Results
In the period from 01.01.2001 – to 31.12.2011, 571 of 16794 (3.4%) singleton term pregnancies were breech presentations at Sorlandet Hospital Kristiansand (Figure 1). Three cases were excluded due to known fetal anomaly. Of the remaining 568 women, elective caesarean section was planned in 279 (49%) cases, whereas vaginal delivery was planned in 289 (51%) cases. The guidelines were followed in all cases. We went through the medical charts for infants who were transferred to the NICU (37/568) after birth, with a median follow-up time of 6 years (range 1 – 11 years). One infant was diagnosed with Down's syndrome post partum and one with autism at two years' age. These two were not excluded from the analyses. Acute caesarean section was performed in 104 of the planned vaginal deliveries due to complications before or during labor. Hence, our study sample consisted of 185 vaginal births, which constituted 33% of the women with singleton fetuses in breech presentation at term. There were no neonatal deaths and two cases of serious neonatal morbidity in this period (outlined below).
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Figure 1.
Study flow chart.
Table 1 reports maternal and obstetric characteristics for the planned vaginal and caesarean section delivery groups. In Table 2, fetal outcomes for the two groups are reported. Thirteen percent (76/568) were SGA infants, with 51 infants in the planned vaginal group. Of these, a minority were transferred to the NICU (N = 11). Cord blood was sampled in 149 cases, 130 in the planned vaginal group and 19 in the planned cesarean section group. Acidemia (pH < 7.00) was reported in 5 (4%) cases in the planned vaginal group, and none in the planned cesarean section group. Two infants in the planned vaginal group had a cord blood base deficit of at least 15. Seven infants in the planned vaginal group had an Apgar score < 7 after five minutes versus none in the planned cesarean section group. Of these, one infant had an Apgar score < 4 after five minutes (serious morbidity). Thirty seven infants were transferred to the NICU, 29 in the planned vaginal group and eight in the planned cesarean section group (p < 0.001). Of these, one infant in the planned vaginal group was admitted for more than four days (serious morbidity). This infant was delivered vaginally, and had neurological morbidity comprising neonatal seizures, brachial plexus injury, cephalhematoma, and mechanical ventilation treatment. She is now seven years old, and according to the medical chart, she has been through several psychomotor tests showing ability levels within the normal range, although she demonstrates some mild visual-spatial impairment. The infant with Apgar score < 4 after five minutes was delivered with acute cesarean section due to fetal distress. Her Apgar score was 9 after 10 minutes, and she was discharged from NICU after one day's observation. She is now twelve years old, and has shown normal cognitive and psychomotor development.
In the planned vaginal delivery group, the number of successful vaginal deliveries was higher among multiparous versus nulliparous women (98/137 vs 87/152, p = 0.01). 82/568 (14%) infants had birth-weight ≥ 4000 g. Of these, vaginal delivery was planned in 40%, but only 15 infants were delivered by this method (weight range 4012 g – 4790 g). 2/15 had Apgar score < 7 after five minutes, but none were transferred to NICU. Fifteen percent (83/568) of the women had an undiagnosed breech presentation at birth, and of these 51 women (61%) delivered vaginally. Of those with vaginal delivery, an episiotomy was applied in 54%, and a third degree anal sphincter rupture was reported in 2% (Table 1). Of the maternal postoperative complications analyzed, mean blood loss was the only variable that was significantly higher in the cesarean section group versus in the vaginal delivery group (435 ml, SD 317 ml versus 359 ml, SD 231 ml) (p < 0.001). Four women had blood loss > 1500 ml in the planned vaginal group, compared to five in the planned cesarean section group. Table 3 reports management during labor and delivery for vaginal births.