Evaluation of a decision protocol for type of delivery of infants in breech presentation at term

https://doi.org/10.1016/j.ejogrb.2011.05.003Get rights and content

Abstract

Objectives

To assess the safety of a decision protocol for type of delivery of breech presentations after 37 weeks of gestation. This protocol was based on a comparison of fetal head and maternal pelvic measurements.

Study design

Retrospective before-and-after study of 1133 breech infants born between 2000 and 2008 in a tertiary centre, analysing neonatal condition and percentage of vaginal deliveries by study period.

Results

Application of the protocol was accompanied by an increase in the percentage of vaginal deliveries of breech presentations from 24.0% in 2000–2004 to 38.5% in 2004–2008 (p < 0.001), without impairment of neonatal condition [composite mortality/morbidity variable: 3/567 (0.5%) vs 4/566 (0.7%), respectively; p > 0.99; neonatal arterial pH < 7.0: 8/521 (1.5%) vs 4/529 (0.8%), respectively; p = 0.23].

Conclusion

The use of a protocol based on objective criteria at the authors’ centre made it possible to increase the percentage of vaginal deliveries of breech presentations without impairing neonatal condition.

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,

References (21)

There are more references available in the full text version of this article.

Cited by (34)

  • Breech presentation induction compared to cephalic presentation: Effectiveness and characteristics

    2023, European Journal of Obstetrics and Gynecology and Reproductive Biology
  • Cervical maturation in breech presentation: Mechanical versus prostaglandin methods

    2022, Journal of Gynecology Obstetrics and Human Reproduction
    Citation Excerpt :

    Exclusion criteria were medical termination of pregnancy, intrauterine death, fetal malformation, and spontaneous labor. The trial of labor protocol in breech presentation cases has been previously published [12]. Briefly, vaginal delivery was considered appropriate when three conditions were met: the difference between the promonto-retropubic diameter and the bi-parietal diameter was greater than 15mm, the difference between the transverse median diameter and the bi-parietal diameter was greater than 25mm, and the difference between the interspinous diameter and the bi-parietal diameter was greater than 0mm.

  • Type of breech presentation and prognosis for delivery

    2020, Journal of Gynecology Obstetrics and Human Reproduction
    Citation Excerpt :

    Consistent evidence is needed on the role of the fetal leg posture in vaginally intended breech deliveries at term. Because our maternity ward has fairly extensive experience with vaginal deliveries of breech presentations [18], we conducted a study intended to compare delivery maternal morbidity and neonatal morbidity according to the type of breech presentation. This retrospective study in a level 3 university hospital examined the outcome of trials of vaginal delivery of singleton fetuses in breech presentation at or after 37 weeks of gestation.

  • Comparison of antepartum management of breech versus cephalic presentation

    2020, Gynecologie Obstetrique Fertilite et Senologie
View all citing articles on Scopus
View full text