European Journal of Obstetrics & Gynecology and Reproductive Biology
Evaluation of a decision protocol for type of delivery of infants in breech presentation at term
Introduction
Since the Term Breech Trial report by Hannah et al. in 2000 [1], the caesarean rate for breech presentations after 37 weeks of gestation has increased substantially in numerous countries [2]. In France, the caesarean rate before labour for breech presentations after 37 weeks of gestation increased from 42.6% in 1995–1998 to 74.5% in 2003, while the percentage of vaginal deliveries decreased from 39.2% to 16.7% [3]. As the practice of breech deliveries decreases, skills and experience are lost. This decrease also contributes to the continuing rise in caesarean rates and their short- and long-term complications [4].
The Term Breech Trial [1] has been widely criticized, largely due to its lack of rigor in patient selection, the inexperience of some participating practitioners with breech deliveries, and the inclusion of deaths unrelated to delivery in neonatal mortality [5], [6]. Several recent studies and reviews have shown that vaginal delivery of breech presentations is possible in appropriate conditions [7], [8], [9], [10], [11], including physician experience, patient selection criteria and, when possible, a written protocol. Guidelines in France [5], the USA [12], the UK [13] and Canada [14] have approved vaginal delivery in these circumstances.
One weakness of these guidelines is that they are not based on consensual or validated protocols for deciding the type of delivery. A recent study in France showed wide variation in the protocols applied in 19 different university centres, and reported that none of these protocols had been assessed [15]. As such, the authors’ team developed a consensus protocol with the aim of increasing the percentage of vaginal deliveries of breech presentations; the criteria used are as evidence based and logical as possible. In contrast to other protocols used in France [15], the current protocol considers the biparietal diameter of the fetus and the pelvic diameter of the mother. This report assesses the application of this protocol (Fig. 1).
Section snippets
Materials and methods
This retrospective before-and-after study included all singleton deliveries of fetuses in breech presentation at ≥37 weeks of gestation from 1 January 2000 to 31 December 2008 in a level 3 university hospital.
Before 2003, the authors’ department had no written protocol for breech delivery, except for the general French recommendations for radiographic assessment of maternal pelvimetry and ultrasonographic evaluation of fetal size. The authors’ team set up a working group to develop a protocol
Results
There were 40,707 deliveries in the study hospital during the 9-year period; 39,482 were singletons and 1183 were in breech presentation ≥37 weeks of gestation (3.0%). Twenty-four deliveries were excluded from the study because the records were incomplete (2.0%). Of the 1159 files examined, 26 were excluded because of severe fetal malformations diagnosed prenatally (2.2%). The analysis therefore covered 1133 deliveries.
More than half of the women studied were nulliparous, and approximately 10%
Comment
This study found that application of a protocol comparing fetal head and maternal pelvic measurements led to an increase in the proportion of breech presentations delivered vaginally from 24% to 38% (60% increase) without any impairment of neonatal condition.
Given the low incidence of neonatal complications, these results require confirmation in a larger study. Taking into account the incidence of vaginal delivery of breech presentations in the 2000–2004 period, the power of the comparisons to
Acknowledgements
The Lille Breech Study Group met regularly to reach consensus to determine the type of delivery appropriate for fetuses in breech presentation. Members were: R. Boodhun, L. Boulanger, M. Boukerrou, A. Bourgain, S. Bresson, C. Brochot, F. Caquant, E. Closset, P. Collinet, M. Cosson, C. Coulon, J. Coursier Le Goarant, N. Coutty, D. Couvreux, B. Dedet, E. Delarue, A. Delelis, P. Deruelle, O. Descamps, P. Dufour, M.H. Fline, J.M. Girard, V. Houfflin-Debarge, J.L. Houpeau, E. Lambaudie, J.P. Lucot,
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