Advertisement

Breech presentation induction compared to cephalic presentation: effectiveness and characteristics

Published:January 25, 2023DOI:https://doi.org/10.1016/j.ejogrb.2023.01.030

      Highlights

      • To our knowledge, no recent trial has compared the characteristics of cases involving induction of breech with those of cephalic presentation. Our study included a larger cohort of breech babies than often found in the literature, and it was conducted at a level III maternity hospital, where vaginal delivery of breech babies is governed by well-defined protocols and performed by trained obstetric teams (
        • Michel S.
        • Drain A.
        • Closset E.
        • Deruelle P.
        • Ego A.
        • Subtil D.
        Evaluation of a decision protocol for type of delivery of infants in breech presentation at term.
        ). The single-center nature of our study limits the bias linked to the center effect but reduces the ability to extrapolate our results.
      • The matching of patients beforehand enabled us to avoid possible confusion bias between the two groups studied. The data were collected similarly for both groups, although the retrospective design did not allow us to match parity perfectly because we had to correct parity errors encountered after checking the files. Matching also created some selection bias in the cephalic population because it represented only a portion, but not all, of the cephalic induced births during the data collection period. Although long, the inclusion period, that started in 2014 required us to remain vigilant because the induction and labor protocols were constantly updated at our center.
      • Limitations to this study are inherent to the non-randomized design. The present findings are derived from observational analyses, which are subject to well-known limitations. Since no formal study sample size was calculated, we could not exclude that we lacked adequate statistical power. In a posterior power calculation, we calculated the smallest significant odds ratio that our study allowed us to detect for both primary outcomes with an 80% power and by using the observed outcome rates in cephalic group (considered as control group). For vaginal delivery we could detect an OR of 2.50 (or 0.48 in cases of negative effect of breech vs. cephalic group) by considering an outcome rate of 74.3%, in cephalic group and for transition to active phase we could detect an OR of 2.96 (or 0.46 in case of negative effect) by considering an outcome rate of 80.7%, in cephalic group, which correspond to large effect sizes.
      • Similarly, our small number of triggered breech births did not allow us to perform multivariate analysis to identify the factors that predict successful induction.
      • Conclusion.
      • Breech presentation, especially when associated with induction, remains an obstetric problem, and our study has provided some additional data about its management. Despite some differences with the cephalic presentation, induction of labor in breech presentation seems to be as effective and as safe as cephalic presentation at the maternal level. Induce a breech fetus can therefore be considered as an option provided that patients eligible for vaginal delivery are selected.

      Abstract

      Introduction

      The objective of our study was to compare the effectiveness of induction in cephalic presentations to that of breech presentations as well as the characteristics of the latter and the maternal-fetal morbidity and mortality.

      Material and methods

      This was a single-center retrospective study carried out at the Lille University Hospital in the Jeanne de Flandre Maternity Hospital including all patients with a breech fetus for whom an induction was indicated beyond 37 weeks of gestation between January 2014 and December 2020. A matching was performed to include 2 cephalic presentations for one breech presentation. The primary outcome was successful induction defined by two things: passage into the active phase (cervical dilatation > 5 cm) and vaginal delivery.

      Results

      101 inductions of breech presentations were included and matched to 202 cephalic presentations. After adjustment by BISHOP score, there was no significant difference in the caesarean section rate between the two groups (25.7% in cephalic vs 33.7% in breech, OR 0.67 [CI95% 0.38-1.18]) or in the rate of transition to active phase (80.7% in cephalic vs 82.2% in breech, OR 1.26 [CI95% 0.65-2.44]). Post-partum blood loss was not significantly different between the two groups (14.4% in cephalic vs 12.9% in breech, OR 1.22 [CI95% 0.57-2.57]). Moderate neonatal acidosis was more frequent in the breech group (6,4% in cephalic vs. 15,8% in breech, OR 3.04 [CI95% 1.38-6.71]).

      Conclusion

      Induction of breech births beyond 37 weeks of gestation appeared to be as effective as induction of cephalic presentations. There was no difference in the rate of caesarean section and transition to active labor. Maternal morbidity was not increased.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      References

      1. Blondel B, Gonzalez L, Raynaud P. Enquête nationale périnatale 2016. Les naissances et les établissements. Situation et évolution depuis 2010. INSERM; 2017 oct.

        • Glantz J.C.
        Elective induction vs. spontaneous labor associations and outcomes.
        J Reprod Med. avr. 2005; 50: 235-240
        • Vardo J.H.
        • Thornburg L.L.
        • Glantz J.C.
        Maternal and neonatal morbidity among nulliparous women undergoing elective induction of labor.
        J Reprod Med. févr. 2011; 56: 25-30
        • Grobman W.A.
        • Rice M.M.
        • Reddy U.M.
        • Tita A.T.N.
        • Silver R.M.
        • Mallett G.
        • et al.
        Labor Induction versus Expectant Management in Low-Risk Nulliparous Women.
        N Engl J Med. 2018; 379: 513-523
        • Grobman W.A.
        • Caughey A.B.
        Elective induction of labor at 39 weeks compared with expectant management: a meta-analysis of cohort studies.
        Am J Obstet Gynecol. Oct 2019; 221: 304-310
      2. Gibson KS, Waters TP, Bailit JL. Maternal and neonatal outcomes in electively induced low-risk term pregnancies. American Journal of Obstetrics and Gynecology. sept 2014;211(3):249.e1-249.e16

      3. Cheng YW, Kaimal AJ, Snowden JM, Nicholson JM, Caughey AB. Induction of labor compared to expectant management in low-risk women and associated perinatal outcomes. American Journal of Obstetrics and Gynecology. déc 2012;207(6):502.e1-502.e8

        • Hannah M.E.
        • Hannah W.J.
        • Hewson S.A.
        • Hodnett E.D.
        • Saigal S.
        • Willan A.R.
        Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial.
        The Lancet. Oct 2000; 356: 1375-1383
        • Goffinet F.
        • Carayol M.
        • Foidart J.M.
        • Alexander S.
        • Uzan S.
        • Subtil D.
        • et al.
        Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium.
        Am J Obstet Gynecol. avr. 2006; 194: 1002-1011
        • Whyte H.
        • Hannah M.E.
        • Saigal S.
        • Hannah W.J.
        • Hewson S.
        • Amankwah K.
        • et al.
        Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: The international randomized Term Breech Trial.
        American Journal of Obstetrics and Gynecology. sept. 2004; 191: 864-871
        • Pradhan P.
        • Mohajer M.
        • Deshpande S.
        Outcome of term breech births: 10-year experience at a district general hospital.
        BJOG. févr. 2005; 112: 218-222
        • Ulander V.M.
        • Gissler M.
        • Nuutila M.
        • Ylikorkala O.
        Are health expectations of term breech infants unrealistically high?.
        Acta Obstetricia et Gynecologica Scandinavica. 2004; 83: 180-186
        • Macharey G.
        • Väisänen-Tommiska M.
        • Gissler M.
        • Ulander V.M.
        • Rahkonen L.
        • Nuutila M.
        • et al.
        Neurodevelopmental outcome at the age of 4 years according to the planned mode of delivery in term breech presentation: a nationwide, population-based record linkage study.
        Journal of Perinatal Medicine. 1 avr 2018,; 46: 333-339
      4. [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. Gynecol Obstet Fertil Senol. 2020;48(1):70‑80.

        • Burgos J.
        • Arana I.
        • Garitano I.
        • Rodríguez L.
        • Cobos P.
        • Osuna C.
        • et al.
        Induction of labor in breech presentation at term: a retrospective cohort study.
        J Perinat Med. 1 avr 2017,; 45: 299-303
        • Fait G.
        • Daniel Y.
        • Lessing J.B.
        • Bar-Am A.
        • Gull I.
        • Shenhav M.
        • et al.
        Can Labor with Breech Presentation Be Induced?.
        Gynecol Obstet Invest. 1998; 46: 181-186
        • Jarniat A.
        • Eluard V.
        • Martz O.
        • Calmelet P.
        • Calmelet A.
        • Dellinger P.
        • et al.
        Induced labour at term and breech presentation: Experience of a level IIB French maternity.
        J Gynecol Obstet Hum Reprod. sept. 2017; 46: 597-600
        • Macharey G.
        • Ulander V.M.
        • Heinonen S.
        • Kostev K.
        • Nuutila M.
        • Väisänen-Tommiska M.
        Induction of labor in breech presentations at term: a retrospective observational study.
        Arch Gynecol Obstet. mars. 2016; 293: 549-555
        • Marzouk P.
        • Arnaud E.
        • Oury J.F.
        • Sibony O.
        Induction of labour and breech presentation: experience of a French maternity ward.
        J Gynecol Obstet Biol Reprod (Paris). Nov 2011; 40: 668-674
        • Rojansky N.
        • Tsafrir A.
        • Ophir E.
        • Ezra Y.
        Induction of labor in breech presentation.
        Int J Gynaecol Obstet. août. 2001; 74: 151-156
        • Sun W.
        • Liu F.
        • Liu S.
        • Gratton S.M.
        • El-Chaar D.
        • Wen S.W.
        • et al.
        Comparison of outcomes between induction of labor and spontaneous labor for term breech - A systemic review and meta analysis.
        Eur J Obstet Gynecol Reprod Biol. mars. 2018; 222: 155-160
      5. Welle‐Strand JAH, Tappert C, Eggebø TM. Induction of labor in breech presentations ‐ a retrospective cohort study. Acta Obstet Gynecol Scand. 2 févr 2021;aogs.14083.

        • Dupont C.
        • Carayol M.
        • Le Ray C.
        • Barasinski C.
        • Beranger R.
        • Burguet A.
        • et al.
        Recommandations pour l’administration d’oxytocine au cours du travail spontané. Texte court des recommandations.
        La Revue Sage-Femme. févr. 2017; 16: 111-118
        • Vendittelli F.
        • Pons J.C.
        • Lemery D.
        • Mamelle N.
        The term breech presentation: Neonatal results and obstetric practices in France.
        European Journal of Obstetrics & Gynecology and Reproductive Biology. avr. 2006; 125: 176-184
        • Liu A.
        • Lv J.
        • Hu Y.
        • Lang J.
        • Ma L.
        • Chen W.
        Efficacy and safety of intravaginal misoprostol versus intracervical dinoprostone for labor induction at term: A systematic review and meta-analysis: Misoprostol or dinoprostone.
        J Obstet Gynaecol Res. avr. 2014; 40: 897-906
        • O’Herlihy C.
        Vaginal prostaglandin E2 gel and breech presentation.
        Eur J Obstet Gynecol Reprod Biol. avr. 1981; 11: 299-303
        • Breton A.
        • Gueudry P.
        • Branger B.
        • Le Baccon F.A.
        • Thubert T.
        • Arthuis C.
        • et al.
        Comparison of obstetric prognosis of attempts of breech delivery: Spontaneous labor versus induced labor.
        Gynecol Obstet Fertil Senol. 2018; 46: 632-638
        • Benzekri C.
        • Ghesquière L.
        • Drumez E.
        • Houfflin-Debarge V.
        • Subtil D.
        • Garabedian C.
        Comparison of antepartum management of breech versus cephalic presentation.
        Gynecol Obstet Fertil Senol. Oct 2020; 48: 722-728
        • Peru J.
        • Garabedian C.
        • Drumez E.
        • Ghesquière L.
        Quel est l’impact de la rupture des membranes amniotiques sur le rythme cardiaque fœtal au cours du travail spontané ?.
        Gynécologie Obstétrique Fertilité & Sénologie. Oct 2020; 48: 715-721
        • Jozwiak M.
        • Oude Rengerink K.
        • Ten Eikelder M.L.G.
        • van Pampus M.G.
        • Dijksterhuis M.G.K.
        • de Graaf I.M.
        • et al.
        Foley catheter or prostaglandin E2 inserts for induction of labour at term: an open-label randomized controlled trial (PROBAAT-P trial) and systematic review of literature.
        European Journal of Obstetrics & Gynecology and Reproductive Biology. sept. 2013; 170: 137-145
        • Du Y.
        • Zhu L.
        • Cui L.
        • Jin B.
        • Ou J.
        Double-balloon catheter versus prostaglandin E2 for cervical ripening and labour induction: a systematic review and meta-analysis of randomised controlled trials.
        BJOG: Int J Obstet Gy. mai 2017,; 124: 891-899
        • Christian S.S.
        • Brady K.
        Cord blood acid-base values in breech-presenting infants born vaginally.
        Obstet Gynecol. Nov 1991; 78: 778-781
        • Daniel Y.
        • Fait G.
        • Lessing J.B.
        • Jaffa A.
        • Gull I.
        • Shenav M.
        • et al.
        Umbilical cord blood acid-base values in uncomplicated term vaginal breech deliveries.
        Acta Obstet Gynecol Scand. févr. 1998; 77: 182-185
        • Toivonen E.
        • Palomäki O.
        • Huhtala H.
        • Uotila J.
        Selective vaginal breech delivery at term - still an option: Vaginal breech delivery at term.
        Acta Obstetricia et Gynecologica Scandinavica. Oct 2012; 91: 1177-1183
        • Adjaoud S.
        • Demailly R.
        • Michel-Semail S.
        • Rakza T.
        • Storme L.
        • Deruelle P.
        • et al.
        Is trial of labor harmful in breech delivery? A cohort comparison for breech and vertex presentations.
        J Gynecol Obstet Hum Reprod. mai. 2017; 46: 445-448
        • Vannerum M.
        • Subtil D.
        • Drumez E.
        • Brochot C.
        • Houfflin-Debarge V.
        • Garabedian C.
        Per-partum risk factors of neonatal acidemia in planned vaginal delivery for fetuses in breech presentation.
        Gynecol Obstet Fertil Senol. janv. 2019; 47: 11-17
        • Su M.
        • McLeod L.
        • Ross S.
        • Willan A.
        • Hannah W.J.
        • Hutton E.
        • et al.
        Factors associated with adverse perinatal outcome in the Term Breech Trial.
        Am J Obstet Gynecol. sept. 2003; 189: 740-745
        • Michel S.
        • Drain A.
        • Closset E.
        • Deruelle P.
        • Ego A.
        • Subtil D.
        Evaluation of a decision protocol for type of delivery of infants in breech presentation at term.
        European Journal of Obstetrics & Gynecology and Reproductive Biology. Oct 2011; 158: 194-198