The influence of uterine fibroids on adverse outcomes in pregnant women: a meta-analysis.

OBJECTIVE: The objective of the meta-analysis was to determine the influence of uterine fibroids on adverse outcomes, with specific emphasis on multiple or large (≥ 5 cm in diameter) fibroids. MATERIALS AND METHODS: We searched PubMed, Embase, Web of Science, ClinicalTrials.gov, China National Knowledge Infrastructure (CNKI), and SinoMed databases for eligible studies that investigated the influence of uterine fibroids on adverse outcomes in pregnancy. The pooled risk ratio (RR) of the variables was estimated with fixed effect or random effect models. RESULTS: Twenty-four studies with 237 509 participants were included. The pooled results showed that fibroids elevated the risk of adverse outcomes, including preterm birth, cesarean delivery, placenta previa, miscarriage, preterm premature rupture of membranes (PPROM), placental abruption, postpartum hemorrhage (PPH), fetal distress, malposition, intrauterine fetal death, low birth weight, breech presentation, and preeclampsia. However, after adjusting for the potential factors, negative effects were only seen for preterm birth, cesarean delivery, placenta previa, placental abruption, PPH, intrauterine fetal death, breech presentation, and preeclampsia. Subgroup analysis showed an association between larger fibroids and significantly elevated risks of breech presentation, PPH, and placenta previa in comparison with small fibroids. Multiple fibroids did not increase the risk of breech presentation, placental abruption, cesarean delivery, PPH, placenta previa, PPROM, preterm birth, and intrauterine growth restriction. Meta-regression analyses indicated that maternal age only affected the relationship between uterine fibroids and preterm birth, and BMI influenced the relationship between uterine fibroids and intrauterine fetal death. Other potential confounding factors had no impact on malposition, fetal distress, PPROM, miscarriage, placenta previa, placental abruption, and PPH. CONCLUSION: The presence of uterine fibroids poses increased risks of adverse pregnancy and obstetric outcomes. Fibroid size influenced the risk of breech presentation, PPH, and placenta previa, while fibroid numbers had no impact on the risk of these outcomes.

The risk of DDH between breech and cephalic-delivered neonates using Graf ultrasonography.

PURPOSE: Developmental dysplasia of the hip (DDH) is one of the most common musculoskeletal disorder in infants. The most significant risk factors include female gender, breech presentation, left hip and family history. In this study, we utilized the Graf method at different time intervals to evaluate both breech-delivered and cephalic-born newborns. The objectives were to compare the incidence of DDH in cephalic and breech-delivered neonates and investigate whether the hip joints of neonates delivered in the breech position exhibit a distinct maturation pattern. MATERIAL AND METHODS: We studied prospectively 618 hip joints (309 newborns). Each hip joint was examined with the Graf method in four time periods as follows: Phase #1 (0-1 weeks), Phase #2 (1-4 weeks), Phase #3 (4-7 weeks), and Phase #4 (7-10 weeks). The α and ß angles for each hip joint were measured, and the hips were classified according to Graf classification. With our statistical analysis within the different phases, we were able to investigate potential variations in the maturation patterns between newborns delivered in the breech and cephalic delivery positions. RESULTS: A significant difference (at the 5% level) was observed in Phase 1 between breech and cephalic-delivered neonates (35.6-8.6%). This difference tended to decrease in next phases (13.6-1% in Phase 2, 2.5-0% in Phase 3 and 1.7-0% in Phase 4). A significant difference (at the 5% level) for cephalic-delivered neonates was also observed between Phase 1 and Phase 4 (8.5-0%), but the percentages were low. Additionally, the breech-delivered had extreme difference in incidence of DDH from Phase 1 to Phase 4 (35.6-11.9%, 2.5%, and 1.7%, respectively). CONCLUSION: It appears that there is an actual difference in the incidence of DDH between breech-delivered and cephalic-delivered neonates, although the difference may be less significant than previously considered. The majority of the breech-delivered neonates that were initially considered as pathological (Phase 1) are, in fact, healthy. This is ascertained in subsequent ultrasound examinations conducted in later phases (Phases 2-4), when the incidence of pathological cases decreases. This could be attributed to potential different maturation pattern between these groups.

Undiagnosed uterine anomalies revealed by breech on ultrasound prior to external cephalic version - A chance to take a closer look.

OBJECTIVE: Uterine anomalies (UA) occur in up to 6.7% of women. Breech is eight times more likely to occur with UA which may not be diagnosed prior to pregnancy and may only be found in the third trimester with breech. The objective of the study is to assess the prevalence of both already known and newly sonographically diagnosed UA in breech from 36 weeks of gestation and its impact on external cephalic version (ECV), delivery options and perinatal outcomes. STUDY DESIGN: We recruited 469 women with breech at 36 weeks of gestation over a 2-year period at the Charité University Hospital, Berlin. Ultrasound examination was performed to rule out UA. Patients with known and newly 'de novo' diagnosed anomalies were identified and delivery options and perinatal outcomes analyzed. RESULTS: The 'de novo' diagnosis of UA at 36-37 weeks of pregnancy with breech was found to be significantly higher compared to the diagnosis prior to pregnancy with 4.5% vs 1.5% (p < 0.001 and odds ratio 4 with 95% confidence interval 2.12-7.69). Anomalies found included 53.6% bicornis unicollis, 39.3% subseptus, 3.6% unicornis and 3.6% didelphys. A trial of vaginal breech delivery was successful in 55.5% of cases when attempted. There were no successful ECVs. CONCLUSION: Breech is a marker for uterine malformation. Diagnosis of UA with breech can be up to four times improved with focused ultrasound screening in pregnancy even from 36 weeks of gestation prior to ECV to identify missed anomalies. Timely diagnosis aids antenatal care and delivery planning. Importantly, definitive diagnosis and treatment can be planned postpartum to improve outcomes in future pregnancies. ECV plays a limited role in selected cases.

Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study.

BACKGROUND: Accurate knowledge of fetal presentation at term is vital for optimal antenatal and intrapartum care. The primary objective was to compare the impact of routine third trimester ultrasound or point-of-care ultrasound (POCUS) with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes. METHODS AND FINDINGS: This was a retrospective multicentre cohort study where we included data from St. George's (SGH) and Norfolk and Norwich University Hospitals (NNUH). Pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH). Women with multiple pregnancy, preterm birth prior to 37 weeks, congenital abnormality, and those undergoing planned cesarean section for breech presentation were excluded. Undiagnosed breech presentation was defined as follows: (a) women presenting in labour or with ruptured membranes at term subsequently discovered to have a breech presentation; and (b) women attending for induction of labour at term found to have a breech presentation before induction. The primary outcome was the proportion of all term breech presentations that were undiagnosed. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE), and perinatal mortality (including stillbirths and early neonatal deaths). We employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood). The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models. All analyses were conducted using R for Statistical Software (v.4.2.0). Before and after the implementation of routine third trimester scan or POCUS, there were 16,777 and 7,351 births in SGH and 5,119 and 4,575 in NNUH, respectively. The rate of breech presentation in labour was consistent across all groups (3% to 4%). In the SGH cohort, the percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before (years 2016 to 2020) and 2.8% (7/251) after (year 2020 to 2021) the implementation of universal screening (p < 0.001). Similarly, in the NNUH cohort, the percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before (year 2015) and 3.5% (5/142) after (year 2020 to 2021) the implementation of universal POCUS screening (p < 0.001). Bayesian regression analysis with informative priors showed that the rate of undiagnosed breech was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9%. Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9%. There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). We do not have reliable data on number of facility-based ultrasound scans via the standard antenatal referral pathway or external cephalic versions (ECVs) performed during the study period. CONCLUSIONS: In our study, we observed that both a policy of routine facility-based third trimester ultrasound or POCUS are associated with a reduction in the proportion of term breech presentations that were undiagnosed, with an improvement in neonatal outcomes. The findings from our study support the policy of third trimester ultrasound scan for fetal presentation. Future studies should focus on exploring the cost-effectiveness of POCUS for fetal presentation.

The impact of assisted reproductive technology and ovulation induction on breech presentation: A whole of population-based cohort study.

AIMS: Multiple studies have suggested a likely association between breech presentation and assisted reproductive technology (ART) for conception. The aims were to determine whether conception via in vitro fertilisation (IVF) and ovulation induction (OI) is associated with fetal malpresentation at birth and to ascertain what mediating factors most significantly contribute to fetal malpresentation. METHODS: This whole-population-based cohort study included 355 990 singleton pregnancies born in Queensland, Australia, between July 2012 and July 2018. Multinomial logistic regression models estimated the adjusted odds of breech, transverse/shoulder and face/brow malpresentations in pregnancies conceived via spontaneous conception, OI (OI group) and IVF with or without intracytoplasmic sperm injection (ART group). RESULTS: After adjustment for potential confounding factors, breech presentation occurred approximately 20% more often in singleton pregnancies conceived via both ART (adjusted odds ratio: 1.20, 95% confidence interval: 1.10-1.30, P < 0.001) and OI (1.21, 95% confidence interval: 1.04-1.39, P < 0.05). No significant associations were observed between the three modes of conception and transverse/shoulder or face/brow presentations. Low birthweight was found to be the most significant mediating factor for breech presentation in pregnancies conceived via ART and OI. CONCLUSIONS: Similar levels of increased odds of breech presentation are present in pregnancies conceived via OI and ART, suggesting a shared underlying mechanism for the aetiology of breech presentation. For women who are considering or have conceived via these methods, counselling with respect to this increased risk is recommended.

Fetal size at the 32nd gestational week is associated with the risk of breech presentation at term birth.

OBJECTIVES: The association patterns between breech presentation at birth and fetal biometry at the first, second, and third trimesters, newborn size but also maternal age, body height, prepregnancy weight status as well as gestational weight gain, were analyzed using a dataset of 4501 singleton term birth in Vienna, Austria. METHODS: In this medical record-based study, fetal biometry was reconstructed based on the results of three ultrasound examinations conducted at the 11th/12th, 20th, and 32nd gestational weeks. Head dimensions, abdominal dimensions, and femur length were determined by sonography. Birth weight, birth length, and head circumference were measured immediately after birth. RESULTS: The total breech presentation rate at birth was 6.2%. Breech newborns were significantly (p < 0.001) shorter and lighter at the time of birth, their head circumferences, however, were significantly larger (p = 0.001). At the 32nd week, breech fetuses showed significantly smaller biparietal breadths, but highly significantly longer heads. Their abdominal dimensions were significantly smaller, and their femora were shorter. Higher maternal age, and a longer, but narrower fetal head as well as smaller abdominal dimensions at the 32nd gestational week were independently related to a higher risk of breech presentation at the time of birth. CONCLUSIONS: Fetuses who remain in a breech presentation until term birth (≥37 gestational weeks) differed significantly in head and abdominal dimensions from cephalic fetuses from the 32nd gestational week onwards.

Cesarean versus vaginal delivery for breech presentation is an independent risk factor for long-term pediatric respiratory hospitalization of the offspring.

OBJECTIVES: To compare the long-term respiratory morbidity of offspring born by cesarean delivery for breech presentation with that of those delivered vaginally. METHODS: A population-based cohort analysis including all singleton breech deliveries between the years 1991 and 2014, comparing long-term respiratory morbidity of offspring born in breech presentation, according to mode of delivery. Offspring with congenital malformations, perinatal deaths, and instrumental deliveries were excluded. Respiratory morbidity included hospitalizations (up to age 18 years), as recorded in hospital records. A Kaplan-Meier survival curve compared cumulative respiratory morbidity. A Weibull parametric survival model controlled for confounders and repeat deliveries. RESULTS: A total of 7337 breech deliveries were included; 6376 (86.9%) cesarean deliveries and 961 (13.1%) vaginal breech deliveries. The Kaplan-Meier survival curve demonstrated higher cumulative incidence of respiratory morbidity in the cesarean delivery group compared with vaginal delivery (log rank test P = 0.006). Using a Weibull parametric survival model to control for confounders, cesarean delivery was found to be an independent risk factor for long-term respiratory morbidity of the offspring (adjusted hazard ratio 1.87, 95% confidence interval 1.32-2.65, P < 0.001). CONCLUSIONS: Cesarean versus vaginal delivery for breech presentation is an independent risk factor for long-term pediatric respiratory morbidity of the offspring.

Depression, anxiety and stress in women with breech pregnancy compared to women with cephalic presentation-a cross-sectional study.

PURPOSE: This study aims to evaluate the level of psychological distress for women with breech compared to cephalic presentation. We hypothesized, that women with breech presentation have higher levels of depression, stress and anxiety. Secondary objectives were to analyze potential demographic risk factors and comorbidity of psychological distress in breech pregnancy. METHODS: The breech study group was formed by 379 women with breech presentation. A sample of 128 women with cephalic presentation was recruited during routine clinical care. Depression, anxiety and stress symptoms were ascertained by means of the Depression-Anxiety-Stress-Score (DASS)-21 questionnaire. Categorial data was analyzed with Chi-square or exact test, continuous data with unpaired t test or Mann-Whitney U test. Demographic risk factors were identified using a binary logistic regression model. RESULTS: Prevalence of psychological distress among women with breech was not higher compared to those of other pregnant women. Symptomatic depression, anxiety and stress affected 5.8%, 14.5% and 11.9% of women with breech, respectively. Decreasing age was identified as a risk factor for anxiety (p = 0.006). Multiparity increased risk for depression (p = 0.001), for anxiety (p = 0.026) and for perinatal stress (p = 0.010). More than 80% of women with depressive symptoms had comorbidities of psychological distress. CONCLUSIONS: Breech presentation compared to cephalic presentation was not associated with higher levels of psychological distress. However, breech pregnancies are affected by symptoms of potential mental disorder. Multiparous women and younger women may need additional support and would benefit from a standardized screening tool for the assessment of perinatal psychological distress. CLINICAL TRIAL REGISTRATION: Ethical approval (EA2/241/18) was granted by the Ethics Commission of the Charité University Hospital on the 23.01.2019 (ClinicalTrials.gov Identifier: NCT03827226).

Factors influencing the effect of external cephalic version: a retrospective nationwide cohort analysis.

OBJECTIVE: This study aims to assess the factors associated with the success and failure rate of the external cephalic version (ECV) in breech fetuses. Secondary outcomes were fetal presentation in labor and mode of delivery. METHODS: This cross-sectional study examined the live birth certificates from 2003 through 2020 from US states and territories that implemented the 2003 revision. A total of 149,671 singleton pregnancies with information about ECV success or failure were included. The outcome was ECV success/failure, while the exposures were possible factors associated with the outcome. RESULTS: The successful ECV procedures were 96,137 (64.23%). Among the successful ECV procedures, the prevalence of spontaneous vaginal delivery was 71.63%. Among the failed ECV procedures, 24.74% had a cephalic presentation at delivery, but 63.11% of these pregnancies were delivered by cesarean section. Nulliparity, female sex, low fetal weight centile, high pre-pregnancy BMI, high BMI at delivery, and high maternal weight gain during pregnancy were associated with an increased ECV failure (p < 0.001). African American, American Indian and Alaska Native race categories were significant protective factors against ECV failure (p < 0.001). Maternal age had a U-shape risk profile, whereas younger maternal age (< 25 years) and old maternal age (> 40 years) were significant protective factors against ECV failure (p < 0.001). CONCLUSIONS: A high prevalence of successful ECV procedures and subsequent spontaneous vaginal delivery were found. The present results found nulliparity, maternal race, maternal age, female fetal sex, low fetal weight, and maternal anthropometric features correlated to ECV results. These findings can potentially improve the knowledge about the factors involved in ECV, allowing more informed counseling to the women undergoing this procedure.

Birth injury in breech delivery: a nationwide population-based cohort study in Finland.

PURPOSE: Previous studies have examined the optimal mode of breech delivery extensively, but there is a scarcity of publications focusing on the birth injuries of neonates born in breech presentation. This study aimed to examine birth injury in breech deliveries. METHODS: In this retrospective register-based nationwide cohort study, data on birth injuries in vaginal breech deliveries with singleton live births were compared to cesarean section with breech presentation and cephalic vaginal delivery between 2004 and 2017 in Finland. The data were retrieved from the National Medical Birth Register. Primary outcome variables were severe and mild birth injury. Incidences of birth injuries in different gestational ages and birthweights were calculated in different modes of delivery. Crude odds ratios of risk factors for severe birth injury were analyzed. RESULTS: In vaginal breech delivery (n = 4344), there were 0.8% of neonates with severe birth injury and 1.5% of neonates with mild birth injury compared to 0.06% and 0.2% in breech cesarean section (n = 16,979) and 0.3% and 1.9% in cephalic vaginal delivery (n = 629,182). Brachial plexus palsy was the most common type of injury in vaginal breech delivery. Increasing gestational age and birthweight had a stronger effect on the risk for injury among cephalic vaginal deliveries than among vaginal breech deliveries. CONCLUSION: Birth injuries were rare in vaginal breech deliveries. The incidence of severe birth injury was two times higher in vaginal breech delivery compared to cephalic vaginal delivery. Brachial plexus palsy was the most common type of injury in vaginal breech delivery.

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.

Impact of full vs empty urinary bladder on external cephalic version success: a randomized controlled trial.

BACKGROUND: External cephalic version is a procedure used to turn a fetus from a breech position to a cephalic position before delivery. The success rate of the external cephalic version can be affected by various factors; however, the effect of bladder volume on the success rate of the external cephalic version remains controversial. OBJECTIVE: This study aimed to determine the effect of urinary bladder status (full or empty) on the success rate of the external cephalic version through a prospective randomized study. STUDY DESIGN: This was a prospective randomized controlled trial conducted at a tertiary care obstetrical center. Overall, 70 women with a singleton breech presentation at term undergoing external cephalic version were randomly allocated into 2 groups: external cephalic version with an empty bladder and external cephalic version with a full bladder. The external cephalic version procedure was performed by experienced obstetricians under ultrasound guidance. The primary outcome was the success rate of the external cephalic version. RESULTS: The success rate of the external cephalic version was 67.56% (25/37) in the full bladder group and 54.54% (18/33) in the empty bladder group, with no statistically significant difference between the groups (P=.26). In addition, the relative risk of successful external cephalic version was 1.23 (95% confidence interval, 0.84-1.81), indicating no significant difference. CONCLUSION: This randomized controlled trial demonstrated that the presence of a full or empty urinary bladder does not significantly affect the success rate of the external cephalic version in women with singleton breech presentation at term. Our findings suggest that women undergoing an external cephalic version do not need to have a full bladder to improve the success rate of the procedure.

Short-term neonatal outcomes in vaginal breech delivery: Results of a retrospective single-centre study.

BACKGROUND: Vaginal breech delivery (VBD) has been widely discouraged over the last two decades due to associated neonatal risks. However, many gynaecologists are still challenging this approach, at least in selected settings. OBJECTIVE: To study short-term neonatal outcomes in singleton pregnancies undergoing VBD. MATERIALS AND METHODS: Retrospective cohort study conducted on singleton pregnancies who delivered in breech presentation between 2012 and 2019. Neonatal complications in terms of mortality, umbilical artery (UA) pH, 5-min Apgar score, and postnatal admission to neonatal intensive care unit (NICU) were evaluated. RESULTS: Overall, 804 breech deliveries were considered. Of these, 53.86 % had VBD, 26.62 % had emergency caesarean sections (CS) and 19.53 % had elective CS. No perinatal deaths were reported. After multivariate adjustment, VBD was associated with higher incidence of UA pH < 7.10 compared with both elective and emergency CS. No significant associations were found between VBD and UA pH < 7.00 or 5-min Apgar score < 3 or < 7. No significant differences in NICU hospitalization were observed for different modes of delivery. Gestational age was inversely correlated with UA pH < 7.00, 5-min Apgar score < 3 and < 7, and NICU hospitalization. CONCLUSIONS: VBD in an experienced setting does not increase the risk of negative short-term perinatal outcomes significantly. Gestational age was the most important risk factor for low UA pH or 5-min Apgar score and NICU hospitalization, independent of mode of delivery.

Cervical maturation in breech presentation: Mechanical versus prostaglandin methods.

OBJECTIVE: Breech presentation at term accounts for around 5% of births. Few studies have evaluated the effectiveness of different induction methods for breech presentations. We aim to compare the mode of delivery after induction by intra cervical dilatation balloon compared to prostaglandin (PGE2) in breech presentation. We also evaluated the risk factors associated with a failure of induction. METHODS: Single-center retrospective study from January 2000 to December 2020 including all women induced from 36 weeks, breech presentation, with a single pregnancy without contraindication to vaginal delivery and with an unfavorable cervix (Bishop<6). The primary endpoint was the mode of delivery. Failure of induction was defined as the need of a cesarean section. RESULTS: One hundred seventy six patients were included, 96 in the balloon group and 80 in the prostaglandin group. The cesarean section rate in the balloon group was not significantly different from the prostaglandin group (34.4% vs. 26.3%, p= 0.24). Fifty percent of the patients in the balloon group required additional maturation with prostaglandins after the balloon was dropped or removed. In our overall population, the factors associated with induction failure were nulliparity (OR= 3.144; CI95%: (1.496-6.661)) and BMI > 30 kg/m2 (OR= 3.15 CI95%: (1,374 - 7,224)). CONCLUSION: Mode of delivery after mechanical methods in breech delivery induction appears similar to prostaglandins. However, it should be noted that in half of the cases, additional maturation with prostaglandin was necessary, calling into question the value of the mechanical methods. Factors associated with cesarean were maternal characteristics (nulliparity and BMI > 30 kg/m2) but not induction method.

Is it reasonable to propose vaginal delivery with twin pregnancies, when the first twin is in breech presentation?

BACKGROUND: Breech presentation of the first twin occurs in 20% of twin pregnancies. However, the impact of delivery mode on morbimortality in breech fetuses remains controversial in the literature generally, and has been infrequently studied in twin pregnancies specifically. The aim herein was to evaluate neonatal and maternal outcomes according to delivery mode when the first twin was in breech presentation, and to compare these results with those in the current literature. MATERIAL AND METHODS: This was a single-center, retrospective study in Lille, France, from January 2010 to December 2017, including twin pregnancies in which the first twin was in breech presentation and delivery was after 32 weeks of amenorrhea. Two groups were defined: planned vaginal delivery (PVD) and planned cesarean delivery (PCD). The primary outcome was neonatal morbidities, defined as a 5-minute Apgar score < 7, cord pH < 7.10 at birth, sepsis, and acute respiratory distress syndrome. RESULTS: Among the 184 patients included, 116 attempted a vaginal delivery (63%). Morbidity did not differ between PVD and PCD for the first twin (12/116 (10.3%) versus 7/68 (10.3%), respectively, p = 0.99), the second twin (18/116 (15.5%) versus 7/68 (10.3%), respectively, p = 0.31), or either twin (27/116 (23.2%) versus 11/68 (16.2%), respectively, p = 0.25). The rate of postpartum hemorrhage was significantly lower in the PVD group (PVD 36/116 (31%) versus PCD 41/68 (58.8%), p = 0.001). CONCLUSION: PVD is a reasonable option when the first twin is in breech presentation with probably no higher neonatal mortality and morbidity and less risk of maternal severe postpartum hemorrhage.

Delivery mode and severe maternal and neonatal morbidity among singleton term breech births: A population-based cohort study.

OBJECTIVE: The aim of this study was to examine the association between delivery mode and severe maternal and neonatal morbidity in singleton term breech births. STUDY DESIGN: This nationwide population-based cohort study includes 41 319 singleton term and post-term breech births (37 + 0-42 + 6 gestational weeks) in Sweden from 1998 to 2016. Data was retrieved from the Swedish Medical Birth Register. The primary outcomes were two separate composite outcomes, maternal and neonatal severe morbidity. Secondary outcomes were separate severe maternal and neonatal morbidity outcomes. Hospitalization and out-patient visits during childhood were also analyzed in ages 0-5 years. Logistic regression was used to estimate unadjusted and adjusted odds ratios (aOR) with 95% confidence intervals (CI) of severe maternal and neonatal morbidity in women with vaginal breech birth or intrapartum cesarean section. Women with a prelabor breech cesarean section was used as the reference group. RESULTS: No difference between vaginal delivery and prelabor cesarean section was seen regarding maternal morbidity. Intrapartum cesarean section was associated with elevated odds for maternal morbidity (aOR 1.27, 95% CI 1.10-1.47) compared with prelabor cesarean section. A similar result was observed for vaginal delivery and intrapartum cesarean section combined (aOR 1.29, 95% CI 1.11-1.50). Vaginal delivery was associated with higher odds for composite neonatal morbidity (aOR 1.85, CI 1.54-2.21) and most separate outcomes, as well as increased number of hospital nights and out-patient visits during first year of life, compared with prelabor cesarean section. CONCLUSIONS: Prelabor cesarean section in breech births improved short-term neonatal health without increasing risks for severe maternal short-term complications.

Neonatal outcome in vaginal breech labor at 32 + 0-36 + 0 weeks of gestation: a nationwide, population-based record linkage study.

BACKGROUND: In many countries, vaginal breech labor at term is an option in selected cases. However, the safety of vaginal breech labor in preterm is still unclear. Therefore our study aimed to evaluate the safety of vaginal breech labor in late preterm deliveries. DESIGN: A retrospective register-based study. SETTING: Maternity hospitals in Finland, 2004-2017. PARTICIPANTS: The study population included 762 preterm breech deliveries at 32 + 0-36 + 6 gestational weeks according to the mode of delivery, 535 (70.2%) of them were born vaginally in breech presentation, and 227 (29.8%) were delivered by non-urgent cesarean section. METHODS: The study compared short-term neonatal adverse outcomes of singleton vaginal breech deliveries with non-urgent cesarean deliveries at 32 + 0 to 36 + 6 weeks of gestation. An odd ratio with 95% confidence intervals was calculated to estimate the relative risk of adverse outcomes. OUTCOME MEASURES: Neonatal death, an arterial umbilical pH below seven, a five-minute Apgar score below four and seven, admission to neonatal intensive care unit, neonatal intubation, neonatal antibiotic therapy, neonatal birth trauma, respiratory distress syndrome, neonatal convulsions, cerebral ischemia, hypoxic-ischemic encephalopathy, congenital hypotonia, and a composite of severe adverse outcomes. RESULTS: A five-minute Apgar scores below seven were increased in vaginal breech labor at 32 + 0 to 36 + 6 weeks of gestation compared to non-urgent cesarean sections (aOR 2.48, 95% CI 1.08-5.59). Neonatal antibiotic therapy, the admission to neonatal intensive care unit, and neonatal respiratory distress syndrome were decreased after vaginal breech labor compared to the outcomes of non-urgent cesarean section (neonatal antibiotic therapy aOR 0.60, 95% CI 0.40-0.89; neonatal NICU admission aOR 0.47, 95% CI 0.33-0.68; respiratory distress syndrome aOR 0.30, 95% CI 0.19-0.48). CONCLUSION: Vaginal breech labor at 32 + 0-36 + 6 gestational weeks does not increase severe neonatal short-term morbidity or mortality compared to cesarean section.

Spontaneous cephalic version and risk factors for persistent breech presentation: a longitudinal retrospective cohort study.

AIMS: To address the rate of spontaneous version in breech presentation until term and explore the risk factors for persistent breech presentation diagnosed by the second-trimester ultrasound examination. METHODS: This is a retrospective cohort study of pregnant women with a singleton pregnancy who had their ultrasound examination conducted at the time of 22-26 weeks of gestation in the Guangzhou Women and Children's Medical Center. Cox regressions were applied to determine the strength of association between selected risk factors and persistent breech presentation. RESULTS: Among 25,313 pregnant women eligible for analysis, the prevalence of breech presentation was 36.8% (9,306/25,313) at 22-26 weeks of gestation, 4.2% (376/8,876) of which would remain in the breech presentation at the onset of labor (adjusted odds ratio [aOR], 0.39, 95% confidence interval [CI], 0.17-0.88). Multiparity (aOR, 0.39, 95% CI, 0.30-0.52) and longer gestational weeks at delivery (aOR, 0.50, 95% CI, 0.44-0.56) were associated with a lower risk of persistent breech presentation (PBP). Female fetus, lateral or fundal placenta, and known uterine malformation was each associated with an increased odd of 1.4 (aOR, 95% CI, 1.11-1.70), 2.4 (aOR, 95% CI,1.50-3.73), 3.1 (aOR, 95% CI, 1.71-5.53) and 8.7 (aOR, 95% CI, 3.84-19.84) times in the persistent breech presentation, respectively. CONCLUSION: The prevalence of the breech presentation was 36.8% between 22 and 26 weeks of gestation, and approximately 4% would have been in the persistent breech presentation until the onset of labor. Higher educational attainment, multiparity and longer gestational weeks at delivery were significantly decreasing the risk of persistent breech presentation. While the pregnant women with age >40 years, female fetus, lateral or fundal placenta and known uterine malformation were associated increased risk of persistent breech presentation.

Association between hospitals' cesarean delivery rates for breech presentation and their success rates for external cephalic version.

INTRODUCTION: Success rates of external cephalic version (ECV) are heterogenous in the published literature. Some individual factors are already known to be associated with ECV success but probably do not fully explain the differences. The objective of this review is to assess the association between hospitals' cesarean delivery rates for breech presentations after ECV failure and their ECV success rates. MATERIAL AND METHODS: We performed a review of the literature using the Medline and Cochrane Library computer databases and by searching on clinicaltrials.gov, from 1985 through 2020. This analysis included all studies reporting ECV success rates and cesarean delivery rates for breech presentations. The prognostic factors for successful ECV, such as rates of nulliparity, gestational age at ECV, BMI, and tocolysis use, were also collected and analyzed. Median ECV success rates from the included studies were compared according to these factors. The cesarean rate for persistent breech presentation after ECV failure reported in these studies was considered a proxy indicator of the unit's policy for breech presentations. The correlation between ECV success rates and cesarean delivery rates was analyzed and is presented as a scatter plot. RESULTS: This analysis included 22 studies reporting rates of both successful ECV and cesarean deliveries for persistent breech presentation after ECV failure. The ECV success rates ranged from 16.3% to 82.5% with a median of 48.8% (interquartile range: 36.9-62.9). The median ECV success rate was higher in the studies that used tocolysis than in those that did not (51.3% versus 22.0%, P = .001) and in the studies with the highest cesarean rates for breech presentations than in those with the lowest cesarean rates (57.9% versus 36.2%, P = .006). The ECV success rates were significantly correlated with cesarean delivery rates for persistent breech presentations (R = 0.67; P = .001). CONCLUSION: The likelihood of successful ECV appears higher in hospitals with policies that generally result in cesarean delivery for persistent breech presentation.

What is the relationship between the breech presentation and femoral trochlear dysplasia? An experimental study of the breech presentation model in neonatal rats.

BACKGROUND: The relationship between breech presentation and trochlear dysplasia has been confirmed. However, the pathological process of breech-related trochlear dysplasia remains unclear. This study aimed to establish an animal model to simulate breech presentation and to analyze the pathological process of the femoral trochlea. MATERIALS AND METHODS: One hundred and twenty neonatal rats were randomly assigned into a control group and two experimental groups that were swaddled (using surgical tape) to keep the hip flexed and knees extended to simulate human breech presentation for the 5 days (short Swaddling) and the 10 days (prolonged Swaddling) of life. Gross and cross-sectional observation, histological staining measurement in two experimental time points (5 and 10 days after birth) were conducted to evaluate the morphological changes of the femoral trochlea. RESULTS: The incidence of trochlear dysplasia increased with the Swaddling time. Rats in the prolonged Swaddling group had the high prevalence of trochlea dysplasia (52 of 60), followed by short Swaddling group (42 of 60). Gross and cross-sectional observation showed a shallower trochlea groove in two experimental groups. Histologicalstaining measurement indicated that the trochlear sulcus angle and trochlear sulcus depth were significantly different between the experimental group and the control group since day 5 and day 10. CONCLUSION: In this model, breech presentation had an adverse effect on neonatal knees and could induce trochlear dysplasia. In addition, this study also showed that the more time in breech presentation, the more incidence of trochlear dysplasia.