Maternal and neonatal outcome after vaginal breech delivery at term of children weighing more or less than 3.8 kg: A FRABAT prospective cohort study

Abstract

IntroductionThe clinical management of breech presentations at term is still a controversially discussed issue among clinicians. Clear predictive criteria for planned vaginal breech deliveries are desperately needed to prevent adverse fetal and maternal outcomes and to reduce elective cesarean section rates. The green-top guideline considers an estimated birth weight of 3.8 kg or more an indication to plan a cesarean section despite the lack of respective evidence.ObjectiveTo compare maternal and neonatal outcome of vaginal intended breech deliveries of births with children with a birth weight of 2.5 kg– 3.79 kg and children with a birth weight of 3.8 kg and more.DesignProspective cohort study.SampleAll vaginal intended deliveries out of a breech position of newborns weighing between 2.5 kg and 4.5 kg at the Obstetrics department at Goethe University Hospital Frankfurt from January 2004 until December 2016MethodsNeonatal and maternal outcome of a light weight group (LWG) (< 3.8 kg) was compared to and a high weight group (HWG) (≥ 3.8 kg) using Pearson’s Chi Square test and Fishers exact test. A logistic regression analysis was performed to detect an association between cesarean section rates, fetal outcome and the birth weight.ResultsNo difference in neonatal morbidity was detected between the HWG (1.8%, n = 166) and the LWG (2.6%, n = 888). Cesarean section rate was significantly higher in the HWG with 45.2% in comparison to 28.8% in the LWG with an odds ratio of 1.57 (95% CI 1.29–1.91, p<0.0001). In vaginal deliveries, a high birth weight was not associated with an increased risk of maternal birth injuries (LWG in vaginal deliveries: 74.3%, HWG in vaginal deliveries: 73.6%; p = 0.887; OR = 1.9 (95% CI 0.9–1.1))ConclusionA fetal weight above 3.79 kg does not predict increased maternal or infant morbidity after delivery from breech presentation at term. Neither the literature nor our analyses document evidence for threshold of estimated birth weight that is associated with maternal and/or infant morbidity. However, patients should be informed about an increased likelihood of cesarean sections during labor when attempting vaginal birth from breech position at term in order to reach an informed shared decision concerning the birth strategy. Further investigations in multi center settings are needed to advance international guidelines on vaginal breech deliveries in the context of estimated birth weight and its impact on perinatal outcome.

The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term – A FRABAT prospective cohort study

“…Each parameter on its own did not show a significant difference when all vaginal intended deliveries were compared between FB and CB group. A modified PREMODA score was used [14,16] to refine our analysis. There was no significant difference in neonatal morbidity possibly related to mode of delivery (after exclusion of cases of chorioamnionitis, perinatal infection and congenital fetal malformations/diseases) between FB group (2.5%) and CB group (2.8%) with a p value of 0.761 (Table 3).…”

“…The counseling process, as well as patient selection and procedures at our center has been previously described [11,14].…”

“…Compared groups consisted of unequal sample sizes. To additionally demonstrate statistical accuracy, all tests were performed after equalizing sample sizes through random selection of patients within the larger group (frank breech group) [14,15]. There were no different results after performing those analyzes if not otherwise indicated.…”

Adherence to guidelines and suboptimal practice in term breech delivery with perinatal death- a population-based case-control study in Norway

“…In our study a stricter weight criterion for vaginal delivery might have prevented one death. However a recent study published in 2018 did not report increased infant morbidity after delivery of infants with a birthweight between 3.8 and 4.5 kg compared to those with a birthweight below 3.8 kg [30]. Another potential improvement of the guidelines might be to recommend pelvimetry in all cases of breech presentation before the decision of mode of delivery, since difficult delivery of the head was observed in four case deliveries.…”

Up against a wall: A patient and obstetrician’s perspective on the mode of breech delivery

“…To train more providers in this skill set, several international education initiatives exist aimed at disseminating information on how to safely deliver a breech baby vaginally. The Coalition for Breech Birth, Shawn Walker in the United Kingdom, Betty‐Anne Davis in Ontario, and the Frankfurt Breech at Term Study Group in Germany have made great efforts to ensure the art of breech vaginal delivery is not lost and to improve the safety of breech vaginal delivery . For instance, the Frankfurt Breech at Term Study Group has published research on the benefits of an upright positioning during a breech vaginal delivery to improve outcomes…”