Preterm Breech Delivery: Cesarean vs. Vaginal Delivery
Preterm Breech Delivery: Cesarean vs. Vaginal Delivery
Abstract & commentary
Synopsis: Cesarean delivery for early preterm breech delivery at 26-31 weeks does not improve survival without disability or handicap.
Source: Wolf H, et al. Br J Obstet Gynaecol 1999;106: 486-491.
To determine the best route of delivery for the early preterm fetus in a breech presentation, Wolf and colleagues performed a retrospective comparison of all singleton infants delivered between 1984-1989 at a gestational age of 26-31 weeks at two hospitals in The Netherlands, one center preferring vaginal delivery, while the other favored cesarean delivery. Infants with fetal malformations and pregnancies complicated by placenta previa, placental abruption, fetal death, or a non-reassuring fetal heart rate pattern before the onset of labor were excluded. The primary outcome measure was survival without disability or handicap at follow-up two years after delivery. Both centers administered corticosteroids to accelerate fetal lung maturity, and continuous electronic fetal heart rate monitoring was used during labor. Epidural anesthesia was never used for vaginal delivery nor were episiotomies or forceps routinely used.
There were 101 preterm breech infants delivered in the center which preferred vaginal delivery and 46 in the center which favored cesarean delivery. The cesarean delivery rate was 85% in the hospital preferring this route and 17% in the other center. Of note, in the center preferring cesarean delivery, 13% of the labors progressed too fast and a vaginal delivery was performed while in the center which favored vaginal delivery, the attending obstetrician performed a cesarean delivery in 17% of cases for non-reassuring fetal heart rate patterns, cord complications, infection, or a high presentation. To avoid bias, these infants were analyzed as if they had been delivered by the route preferred in that center. Follow-up was obtained on more than 90% of the infants.
No significant difference in survival without disability or handicap was noted between the centers. Only higher birthweight (odds ratio 2.0 for each additional 250 grams) and corticosteroids given more than 24 hours before birth (odds ratio 2.7) were found to have a significant improve-ment in outcome, while footling breech presentation had a negative influence (odds ratio 0.4). Maternal morbidity was more likely at the center preferring cesarean delivery. The length of stay was significantly longer by 2.1 days and the instance of postpartum fever, fever greater than 38°C for more than two days, was increased from 3% to 9%.
Wolf et al conclude that cesarean delivery for early preterm breech delivery at 26-31 weeks does not improve survival without disability or handicap.
COMMENT BY STEVEN G. GABBE, MD
The preferred route of delivery for the preterm breech infant remains controversial. Those who advocate cesarean delivery point to an increased risk of head entrapment, birth asphyxia, or traumatic injury with resulting long-term morbidity as reasons for this choice. Yet, there are no prospective, randomized studies to support this position. Such trials have been attempted, but failed when physi-cians were unwilling to enter their patients in the random-ization process. As noted by Wolf et al, they would haveneeded 1000 patients in their study to achieve statistical significance. They chose a unique study design including two centers in The Netherlands responsible for approximately 20% of early preterm births in that country, each with a different approach to preterm breech delivery. And, as in other retrospective studies, they were unable to document a difference in survival without disability or handicap. Furthermore, women who had a cesarean delivery required an extension of the incision into the uterine corpus or a "T" incision in eight of 17 (47%) cesareans in the center preferring vaginal birth, and six of 39 (15%) in the hospital preferring cesarean delivery, increasing the risks for uterine rupture in a future pregnancy. Despite these findings, given the medicolegal climate and the relatively limited experience with vaginal breech delivery duringthe past two decades, it is likely that most obstetricians in the United States will continue to favor cesarean delivery for the early preterm breech infant.
In the study by Wolf et al, which of the following significantly improved intact survival for the preterm breech infant?
a. Cesarean delivery
b. Complete breech extraction
c. Forceps to the aftercoming head
d. Corticosteroid therapy for more than 24 hours
e. Mediolateral episiotomy
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