RESUMEN
INTRODUCTION: 3-4% of pregnant women present with a fetal breech position at term. National societies regard vaginal breech delivery as a safe option, but only for a specific and thoroughly counseled group of patients. To avoid adverse outcome, many practitioners recommend elective cesarean section once their patients go past the estimated due date. Since encompassing evidence is missing, the evaluation on this common clinical practice is needed. OBJECTIVE: This study compares the short-term maternal and fetal outcome in intended vaginally breech deliveries before the estimated due date (until 40 0/7 weeks of gestation) to the outcome of deliveries carried out past the estimated due date (later than 40 0/7 weeks of gestation). METHODS: This prospective cohort study includes 827 women who presented for an intended vaginal breech delivery of a singleton at our perinatal center between January 2010 and December 2016. RESULTS: 447 patients (54%) delivered before or at their estimated due date, 380 (46%) of pregnancies continued after the estimated due date. Comparing both groups, no significant difference in maternal and neonatal short-term mortality and morbidity was found. The rate of caesarian sections was increased in the group of patients, who delivered later than 40 1/7 weeks of gestation. Here, the likelihood for delivery maneuvers was also increased. CONCLUSION: This study provides evidence, that an elective cesarean section for breech presentations at term is not obligatory when the estimated due date has passed in singleton pregnancy.
Asunto(s)
Presentación de Nalgas , Cesárea , Parto Obstétrico , Femenino , Humanos , Mortalidad Infantil , Recién Nacido , Embarazo , Resultado del Embarazo/epidemiología , Estudios ProspectivosRESUMEN
INTRODUCTION: The best way to deliver a term breech infant is still a much discussed topic among obstetricians. The question whether nulliparity should be considered an exclusion criterion for an intended vaginal breech delivery is not fully answered. OBJECTIVE: We compared maternal and neonatal outcome of intended vaginal breech deliveries of nulliparous versus multiparous women at term. STUDY DESIGN: We conducted a prospective case-control study between January 2004 and December 2016. 1046 women expecting singletons at term with favorable pelvic measurements were enrolled in the study. RESULTS: Neonatal morbidity and mortality was not significantly different in deliveries of nulliparous (n = 647) versus multiparous (n = 399) women. Nulliparous women had a significantly higher rate of a cesarean section during labor than multiparous women. Maternal birth-injury rates and the use of epidural anesthesia were significantly higher comparing vaginal births of nulliparous (n = 384) versus multiparous (n = 331) women. CONCLUSION: Nulliparity seems not be an exclusion criterion for intended vaginal breech birth at term. It is still important to inform the women of an increased risk of a cesarean section during labor. A clinical management built on this evidence might reduce negative implications for future pregnancies.
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Presentación de Nalgas , Cesárea , Estudios de Casos y Controles , Parto Obstétrico , Femenino , Humanos , Recién Nacido , Paridad , Embarazo , Estudios ProspectivosRESUMEN
INTRODUCTION: Vaginal delivery out of a breech presentation in pregnancies at term are being re-implemented into clinical practice. Still, recommendations regarding exclusion criteria leading to caesarean sections are based on expert opinions, not on evidence-based guidelines. The difference in perinatal outcome and course of delivery in births with babies in frank breech position and babies in incomplete or complete breech presentation never has been investigated in a large patient cohort. OBJECTIVE: To compare perinatal outcome of vaginally intended breech deliveries between births out of frank breech position and incomplete/complete breech presentation. DESIGN: Prospective cohort study. SAMPLE: 884 women at term with a singleton in frank breech presentation (FB) and 284 women with incomplete or complete breech presentation (CB) intending vaginal birth between January 2004 and December 2018. METHODS: Maternal and fetal outcome was compared between groups using Pearson's Chi Square test. Birth duration parameters were analysed using logistic regression. RESULTS: There were no differences in cesarean section rates (FB: 25.1%, CB 22.2%, p = 0.317). Short-term fetal morbidity did not differ between groups (FB: 2.5%, CB: 2.8%, p = 0.761). In vaginal deliveries the necessity to perform manual assistance was significantly more frequent in deliveries of infants in CB (FB: 39.9%, CB: 51.6%, p = 0.0013). Cord loops (FB: 10.1%, CB: 18.0%, p = 0.0004) and cesarean sections necessary because of cord prolapses (FB: 1.4%, CB 8.1%, p = 0.005) were significantly more often in deliveries with babies in CB. CONCLUSION: This study provides evidence, that perinatal morbidity is not associated with the fetal leg posture in vaginally intended breech deliveries. The higher risk for the need of manual assistance during vaginal birth in deliveries of babies out of complete or incomplete breech presentation suggests that obstetrical departments re-implementing the vaginal breech in their repertoire might start with births of babies out of frank breech presentation.
Asunto(s)
Presentación de Nalgas/diagnóstico , Cesárea/estadística & datos numéricos , Resultado del Embarazo , Adulto , Peso al Nacer , Presentación de Nalgas/cirugía , Estudios de Casos y Controles , Femenino , Humanos , Recién Nacido , Embarazo , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
BACKGROUND: Postpartum hemorrhage is the leading cause of maternal death. Recently, the WOMAN trial showed that early administration of tranexamic acid leads to a reduced mortality due to bleeding. The aim was to study whether the results of the WOMAN trial have influenced the institutional standard operating procedures in treating postpartum hemorrhage. METHODS: We performed a paper-based survey during the German Perinatal Congress in 2017 located in Berlin. A total of thirteen questions covered the fields of incidence, training, and treatment of postpartum hemorrhage. RESULTS: 250 questionnaires were handed out to all participants of three different sessions during the congress. 72 questionnaires were returned, resulting in a return rate of 29%. 94% (n = 65) of all participants stated that they had implemented a standard operating procedure to treat postpartum hemorrhage prior to the WOMAN trial. 18 of these standard operating procedures were revised after the publication of the WOMAN trial, resulting in an early inclusion of tranexamic acid in 100% of all standard operating procedures. CONCLUSION: We recognized a correlation between the publication of the WOMAN trial and the administration of tranexamic acid at an early time-point in all standard operating procedures of the participating institutions to treat postpartum hemorrhage. In all those clinics whose algorithms initially did not contain any tranexamic acid, it was supplemented. This resulted in a 100% implementation of tranexamic acid.
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Antifibrinolíticos/uso terapéutico , Obstetricia/normas , Hemorragia Posparto/tratamiento farmacológico , Ácido Tranexámico/administración & dosificación , Algoritmos , Berlin , Tasa de Natalidad , Ensayos Clínicos como Asunto , Femenino , Humanos , Obstetricia/métodos , Obstetricia/tendencias , Pautas de la Práctica en Medicina/estadística & datos numéricos , Embarazo , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
INTRODUCTION: The clinical management of breech presentations at term is still a controversially discussed issue among clinicians. Clear predictive criteria for planned vaginal breech deliveries are desperately needed to prevent adverse fetal and maternal outcomes and to reduce elective cesarean section rates. The green-top guideline considers an estimated birth weight of 3.8 kg or more an indication to plan a cesarean section despite the lack of respective evidence. OBJECTIVE: To compare maternal and neonatal outcome of vaginal intended breech deliveries of births with children with a birth weight of 2.5 kg- 3.79 kg and children with a birth weight of 3.8 kg and more. DESIGN: Prospective cohort study. SAMPLE: All vaginal intended deliveries out of a breech position of newborns weighing between 2.5 kg and 4.5 kg at the Obstetrics department at Goethe University Hospital Frankfurt from January 2004 until December 2016. METHODS: Neonatal and maternal outcome of a light weight group (LWG) (< 3.8 kg) was compared to and a high weight group (HWG) (≥ 3.8 kg) using Pearson's Chi Square test and Fishers exact test. A logistic regression analysis was performed to detect an association between cesarean section rates, fetal outcome and the birth weight. RESULTS: No difference in neonatal morbidity was detected between the HWG (1.8%, n = 166) and the LWG (2.6%, n = 888). Cesarean section rate was significantly higher in the HWG with 45.2% in comparison to 28.8% in the LWG with an odds ratio of 1.57 (95% CI 1.29-1.91, p<0.0001). In vaginal deliveries, a high birth weight was not associated with an increased risk of maternal birth injuries (LWG in vaginal deliveries: 74.3%, HWG in vaginal deliveries: 73.6%; p = 0.887; OR = 1.9 (95% CI 0.9-1.1)). CONCLUSION: A fetal weight above 3.79 kg does not predict increased maternal or infant morbidity after delivery from breech presentation at term. Neither the literature nor our analyses document evidence for threshold of estimated birth weight that is associated with maternal and/or infant morbidity. However, patients should be informed about an increased likelihood of cesarean sections during labor when attempting vaginal birth from breech position at term in order to reach an informed shared decision concerning the birth strategy. Further investigations in multi center settings are needed to advance international guidelines on vaginal breech deliveries in the context of estimated birth weight and its impact on perinatal outcome.