Vaginal Breech Birth: Learnings from 21 Years of Retrospective Data Analysis

Abstract

Introduction

Optimal delivery mode for vaginal breech birth at term remains controversial, with varying recommendations across international guidelines. This study aimed to evaluate common perceptions and outcomes associated with VBB using retrospective data, including benefits of cesarean section, maternal and neonatal risks.

Material and Methods

We conducted a monocentric, retrospective cohort study over 21 years at a German tertiary perinatal center, examining term breech deliveries. Outcomes were compared between planned cesarean section and intended vaginal breech birth, with the latter group further categorized by successful and unsuccessful vaginal breech birth attempts.

Results

Of all deliveries, 3.6% (3172) were singleton breech presentations beyond 36 weeks gestation. Among these, 2501 cases (78.8%) were planned cesarean sections, while 671 cases (21.2%) were intended vaginal breech births. Within the intended vaginal breech birth group, 524 (78%) achieved vaginal delivery, whereas 147 (22%) required secondary cesarean section. Maternal outcomes showed significant differences in blood loss (p < 0.001) and hospital stay (p < 0.001), favoring the vaginal breech birth group with lower blood loss and shorter hospital stays. However, neonatal interventions, including bag-mask ventilation and resuscitation, were significantly more frequent in the vaginal breech birth group (p < 0.001), along with increased short-term neonatal morbidity such as neonatal infections (p < 0.001), transient tachypnea (p = 0.002), and hypoxic-ischemic encephalopathy (p = 0.008).

Conclusion

The findings highlight an increase in intended vaginal breech births with a high rate of successful vaginal deliveries. Vaginal breech birth was associated with fewer maternal complications but elevated short-term neonatal morbidity. The results underscore the importance of individualized counseling and skilled provider presence when considering vaginal breech birth, supporting informed maternal choice and optimized delivery outcomes.

Zusammenfassung

Einleitung

Der optimale Entbindungsmodus für eine termingerechte vaginale Geburt aus Beckenendlage wird immer noch kontrovers diskutiert. Die in internationalen Richtlinien gemachten Empfehlungen variieren. Ziel dieser Studie war eine Evaluierung der verbreiteten Auffassungen sowie den mit einer vaginalen Beckenendlagengeburt assoziierten Ergebnissen. Hierzu wurden retrospektive Daten verwendet, die auch die Vorteile einer Kaiserschnittentbindung sowie mütterliche und neonatale Risiken berücksichtigten.

Material und Methoden

Es wurde eine monozentrische retrospektive Kohortenstudie über einen Zeitraum von 21 Jahren in einem deutschen Perinatalzentrum der Tertiärversorgung zur Untersuchung von termingerechten Entbindungen in Beckenendlage durchgeführt. Die Ergebnisse von geplanten Kaiserschnittentbindungen wurden mit den Ergebnissen von beabsichtigten vaginalen Entbindungen in Beckenendlage verglichen. Letztere Gruppe wurde weiter in erfolgreiche und erfolglose Versuche einer vaginalen Entbindung in Beckenendlage unterteilt.

Ergebnisse

Von der Gesamtgruppe aller Entbindungen waren 3,6% (3172) Einlingsgeburten in Beckenendlage nach der 36. Schwangerschaftswoche. Davon waren 2501 (78,8%) geplante Kaiserschnittentbindungen, während in 671 Fällen (21,2%) eine vaginale Beckenendlagengeburt beabsichtigt wurde. In der Gruppe der beabsichtigten vaginalen Beckenendlagengeburten hatten 524 (78%) eine vaginale Entbindung, während 147 (22%) einen sekundären Kaiserschnitt benötigten. Bei den mütterlichen Outcomes gab es signifikante Unterschiede bezüglich Blutverlust (p < 0,001) und Krankenhausaufenthalt (p < 0,001), wobei die Gruppe der vaginalen Beckenendlagengeburten einen geringeren Blutverlust und einen kürzeren Krankenhausaufenthalt aufwies. Allerdings wurden neonatale Interventionen, darunter Masken-Beutel-Beatmung und Wiederbelebung, signifikant häufiger in der Gruppe der vaginalen Beckenendlagengeburten benötigt (p < 0,001), und kurzfristige neonatale Morbiditäten wie z. B. neonatale Infektionen (p < 0,001), transiente Tachypnoe (p = 0,002) und hypoxisch-ischämische Enzephalopathie (p = 0,008) waren höher.

Schlussfolgerung

Diese Ergebnisse wiesen auf eine Zunahme geplanter vaginaler Beckenendlagengeburten mit einer hohen Rate erfolgreicher vaginaler Entbindungen hin. Die vaginale Beckenendlagengeburt war mit geringeren mütterlichen Komplikationen, aber einer höheren kurzfristigen neonatalen Morbidität verbunden. Wenn eine vaginale Beckenendlagengeburt in Erwägung gezogen wird, unterstreichen diese Ergebnisse die Bedeutung einer individualisierten Beratung sowie der Anwesenheit eines erfahrenen Geburtshelfers, um die Mutter bei der informierten Entscheidung zu unterstützen und das Geburts-Outcome zu optimieren.

Keywords

breech birth - delivery mode - cesarean section - upright birth position - external cephalic version

Schlüsselwörter

vaginale Beckenendlagengeburt - Entbindungsmodus - Kaiserschnitt - aufrechte Geburtsposition - äußere Wendung

Publication History

Received: 03 November 2024

Accepted after revision: 01 February 2025

Article published online:
03 March 2025

• References

• 1 Hickok DE, Gordon DC, Milberg JA. et al. The frequency of breech presentation by gestational age at birth: a large population-based study. Am J Obstet Gynecol 1992; 166: 851-852
• 2 Morris S, Geraghty S, Sundin D. Breech presentation management: A critical review of leading clinical practice guidelines. Women Birth 2022; 35: e233-e242
• 3 Nothelfer A, Friedl TWP, Dayan D. et al. Trial and error – Outcome of breech presentation depending on birth mode and root cause analysis of severe adverse events. Eur J Obstet Gynecol Reprod Biol 2024; 299: 309-316
• 4 Irion O, Hirsbrunner Almagbaly P, Morabia A. Planned vaginal delivery versus elective caesarean section: a study of 705 singleton term breech presentations. Br J Obstet Gynaecol 1998; 105: 710-717
• 5 Goffinet F, Carayol M, Foidart JM. 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 2006; 194: 1002-1011
• 6 Vincent H, Walker S, Hodder A. et al. Barriers and facilitators for implementation of OptiBreech collaborative care: A qualitative study as part of an implementation process evaluation. Women Birth 2024; 37: 101656
• 7 Jennewein L, Brüggmann D, Fischer K. et al. Learning Breech Birth in an Upright Position Is Influenced by Preexisting Experience-A FRABAT Prospective Cohort Study. J Clin Med 2021; 10: 2117
• 8 Louwen F, Wagner U, Abou-Dakn M. et al. Caesarean Section. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/084, June 2020). Geburtshilfe Frauenheilkd 2021; 81: 896-921
• 9 Toivonen E, Palomäki O, Huhtala H. et al. Selective vaginal breech delivery at term – still an option. Acta Obstet Gynecol Scand 2012; 91: 1177-1183
• 10 Fuxe V, Brismar Wendel S, Bohm-Starke N. et al. Delivery mode and severe maternal and neonatal morbidity among singleton term breech births: A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2022; 272: 166-172
• 11 Institut für Qualitätssicherung und Transparenz im Gesundheitswesen (IQTIG). Bundesauswertung Perinatalmedizin: Geburtshilfe Erfassungsjahr 2021. 2022 Accessed February 19, 2024 at: https://iqtig.org/downloads/auswertung/2021/pmgebh/DeQS_PM-GEBH_2021_BUAW_V01_2022-06-30.pdf
• 12 Walker S, Scamell M, Parker P. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery 2016; 34: 7-14
• 13 Dhingra S, Raffi F. Obstetric trainees’ experience in VBD and ECV in the UK. J Obstet Gynaecol 2010; 30: 10-12
• 14 Walker S, Breslin E, Scamell M. et al. Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth 2017; 44: 101-109
• 15 Mattiolo S, Spillane E, Walker S. Physiological breech birth training: An evaluation of clinical practice changes after a one-day training program. Birth 2021; 48: 558-565
• 16 Management of Breech Presentation: Green-top Guideline No. 20b. BJOG [Anonym]. 2017; 124: e151-e177
• 17 Kielland-Kaisen U, Paul B, Jennewein L. et al. Maternal and neonatal outcome after vaginal breech delivery of nulliparous versus multiparous women of singletons at term-A prospective evaluation of the Frankfurt breech at term cohort (FRABAT). Eur J Obstet Gynecol Reprod Biol 2020; 252: 583-587
• 18 Miranda J, Rodriguez-Lopez M, Triunfo S. et al. Prediction of fetal growth restriction using estimated fetal weight vs a combined screening model in the third trimester. Ultrasound Obstet Gynecol 2017; 50: 603-611
• 19 Klemt AS, Schulze S, Brüggmann D. et al. MRI-based pelvimetric measurements as predictors for a successful vaginal breech delivery in the Frankfurt Breech at term cohort (FRABAT). Eur J Obstet Gynecol Reprod Biol 2019; 232: 10-17
• 20 Franz M, von Bismarck A, Delius M. et al. MR pelvimetry: prognosis for successful vaginal delivery in patients with suspected fetopelvic disproportion or breech presentation at term. Arch Gynecol Obstet 2017; 295: 351-359
• 21 Dathan-Stumpf A, Lia M, Meigen C. et al. Novel Three-Dimensional Body Scan Anthropometry versus MR-Pelvimetry for Vaginal Breech Delivery Assessment. J Clin Med 2023; 12: 6181
• 22 Louwen F, Daviss BA, Johnson KC. et al. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?. Int J Gynaecol Obstet 2017; 136: 151-161
• 23 Casteels M, Podevyn K, Vanoverschelde H. et al. Implementation of a breech program in a Belgian obstetric team. Int J Gynaecol Obstet 2022; 158: 432-438
• 24 Schafer R, Dietrich MS, Kennedy HP. et al. “I had no choice”: A mixed-methods study on access to care for vaginal breech birth. Birth 2024; 51: 413-423
• 25 Morris SE, Sundin D, Geraghty S. Women’s experiences of breech birth decision making: An integrated review. Eur J Midwifery 2022; 6: 2
• 26 Wang XR, Cotter H, Fahey M. Women’s Selection of Mode of Birth for their Breech Presentation. J Obstet Gynaecol Can 2021; 43: 716-720
• 27 External Cephalic Version and Reducing the Incidence of Term Breech Presentation: Green-top Guideline No. 20a. BJOG [Anonym]. 2017; 124: e178-e192
• 28 Hannah ME, Hannah WJ, Hewson SA. et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000; 356: 1375-1383
• 29 Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies. BJOG 2016; 123: 49-57
• 30 Bjellmo S, Andersen GL, Martinussen MP. et al. Is vaginal breech delivery associated with higher risk for perinatal death and cerebral palsy compared with vaginal cephalic birth? Registry-based cohort study in Norway. BMJ Open 2017; 7: e014979
• 31 Korb D, Schmitz T, Alexander S. et al. Association between planned mode of delivery and severe maternal morbidity in women with breech presentations: A secondary analysis of the PREMODA prospective general population study. J Gynecol Obstet Hum Reprod 2020; 49: 101662
• 32 Macharey G, Väisänen-Tommiska M, Gissler 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. J Perinat Med 2018; 46: 333-339
• 33 Fernández-Carrasco FJ, Cristóbal-Cañadas D, Gómez-Salgado J. et al. Maternal and fetal risks of planned vaginal breech delivery vs planned caesarean section for term breech birth: A systematic review and meta-analysis. J Glob Health 2022; 12: 04055
• 34 Chaillet N, Mâsse B, Grobman WA. et al. Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial. Lancet 2024; 403: 44-54
• 35 Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med 2018; 15: e1002494
• 36 Macharey G, Toijonen A, Hinnenberg P. et al. Term cesarean breech delivery in the first pregnancy is associated with an increased risk for maternal and neonatal morbidity in the subsequent delivery: a national cohort study. Arch Gynecol Obstet 2020; 302: 85-91
• 37 Allen KA, Brandon DH. Hypoxic Ischemic Encephalopathy: Pathophysiology and Experimental Treatments. Newborn Infant Nurs Rev 2011; 11: 125-133
• 38 Clark SL, Hankins GD. Temporal and demographic trends in cerebral palsy--fact and fiction. Am J Obstet Gynecol 2003; 188: 628-633
• 39 Bevis KS, Straughn jr. JM, Kendrick JE. et al. Morbidity and mortality conference in obstetrics and gynecology: a tool for addressing the 6 core competencies. J Grad Med Educ 2011; 3: 100-103
• 40 Graham EM, Ruis KA, Hartman AL. et al. A systematic review of the role of intrapartum hypoxia-ischemia in the causation of neonatal encephalopathy. Am J Obstet Gynecol 2008; 199: 587-595
• 41 Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev 2015; (07) CD000166
• 42 Abdessalami S, Rota H, Pereira GD. et al. The influence of counseling on the mode of breech birth: A single-center observational prospective study in The Netherlands. Midwifery 2017; 55: 96-102