Analysis of spontaneous labor progression of breech presentation at term.

BACKGROUND: Cervical dilatation curves are widely used to describe normal and abnormal labor progression for cephalic presentation. Labor curves for breech presentations have never been described. OBJECTIVES: The aims of this study were to examine the pattern of labor progression in women with a breech presentation and to determine whether the type of breech or parity can influence the speed of cervical dilatation. STUDY DESIGN: We analyzed the labor data from 349 women with a term, singleton, and breech fetus after spontaneous onset of labor in 2010-2018. Cesarean deliveries were excluded. The patterns of labor progression were described by examining the relationship between the elapsed times from the full dilatation and cervical dilatation stages. Average labor curves were developed using repeated-measures analysis with 3rd degree polynomial modeling. The results were interpreted according to parity and the type of breech. RESULTS: The first stage of labor progression was divided into a latency phase from 0 to 5 cm of dilatation and an active phase from 5 to 10 cm. In the active phase, the median speed of cervical dilatation was 1.67 cm/h [1.25, 2.61] (2 cm/h for multipara and 1.54 cm/h for nullipara). The difference by parity was significant in the active phase (p< 0.05). The cervical dilatation rate from 3 cm to 10 cm did not significantly differ between the complete and frank breeches (1.56 cm/h vs 1.75 cm/h, p = 0.48). However, the median cervical dilatation rate from 8 cm to complete dilatation was faster for complete breeches (1.92 cm/h versus 1.33 cm/h, p = 0.045). CONCLUSION: As with cephalic presentation, the first stage of labor progression for breech presentation can be divided into a latent and active phase. Labor progression should be interpreted with respect to parity, and women should be informed that the type of breech does not seem to influence the cervical dilatation rate when there is adequate management.

Impact of a selective use of episiotomy combined with Couder's maneuver for the perineal protection.

PURPOSE: To evaluate the impact of a selective use of episiotomy combined with Couder's maneuver on the incidence of perineal tears in spontaneous term deliveries. METHODS: A comparative, retrospective, mono-centric study in a university maternity unit was designed and included all primiparous women who delivered spontaneously after 37 weeks of gestation in cephalic presentation. Two cohorts were studied, before and after the practice of Couder's maneuver. In the first cohort, the ''OSE cohort'' only selective episiotomies were performed from January 2009 to December 2010. In the second cohort, from January 2016 to December 2017, the ''SEC cohort'' selective episiotomies combined with Couder's maneuver were performed by midwives and obstetricians. The primary outcome was the type of perineal tears, according to the Royal College of Obstetricians and Gynaecologists (RCOG) classification. RESULTS: A total of 2081 patients were included: 909 patients in the OSE cohort and 1172 patients in the SEC cohort. Couder's maneuver was performed in 59% of the SEC cohort. In the SEC cohort, there were an increase in the number of intact perinea (55% versus 63%, p < 0.001), a decrease in second-degree perineal tears (18% versus 11%, p < 0.001) and a decrease in labia minora tears (48% versus 37%, p < 0.001). The rate of obstetrical anal sphincter injuries was less than 1% in both cohorts (0.3% versus 0.5%, p = 0.7). CONCLUSION: A selective use of episiotomy combined with Couder's maneuver could reduce the incidence of perineal tears, particularly second-degree perineal tears, without increasing the rate of obstetrical anal sphincter injuries.