Breech delivery in low-income settings: A systematic review of perinatal and maternal outcomes in vaginal versus cesarean breech deliveries.

Most studies comparing vaginal breech delivery (VBD) with cesarean breech delivery (CBD) have been conducted in high-income settings. It is uncertain whether these results are applicable in a low-income setting. To assess the neonatal and maternal mortality and morbidity for singleton VBD compared to CBD in low- and lower-middle-income settings,the PubMed database was searched from January 1, 2000, to January 23, 2020 (updated April 21, 2021). Randomized controlled trials (RCTs) and non-RCTs comparing singleton VBD with singleton CBD in low- and lower-middle-income settings reporting infant mortality were selected. Two authors independently assessed papers for eligibility and risk of bias. The primary outcome was relative risk of perinatal mortality. Meta-analysis was conducted on applicable outcomes. Eight studies (one RCT, seven observational) (12 510 deliveries) were included. VBD increased perinatal mortality (relative risk [RR] 2.67, 95% confidence interval [CI] 1.82-3.91; one RCT, five observational studies, 3289 women) and risk of 5-minute Apgar score below 7 (RR 3.91, 95% CI 1.90-8.04; three observational studies, 430 women) compared to CBD. There was a higher risk of hospitalization and postpartum bleeding in CBD. Most of the studies were deemed to have moderate or serious risk of bias. CBD decreases risk of perinatal mortality but increases risk of bleeding and hospitalization.

The Charité external cephalic version for leading twin breech without regional anesthesia and tocolysis. A prospective study on feasibility, sonographic assessment and outcomes.

OBJECTIVES: To assess the feasibility of external cephalic version (ECV) for the leading twin (twin A) in breech presentation in dichorionic and diamniotic twin pregnancies without the use of regional anesthetics and tocolysis and to characterize the sonographic parameters, maternal and neonatal outcomes. STUDY DESIGN: Prospective study performed in the Charité University Hospital outpatient obstetric department in Berlin, Germany. A total of 23 women from the 35th completed week of pregnancy with confirmed dichorionic-diamniotic twin pregnancy were recruited. ECVs were performed by the lead consultant for the breech and ECV clinic. Ethical approval provided by the Charité Ethics Commission (EA2/241/18). Demographic data were recorded. Fetal sonographic parameters were assessed. The success rate of ECV, duration of the ECV, gestational age at delivery, mode of delivery for both fetuses, maternal and neonatal outcomes were analyzed. RESULTS: Our main finding showed that ECV for twin A breech in dichorionic-diamniotic twins is successful in 56% (10/18) of cases without the need for regional anesthesia and without tocolysis. There is a significant increase in the spontaneous vaginal delivery rate for both twins of 95% (19/20) vs 12.5% (2/16) (p < 0.001). There is also a significant reduction in blood loss at delivery of 300 ml vs 500 ml (p = 0.034) in successful cases. CONCLUSIONS: We show that ECV for twin A in breech is feasible and in 56% (10/18) successful without regional anesthesia and tocolysis. The option of ECV for twin A breech should be offered to women.

Routine Third Trimester Sonogram: Friend or Foe.

Several risk factors for adverse pregnancy outcomes can be identified by a routine third trimester ultrasound scan. However, there is also potential for harm, anxiety, and additional health care costs through unnecessary intervention due to false positive results. The evidence base informing the balance of risks and benefits of universal screening is inadequate to fully inform decision making. However, data on the diagnostic effectiveness of universal ultrasound suggest that better methods are required to result in net benefit, with the exception of screening for presentation near term, where a clinical and economic case can be made for its implementation.

Breech progression angle: new feasible and reliable transperineal ultrasound parameter for assessment of fetal breech descent in birth canal.

OBJECTIVE: To assess the feasibility and reliability of transperineal ultrasound in the assessment of fetal breech descent in the birth canal, by measuring the breech progression angle (BPA). METHODS: Women with a singleton pregnancy with the fetus in breech presentation between 34 and 41 weeks' gestation were recruited. Transperineal ultrasound images were acquired in the midsagittal view for each woman, twice by one operator and once by another. Each operator measured the BPA after anonymization of the transperineal ultrasound images. BPA was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the pubic symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded to all other measurements performed for each woman. Intra- and interobserver reproducibility of BPA measurement was evaluated using the intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using Bland-Altman analysis. Student's t-test and Levene's W0 test were used to investigate whether a number of different clinical factors had an effect on systematic differences and homogeneity, respectively, between BPA measurements. RESULTS: Overall, 44 women were included in the analysis. BPA was measured successfully by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility in BPA measurement, with ICCs of 0.88 (95% CI, 0.80-0.93) and 0.83 (95% CI, 0.71-0.90), respectively. The mean difference between measurements was 0.4° (95% CI, -1.4 to 2.2°) for intraobserver repeatability and -0.4° (95% CI, -2.6 to 1.8°) for interobserver repeatability. The upper limits of agreement were 12.0° (95% CI, 8.9-15.1°) and 13.6° (95% CI, 9.9-17.3°) for intra- and interobserver repeatability, respectively. The lower limits of agreement were -11.2° (95% CI, -14.3 to -8.1°) and -14.4° (95% CI, -18.2 to -10.7°) for intra- and interobserver repeatability, respectively. No systematic difference between BPA measurements was found on either intra- or interobserver agreement analysis. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- or interobserver reliability. CONCLUSIONS: BPA represents a new feasible and highly reproducible measurement for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and breech vaginal delivery are needed. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States.

BACKGROUND: Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed. OBJECTIVE: This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States. STUDY DESIGN: This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation. RESULTS: Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1). CONCLUSION: Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.

The impact of a routine late third trimester growth scan on the incidence, diagnosis, and management of breech presentation in Oxfordshire, UK: A cohort study.

BACKGROUND: Breech presentation at term contributes significantly to cesarean section (CS) rates worldwide. External cephalic version (ECV) is a safe procedure that reduces term breech presentation and associated CS. A principal barrier to ECV is failure to diagnose breech presentation. Failure to diagnose breech presentation also leads to emergency CS or unplanned vaginal breech birth. Recent evidence suggests that undiagnosed breech might be eliminated using a third trimester scan. Our aim was to evaluate the impact of introducing a routine 36-week scan on the incidence of breech presentation and of undiagnosed breech presentation. METHODS AND FINDINGS: We carried out a population-based cohort study of pregnant women in a single unit covering Oxfordshire, United Kingdom. All women delivering between 37+0 and 42+6 weeks gestational age, with a singleton, nonanomalous fetus over a 4-year period (01 October 2014 to 30 September 2018) were included. The mean maternal age was 31 years, mean BMI 26, 44% were nulliparous, and 21% were of non-white ethnicity. Comparisons between the 2 years before and after introduction of routine 36-week scan were made for 2 primary outcomes of (1) the incidence of breech presentation and (2) undiagnosed breech presentation. Secondary outcomes related to ECV, mode of birth, and perinatal outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. A total of 27,825 pregnancies were analysed (14,444 before and 13,381 after). A scan after 35+0 weeks was performed in 5,578 (38.6%) before, and 13,251 (99.0%) after (p < 0.001). The incidence of breech presentation at birth did not change significantly (2.6% and 2.7%) (RR 1.02; 95% CI 0.89, 1.18; p = 0.76). The rate of undiagnosed breech before labour reduced, from 22.3% to 4.7% (RR 0.21; 95% CI 0.12, 0.36; p < 0.001). Vaginal breech birth rates fell from 10.3% to 5.3% (RR 0.51; 95% CI 0.30, 0.87; p = 0.01); nonsignificant increases in elective CS rates and decreases in emergency CS rates for breech babies were seen. Neonatal outcomes were not significantly altered. Study limitations include insufficient numbers to detect serious adverse outcomes, that we cannot exclude secular changes over time which may have influenced our results, and that these findings are most applicable where a comprehensive ECV service exists. CONCLUSIONS: In this study, a universal 36-week scan policy was associated with a reduction in the incidence but not elimination of undiagnosed term breech presentation. There was no reduction in the incidence of breech presentation at birth, despite a comprehensive ECV service.

Assessment of Indications and Complications of Caesarean Section in A Private Medical College Hospital of Bangladesh.

Caesarean section (CS) is the most frequently performed major operation in obstetrics. Its frequency is gradually increasing because of extended indications. Now-a-days, caesarean section is also being performed at patient's request in absence of a medical indication. It is necessary to assess the risk and benefits to take a judicious decision to select cases for caesarean section. The cross sectional descriptive type of observational study was carried out among purposively selected 100 pregnant women admitted to the department of Obstetrics and Gynaecology of Community Based Medical College Hospital, Mymensingh, Bangladesh during the period of August 2011 to January 2012 to identify elective and emergency indications of caesarean section, to identify the common complications to identify the risk factors associated with complications and to establish a comparison between complications of elective and emergency caesarean section. The median age group of patients being operated was 20 to 25 years and operation were carried out on patients due to various indications. Principal indications were faetal distress (26%), PROM (15%), failed progress of labour and breech presentation were 8% each, other indications were eclampsia (4%), obstructed labour (5%), scar tenderness (4%), history of previous 2 caesarian section 5%. The rate of elective caesarean section was 21% while emergency operations were done in 79% of cases. Among the 100 patients 19% patients developed complications. Among the complications wound infection was most common (37%), then post partum haemorrhage and urinary tract infection 26% and 11% respectively. Other complications were abdominal distension, Puerperal sepsis, anaemic heart failure, wound dehiscence and Wound haematoma 5% each. We should try to keep the rate of caesarean section within optimum ranges (10%) as recommended by World Health Organization.

Applying the Robson classification to routine facility data to understand the Caesarean section practice in conflict settings of South Kivu, eastern DR Congo.

INTRODUCTION: Sub-Saharan Africa has low Caesarean (CS) levels, despite a global increase in CS use. In conflict settings, the pattern of CS use is unclear because of scanty data. We aimed to examine the opportunity of using routine facility data to describe the CS use in conflict settings. METHODS: We conducted a facility-based cross-sectional study in 8 health zones (HZ) of South Kivu province in eastern DR Congo. We reviewed patient hospital records, maternity registers and operative protocol books, from January to December 2018. Data on direct conflict fatalities were obtained from the Uppsala Conflict Data Program. Based on conflict intensity and chronicity (expressed as a 6-year cumulative conflict death rate), HZ were classified as unstable (higher conflict death rate), intermediate and stable (lower conflict death rate). To describe the Caesarean section practice, we used the Robson classification system. Based on parity, history of previous CS, onset of labour, foetal lie and presentation, number of neonates and gestational age, the Robson classification categorises deliveries into 10 mutually exclusive groups. We performed a descriptive analysis of the relative contribution of each Robson group to the overall CS rate in the conflict stratum. RESULTS: Among the 29,600 deliveries reported by health facilities, 5,520 (18.6%) were by CS; 5,325 (96.5%) records were reviewed, of which 2,883 (54.1%) could be classified. The overall estimated population CS rate was 6.9%. The proportion of health facility deliveries that occurred in secondary hospitals was much smaller in unstable health zones (22.4%) than in intermediate (40.25) or stable health zones (43.0%). Robson groups 5 (previous CS, single cephalic, ≥ 37 weeks), 1 (nulliparous, single cephalic, ≥ 37 weeks, spontaneous labour) and 3 (multiparous, no previous CS, single cephalic, ≥ 37 weeks, spontaneous labour) were the leading contributors to the overall CS rate; and represented 75% of all CS deliveries. In unstable zones, previous CS (27.1%) and abnormal position of the fetus (breech, transverse lie, 3.3%) were much less frequent than in unstable and intermediate (44.3% and 6.0% respectively) and stable (46.7%and 6.2% respectively). Premature delivery and multiple pregnancy were more prominent Robson groups in unstable zones. CONCLUSION: In South Kivu province, conflict exposure is linked with an uneven estimated CS rate at HZ level with at high-risks women in conflict affected settings likely to have lower access to CS compared to low-risk mothers in stable health zones.

Assessment of Acute Obstetrical Needs and the Potential Utility of Point-Of-Care Ultrasound in the North East Region of Haiti: A Cross-Sectional Study.

Background: Point-of-care ultrasound (POCUS) implemented through task shifting to nontraditional users has potential as a diagnostic adjuvant to enhance acute obstetrical care in resource-constrained environments with limited access to physician providers. Objective: This study evaluated acute obstetrical needs and the potential role for POCUS programming in the North East region of Haiti. Methods: Data was collected on all women presenting to the obstetrical departments of two Ministry of Public Health and Population (MSPP)-affiliated public hospitals in the North East region of Haiti: Fort Liberté Hospital and Centre Medicosocial de Ouanaminthe. Data was obtained via retrospective review of hospital records from January 1 through March 31, 2016. Trained personnel gathered data on demographics, obstetrical history, diagnoses, clinical care and outcomes using a standardized tool. Diagnoses a priori, defined as those diagnoses whose detection could be assisted with POCUS, included multi-gestations, non-vertex presentation, cephalopelvic disproportion, placental abruption, placenta previa, spontaneous abortions, retained products and ectopic pregnancy. Results: Data were collected from 589 patients during the study period. Median maternal age was 26 years and median gestational age was 38 weeks. The most common reason for seeking care was pelvic pain (85.2%). Sixty-seven (11.5%) women were transferred to other facilities for higher-level care. Among cases not transferred, post-partum hemorrhage, infant mortality and maternal mortality occurred in 2.4%, 3.0% and 0.6% of cases, respectively. There were 69 cases with diagnoses that could have benefited from POCUS use. Between sites, significantly more cases had the potential for improved diagnostics with POCUS at Fort Liberté Hospital (19.8%) than Centre Medicosocial de Ouanaminthe (8.2%) (p < 0.001). Conclusion: Acute obstetrical care is common and POCUS has the potential to impact the care of obstetrical patients in the North East region of Haiti. Future programs evaluating the feasibility of task shifting and the sustainable impacts of acute obstetric POCUS in Haiti will be important.

Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis.

BACKGROUND: Despite the relative ease with which breech presentation can be identified through ultrasound screening, the assessment of foetal presentation at term is often based on clinical examination only. Due to limitations in this approach, many women present in labour with an undiagnosed breech presentation, with increased risk of foetal morbidity and mortality. This study sought to determine the cost effectiveness of universal ultrasound scanning for breech presentation near term (36 weeks of gestational age [wkGA]) in nulliparous women. METHODS AND FINDINGS: The Pregnancy Outcome Prediction (POP) study was a prospective cohort study between January 14, 2008 and July 31, 2012, including 3,879 nulliparous women who attended for a research screening ultrasound examination at 36 wkGA. Foetal presentation was assessed and compared for the groups with and without a clinically indicated ultrasound. Where breech presentation was detected, an external cephalic version (ECV) was routinely offered. If the ECV was unsuccessful or not performed, the women were offered either planned cesarean section at 39 weeks or attempted vaginal breech delivery. To compare the likelihood of different mode of deliveries and associated long-term health outcomes for universal ultrasound to current practice, a probabilistic economic simulation model was constructed. Parameter values were obtained from the POP study, and costs were mainly obtained from the English National Health Service (NHS). One hundred seventy-nine out of 3,879 women (4.6%) were diagnosed with breech presentation at 36 weeks. For most women (96), there had been no prior suspicion of noncephalic presentation. ECV was attempted for 84 (46.9%) women and was successful in 12 (success rate: 14.3%). Overall, 19 of the 179 women delivered vaginally (10.6%), 110 delivered by elective cesarean section (ELCS) (61.5%) and 50 delivered by emergency cesarean section (EMCS) (27.9%). There were no women with undiagnosed breech presentation in labour in the entire cohort. On average, 40 scans were needed per detection of a previously undiagnosed breech presentation. The economic analysis indicated that, compared to current practice, universal late-pregnancy ultrasound would identify around 14,826 otherwise undiagnosed breech presentations across England annually. It would also reduce EMCS and vaginal breech deliveries by 0.7 and 1.0 percentage points, respectively: around 4,196 and 6,061 deliveries across England annually. Universal ultrasound would also prevent 7.89 neonatal mortalities annually. The strategy would be cost effective if foetal presentation could be assessed for £19.80 or less per woman. Limitations to this study included that foetal presentation was revealed to all women and that the health economic analysis may be altered by parity. CONCLUSIONS: According to our estimates, universal late pregnancy ultrasound in nulliparous women (1) would virtually eliminate undiagnosed breech presentation, (2) would be expected to reduce foetal mortality in breech presentation, and (3) would be cost effective if foetal presentation could be assessed for less than £19.80 per woman.

Assessment of Current Epidemiology and Risk Factors Surrounding Brachial Plexus Birth Palsy.

PURPOSE: Brachial plexus birth palsy (BPBP) is common; however, the current incidence is unknown and more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known risk factors, and evaluate hypotonia as a new risk factor, as well as estimate the length of stay (LOS) and direct costs of children with an associated BPBP injury. METHODS: Data from the 1997 to 2012 Kids' Inpatient Database data sets were evaluated to identify patients with a BPBP injury and various risk factors. Evaluation of LOS data and direct costs was also performed. Multivariable logistic regression analysis was utilized to assess the association of BPBP with its known and previously undescribed risk factors. RESULTS: The incidence of BPBP has steadily decreased from 1997 to 2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number 1 risk factor for the development of a BPBP injury. Hypotonia is a newly recognized risk factor for the development of BPBP. Fifty-five percent of infants with BPBP have no known perinatal risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury and the hospital stay direct costs are approximately 40% higher. CONCLUSIONS: The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the most common risk factor for sustaining a BPBP injury. Children with a BPBP injury have longer LOSs and hospital direct costs compared with children without a BPBP injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Caesarean Section at Full Dilatation and Risk of Major Obstetric Haemorrhage.

The purpose of the study was to examine the risk factors for caesarean section (CS) at full dilatation and to assess the risk and management of haemorrhage. The study took place in a tertiary referral maternity hospital. Women who had a CS at full dilatation were included. Clinical and demographic details were recorded. There were 199 cases. The average age was 30.3 years and average BMI was 25.8kg/m2. There were 79.9 % (159) primigravidas and 20.1% (40) multigravidas. The average gestation at delivery was 39.4 weeks. Labour was induced in 46.9 % (92) and spontaneous in 53.8% (107). Oxytocin was used in 67.8 % (135). An instrumental delivery was attempted in 46.7 % (93). The rate of malposition was 46.5 % (92). The average birthweight was 3,629g and 9 babies weighed ?4.5kg. The average estimated blood loss (EBL) was 665mls and 34 had EBL>1L. Most had an oxytocin infusion (141). Other uterotonic agents were used in 70 women. Seven women had blood transfusions. The highest rate of CS at full dilatation was in primigravidas due to malposition. There was a low rate of major obstetric haemorrhage.

Outcome of caesarean section at the Edward Francis Small Teaching Hospital, Banjul The Gambia.

BACKGROUND: Caesarean section is a very important procedure to decrease maternal and perinatal morbidity and mortality. Anecdotal evidence suggests that more than half of all caesarean sections done in The Gambia are done at the Edward Francis Small Teaching Hospital. OBJECTIVE: The aim of the study was to determine the caesarean section rate at the Edward Francis Small teaching Hospital. The study also aimed to determine the socio-demographic factors associated with caesarean section and maternal and fetal outcomes of caesarean section at the hospital. METHOD: A retrospective review of all caesarean sections carried out at the Edward Francis Small Teaching Hospital from 1st January 2014 to 31st December 2014 was done. Data was extracted from patients' record. Descriptive statistics was done using Epi Info 7 statistical software. RESULTS: The Caesarean section rate in the hospital is 24.0%. The commonest indications for caesarean section were previous caesarean section (20.6%) and cephalopelvic disproportion (20.2%). There were 21 maternal deaths (1.8%) and 71 fresh stillbirths (6.0%) in the study population. CONCLUSION: About a quarter of all deliveries in the hospital were caesarean sections most of which were done as emergencies. The commonest indications for caesarean section were cephalopelvic disproportion and previous caesarean section.

Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States.

BACKGROUND: There is little agreement on who is a good candidate for community (home or birth center) birth in the United States. METHODS: Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gestational diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, history of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education. RESULTS: The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6). Cesarean births were most common in the breech (44.7%), preeclampsia (30.6%), history of cesarean without vaginal birth (22.1%), and primipara (11.0%) groups. DISCUSSION: The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.

Trends in the delivery route of twin pregnancies in the United States, 2006-2013.

OBJECTIVES: To determine the trends of cesarean delivery rate among twin pregnancies from 2006 to 2013. STUDY DESIGN: This is a population-based, cross-sectional analysis of twin live births from United State birth data files of the National Center for Health Statistics for calendar years 2006 through 2013. We stratified the population based on the gestational age groups, maternal race/ethnicity, advanced maternal age (AMA) which was defined by age more than 35 years and within the standard birth weight groups (group 1: birth weight 500-1499g, group 2: birth weight 1500-2499g and group 3: birth weight >2500g). We also analyzed the effect of different risk factors for cesarean delivery in twins. RESULTS: There were 1,079,102 infants born of twin gestations in the U.S. from 2006 to 2013, representing a small but significant increase in the proportion of twin births among all births (3.2% in 2006 versus 3.4% in 2013). The rate of cesarean delivery in twin live births peaked at 75.3% in 2009, and was significantly lower (74.8%) in 2013. The rate of the twin live birth with the breech presentation increased steadily from 26.3% in 2006 to 29.1% in 2013. For the fetus of the twin pregnancy presented as breech, the cesarean delivery rate peaked at 92.2% in 2010, falling slightly but significantly in the ensuing 3 years. The results demonstrated that the decrease in cesarean delivery rate was due to fewer cesareans in non-Hispanic white patients; all other ethnic subgroups showed increasing rates of cesarean delivery throughout the study. Gestational diabetes, gestational hypertension, previous cesarean delivery and breech presentation were all significant risk factors for cesarean delivery during the entire study period. Induction of labor and premature rupture of the membranes were associated with lower rates of cesarean delivery in twins. CONCLUSION: The recent decrease in the cesarean delivery rate in twin gestation appears to be largely attributable to a decline in cesarean among pregnancies complicated by breech presentation in non-Hispanic white women, and may reflect a health care disparity that deserves further research.

The Cost Implications in Ontario, Alberta, and British Columbia of Early Versus Delayed External Cephalic Version in the Early External Cephalic Version 2 (EECV2) Trial.

OBJECTIVE: According to the Early External Cephalic Version (EECV2) Trial, planning external cephalic version (ECV) early in pregnancy results in fewer breech presentations at delivery compared with delayed external cephalic version. A Cochrane review conducted after the EECV2 Trial identified an increase in preterm birth associated with early ECV. We examined whether a policy of routine early ECV (i.e., before 37 weeks' gestation) is more or less costly than a policy of delayed ECV. METHODS: We undertook this analysis from the perspective of a third-party payer (Ministry of Health). We applied data, using resources reported in the EECV2 Trial, to the Canadian context using 10 hospital unit costs and 17 physician service/procedure unit costs. The data were derived from the provincial health insurance plan schedule of medical benefits in three Canadian provinces (Ontario, Alberta, and British Columbia). The difference in mean total costs between study groups was tested for each province separately. RESULTS: We found that planning early ECV results in higher costs than planning delayed ECV. The mean costs of all physician services/procedures and hospital units for planned ECV compared with delayed ECV were $7997.32 versus $7263.04 in Ontario (P < 0.001), $8162.82 versus $7410.55 in Alberta (P < 0.001), and $8178.92 versus $7417.04 in British Columbia (P < 0.001), respectively. CONCLUSION: From the perspective of overall cost, our analyses do not support a policy of routinely planning ECV before 37 weeks' gestation.

Development and validation of an objective structured assessment of technical skill tool for the practice of breech presentation delivery.

OBJECTIVE: To develop and test the validity of an Objective Structured Assessment of Technical Skills (OSATS) tool for breech presentation delivery. MATERIALS AND METHODS: Monocentric prospective study conducted in the Department of Gynecology, Obstetrics, Fetal Medicine and Reproductive Medicine at the University Hospital of Nice. The study consisted of two parts, the development of the OSATS scoring system and its objective validation. Several experts in obstetrics from university hospital centers and private French hospitals were invited to participate in the development phase of the scoring system. For the validation phase, we formed a group of 20 novices and a group of 20 experts, who had to perform a breech presentation delivery on a simulator, according to a standardized scenario. Each participant was filmed and two experts would then evaluate their performance by viewing anonymized videos and using the OSATS score. RESULTS: The scores obtained by the expert group were significantly higher than those of the novice group, with a total score of 21.73/25 versus 6.95/25 (p < 0.0001), a task-specific score of 87.2/110 versus 44.3/110 (p < 0.0001) and an overall score of 108.93/135 versus 51.25/135 (p < 0.0001), respectively. CONCLUSION: The OSATS score developed in this study for breech presentation delivery is a reliable model to assess the competence level in procedural skills using a simulator.

Mortality and morbidity in early preterm breech singletons: impact of a policy of planned vaginal delivery.

OBJECTIVE: To compare neonatal morbidity and mortality rates in preterm singleton breech deliveries from 26(0/7) to 29(6/7) weeks of gestation in centers with a policy of either planned vaginal delivery (PVD) or planned cesarean delivery (PCD). STUDY DESIGN: Women with preterm singleton breech deliveries occurring after preterm labor or preterm premature rupture of membranes (pPROM) were identified from the databases of five perinatal centers and classified as PVD or PCD according to the center's management policy. The independent association between planned mode of delivery and the risk of neonatal hospital death or morbidity was tested and quantified with ORs through two-level multivariable logistic regression modeling. RESULTS: Of 142 782 deliveries during the study period, 626 (0.4%) were singletons in breech presentation from 26(0/7) to 29(6/7) weeks of gestation: after exclusions, 130 were in the PVD group and 173 in the PCD group. Severe newborn morbidity was similar in the two groups. Newborn mortality was 12% in the PCD group and 16% in the PVD group. Three neonates (1.7%, 95% CI: 0.34-5.0) died from head entrapment after vaginal delivery in the PVD group. Nonetheless, the policy of PVD was not associated with increased risks of neonatal death (aOR: 1.01, 95% CI: 0.33-2.92) or severe morbidity. CONCLUSION: Risks of mortality and severe morbidity in preterm breech were not increased by a policy of vaginal delivery. Head entrapment leading to death is however possible in cases of vaginal delivery but its rarity should be balanced with the maternal consequences of early preterm cesarean delivery.