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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 7
| Issue : 1 | Page : 32-36 |
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A study of labour outcome in breech delivery
Suman Budania, Mukesh Kumar Beniwal, Geeta Choudhary
Department of Obstetrics and Gynaecology, S.P. Medical College and Hospital, Bikaner, Rajasthan, India
| Date of Web Publication | 6-Feb-2017 |
Correspondence Address:
Suman Budania
Department of Obstetrics and Gynaecology, S.P. Medical College and Hospital, Bikaner, Rajasthan
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2321-8568.199534
Aim: Breech is the most common form of malpresentation. It is defined as when foetus occupies a longitudinal lie with the pelvic extremity at the pelvic brim and head at the fundus of the uterus. The present study was conducted on 100 cases of breech presentation to find out the labour outcome in breech deliveries and various factors affecting it. Materials and Methods: The present study was conducted in the Department of Obstetrics and Gynaecology, Umaid Hospital, attached to Dr. S.N. Medical College, Jodhpur. A total of 100 cases of breech presentation including single as well as plural pregnancies in which one or more foetuses were presenting as breech were taken. Both booked and unbooked cases in primigravidae and multigravidae were studied. The cases were selected at random among those who got admitted in labour room. Results: In the present series, incidence of breech deliveries came to be 4.1094%. Incidence of breech presentation was maximum (45%) in the age group of 21–25 years. In this study, out of 100 cases, 62 were multigravidae and 38 were primigravidae, and 43 cases (43%) were associated with factors which endanger of life of the foetus, among which twin pregnancy and pre-eclamptic toxaemia were the most commonly associated factors. In the present series, among 100 cases studied, 14 were breech babies and congenital malformation, of which hydrocephalus was the most common malformation found. Conclusion: The study concludes that prematurity is associated with high incidence of breech presentation. The most common variety of breech presentation is flexed breech, which is found more in multigravidae. Caesarean section is the mode of delivery of choice as it carries minimal foetal loss. Extended variety of breech is safest for the baby and carries minimal foetal loss. Keywords: Breech, caesarean, delivery, gravidae
How to cite this article:
Budania S, Beniwal MK, Choudhary G. A study of labour outcome in breech delivery. Adv Hum Biol 2017;7:32-6 |
| Introduction | |  |
One of the principal processes of life is reproduction without which there could be no existence of any kind, simple or complex, plant or animal. The nature tries to deliver the child in such a way so as to cause minimum trauma to the mother and least damage to the child, which is achieved by the delivery of cephalic pole foremost (which is the most common), next with its lower extremity foremost.[1] Hence, breech is the most common form of malpresentation. It is defined as when foetus occupies a longitudinal lie with the pelvic extremity (breech) at the pelvic brim and head at the fundus of the uterus.[2]
The incidence of breech presentation varies with the foetal maturity. Breech presents in 3%–-4% of all women at the onset of labour (Williams 1997). However, the incidence of breech varies with the type of institution, its policies towards prophylactic version and the type of patients dealt with. An incidence of 16% at 32 weeks falling to 7% as 38 weeks (Turnbull's 1996) has been found, so breech presentation should not be considered abnormal until late in pregnancy and causes no problem unless premature labour intervenes.[3]
There are several factors which predispose to breech presentation, which are divided into maternal and foetal.
Maternal factors which predispose to breech are multiparity, placenta previa, polyhydramnios, space-occupying lesion in the pelvis, uterine anomalies and cornual implantation of the placenta.[4]
Foetal factors which predispose to breech are prematurity, extended legs, plural pregnancy, congenital abnormalities such as hydrocephalus, anencephaly and short cord.[5]
When the breech presentation persists or reverts, the decision regarding vaginal delivery is based on the Zatuchni-Andros scoring which includes gravida, previous successful breech delivery, gestational age, estimated foetal weight, cervical dilatation and station of the breech [Table 1].[6]
A score of <4 predicted poor outcome.
Aims and objectives
- To find out the incidence and the more common type of breech delivery occurring in Umaid Hospital, Jodhpur
- To assess the foetal outcome in breech deliveries
- To assess the most favourable route of delivery in breech presentation
- To assess the relation between mode of delivery and the foetal outcome
- To assess the safest mode of delivery in regard to maternal and foetal outcome.
| Materials and Methods | | |
The Present study was conducted in the Department of Obstetrics and Gynaecology, Umaid Hospital, attached to Dr. S.N. Medical College, Jodhpur.
A total of 100 cases of breech presentation including single as well as plural pregnancies in which one or more foetuses were presenting as breech were taken. Both booked and unbooked cases in primigravidae and multigravidae were studied. The cases were selected at random among those who got admitted in labour room.
On admission, case history was recorded. Her age, her menstrual history and previous obstetrical history were taken. History of any significance, of any operative intervention inquired into and of any drug intake was recorded.
Under general examination, her pulse rate, blood pressure, temperature, height, weight, condition of heart and lungs, any evidence of anaemia and oedema over feet or any part of body was noted.
The history of onset of regular uterine contractions was noted. In this way, time and date of onset of labour were noted.
Per-abdominal examination was done to find out the presentation and position of presenting part and to watch for the progress of labour. Foetal heart sounds were auscultated at the time of admission and every half hourly during the first stage and every 5 min during the second stage of labour.
A routine internal examination was carried out in most of the cases to note condition of the cervix, its dilatation and consistency, position, whether taken up or not, condition of membranes whether intact or absent, type of presenting part, relation of presenting part to the pelvic brim and ischial spine, colour of discharge, cord prolapsed and assessment of pelvic size.
Per vaginum examination was repeated as and when indicated. Eligible women were divided into two groups:
- Group A – Full term – pregnancy between 37 and 40 weeks of gestation
- Group B – Premature – pregnancy between 28 and 36 weeks of gestation.
The duration of gestation was recorded from the last menstrual period date whenever it was available and in other cases by the fundal height. Ultrasonography was used routinely in all the patients for the gestational age, placental localisation, foetal weight, for the amount of liquor and for the confirmation of position of the foetus.
Prematurity regardless to the period of gestation was considered when the weight of the baby was <2 kg at the time of birth. Associated maternal factors in breech presentation such as pre-eclamptic toxaemia, eclampsia, antepartum haemorrhage, hydramnios and medical diseases complicating pregnancies such as severe anaemia, hypertension and diabetes heart disease which endanger the life of the foetus were recorded.
Nature of presentation and nature of delivery were noted. Indications for instrumental deliveries and abdominal deliveries were noted.
The neonates were assessed by thorough clinical examination including birth weight, sex, Apgar score at 1 and 5 min of birth (the evaluation was repeated after 15 min if the infant was found asphyxiated), whether cry was immediate or delayed and any congenital anomaly present was noted. The cases were followed during lying in the period in the hospital and then were followed after 6 weeks to see mortality and morbidity and their follow-up is then matched retrospectively with maternal mode of delivery.
The tests used for statistical were Student's t-test and Chi-square test.
| Results | | |
The present study was conducted on 100 cases of breech presentation to find out the labour outcome in breech deliveries and various factors affecting it.
In the present series, there were 17,691 deliveries in this hospital in the study period from January 2007 to December 2007. Out of them, 727 were breech deliveries. The gross incidence of breech deliveries came to be 4.1094% [Table 2]. The first hundred cases were taken in this study.
Incidence of breech presentation was maximum (45%) in the age group of 21–25 years, [Table 3], [Graph 1] while incidence was minimum 2% in the age group of 36–40 years. Out of 100 cases, 62 were multigravidae and 38 were primigravidae [Table 4]. Hence, this concludes that incidence of breech presentation is more in multigravidae as compared to primigravidae. Among the multigravidae, maximum incidence was among second gravidae. | Table 3: The incidence of breech deliveries in relation to age of the mother
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 | Table 4: Reveals the incidence of breech presentation in relation to gravidity
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In the present series, out of 100 cases of breech deliveries, 14% were between the gestational age of 28 and 33 weeks and 32% were between the gestational age of 33 and 36 weeks [Table 5]. Incidence of full-term cases was 54%. By this, it is concluded that prematurity is associated with considerably high incidence of breech presentation. Moreover, out of 100 cases, extended variety of breech was present in 36 cases, of which 21 were primigravidae and 15 were multigravidae. The cases were diagnosed through sonography, through per vaginam examination. Flexed variety of breech was present in 45 cases. Out of which, 39 were multigravidae and 6 were primigravidae. Footling variety was present in 19 cases, of which 11 were primigravidae and 8 were multigravidae [Table 6]. | Table 5: Reveals incidence of breech presentation in relation to gestational age
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In the present series, multiparity, prematurity and extended legs respectively are the most common etiological factors of breech presentation [Table 7]. The incidence of twin pregnancy was 11%. Uterine anomalies account for 3% of factors. In the present series, caesarean section was done in 45% of cases [Table 8]. Forty-nine per cent cases required assistance at the time of delivery of arms and after coming head and were delivered by different methods such as Burns-Marshall, Loveset's manoeuvres and by Jaw and shoulder traction applied to the after coming head. In the present series, in 100 cases studied, cord prolapsed occurred in five cases out of which four breech were of footling variety and one of flexed variety. The most common foetal complication was of prematurity which occurred in 19 cases, out of which 11 cases were of 1.5 kg and less [Table 9]. | Table 7: Incidence of various etiological factors in breech presentation
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 | Table 9: Reveals the foetal complications commonly occurring during labour in breech deliveries
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In the present series, out of 100 cases, 43 cases (43%) were associated with factors which endanger of life of the foetus, among which twin pregnancy and pre-eclamptic toxaemia were the most commonly associated factors [Table 10], [Graph 2]. | Table 10: Reveals incidence of associated maternal factors which endanger the life of breech baby
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In the present series, among 100 cases studied, 14 breech babies and congenital malformation, out of which hydrocephalus was the most common malformation found [Table 11]. Moreover, out of 100 cases studied, 85% of cases of breech delivery went home with no complications [Table 12]. In addition, maximum numbers of deaths were macerated births (7%). | Table 11: Reveals incidence of associated congenital malformations associated with breech delivery
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| Discussion and Conclusion | | |
The present study was conducted on 100 cases of breech deliveries to find out the pattern of labour outcome and various factors affecting it. Incidence of breech deliveries is fairly high in Umaid Hospital, Jodhpur. Gross incidence of breech deliveries is 4.17%. Prematurity is associated with high incidence of breech presentation.
- External cephalic version is not favoured in this hospital
- The maximum incidence of breech presentation is found in the maternal age group 21–25 years, and incidence of breech is more in multigravidae as compared to primigravidae
- The main etiological factors of breech presentation are multiparity, prematurity, extended legs and multiple pregnancy, which themselves increase the risk to the foetus, except extended legs
- The most common variety of breech presentation is flexed breech, which is found more in multigravidae and compared to primigravidae. Among multigravidae, most commonly found in the second gravidae. Next common variety of breech presentation is extended breech, having maximum incidence in primigravidae as compared to multigravidae. Footling variety is least common variety of breech presentation
- Incidence of caesarean section is 45% in this series
- Common complications occurring during labour in breech deliveries are premature rupture of membranes, cord prolapsed, cord compression, inadequate cervical difficulty in the judgement of disproportion, intrapartum asphyxia, intrapartum foetal death and stillbirths
- Gross perinatal mortality in breech deliveries is 15% and after making correction for prematurity, congenital anomalies, etc., corrected perinatal mortality is 3%
- The incidence of perinatal mortality is much higher in unbooked cases as compared to booked cases and is due to lack of antenatal care in such cases.[7] The incidence of perinatal mortality is high in the maternal age group 31–35 and 36–40 years of age group. Incidence is more in multigravidae as compared to primigravida due to higher incidence of flexed variety in multigravidae whereas corrected perinatal mortality is more in primigravidae; due to the fact that footling variety came out to be more in primigravidae and also intrapartum foetal complications occur more in vaginally delivered primigravidae
- Extended variety of breech is safest for the baby and carries minimal foetal loss while flexed and footling varieties are dangerous because these are associated with high incidence of complications during labour such as premature rupture of membranes and cord prolapsed. Footling variety is most dangerous regarding foetal prognosis [8]
- Caesarean section is the mode of delivery of choice as it carries minimal foetal loss. Foetal loss is maximum with breech extraction
- Associated maternal factors such as severe anaemia, toxaemia and placenta previa increase the risk to the foetus
- Incidence of congenital anomalies such as hydrocephalus, anencephalus, omphalocele, gastroschisis and immobility of joint (lower limbs) are high with breech presentation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Hodnett ED, Hannah ME, Hewson S, Whyte H, Amankwor K, Cheng M, et al. Mothers view of their child birth experience 2 year after plan caesarean section vs. planned vaginal delivery for breech presentation at term. J Obstet Gynecol 2005;27:224-31. |
| 3. | Krebs L, Langhoff-Roos J. Breech delivery at term in Denmark, 1982-92: A population-based case-control study. Paediatr Perinat Epidemiol 1999;13:431-41. |
| 4. | Rosen MG, Chik L. The effect of delivery route on outcome in breech presentation. Am J Obstet Gynecol 1984;148:909-14. |
| 5. | Muhuri PK, Macdorman MF, Menacker F. Method of delivery and neonatal mortality among very low birth weight infants in the United States. Matern Child Health J 2006;10:47-53. |
| 6. | Obwegeser R, Ulm M, Simon M, Ploeckinger B, Gruber W. Breech infants: Vaginal or cesarean delivery? Acta Obstet Gynecol Scand 1996;75:912-6. |
| 7. | Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by mode of delivery among term breech births: Swedish experience 1987-1993. Obstet Gynecol 1998;92:945-50. |
| 8. | Wolf H, Schaap AH, Bruinse HW, Smolders-de Haas H, van Ertbruggen I, Treffers PE. Vaginal delivery compared with caesarean section in early preterm breech delivery: A comparison of long term outcome. Br J Obstet Gynaecol 1999;106:486-91. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]
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