Breech Presentation

We wished to gain insight into Canadian hospital policy changes between 2000 and 2007 in response to (1) the initial results of the Term Breech Trial suggesting delivery by Caesarean section was preferable for term breech presentation, and (2) the trial's two-year follow-up and other research and commentary suggesting that risks associated with vaginal breech delivery and delivery by Caesarean section were similar. We also wished to determine the availability of vaginal breech delivery and the feasibility of establishing breech clinics and on-call squads, and whether these could include midwives. In 2006, we sent surveys to the 30 largest maternity centres in Canada asking about their changes in practice in response to results of the initial Term Breech Trial and the subsequent two-year follow-up and the possibility of establishing breech clinics and on-call delivery squads and whether they could include midwives. Of the 30 surveys sent, responses were received from 20 maternity...

Accurate identification of the presentation of the fetus as term approaches is very important for the management and outcome of the birth. Using the term "unstable lie" might be seen as a baseless excuse for inducing labor after the baby turns from breech to head down, reflecting lack of understanding of gravity and the physiological limits of fetal mobility. There are a range of techniques for turning a term breech baby. These include: External Cephalic Version (ECV) using hands and ultrasound only; Acupuncture Point stimulation by needle or moxibustion, Chiropractic " Webster " technique,. Hypnotherapy, and 'Special exercises'. Fifty to sixty percent of fetuses in the breech position at 34 weeks will turn to a cephalic presentation by themselves by 38 weeks. Therefore, to be considered effective, a technique for turning the breech at 34 or 35 weeks must turn the baby and keep it in the required position more than 60% of the time. Only ECV with an experienced practitioner has been documented to have a greater than 50% average success rate at 37 weeks. During ECV, women can experience the fetus turning by hand as quick but very painful. Other techniques have not been reported with the same effectiveness and require more time investment. (judyslome@hotmail.com)

This paper reviews global data on caesarean section (CS) focusing on Eastern Mediterranean Region (EMR) countries for which data could be obtained. CS rates in the EMR tend to average around 10%. The data, however, are often not representative of the whole country, being mostly hospital rather than community based. Global and regional CS trends, determinants, and outcomes are presented. Controversies and consensus over the indications for CS are reviewed. The cost of rising CS rates, women's involvement in decision-making, the role of health workers, data quality and legal aspects are highlighted, with discussion of the aim of reducing unduly high CS rates and promoting high-quality maternity care.

Objective: To evaluate the success of external cephalic version (ECV) using an adjusted bolus dose intravenous salbutamol compared with no tocolysis. Methods: An open-label randomized study of 114 women with a term breech fetus randomized to receive either an intravenous bolus dose of 0.1 mg salbutarnol with further boluses every 5 minutes, as required, before commencing ECV, or no tocolysis. Primary outcomes were successful ECV and rate of cesarean delivery. Results: Salbutamol tocolysis resulted in a higher rate of successful ECV compared with no tocolysis (70.2% [40/57] vs 36.8% [21/57]; RR 1.9, 95% CI 1.3-2.8; P<0.001). Cesarean delivery rate was lower in the salbutamol group compared with the control group (31.6% [18/57] vs 63.2% [36/57]; RR 0.5. 95% CI 0.3-0.8: P=0.001). Salbutamol dose ranged from 0.1-0.4 mg and Outcome was not related to dose. Conclusion: Adjusted dose intravenous salbutamol tocolysis prior to ECV increases its success rate and reduces the cesarean delivery rate. (C) 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Background Screening and monitoring in pregnancy are strategies used by healthcare providers to identify high-risk pregnancies so that they can provide more targeted and appropriate treatment and follow-up care, and to monitor fetal well-being in both low- and high-risk pregnancies. The use of many of these techniques is controversial and their ability to detect fetal compromise often unknown. Theoretically, appropriate management of maternal and fetal risk factors and complications that are detected in pregnancy and labour could prevent a large proportion of the world's 3.2 million estimated annual stillbirths, as well as minimise maternal and neonatal morbidity and mortality. Methods The fourth in a series of papers assessing the evidence base for prevention of stillbirths, this paper reviews available published evidence for the impact of 14 screening and monitoring interventions in pregnancy on stillbirth, including identification and management of high-risk pregnancies, advanced monitoring techniques, and monitoring of labour. Using broad and specific strategies to search PubMed and the Cochrane Library, we identified 221 relevant reviews and studies testing screening and monitoring interventions during the antenatal and intrapartum periods and reporting stillbirth or perinatal mortality as an outcome. Results We found a dearth of rigorous evidence of direct impact of any of these screening procedures and interventions on stillbirth incidence. Observational studies testing some interventions, including fetal movement monitoring and Doppler monitoring, showed some evidence of impact on stillbirths in selected high-risk populations, but require larger rigourous trials to confirm impact. Other interventions, such as amniotic fluid assessment for oligohydramnios, appear predictive of stillbirth risk, but studies are lacking which assess the impact on perinatal mortality of subsequent intervention based on test findings. Few rigorous studies of cardiotocography have reported stillbirth outcomes, but steep declines in stillbirth rates have been observed in high-income settings such as the U.S., where cardiotocography is used in conjunction with Caesarean section for fetal distress. Conclusion There are numerous research gaps and large, adequately controlled trials are still needed for most of the interventions we considered. The impact of monitoring interventions on stillbirth relies on use of effective and timely intervention should problems be detected. Numerous studies indicated that positive tests were associated with increased perinatal mortality, but while some tests had good sensitivity in detecting distress, false-positive rates were high for most tests, and questions remain about optimal timing, frequency, and implications of testing. Few studies included assessments of impact of subsequent intervention needed before recommending particular monitoring strategies as a means to decrease stillbirth incidence. In high-income countries such as the US, observational evidence suggests that widespread use of cardiotocography with Caesarean section for fetal distress has led to significant declines in stillbirth rates. Efforts to increase availability of Caesarean section in low-/middle-income countries should be coupled with intrapartum monitoring technologies where resources and provider skills permit.

In our maternity ward, vaginal-breech birth is favoured when the protocol for patient&#39;s eligibility is respected. But in our practice, 20% patients have a cesarean section during labor for vaginal-birth failure, with a higher rate of neonatal and maternal morbidities. This study tried to consider if some obstetrical elements, not usually used, could help select the candidates in a more efficient way. This retrospective study included all the singleton-breech deliveries with a gestational age over 37 weeks in our maternity ward from 1994 to 2004. An analysis of obstetrical elements, available before and during labour, has been carried out. Three hundred and seventy-six deliveries were indexed for a vaginal-birth trial. We carried out a cesarean section in 21.3% cases. We have found five obstetrical elements, not used in the vaginal birth protocol, which were significant risk factors for a cesarean section: nulliparity (OR=0.25 [0.11-0.57]), maternal height (OR=0.56 [0.30-1.03]), ...

The authors note significant room for improvement in facilitating informed consent in the management of breech presentation. New Zealand maternity care providers, including midwives, general practitioners and specialist obstetricians, have legal duties to provide full and unbiased information about risks and benefits of all relevant treatment options. In the case of breech presentation, such options include the interventions of external cephalic version or planned caesarean section, as well as the option to decline intervention and proceed with a planned vaginal breech birth. Information should be presented in a balanced and accessible way and not limited to the provider&#39;s personal preferences. Women have legal rights to make an informed choice, to give or refuse consent, to a second opinion and to co-operation among providers. The right of competent persons to refuse medical treatment, including the right to refuse caesarean section, is well established. Clinical policies there...

Background and Objective: Management of caesarean myomectomy (CM) in lower uterine segment obstruction is a hard process. Here I present a pregnant woman with multiple fibroid pregnancy and an obstructing intramural fibroid in the lower segment. The CM procedure was modified here with initially excision of obstructing myoma and delivery of baby.
Case Presentation:  A primigravida woman visited emergency room with abdominal pain at 22 week gestation, receiving antenatal care elsewhere. The emergency abdomen USG showed multiple fibroids in pregnancy with a huge obstructing fibroid in lower segment and a breech presentation with no anomalies. Comparing earlier USG reports exposed that the multiple fibroids were growing across the gestation weeks along the developing fetus. The mother was followed for watchful expectancy till 37 weeks gestation and delivery was planned as elective LSCS. Cesarean myomectomy was carried out through initial excision of lower uterine segment myoma to remove the obstruction, and then deliver the baby through the same incision.
Conclusion: Here the cesarean myomectomy procedure was altered from a regular one, featuring preliminary myomectomy of uterine fibroid in the lower segment, and then delivering the baby and myomectomies again. The outcome was delivering a live baby with hemostasis in a case, with multiple and large fibroids.

To evaluate the efficacy of subcutaneous terbutaline therapy on the success rate of external cephalic version in term gestation. Women with singleton noncephalic gestations were assigned randomly to receive either terbutaline (0.25 mg) or placebo. Physicians were blinded to the assignment. Fifteen to 30 minutes after the study drug was administered, external cephalic version was attempted. It was discontinued after three attempts, for patient discomfort, for fetal heart rate decelerations, or when successful. Patients were discharged home after the procedure and allowed to enter spontaneous labor. Primary outcomes evaluated included initial success of version, presentation in labor, and route of delivery. One hundred three women were enrolled in the study between January 1994 and June 1995, of whom 52 were assigned to terbutaline and 51 to placebo. External cephalic version was successful in 27 of 52 (52%) women receiving terbutaline compared with 14 of 51 (27%) of those receiving p...

Objective: To evaluate the preferred types of uterine closure at Caesarean section among Quebec&#39;s obstetrician-gynaecologists. Methods: An anonymous survey with multiple-choice and open questions was sent by email to all members of the Association des Obstétriciens-Gynécologues du Québec in clinical practice. The primary response of interest was the type of uterine closure that would be favoured for a primigravida undergoing an elective CS at term for a breech fetus. Secondary responses of interest included type of uterine closure for CS performed for other indications, and methods of closure for the bladder flap, parietal peritoneum, rectus abdominis muscle, subcutaneous tissue, and skin. Results were stratified according to the number of years in practice. Results: Of 454 persons targeted, 176 (39%) responded. Responders were more likely to have fewer years in practice than the targeted population in general. The closures for a primigravida undergoing an elective CS at term fo...

A population-based observational study investigated the contribution of obstetric factors to the survival and postnatal development of extremely preterm infants. Mortality up to one year and neurodevelopment at 2.5 years (Bayley-III test, cerebral palsy, vision, hearing) were evaluated in infants born &lt;27 gestational weeks in Sweden 2004-2007 (n=1,011), using logistic regression analyses of risk factors. Of 844 fetuses alive at admission, 8.4% died in utero before labour, 7.8% died intra partum. Of 707 live-born infants, 15% died within 24 h, 70% survived ≥365 days, 64% were assessed at 2.5 years. The risk of death within 24h after birth decreased with gestational age (OR 0.3; 95%CI: 0.2-0.4), antenatal corticosteroids (OR 0.3; 95%CI: 0.1-0.6), and cesarean section (OR 0.4; 95%CI: 0.2-0.9); it increased with multiple birth (OR 3.0; 95%CI: 1.5-6.0), vaginal breech delivery (OR 2.3; 95%CI: 1.0-5.1), 5-minute Apgar score &lt;4 (OR 50.4; 95%CI: 28.2-90.2), and birth at level II hospi...