Heart rate markers for prediction of fetal acidosis in an experimental study on fetal sheep.

To overcome the difficulties in interpreting fetal heart rate (FHR), several tools based on the autonomic nervous system and heart rate variability (HRV) have been developed. The objective of this study was to use FHR and HRV parameters for the prediction of fetal hypoxia. It was an experimental study in the instrumented fetal sheep. Repeated umbilical cord occlusions were performed to achieve severe acidosis. Hemodynamic parameters, ECG, and blood gases were analyzed. The variables used were heart rate baseline, HRV analysis (RMSSD, SDNN, LF, HF, HFnu, Fetal Stress Index (FSI), …), and morphological analysis of decelerations. The gold standard used to classify hypoxia was the fetal arterial pH (pH < 7.10). Different multivariable statistical methods (logistic regression and decision trees) were applied for the detection of acidosis. 21 lambs were instrumented. A total of 130 pairs of FHR/fetal pH analysis were obtained of which 29 in the acidosis group and 101 in the non-acidosis group. After logistic regression model with bootstrap resampling and stepwise backward selection, only one variable was selected, FSI. The AUC of FSI alone in this model was 0.81 with a sensitivity of 0.66, specificity of 0.88, PPV of 0.61, and NPV of 0.90 considering a threshold of 68. Decision trees with CHAID and CART algorithms showed a sensitivity of 0.48 and 0.59, respectively, and a specificity of 0.94 for both. All employed methods identified HRV variables as the most predictive of acidosis. The primary variables selected automatically were those from the HRV. Supporting the use of FHRV measures for the screening of fetal acidosis during labour is interesting.

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.

Evaluation and impact of fetal physiology training on fetal heart rate analysis.

INTRODUCTION: Evaluation of fetal well-being during labor is based on fetal heart rate (FHR) analysis, which requires physiology expertise. The aim of the present study was to assess medical residents' fetal physiology training in terms of theoretical knowledge, FHR interpretation, and use of second-line examinations. METHODS: This single-center, prospective study of obstetrics and gynecology residents (N = 34) at CHU de Lille Hospital (Lille, France) was conducted from November 2017 to November 2018. Evaluation and training were conducted in three stages. First, residents' pre-training knowledge of FHR interpretation and use of fetal scalp blood sampling (FBS) was assessed using clinical cases. Second, a didactic training session on fetal physiology was delivered. Finally, post-training knowledge was evaluated using the same cases presented during pre-training. I: Pre-training, 3%, 11.8%, and 14.7% of residents considered their training on fetal physiology, FHR analysis, and second-line examinations, respectively, to be sufficient. Training significantly improved their theoretical knowledge, which was assessed using multiple-choice questions (median [interquartile range]: 1.5 [1.0-2.0] vs. 4.0 [3.0-4.5], p<0.001), and reduced the number of FBS requested (36.3% vs. 29.5%, p = 0.002). Krippendorff's alpha coefficient for the reproducibility of residents' responses improved significantly, reflecting greater homogenization of clinical practice decisions (alpha [95% confidence interval]: 0.60 [0.55-0.65] vs. 0.72 [0.67-0.76]). CONCLUSION: Improved fetal physiology knowledge promotes more accurate FHR interpretation, better indications for second-line examinations, and greater homogenization of clinical practice decisions. Future studies should evaluate the impact of fetal physiology training on clinical practice.

Fetal heart rate variability analysis for neonatal acidosis prediction.

Fetal well-being during labor is usually assessed by visual analysis of a fetal heart rate (FHR) tracing. Our primary objective was to evaluate the ability of automated heart rate variability (HRV) analysis methods, including our new fetal stress index (FSI), to predict neonatal acidosis. 552 intrapartum recordings were analyzed. The analysis occurred in the last 90 min before birth and was conducted during two 5-min intervals: (i) a stable period of FHR and (ii) the period corresponding to the maximum FSI value. For each period, we computed the mean FHR, FSI, short-term variability (STV), and long-term variability (LTV). Visual FHR interpretation was performed using the FIGO classification. The population was separated into two groups: (i) an acidotic group with an arterial pH at birth ≤ 7.10 and a control group. Prediction of a neonatal pH ≤ 7.10 was assessed by computing the receiver-operating characteristic area under the curve (AUC). FHR, FSI, STV, and LTV did not differ significantly between groups during the stable period. During the FSI max peak period, LTV and STV correlated significantly in the acidotic group (- 5.85 ± 2.19, p = 0.010 and - 0.62 ± 0.29, p = 0.037, respectively). The AUC values were 0.569 for FIGO classification, 0.595 for STV, and 0.622 for LTV. The multivariate model (FIGO, FSI, FC, STV, LTV) had the greatest accuracy for predicting acidosis (AUC = 0.719). FSI was not predictive of neonatal acidosis probably because of the low quality of the FHR signal in cardiotocography. When used separately, HRV indexes and visual FHR analysis were poor predictors of neonatal acidosis. Including all indexes in a multivariate model increased the predictive ability.

[Comparison of antepartum management of breech versus cephalic presentation]. / Comparaison de la prise en charge per-partum des présentations podaliques par rapport aux présentations céphaliques.

OBJECTIVES: Delivery mode of term breech presentation is still being discussed. The aim of this study was to compare the labor management of a breech presentation to a vertex presentation during a vaginal delivery attempt. METHODS: It was a single-center, comparative, descriptive retrospective study from 2014 to 2017. We studied fetal heart rate (FHR) during labor and expulsion, duration of the different stage of labor, mode of delivery and neonatal outcomes for breech and vertex presentations. RESULTS: Two hundred and thirty-nine patients were included whom 106 (44%) breech presentation. The use of oxytocin was more common in breech group (63,2% versus 48,1%, P=0.020). Average dilatation rate was slower for breech presentation than for vertex presentation (1.9cm/h vs. 2.8cm/h; P=0.005). There was more FHR with high risk of acidosis in the breech presentations (37.2% vs 19.1%, P=0.001) and Melchior's FHR classification were comparable in both groups. CONCLUSIONS: The per-partum management of a fetus in breech presentation differs from a fetus in cephalic presentation. It must be known and anticipated for an optimal management in the delivery room.

Comparison of multiple cardiac signal acquisition technologies for heart rate variability analysis.

Heart rate variability analysis is a recognized non-invasive tool that is used to assess autonomic nervous system regulation in various clinical settings and medical conditions. A wide variety of HRV analysis methods have been proposed, but they all require a certain number of cardiac beats intervals. There are many ways to record cardiac activity: electrocardiography, phonocardiography, plethysmocardiography, seismocardiography. However, the feasibility of performing HRV analysis with these technologies and particularly their ability to detect autonomic nervous system changes still has to be studied. In this study, we developed a technology allowing the simultaneous monitoring of electrocardiography, phonocardiography, seismocardiography, photoplethysmocardiography and piezoplethysmocardiography and investigated whether these sensors could be used for HRV analysis. We therefore tested the evolution of several HRV parameters computed from several sensors before, during and after a postural change. The main findings of our study is that even if most sensors were suitable for mean HR computation, some of them demonstrated limited agreement for several HRV analyses methods. We also demonstrated that piezoplethysmocardiography showed better agreement with ECG than other sensors for most HRV indexes.

Is homecare management associated with longer latency in preterm premature rupture of membranes?

PURPOSE: According to national guidelines, conventional management of preterm premature rupture of membranes (PPROM) is hospitalization until induction. Outpatient management could be another option. Our objective was to compare latency period between patients managed in hospital versus outpatients. METHODS: A retrospective before/after monocentric study that occured from 2002 to 2015. Were included all patients with PPROM prior to 35 weeks with homecare inclusion criteria. The primary outcome measure was to study length of latency period (delay between PPROM and delivery). Second outcome measures were maternal and perinatal morbidities and mortalities. RESULTS: Among the 395 women included after PPROM, 191 were managed as outpatients and 204 in hospital. In the outpatient group, the length of latency period was longer than in the inpatient group [39 (IQR 20 to 66) versus 21 (IQR 13 to 42) days; p < 0.001]. Clinical chorioamnionitis was observed in 30 (15.7%) in outpatient group versus 49 (24.0%) in inpatient group (p = 0.039). Concerning neonatal outcome, there were less neonatal transfer (49.2% versus 77.2%, p < 0.001), less respiratory distress syndrome (29.4% versus 47.5%; p < 0.001), less neonatal sepsis (13.9% versus 22.1%; p = 0.037), less bronchodysplasia (2.7% versus 9.8%; p = 0.004), and less pulmonary arterial hypertension (4.8% versus 10.3%; p = 0.040) in the outpatient group than in the inpatient group. CONCLUSION: Home management seems to be a safe option to hospitalization in selected patients with PPROM. However, a randomized study would be required to approve those results.

[Per-partum risk factors of neonatal acidemia in planned vaginal delivery for fetuses in breech presentation]. / Facteurs de risque per-partum d'acidose néonatale en cas de tentative d'accouchement voie basse chez les fœtus en présentation podalique.

OBJECTIVES: Delivery mode of term breech presentation is debated because of higher rate of neonatal acidosis (pH<7.15) in planned vaginal delivery than in planned caesarean section. The objective was to evaluate per-partum risk factors of neonatal acidosis in vaginal delivery for podalic fetuses. METHODS: It was a single-centre, case-control retrospective study that included planned vaginal delivery in singleton term breech presentation between 2012 and 2016. The "case" group defined by neonatal pH≤7.10 and the "control" group defined by neonatal pH≥7.20 were matched. The maternal, labor, and neonatal characteristics were noted. RESULTS: One hundred and thirty-two patients were included: each of 44 patients in "case" group, has been matched according to breech type (legs position) to 2 patients in the "control" group, so 88. In multivariate analysis, significant risk factors identified were oxytocin use [ORa=5.663 (95% CI=1.844-17.397)], "high risk" fetal heart rate (FHR) abnormalities according to FIGO classification [ORa=10.997 (95% CI=1.864-64.866)] and FHR abnormalities during expulsion, Melchior 2 [ORa=8.088 (95% CI=1.192-54.875)] and Melchior 4 [ORa=12.705 (95% CI=1.157-139.541)]. CONCLUSIONS: These risk factors of neonatal acidemia have to be known to improve the labor management in case of breech planned vaginal delivery.

Prenatal diagnosis of esophageal atresia: A case of triple negative screening.

Esophageal atresia (EA) is prenatally diagnosed in less than one third of the cases and is usually only suspected. Recently, magnetic resonance imaging (MRI) with dynamic sequence and biochemistry of the amniotic fluid have been proposed to enhance prenatal diagnosis of EA. We report the case of a triple negative screening (ultrasound, MRI with dynamic sequence and biochemistry of the amniotic fluid) with a postnatal diagnosis of EA type III with a small defect. Even using second line tests, prenatal diagnosis of EA remains a challenge.

Does an intrauterine exchange transfusion improve the fetal prognosis in parvovirus infection cases?

BACKGROUND: Almost 20% of parvovirus B19 foetal infections require intrauterine transfusions. In addition, myocardial dysfunction has been observed in severe parvovirus B19 infections. One objective of an intrauterine exchange transfusion (IUET) is to avoid an overload during the transfusion. Our aim was to study the obstetrical and neonatal outcomes in cases of IUETs performed for foetal parvovirus infections and to compare our survival rate to those studies in which simple in utero transfusions were chosen. STUDY DESIGN AND METHODS: This was a retrospective monocentre study of all patients followed up for parvovirus B19 infections in which IUETs were performed. An IUET was indicated when foetal hydrops was observed and/or when severe foetal anaemia was diagnosed though an elevation in the middle cerebral artery peak systolic velocity. The characteristics of each pregnancy and the neonatal outcomes were studied until hospital discharge. RESULTS: Thirty-five IUETs were performed in 26 foetuses. The median gestational age of the first IUET was 22.6 weeks. Only one foetal bradycardia incidence was recorded during the procedure. Three medical pregnancy terminations were observed in our series, secondary to severe cerebral anomalies confirmed in the magnetic resonance imaging. Five in utero deaths occurred, in which 2 of the foetuses underwent multiple IUETs. All the neonates had normal haemoglobin levels at birth, and none were transferred to the neonatal intensive care unit. The overall survival rate was 70%. CONCLUSION: IUETs exhibit a survival rate similar to that of simple intrauterine transfusions in foetal parvovirus infection cases.

Fetal heart rate classification in routine use: Do your prefer a 3-tier or a 5-tier classification?

OBJECTIVE: To assess the current use of a five-tier fetal heart rate (FHR) classification system (National College of French Obstetricians and Gynecologists, CNGOF, 2007) and of a three-tier system (Federation International of Gynecology and Obstetrics, FIGO, 2015). MATERIALS AND METHODS: This was a single-center prospective study conducted in April 2016. Midwives were asked to classify FHR hourly during their patients' labors according to two classification systems (CNGOF and FIGO). For each system the midwives rated from 0 to 10 the following elements after delivery: ease of FHR classification, the memorization of the classification, access to routine use, and help with the decision of a second-line examination. Finally, they had to choose which classification system seemed most helpful in their clinical practice. RESULTS: Forty-six patients were included in the study. The median score for the ease of FHR classification according to the CNGOF system was 7, versus 8 according to the FIGO system (p<0.05). The median score for the ease of remembering the classification was 4 for CNGOF versus 8 for FIGO (p<0.05). The FIGO classification system was considered the easiest to use in 76% of cases and the CNGOF system was the most helpful in 61% of cases. The CNGOF system was seen as a help in deciding on a second-line examination in 70% of cases and the FIGO was a help in 63% of cases. CONCLUSION: The three-tier FIGO classification system seemed easier to use but the five-tier CNGOF classification system was more helpful. The choice of which system to use should be discussed within each medical team.

Contribution of fetal brain MRI in management of severe fetal anemia.

INTRODUCTION: Intrauterine transfusion (IUT) has changed fetal anemia prognosis. However, long-term neurodevelopmental outcome is altered in 5% of children. Our objective was to study the contribution of fetal MRI to diagnosis brain lesions in case of fetal anemia. MATERIAL AND METHODS: Retrospective monocentric descriptive study from 2005 to 2016, including all patients followed for fetal anemia requiring IUT. The indications for MRI were: hydrops fetalis and / or hemoglobin <5 g / dL and / or more than 3 IUTs and / or acute severe anemia and / or ultrasound abnormality. Fetal and neonatal outcome and pediatric neurological monitoring were studied. RESULTS: 89 patients were followed for fetal anemia with IUT and 28 (29.1%) had fetal MRI, 12 of which were abnormal. Two out of twelve had abnormal ultrasound. Seven out of twelve had poor neurological prognosis: 2 medical terminations of pregnancy were performed; 2 children had severe developmental delay and 3 children had schooling difficulties. Five out of twelve children had favorable neurological prognosis. CONCLUSION: MRI of the fetal brain makes it possible to better detect brain lesions than ultrasound does in the management of severe fetal anemia and seems particularly appropriate in cases of acute anemia.

Management and outcome of neonates with a prenatal diagnosis of esophageal atresia type A: A population-based study.

OBJECTIVE: Evaluate the neonatal management and outcomes of neonates with prenatal diagnosis of esophageal atresia (EA) type A. METHODS: This population-based study was conducted using data from the French National Register for infants with EA born from 2008 to 2014, including all cases of EA type A. We compared prenatal and neonatal characteristics and outcomes in children with prenatal diagnosis of EA type A with those with a postnatal diagnosis until the age of 1. RESULTS: A total of 1118 live births with EA were recorded among which 88 (7.9%) were EA type A. Prenatal diagnoses were performed in 75 cases (85.2%), and counselling with a prenatal specialist was conducted in 84.8% of the prenatal group. Still within that group, the gestational age at delivery was significantly higher than in the postnatal group (36 [35-38] versus 34 [32-36] weeks; P = .048). Inborn births were more frequent in the prenatal group (86.1% vs 7.7%, P < .0001), and mortality and outcome were similar in both groups. CONCLUSION: Prenatal diagnosis is high in EA type A, which enables to offer an antenatal parental counseling and which avoids postnatal transfers. Prognosis of EA types A does not appear to be influenced by the prenatal diagnosis.

When should foetal pH measurements be performed after a prolonged deceleration? An experimental study in a fetal sheep model.

OBJECTIVE: The aim of fetal heart rate monitoring during labour is to identify and prevent foetal distress, but its evaluation is not perfect. Fetal scalp blood sampling for pH measurement is one of the second-line methods of monitoring when fetal heart rate is classified as suspicious. This study aims to determine when pH testing should be performed after a prolonged deceleration. STUDY DESIGN: This was an experimental study in a fetal sheep model. A partial umbilical cord occlusion was performed for seven minutes followed by a recuperation period of 30 min. Hemodynamic parameters (heart rate, mean blood pressure and intra-amniotic pressure) and blood gases were recorded before occlusion (T0), during occlusion (T4), just after the end of occlusion (T7), and then 10, 20 and 30 min after occlusion (T17, T27 and T37 respectively). RESULTS: Ten experiments were carried out. During partial cord occlusion, the fetal pH decreased significantly to acidosis. After a prolonged deceleration with fetal acidosis, the pH recovered to a normal value, defined by a pH greater than or equal to 7.25, after 20 min of recuperation. CONCLUSION: After a prolonged deceleration, fetal pH normalizes between 20 and 30 min thereafter. Thus, if a foetal blood sample is indicated, this delay must be respected in order to avoid inducing an unnecessary intervention decision.

Exploring fetal response to acidosis in ewes: Choosing an adequate experimental model.

INTRODUCTION: Knowledge of fetal physiology during labor has been largely generated from animal models. Our team recently developed a new index to assess parasympathetic activity using different experimental protocols to obtain acidosis. The objective of the present study was to discuss the different protocols and to review other models proposed in the literature. MATERIAL AND METHODS: Pregnant ewes underwent a surgical procedure at the 123±2 days gestational age (term=145 days). Three experimental protocols were used: protocol A consisted of 25%, 50% and 75% umbilical cord occlusion (UCO) for 20min. Protocol B consisted of partial 75% UCO until reaching a pH<7.10. Protocol C consisted of brief, repetitive complete occlusion until severe acidosis occurred. Hemodynamic and blood gas parameters were compared to those of the stability period before UCO. RESULTS: Protocol A led to a progressive response depending on the degree of occlusion (decrease in fetal heart rate, arterial hypertension and pH). Protocol B led to severe acidosis, although the duration of UCO varied per animal. Protocol C also progressively led to acidosis. We observed high inter individual variability in the acidosis response. CONCLUSION: Pregnant ewes are a relevant model for exploring fetal response to acidosis. The frequency of UCO and partial or complete occlusion should be adapted to the expected effects. Knowledge of these protocols is important to respect ethical guidelines and to reduce the required number of animals. Moreover, it is important to consider the high individual variability of the acidosis response in the interpretation of the results.

Correlation of a new index reflecting the fluctuation of parasympathetic tone and fetal acidosis in an experimental study in a sheep model.

The autonomic nervous system plays a leading role in the control of fetal homeostasis. Fetal heart rate variability (HRV) analysis is a reflection of its activity. We developed a new index (the Fetal Stress Index, FSI) reflecting parasympathetic tone. The objective of this study was to evaluate this index as a predictor of fetal acid-base status. This was an experimental study on chronically instrumented fetal lambs (n = 11, surgery at 128 +/- 2 days gestational age, term = 145 days). The model was based on 75% occlusion of the umbilical cord for a maximum of 120 minutes or until an arterial pH ≤ 7.20 was reached. Hemodynamic, gasometric and FSI parameters were recorded throughout the experimentation. We studied the FSI during the 10 minutes prior to pH samplings and compared values for pH>7.20 and pH≤ 7.20. In order to analyze the FSI evolution during the 10 minutes periods, we analyzed the minimum, maximum and mean values of the FSI (respectively FSImin, FSImax and FSImean) over the periods. 11 experimentations were performed. During occlusion, the heart rate dropped with an increase in blood pressure (respectively 160(155-182) vs 106(101-120) bpm and 42(41-45) vs 58(55-62) mmHg after occlusion). The FSImin was 38.6 (35.2-43.3) in the group pH>7.20 and was higher in the group pH less than 7.20 (46.5 (43.3-52.0), p = 0.012). The correlation of FSImin was significant for arterial pH (coefficient of -0.671; p = 0.004) and for base excess (coefficient of -0.632; p = 0.009). The correlations were not significant for the other parameters. In conclusion, our new index seems well correlated with the fetal acid-base status. Other studies must be carried out in a situation close to the physiology of labor by sequential occlusion of the cord.

A new analysis of heart rate variability in the assessment of fetal parasympathetic activity: An experimental study in a fetal sheep model.

Analysis of heart rate variability (HRV) is a recognized tool in the assessment of autonomic nervous system (ANS) activity. Indeed, both time and spectral analysis techniques enable us to obtain indexes that are related to the way the ANS regulates the heart rate. However, these techniques are limited in terms of the lack of thresholds of the numerical indexes, which is primarily due to high inter-subject variability. We proposed a new fetal HRV analysis method related to the parasympathetic activity of the ANS. The aim of this study was to evaluate the performance of our method compared to commonly used HRV analysis, with regard to i) the ability to detect changes in ANS activity and ii) inter-subject variability. This study was performed in seven sheep fetuses. In order to evaluate the sensitivity and specificity of our index in evaluating parasympathetic activity, we directly administered 2.5 mg intravenous atropine, to inhibit parasympathetic tone, and 5 mg propranolol to block sympathetic activity. Our index, as well as time analysis (root mean square of the successive differences; RMSSD) and spectral analysis (high frequency (HF) and low frequency (LF) spectral components obtained via fast Fourier transform), were measured before and after injection. Inter-subject variability was estimated by the coefficient of variance (%CV). In order to evaluate the ability of HRV parameters to detect fetal parasympathetic decrease, we also estimated the effect size for each HRV parameter before and after injections. As expected, our index, the HF spectral component, and the RMSSD were reduced after the atropine injection. Moreover, our index presented a higher effect size. The %CV was far lower for our index than for RMSSD, HF, and LF. Although LF decreased after propranolol administration, fetal stress index, RMSSD, and HF were not significantly different, confirming the fact that those indexes are specific to the parasympathetic nervous system. In conclusion, our method appeared to be effective in detecting parasympathetic inhibition. Moreover, inter-subject variability was much lower, and effect size higher, with our method compared to other HRV analysis methods.

Effectiveness and safety of induction of labor for term breech presentations.

In term breech deliveries, vaginal delivery can be safely envisioned in some conditions (related to patient selection and obstetrician experience). Very few data are currently available, however, about the possibility of inducing labor in these situations. OBJECTIVE: To assess the effectiveness and safety of induction of labor for breech presentations. STUDY DESIGN: Retrospective comparative hospital-based study of a continuous series of term breech deliveries from 2000 to 2010. The condition of term breech newborns delivered vaginally after induction of labor was compared to that of their counterparts delivered vaginally after spontaneous labor. RESULTS: During the study period, 96 women with term fetuses in breech presentations had labor induced and 501 in spontaneous labor had attempted vaginal deliveries. Compared with spontaneous labor, induction was not associated with a significantly higher rate of cesarean delivery during labor (20.8 vs 14.8%, P=0.14), nor with poorer neonatal condition, defined either as moderate acidosis (pH<7.15; 21.6 vs 19.8%, P=0.71) or composite neonatal morbidity (2.1 vs 0.6%, P=0.16). CONCLUSION: Our data indicate that, compared with spontaneous labor, neither cervical ripening nor oxytocin induction of labor is associated with either a poorer neonatal prognosis or an excess rate of obstetric complications in term breech births, and that the success rate of induction is satisfactory.