Background
Breech clinic
Setting up the breech clinic
Professionals
Care pathway
Eligibility criteria for a breech delivery attempt
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Motivated expectant woman
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Estimated fetal weight above 2500 g
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GA more than 37 weeks
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CT-pelvimetry deemed adequate
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No cephalo-pelvimetric disproportion
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No other indication for C-section (two or more previous C-sections, placenta praevia, etc.)
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No hyperextension of the fetal head
Management of labour and delivery
Methods
Study design
Participants
Data collection
Outcomes
Term Breech Trial outcome | PREMODA outcome | Erasme breech clinic outcome |
---|---|---|
Fetal or neonatal mortality | Fetal or neonatal mortality | Fetal or neonatal mortality |
Birth trauma including: - Subdural hematoma - Intracerebral or intraventricular haemorrhage - Spinal cord injury - Basal skull fracture - Peripheral-nerve injury present at discharge - Clinically significant genital injury | Birth trauma including: - Subdural hematoma - Intracerebral or intraventricular haemorrhage - Spinal cord injury - Basal skull fracture - Peripheral-nerve injury present at discharge - Clinically significant genital injury | Birth trauma including: - Subdural hematoma - Intracerebral or intraventricular haemorrhage - Spinal cord injury - Basal skull fracture - Peripheral-nerve injury present at discharge - Clinically significant genital injury |
Seizures occurring at less than 24 h of age or requiring two or more drugs to control them | Seizures occurring at less than 24 h of age | Seizures occurring at less than 24 h of age or requiring two or more drugs to control them |
Five-minute Apgar score of less than four | Five-minute Apgar score of less than four | Five-minute Apgar score of less than four |
Cord-blood base deficit of at least 15 | / | Cord-blood base deficit of at least 15 |
Hypotonia for at least 2 h | / | / |
Stupor | / | / |
Decreased response to pain, or coma | / | / |
Intubation and ventilation for at least 24 h | Intubation and ventilation for at least 24 h | Intubation and ventilation for at least 24 h |
Tube feeding for 4 days or more | Parenteral or tube feeding for at least 4 days | Parenteral or exclusive tube feeding for at least 4 days |
Admission to the neonatal intensive care unit for longer than 4 days | Admission to the neonatal intensive care unit for longer than 4 days | Admission to the neonatal intensive care unit for longer than 4 days |
Analysis
Results
Before (n = 162) n (%) | After (n = 115) n (%) | p-value | |
---|---|---|---|
Maternal age in years | |||
< 21 years | 3 (1.9%) | 0 | 0.34 |
21–34 years | 115 (70.9%) | 82 (71.3%) | |
≥ 35 years | 44 (27.2%) | 33 (28.7%) | |
Body mass index | (/162 observations) | (/113 observations) | |
< 18.5 | 5 (3.1%) | 5 (4.4%) | 0.44 |
18.5–24 | 95 (58.6%) | 69 (61.1%) | |
25–30 | 34 (21%) | 27 (23.9%) | |
> 30 | 28 (17.3%) | 12 (10.6%) | |
Ethnic origin | 0.77 | ||
European | 64 (39.5%) | 54 (47%) | |
Mediterranean Basin | 54 (33.3%) | 32 (27.8%) | |
Sub-saharan Africa | 16 (9.9%) | 3 (2.6%) | |
Other | 28 (17.3%) | 26 (22.6%) | |
Assisted reproductive technology | 9 (5.6%) | 8 (6.9%) | 0.6 |
Smoking | 21 (14.7%) | 12 (11.9%) | 0.53 |
(/143 observations) | (/101 observations) | ||
Primiparity | 99 (61.1%) | 62 (53.9%) | 0.23 |
Uterine scar | 19 (11.7%) | 8 (6.9%) | 0.19 |
External cephalic version | 103 (63.6%) | 92 (80%) | 0.003 OR: 2.3 (95% CI: 1.3–4.0) |
Gestational diabetes | 23 (14.2%) | 18 (15.7%) | 0.74 |
Birth weight mean (± SD) | 3317.6 (± 432.1) | 3253.8 (± 369.6) | 0.20 |
Before (n = 12) n (%) | After (n = 60) n (%) | p-value | |
---|---|---|---|
Induction of labour | 2 (16.7%) | 6 (10%) | 0.5 |
Epidural | 10 (62.5%) | 26 (40.6%) | 0.74 |
Augmentation of labour | 6 (50%) | 23 (38.3%) | 0.45 |
Expulsion efforts > 60 min | 1 (12.5%) | 11 (20.4%) | 0.6 |
Episiotomy | 4 (50%) | 9 (30%) | 0.29 |
Before (n = 162) | After (n = 115) | OR | 95% CI | |
---|---|---|---|---|
Unexpected breech delivery | 15 (9.3%) | 4 (3.5%) | 0.3 | 0.1–0.9 |
Planned vaginal delivery | 12 (7.4%) | 60 (52.2%) | 13.5 | 6.7–27.0 |
Effective vaginal delivery | 7 (4.3%) | 50 (43.5%) | 17.0 | 7.3–39.6 |
Before (n = 162) | After (n = 115) | OR | 95% CI | |
---|---|---|---|---|
n (%) | n (%) | |||
Five-minute Apgar score < 4* | 2 (1.2%) | 1 (0.9%) | 0.7 | 0.1–7.8 |
Five-minute Apgar score < 7 | 5 (3.1%) | 4 (3.5%) | 1.1 | 0.3–4.3 |
Arterial cord blood pH < 7 | 1 (0.6%) | 5 (4.4%) | 7.3 | 0.8–63.5 |
Arterial cord blood base deficit ≥ 12 mEq/L | 2 (1.2%) | 6 (5.2%) | 4.4 | 0.9–22.2 |
Arterial cord blood base deficit ≥ 15 mEq/L* | 0 | 0 | / | / |
NICU admission | 14 (8.6%) | 8 (6.9%) | 0.8 | 0.3–1.9 |
> 4 days* | 2 (1.2%) | 2 (1.7%) | 1.41 | 0.2–10.2 |
Parenteral or exclusive tubal feeding | 4 (2.5%) | 5 (4.4%) | 1.8 | 0.5–6.8 |
> 4 days* | 1 (0.6%) | 0 | / | / |
Birth trauma (severe hematoma)* | 0 | 1 (0.9%) | / | / |
Intubation or ventilation | 9 (5.6%) | 6 (5.2%) | 0.9 | 0.3–2.7 |
> 24 h* | 1 (0.6%) | 2 (1.7%) | 2.9 | 0.3–31.8 |
> 4 days | 0 | 0 | / | / |
Seizures* | 0 | 0 | / | / |
Neonatal death* | 0 | 0 | / | / |
IVH grade I* | 1 (0.6%) | 0 | / | / |
Composite neonatal outcome | 5 (3.1%) | 4 (3.5%) | 1.1 | 0.3–4.3 |
Cases | Breech clinic | Primiparous | Planned delivery | Actual delivery | C-section indication | 2nd stage > 60 min | GA | Birthweight (in grams) | Five-minute Apgar score | Arterial cord blood pH | Arterial cord blood base deficit | NICU stay (in days) | Ventilation > 24 h and < 4 days | IVH grade 1 | Parenteral feeding more than four days | Severe hematoma |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | No | No | Vaginal (Induction) | Vaginal | / | 0 | 37.0 | 2520 | 2 | 7.15 | 9.8 | 0 | No | No | No | No |
2 | Yes | Yes | Vaginal | Vaginal | / | 1 | 40.2 | 3380 | 3 | 7.34 | 9.6 | 3 | No | No | No | No |
3 | No | No | No plan | C-section | Breech presentation | NA | 37.6 | 3130 | 3 | 7.25 | 8.7 | 0 | No | No | No | No |
4 | Yes | Yes | Vaginal | Vaginal | / | 0 | 41.2 | 3395 | 4 | 6.99 | 14.5 | 1 | No | No | No | No |
5 | No | Yes | Vaginal | C-section (10 cms) | Acute fetal distress | 0 | 39.5 | 2895 | 6 | 6.97 | 13.8 | 0 | No | No | No | Yes |
6 | No | No | No plan | C-section | Breech presentation | NA | 39.3 | 2940 | 9 | 7.31 | 2.6 | 6 | No | Yes | No | No |
7 | No | Yes | C-section | C-section | Foeto-pelvic disproportion | NA | 39.1 | 3070 | 10 | Missing value | Missing value | 7 | No | No | Yes | No |
8 | Yes | Yes | No plan | C-section | Acute fetal distress | NA | 39.1 | 3000 | 9 | 7.36 | 1.7 | 3 | Yes | No | No | No |
9 | Yes | Yes | Vaginal | Vaginal | / | 1 | 40.6 | 3260 | 5 | 7 | 14.3 | 5 | Yes | No | No | No |