these cases the attending obstetrician will find herself/himself in the awkward position of having to explain why a CS has not been performed. In order to provide more evidence-based data, in 2000 the Term Breech Trial (TBT) was published, the largest randomized controlled trial ever performed that compared VBD with planned CS Citation[3].
The trial was conducted in 121 centers in 26 countries and included 2183 women at term with fetuses in breech presentation who were randomized for delivery by either planned CS or VBD. The primary outcomes measured were maternal and neonatal mortality and morbidity. The trial was stopped early because interim analysis apparently indicated that planned CS was superior to VBD (as far as perinatal mortality and morbidity were concerned). This single piece of research profoundly and ubiquitously changed medical practice and effectively removed planned VBD from delivery wards in the western world. It came as no surprise that, almost immediately, the medical community enthusiastically embraced the conclusions of the trial, since CS requires fewer skills and the obstetrician feels more protected medico–legally if he/she performs surgery.
Indeed, only 3 years after the publication of the TBT, the lead authors of the TBT reported that 92% of over 80 collaborative centers in 23 countries had completely abandoned planned VBD in favor of CS Citation[4]. In The Netherlands, the CS rate for breech presentation has increased from 57% in 2000 to 81% in 2001 after the publication of the TBT Citation[5].
The TBT was a blatant example of how an inadequate randomized controlled trial can change medical practice. Although inclusion criteria were straightforward, there were many flagrant violations of these. Although planned delivery was required, many women were recruited during active labor. Although the presence of hyperextension of the fetal head was considered an exclusion criterion, over a third of patients did not undergo any relevant diagnostic imaging procedures. Randomization demanded the presence of a live singleton fetus; however, among the 16 cases of perinatal mortality in the study, there was one twin, one case of anencephalus and two stillbirths, the latter having occurred apparently before randomization. A substantial number of fetuses with apparent intrauterine growth retardation were included in the study. Inclusion criteria restricted participation to fetuses weighing less than 4000 g. However, there were significantly more fetuses above this weight limit in the VBD group and in too many instances of VBD there was no attendance of clinicians with adequate expertise. Moreover, participating centers had substantially different levels of standard of care and many actually provided what would definitely be considered substandard by most obstetricians. The TBT was terminated early because 13 out of 16 cases of prenatal mortality occurred in the VBD group. However, a thorough re-evaluation revealed that in ten of these 13 cases neonatal mortality of vaginally delivered infants was not associated with the mode of delivery. These and other severe flaws of the TBT have been addressed by Glezerman Citation[6]. Eventually, the authors of the TBT conceded that most cases of perinatal morbidity in the TBT were not related to the mode of delivery Citation[7]. In this specific publication the authors divided 69 cases of perinatal morbidity into five groups, namely those related to labor (n = 25), those related to delivery (n = 26), those unrelated to either labor and delivery (n = 6) and those in which the outcome remained unexplained (n = 12). From this preliminary division it is already evident that the authors attributed delivery mode-related morbidity to less than 40% of cases. However, even within the subgroup of allegedly delivery-related morbidity, the inclusion of 11 out of 26 fetuses was not justified: there were four cases of stillbirth and the relation to delivery mode remained unclear. In addition, there was one footling presentation, one case with congenital malformations and five fetuses that were probably growth-retarded (birthweight: 2.115–2.550 g). None of these should have been included in the study in the first place. It is noteworthy that two cases of very severe neonatal morbidity (spinal cord injury and basal skull fracture) occurred in infants who were delivered by planned CS, that is, precisely by that delivery method, which, according to the authors, should provide protection for this type of injury.
As mentioned above, the early termination of the TBT and the published conclusions were based on mortality and the surrogate end point of short-term morbidity. However, long-term assessment (2 years) of composite morbidity/mortality showed no difference in outcome between breech infants delivered by planned CS or by VBD Citation[8]. Moreover, the fast-track publication and the review process of the TBT paper were later criticized by one of the reviewers Citation[9]. The conclusions of the TBT should therefore no longer be considered as applicable to modern obstetrics in the western world. However, common practice has hardly changed. VBD has become rare in modern delivery wards and expertise in VBD is vanishing.
High-quality retrospective studies from various countries do not confirm the morbidity and mortality data from the TBT, provided that stringent criteria for breech delivery are applied for VBD Citation[10]. The PREMODA study, published in 2006, was designed as a prospective observational study with an intention-to-treat analysis Citation[11]. The study included over 8000 women with breech presentation at term (∼four-times as many as included in the TBT), which were recruited in 174 French and Belgian centers. The authors did not observe differences in perinatal morbidity or mortality in breech babies delivered by CS versus vaginal delivery.
Major opinion-making institutions, such as the American Congress of Obstetricians and Gynecologists Citation[12,13] and the Cochrane Collaboration Citation[14], which had endorsed the recommendations soon after the publication of the TBT, have since modified their recommendations and support VBD if stringent requirements are met. Others, such as the professional societies of Obstetrics and Gynecology of Canada Citation[15] and the UK Citation[16], have published supportive guidelines that stress the safety of VBD under well-defined conditions. Yet, on most obstetric wards planned VBD has virtually disappeared.
Although an abundance of contemporary literature contradicts the TBT findings, the obsolete conclusions of the TBT are still used today by many obstetricians as a set of arguments in favor of planned CS. Since the publication of the TBT more than a decade ago, almost three generations of physicians in the western world have completed their residencies with no or inadequate training in VBD. Most probably, the point of no return has been reached as far as routine planned vaginal deliveries is concerned. The consequences of this situation are many superfluous CSs, with consequential morbidity to women and the vanishing of obstetrical expertise, with increased risks to those breech babies who need to be delivered vaginally.
The ‘bad quality theory’ of the breech fetus
Breech presentation may be the result rather than the origin of intrauterine pathology, as indicated by faulty implantation of the placenta, the increased incidence of uterine malformations, and the quantitative pathology of amniotic fluid (oligohydramnion or polyhydramnion), all of which may alone be signs of intrauterine pathology that may affect adequate fetal development. It has repeatedly been stressed that fetal outcome is worse for breech babies than for vertex babies, disregarding the mode of delivery Citation[17]. There are also inherent differences between fetuses in breech and those in vertex presentations, the clinical significance of which is still unclear. For example, Ochshorn et al. examined cord characteristics in breech babies and in vertex babies Citation[18]. They showed that the number of umbilical coils in breech babies was significantly lower than that in vertex babies (five and 12, respectively), and cord length in breech babies was also significantly shorter (57 and 64 cm, respectively). Furthermore, the patterns of fetal movements seem to differ between breech and vertex babies: breech babies perform more whole-body movements than vertex babies, while movements of extremities are more common in vertex babies than in breech babies. This may indicate a delay in CNS maturation of breech babies Citation[19]. Moreover, at each gestational week beyond 32 weeks, breech babies constantly have a lower birthweight than vertex babies. Sekulić et al. have reported on a decreased expression of the righting reflex and of locomotor movements in breech babies after delivery Citation[20]. In this prospective trial, 50 breech babies were compared with 87 vertex babies, all of which were delivered electively by CS after an uneventful pregnancy. The differential expression of the righting reflex could not be explained by postural deformities owing to malpresentation.
Last but not least, fetal malformations are more often observed in breech presentation than in vertex presentation, and this difference becomes prominent for all gestational week groups after gestational week 32. Schutte et al. have therefore speculated that “It may be that breech presentation may not be coincidental but rather a product of the quality of the infant…” and have concluded that “…if there is some truth in this supposition, it is unlikely that medical intervention … can improve the outcome…” Citation[17].
Maternal choice & informed consent
Existing evidence does not support the notion that CS is a safer mode of delivery for the parturient with breech presentation. There is also no solid evidence for the statement that CS is safer for the baby. At consultation, the parturient (and definitely the consulting obstetrician) should be aware of this and probably also of the following facts: CS is associated with increased maternal morbidity, including longer hospitalization Citation[21], a four-times higher risk for need of blood transfusion and an over ten-times higher risk for endometritis Citation[22]. van Ham et al. have reported on 9% intraoperative complications and 2.6% postoperative major complications in CS in addition to 23.7% minor postoperative complications Citation[23]. Maternal mortality is 3.8-times higher in CS than in vaginal delivery for previously healthy women who undergo an elective CS Citation[24]. Schutte et al. recently reported on three cases of maternal death after elective CS for breech presentation Citation[5].
These are examples of immediate risks associated with CS. Of even greater concern are complications in subsequent pregnancies. Rageth et al. compared 29,000 parturients with previous CS to 226,000 without previous CS Citation[25]. Surgery was performed for various reasons and not necessarily for malpresentation, because the aim of the study was to evaluate deliveries with or without a uterine scar. In women with previous CS the relative risk (RR) for uterine rupture was 42, for ileus 10, for hysterectomy 6, for transfer to intensive care unit or to another hospital 3, for various placental complications between 1.3 and 8, and for thromboembolic complications 2.8. Pregnant women with a scarred uterus have an increased risk for placental previa or accreta Citation[26], and uterine rupture Citation[27]. All of these are associated with an increased risk for severe peripartum hemorrhage and emergency hysterectomy Citation[28]. In fact, 50% of emergency hysterectomies are performed for placenta previa or placenta accreta. Repeated CS is also associated with an increased risk for injury to the bladder and intestines Citation[29].
There are also increased risks for the fetus associated with CS. Rageth et al. reported on increased neonatal risk after CS for an Apgar score <5 (RR: 1.6) and for pH <7 (RR: 2.5) Citation[25]. Moreover, prelabor CS is associated with substantially increased neonatal respiratory morbidity Citation[30].
Different points of view
Proponents of cesarean delivery for all breech presentations usually claim the following.
Planned CS is a safe procedure with very low maternal morbidity & mortality
These arguments are not substantiated by any hard evidence. On the contrary, planned CS is associated with a higher incidence of maternal morbidity and maternal mortality than vaginal delivery.
Planned CS is safer for the baby
In actual fact, there is no convincing evidence that neonatal morbidity is higher for vaginally delivered breech babies than for those delivered abdominally. Ironically, the two most severe cases of fetal morbidity in the TBT, namely skull fracture and spinal cord injury, occurred in abdominally delivered babies.
Even if maternal mortality & morbidity were slightly higher for CS, abdominal delivery would still be preferable because the risks of elective CS in a nonlaboring woman are outweighed by the decreased risks for a vaginally delivered fetus
The increased relative risks for morbidity and mortality associated with abdominal delivery have been addressed above. However, the immediate surgical risk for the parturient is not the only issue. Potential consequential damages in future pregnancies also need to be considered. With every additional pregnancy, the risks for placental pathology, need for repeated surgery and surgical complications increase. In Israel, the annual number of births is approximately 165,000 and the CS rate approximately 21%. Almost a third of these are being performed because of fetal malpresentation in the current pregnancy or because of a uterine scar due to malpresentation in a previous pregnancy. Since most fetal malpresentations are breech, CS for this condition contributes substantially to the current CS rates. The public health implications for increasing CS rates are striking. With a continuous decline in the incidence of vaginal deliveries, more women undergo CS, which increases the subsequent need for CS and an inherent increased complication rate. The estimated cost for every 5% increase in the CS rate has been calculated for the USA by Plante Citation[31]. At an annual rate of 4,000,000 deliveries, an increase in the CS rate from 29 to 33% would be associated with 33 additional cases of maternal death, 14,000 surgical complications, 33,000 admissions to the neonatal intensive care unit, 8000 neonatal respiratory complications and an increase of 93,000 hospitalization days.
The current medico–legal environment favors CS over vaginal delivery
This is unfortunate but true. However, yielding to nonprofessional pressure means accepting the dictate of defensive medicine and acting contrary to the best interest of the patient. The more ethical attitude would be to confront the legal system with the current evidence related to VBD.
With limited expertise it may be safer to perform a CS than a vaginal delivery
This is absolutely true. Obstetricians should use the tool they feel most comfortable with in a given situation rather than take chances. However, this is a snapshot of an existing deplorable situation and should not be construed as a desirable medical goal.
In contrast to VBD, CS for breech presentation can be planned & performed under optimal conditions
This is indeed a great advantage of abdominal delivery. For parturients in whom vaginal delivery is medically not advisable, for those who reject the option of vaginal delivery or for those who do not plan further pregnancies, the possibility for adequate planning is clearly of benefit. However, this policy does not provide a safe solution in those situations when planning is not feasible.
Proponents for VBD claim the following:
A women with a fetus in breech presentation should be theoretically presented with both options (CS & vaginal delivery) & should be allowed to make a choice
However, in the absence of proficiency or willingness on the part of the obstetrician to perform a vaginal delivery in breech presentation, this informed choice or consent remains virtual and is practically nonexistent.
Breech presentation is a variation of normalcy & therefore vaginal delivery should be the preferred mode of delivery
While the author fully agrees that vaginal delivery of a breech baby should be the preferred mode of delivery in well-defined conditions, the statement of normalcy is highly questionable. The most physiological course of delivery is vertex first and there is also mounting evidence for an increased incidence of pathology in breech babies. Therefore, breech presentation is not a variation of normalcy but a potential pathological fetal condition and breech delivery requires a high degree of obstetric expertise. Babies should be delivered in an environment that provides immediate access to medical expertise dealing with potential fetal pathology associated with breech presentation.
Every obstetrician should be proficient in safe VBD
Given the current situation, this is purely utopian thinking. Most modern obstetricians are untrained in this procedure and many of those who still possess the expertise are unwilling to expose themselves to litigation, or to take upon themselves long hours of following labor instead of performing a planned CS. However, breech presentation will not go away. There will always be situations where CS for breech presentation is not an option owing to contraindications, lack of availability of facilities or a patient’s refusal to be operated on. Kotaska recently reported on perinatal fetal mortality in a woman who refused CS for breech presentation and opted instead for home delivery assisted by a midwife Citation[32]. Based on current law, the midwife declined assistance and the baby died immediately after this unassisted breech delivery was completed. Lawson recently reported on a case of maternal mortality subsequent to emergency CS in a parturient who could have been considered an ideal candidate for VBD Citation[33]. If availability of experienced obstetricians cannot be assured in most delivery wards, other options should be considered to provide expertise without having to rely on on-site experts at all times.
What can & should be done?
Unfortunately, both the skills for and the willingness to perform VBD have virtually vanished from delivery wards in the western world, and a reversal of this situation is very unlikely. There is wide consensus that external cephalic version (ECV) is effective in reducing the incidence of breech presentation Citation[34], and the American College of Obstetricians and Gynecologists Citation[35] and many other medical policy makers suggest that ECV should be offered to all those parturients in whom there are no contraindications for this procedure. It should, however, also be born in mind that even in successful ECVs, there is an increased rate for emergency CS for fetal distress. However, breech presentations will not go away and CS cannot be performed on all parturients. There will always be women for whom CS is not an option and who are going to be delivered by a resident or attending doctor who is not confident because of his/her lack of appropriate skills and the need to perform a challenging obstetric procedure, sometimes under emergency conditions. Under such circumstances, the baby will be at a highly increased risk for complications and the physician will be at risk for medico–legal action. Whenever possible, parturients who are candidates for VBD should be referred to centers that are specialized to perform VBD in a safe manner. For those hospitals who do not have sufficient expertise, and these are certainly the majority, a partial solution to this problem will need to include simulation training for residents and the availability of standby teams of experienced obstetricians. These residency programs should include obligatory simulation courses for training of VBD, and there are plenty of childbirth simulators on the market that can effectively be used to teach and train basic skills for delivering a breech baby. Residents should follow a structured teaching program aimed to provide solid theoretical knowledge on the mechanism of birth in breech presentation and familiarity with indications and contraindications for VBD. Trainees should master the relevant maneuvers for assisted breech delivery and total breech extraction, and should be able to cope with birth complications. The teaching program should include a theoretical and practical examination, and should also be open for attending physicians. This program should be complemented by standby teams of obstetricians experienced in breech delivery. Maier et al. reported on an observational prospective intention-to-treat study on a standby service system for VBD Citation[36]. The authors demonstrated that, under appropriate conditions, the fetal outcome for breech babies delivered vaginally or by planned CS was similar. Owing to the relatively low numbers of suitable candidates for VBD in most single institutions, expert standby services could be multi-institutional in a given geographic area. To create such a setup, given the small and steadily diminishing pool of obstetricians skilled in VBD who are willing to serve in an unfavorable medico–legal environment, is a challenge.
Expert commentary & five-year view
There is possibly and lamentably no return to the times when the definition of ‘obstetric skills’ also included the skills to assist women in VBD. Therefore, the current goal should be to establish specialized centers where safe planned VBD can be offered, and also to impart basic skills by simulation courses in those delivery wards where specific expertise is not available. Standby squads of experienced obstetricians could provide a multi-institutional safety net for these.
Key issues
• Approximately 4% of babies at term are in breech presentation.
• A trial of external cephalic version should be offered to all parturients who do not have contraindications for this procedure.
• The Term Breech Trial, which was published in 2000, indicated that planned cesarean section (CS) provides a better outcome for breech babies than vaginal deliveries. This randomized controlled trial had methodological flaws and the conclusions should no longer be considered as valid.
• There is no convincing evidence that CS is better for the breech baby than assisted vaginal delivery, provided that certain strict criteria are met.
• CS is associated with a higher risk of morbidity and mortality for the parturient than vaginal delivery.
• Repeated CSs carry additional substantial health risk for parturients.
• Currently, most residents and attending obstetricians in western countries lack adequate experience in vaginal breech delivery.
• Women who are candidates for planned vaginal delivery, or those for whom CS is not an option, should be given an opportunity to choose between the two delivery modes. This requires the establishment of supraregional centers that specialize in breech delivery, and for other hospitals the provision of basic training with birthing simulators for all residents in obstetrics. In addition, a system of suprainstitutional standby teams of experienced obstetricians should be established to provide expertise in planned vaginal delivery.
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Planned vaginal breech delivery: current status and the need to reconsider
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Activity Evaluation
1. Your patient is a 24-year-old woman with her first pregnancy. She just completed 35 weeks’ gestation and has breech presentation. What can you tell this patient regarding breech presentation?
□ A Nearly 20% of all pregnancies feature breech presentation
□ B Primiparity is associated with a higher risk for breech presentation
□ C Breech presentation is still considered transient until 38 weeks’ gestation
□ D Risk factors for breech presentation can be found in 90% of cases
2. What are characteristic differences between breech and vertex fetuses that you can describe to this patient?
□ A Breech is associated with a longer umbilical cord
□ B Breech is associated with more limb movements
□ C Breech position generally does not affect birth weight
□ D Breech is associated with a higher risk for fetal malformations
3. How should you counsel this patient regarding the choice of elective vaginal delivery vs cesarean delivery?
□ A Cesarean delivery is clearly safer for the baby compared with vaginal delivery
□ B Vaginal delivery is associated with lower newborn pH vs cesarean delivery in breech deliveries only
□ C Cesarean delivery is associated with a higher risk for endometritis vs vaginal delivery
□ D Vaginal and cesarean delivery are associated with similar needs for blood transfusion after delivery
4. What else should you consider regarding the mode of delivery for this patient?
□ A Mandated training ensures that nearly all obstetricians are comfortable with planned vaginal delivery for breech presentation
□ B A supraregional center staffed by obstetricians experienced in vaginal delivery for breech infants is highly beneficial
□ C Breech presentation is just a normal variation of pregnancy
□ D Successful external cephalic version obviates the risk of emergency cesarean delivery