UCSF's experience with vaginal breech delivery: data from 1980 to 1991

SAN FRANCISCO -- Selected term singletons in breech position can be safely delivered vaginally at appropriate facilities, according to Dr. Linda M. Hopkins.

Her assertion contrasts with a American College of Obstetricians and Gynecologists' committee opinion that identified cesarean section as the preferred method of breech delivery on the basis of the results of the Term Breech Trial. That study, published in 2000, found higher rates of perinatal and neonatal morbidity and mortality in the planned vaginal delivery group.

Controversy over the results have centered on their applicability to all women. Of the 13 deaths in the vaginal delivery group, for example, 8 were in infants who shouldn't have been enrolled in the trial, didn't get adequate monitoring, or died of causes unrelated to the mode of delivery, Dr. Hopkins said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Separate data from UCSF which has used a consistent approach to managing breech deliveries for many years, suggest that appropriate criteria for selecting patients for vaginal breech delivery plus adequate monitoring make this a viable option in many cases, said Dr. Hopkins of the university.

A retrospective review found no neonatal or maternal deaths among 214 planned vaginal deliveries and 511 elective C-section deliveries at the university between 1980 and 1991. Of the planned vaginal deliveries, 65% occurred and the rest were diverted to C-section, but all were included in the vaginal delivery group in the analysis.

Infants in the planned vaginal delivery group were slightly more likely to be admitted to the neonatal intensive care unit. They were more likely to have an umbilical artery base excess below--15 mEq/L and were more likely to spend at least a day on ventilation.

Other neonatal differences between groups were statistically but not clinically significant, including a lower mean umbilical artery pH, lower mean umbilical artery base excess, and greater likelihood of having an umbilical artery pH below 7 in the planned vaginal delivery group.

The groups did not significantly differ in their rates of respiratory distress syndrome, cephalohematoma, fracture, brachial plexus injury, seizure, facial nerve injury, or 5-minute Apgar scores less than 5.

The planned C-section group had a higher rate of overall maternal morbidity due to higher rates of wound infections and endometritis, compared with the vaginal delivery group. The data don't reflect any potential effects of C-section on future pregnancies or surgeries. "The bigger issue is going to become, What's the long-term morbidity of these women who are undergoing C-section?" she said.

UCSF policy is to offer two attempts at external cephalic version to women with singletons in breech presentation with an estimated fetal weight of 3,850 g or less on ultrasound, excluding women with major fetal anomalies, intrauterine fetal demise, or preexisting maternal morbidity.

For a woman to qualify for vaginal delivery if external version fails, her CT pelvimetry should measure an intraspinous distance of at least 11 cm. Look for an anterior-to-posterior measurement of the pelvic inlet of at least 11 cm and a transverse distance of at least 12 cm, or vice versa. An absence of fetal hyperextension of the vertex should be confirmed again at the time of labor. Continuous fetal heart rate monitoring and epidural anesthesia are strongly encouraged during delivery, she said.

"Appropriate resources [such as continuous fetal heart rate monitoring] are needed if you're going to offer vaginal breech delivery," Dr. Hopkins said.

BY SHERRY BOSCHERT San Francisco Bureau

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