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DOI: DOI: http://dx.doi.org/10.21088/ijog.2321.1636.6318.7

Abstract

Background: Breech presentation is the commonest abnormal fetal    presentation met with in practice. It has been attended by a high perinatal morbidity and mortality. The clinical art of conducting vaginal breech delivery and obtaining mastery over the same requires many years of skillful training and supervision. The aim of this study is to assess maternal and fetal outcome in breech presentation.

Methods: The study is conducted in WEST INDIA in a tertiary care centre for a period of 3 years (January 2015 to December 2017). A total of approx 500 antenatal cases with breech presentation with  attending antenatal OPD in our hospital were studied. Patients were subjected to detailed history with respect to age, parity, mode of delivery. Antenatal USG scan was done to confirm breech presentation, type of breech presentation, placental location and uterine anomaly. Maternal parameters (genital tract trauma, wound infection, mortality etc) and fetal parameters (birth weight, APGAR, trauma, NICU admission, mortality etc) documented and analysed using statistical methods. A thorough obstetric and systemic examination was done.

Results: In our study incidence of breech presentation was more common in multigravida patients (55%) as compared to primigravida patients  (45%).Incidence of breech presentation is more  common in age group between 21 to 25 years of age accounting for 48%. In primigravida patients, incidence of cesarean section was more common than multigravida  patients, accounting for 62.50% of total LSCS. In multigravida patient vaginal delivery was more common (56.36%), whereas in primiparous women incidence of cesarean section is higher than vaginal delivery (88.88% v/s 11.11%). Overall maternal morbidity was higher in LSCS than vaginal delivery. Anterior was most common location of placenta, followed by fundal. Incidence of oligohydramnios in breech presentation in our study was 4 % & 1 % in case of polyhydramnios. Incidence of placenta previa was 3%. Distribution of parity according to type of breech was complete breech: 7.80% in primigravida and 92.10% in multigravida. In frank breech 71.92% primigravida and 28.07% in  multigravida. Distribution of type breech among mode of delivery was as follow: Most babies delivered vaginally were of frank variety, about 69.44%. Complete breech accounted for 45% of emergency LSCS, 37.5% of elective LSCS, 30.55% of vaginal deliveries. Most of the babies (47%) were having baby weight in between 2 to 2.5 kg, 37% having birth weight  between 2.5 to 3 kg.The perinatal outcome was good in EL LSCS & EM LSCS with an incidence of 100% & 92.5%. The incidence of low APGAR is 2 times higher in vaginal delivery in comparison with cesarean delivery. The incidence of NICU admission is 7.5% with cesarean delivery and 16.66% with vaginal delivery. The multigravida patients have good perinatal outcome than primigravida (92.72% vs 82.22%). Perinatal mortality is commonly associated with vaginal breech delivery 8.33%. In our study perinatal mortality was more common in frank breech as compared to complete breech.

Conclusion: The perinatal morbidity and mortality rate have played a
huge role in changing the plan -how to deliver a breech baby. But an important fact is presence of experienced obstetrician. Vigorous  intrapartum monitoring and proper technique of breech delivery have been established as the most important determinant for successful outcome in vaginal breech delivery without compromising feto-maternal well-being and curtailing the caesarean section rate. Parents must be informed about potential risks and benefits to the mother and neonate for both vaginal breech delivery and cesarean delivery. Discussion of risks should not be limited only to the current pregnancy. The risks of a cesarean on subsequent pregnancies, including uterine rupture and placental attachment abnormalities (placenta previa, abruption, accreta), as well as maternal and perinatal sequelae from these complications, should be reviewed as well. Delivery of breech fetus where labor is supervised by experienced obstetrician and delivery is performed by or under guidance of experienced obstetrician definitely lowers maternal morbidity, perinatal morbidity and perinatal mortality. External cephalic version (ECV) is a safe alternative to vaginal breech delivery or cesarean delivery, reducing the cesarean delivery rate for breech by 50%. ACOG (2016) recommends offering ECV to all women with a breech fetus near term. Adjuncts such as tocolysis, regional anesthesia, and acoustic stimulation when appropriate may improve ECV success rates. In our study it has been observed that abdominal route of breech delivery is safer though it has its own disadvantages. Cesarean section reduces overall perinatal mortality. But it has also been observed that cesarean section has problems of more hospital stay, and chances of maternal morbidity like in our study wound gap & need of blood transfusion. There is still a place for vaginal breech delivery in selected cases of breech presentations more so in mutiparous women.

Keywords: Breech: Etiology; Risk Factors.

 

Corresponding Author : Nalini Anand, Professor & Head of Department, Department of Obstetrics and Gynaecology, Shri M.P. Shah Medical College, Guru Gobind Singh Hospital, Jamnagar, Gujarat 361008, India