Breech presentation in Spain, 1992: a collaborative study

doi:10.1016/0301-2115(95)02166-5

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 62, Issue 1, September 1995, Pages 19-24

https://doi.org/10.1016/0301-2115(95)02166-5 Get rights and content

Abstract

Objectives: The goals of the present work were to study the incidence of breech deliveries in Spain, the causes for breech presentation and its management and the incidence of cesarean sections and its correlation with the perinatal mortality rates among different centers. Study design: Data from 102 038 deliveries, 3829 of which were singleton breech deliveries attended in 1992, were obtained from 40 hospital centers located in different autonomic communities of Spain and analyzed using a computer statistical package (R-sigma, Horus Hardware). Results: The incidence of breech deliveries was 3.8%, although this proportion varied between different centers and regions. Up to 18% of the cases occurred in preterm. The most frequent causes were prematurity and uterine malformations. In its management, an increase in the tendency to perform elective cesarean section was noticed. The incidence of cesarean sections reached 14.9% of the total and 67.9% in breech deliveries. Perinatal mortality rate in breech deliveries was more than four times that of all deliveries, according to national standards, and more than three times according to international standards (47.8 versus 11.8 × 1000, and 24.7 versus 8 × 1000, respectively). The intrapartum and neonatal mortality in breech deliveries was 13 × 1000. No correlation between incidence of cesarean sections and perinatal mortality rates was found. Primiparity, deflexed head, macrosomia and prematurity were the most decisive parameters to indicate a cesarean section. Neither the external cephalic version nor the total breech extraction were common procedures. Conclusions: The incidence of breech deliveries is variable between different centers (1.7%–5.1%) and Spanish regions (3.3%–4.3%), with a mean of 3.8% in overall and 11.4% in preterm deliveries. There is a tendency to perform cesarean sections, especially in primiparae. There is no correlation between the percentage of cesarean sections in each center and the perinatal mortality rate. External cephalic version and total breech extraction were uncommon procedures.

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Cited by (25)

Evaluation of knowledge of external cephalic version and term breech presentation management preferences in women of childbearing age
2021, Clinica e Investigacion en Ginecologia y Obstetricia
Evaluar los conocimientos generales y preferencias iniciales de las pacientes en edad fértil en España sobre el manejo de la presentación podálica a término.
Se trata de un estudio transversal basado en la administración a las participantes de un cuestionario para evaluar sus conocimientos sobre la versión cefálica externa y preferencias entre esta, la cesárea y el parto de nalgas.
Doscientas mujeres participaron en el estudio. Cuarenta y uno (20,5%) habían oído hablar de la versión cefálica externa. El 29,27% por un ginecólogo, el 12,20% por una matrona, el 39,02% por conocidos, el 26,83% por internet o redes sociales y el 2,44% por la televisión. La edad, la formación académica y el hecho de estar embarazadas no fueron factores influyentes para conocer o no la versión cefálica externa. Las multíparas conocían mejor el procedimiento (OR = 2,1; IC 95%: 1,14-3,88). El 63,5% elegirían la versión cefálica externa frente al 35% que eligieron la cesárea programada. El 1,5% se decantaron por un parto de nalgas. La mayoría de las mujeres consideraron la técnica efectiva (58%) y segura tanto para la madre (55%) como para el feto (46,5%).
El conocimiento de las pacientes sobre la versión cefálica externa y las fuentes de las que dicen tener la información demuestran una carencia en la información que reciben por parte de ginecólogos y matronas.
To assess the knowledge and preferences for term breech management in women of childbearing age.
Cross-sectional study based on a survey for women to evaluate heir knowledge of external cephalic version and their preferences between this procedure, vaginal breech delivery or cesarean section.
200 women participated. 41 women (20.5%) had heard of external cephalic version; 29.27% from gynecologists, 12.20% from midwives, 39.02% from acquaintances, 26.83% from the internet or social networks and 2.44% from television. Multiparous woman knew more about the procedure (OR = 2.1; 95% CI:1.14-3.88). 63.5% would choose external cephalic version. 35% would prefer programmed cesarean section. 1.5% would opt for a breech delivery. Most of the women considered the technique to be effective (58%) and safe for both the mother (55%) and the fetus (46.5%).
Patients’ knowledge of external cephalic version is poor. The results show a lack of information by their healthcare providers.
Pituitary stalk interruption syndrome
2021, Handbook of Clinical Neurology
Citation Excerpt :
Nevertheless, recent advances in biomedical technologies and analysis and especially, the broad application of whole exome sequencing (WES) in large cohorts have prompted a significant change of view with respect to the underlying mechanism of PSIS: from theories pointing to adverse perinatal events, we have gradually moved toward pinpointing a broad spectrum of proven and probable genetic causes that continuously expand (Kulkarni et al., 2012). Adverse perinatal events leading to head trauma, ischemia, hypoxia, or even mechanical rupture of the pituitary stalk and/or affecting the hypothalamus had been suspected in the past as the causative mechanism of PSIS (and in a broader view, pituitary deficiency), based on the increased incidence of dystocia, breech presentation, cesarean section delivery, and potential neonatal distress in patients with PSIS (Demura et al., 1975; Shizume et al., 1977; Maghnie et al., 1991a,b; Acién, 1995; Pinto et al., 1997; Bar et al., 2015; Wang et al., 2017). Indeed, breech delivery is significantly increased among PSIS patients (observed in over 60% in some cohorts) with respect to the 4% observed in the general population (Cruikshank, 1986; Maghnie et al., 1991a,b; Wang et al., 2017).
Pituitary stalk interruption syndrome (PSIS) is a distinct developmental defect of the pituitary gland identified by magnetic resonance imaging and characterized by a thin, interrupted, attenuated or absent pituitary stalk, hypoplasia or aplasia of the adenohypophysis, and an ectopic posterior pituitary. The precise etiology of PSIS still remains elusive or incompletely confirmed in most cases. Adverse perinatal events, including breech delivery and hypoxia, were initially proposed as the underlying mechanism affecting the hypothalamic–pituitary axis. Nevertheless, recent findings have uncovered a wide variety of PSIS-associated molecular defects in genes involved in pituitary development, holoprosencephaly (HPE), neural development, and other important cellular processes such as cilia function. The application of whole exome sequencing (WES) in relatively large cohorts has identified an expanded pool of potential candidate genes, mostly related to the Wnt, Notch, and sonic hedgehog signaling pathways that regulate pituitary growth and development during embryogenesis. Importantly, WES has revealed coexisting pathogenic variants in a significant number of patients; therefore, pointing to a multigenic origin and inheritance pattern of PSIS. The disorder is characterized by inter- and intrafamilial variability and incomplete or variable penetrance. Overall, PSIS is currently viewed as a mild form of an expanded HPE spectrum. The wide and complex clinical manifestations include evolving pituitary hormone deficiencies (with variable timing of onset and progression) and extrapituitary malformations. Severe and life-threatening symptomatology is observed in a subset of patients with complete pituitary hormone deficiency during the neonatal period. Nevertheless, most patients are referred later in childhood for growth retardation. Prompt and appropriate hormone substitution therapy constitutes the cornerstone of treatment. Further studies are needed to uncover the etiopathogenesis of PSIS.
Breech Presentation: CNGOF Guidelines for Clinical Practice – Epidemiology, Risk Factors and Complications
2020, Gynecologie Obstetrique Fertilite et Senologie
Étudier la fréquence, les facteurs associés et les modalités d’accouchement de la présentation du siège. Analyser la morbi-mortalité périnatale de la présentation du siège en comparaison à la présentation céphalique toutes voies d’accouchement confondues.
Recherche bibliographique en langue française et anglaise à partir des bases de données Medline et Cochrane entre 1980 et 2019 et à partir des recommandations de sociétés savantes internationales.
Il existe trois modes de présentation du siège en fonction de la position des membres inférieurs du fœtus : décomplété dans 2/3 des cas, complet dans 1/3 des cas ou, plus rarement, semi-décomplété (NP3). Environ 5 % des femmes accouchent d’un enfant en présentation du siège en France (NP3). La fréquence de la présentation du siège diminuant avec l’avancement de l’âge gestationnel, cette incidence est moins importante après 37 SA et ne représente plus que 3 % des accouchements à terme (NP3). La présence d’une malformation utérine congénitale (NP3) ou de myomes (NP3), l’oligoamnios (NP3), la prématurité (NP3), la présence de certaines malformations congénitales chez le fœtus (NP3) et le petit poids pour l’âge gestationnel (NP3) sont les principaux facteurs retrouvés dans la littérature comme associés à la présentation du siège. En France, une tentative de voie basse est réalisée pour un tiers des femmes avec un fœtus en présentation du siège à terme (NP3) avec un taux de succès de 70 % (NP3). Le mode de présentation du siège (complet ou décomplété) ne semble pas modifier l’issue néonatale en cas de tentative de voie basse à partir de 37 SA (NP3). La morbi-mortalité périnatale après 37 SA en cas de présentation par le siège semble plus importante qu’en cas de présentation céphalique, toutes voies d’accouchement confondues (NP3). Le risque de lésions traumatiques en cas d’accouchement par le siège est estimé à moins de 1 % (NP3). Les lésions les plus fréquemment retrouvées sont les fractures de la clavicule, les hématomes ou contusions et les lésions du plexus brachial (NP3). La présentation par le siège est associée à une augmentation du risque de dysplasie des hanches (NP3), et la césarienne ne semble pas en être un facteur protecteur (NP3). La présentation du siège ne semble pas être associée à une augmentation du risque de paralysie cérébrale en comparaison à la présentation céphalique lorsque les fœtus atteints de malformation congénitale sont exclus (NP3).
Le mode d’accouchement de la présentation du siège dans le monde a profondément été modifié après la publication du Term Breech Trial. Il existe des facteurs intrinsèques associés à la présentation du siège, qu’il ne faut pas méconnaître pour interpréter le surcroît de morbi-mortalité périnatale observé en cas de présentation du siège.
To study the frequency, the risk factors and the mode of delivery of breech presentation. To analyze the perinatal morbidity and mortality associated with breech presentation in comparison to cephalic presentation from all mode of delivery.
MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019.
Three modes of breech presentation exist according to fetal lower limbs position: frank in 2/3 of cases, complete in 1/3 of cases or, more rarely, incomplete (LE3). About 5% of women gave birth in breech presentation in France (LE3). As the frequency of breech presentation decreases with increasing gestational age, this incidence is lower after 37 WG and represents only 3% of term deliveries (LE3). Congenital uterine malformation (LE3) and fibroma (LE3), prematurity (LE3), oligoamnios (LE3), some fetal congenital malformations (LE3) and low birthweight for gestational age (LE3) are the main risk factors with breech presentation. In France, one-third of women with a term fetus in breech presentation attempt a vaginal delivery (LE3), which is successful in 70% of cases (LE3). Neonatal outcome is not associated with type of breech presentation (frank or complete) in case of vaginal delivery attempt after 37 WG (LE3). Overall, perinatal morbidity and mortality after 37 WG of breech presentation appear to be greater than in cephalic presentation from all mode of delivery (LE3). The risk of traumatic injury in breech delivery is estimated under 1% (LE3). The most common injuries are collarbone fractures, hematomas or contusions, and brachial plexus injury (LE3). Breech presentation is associated with an increased risk of hip dysplasia (LE3) and cesarean delivery does not seem to be a protective factor (LE3). Breech presentation does not appear to be associated with an increased risk of cerebral palsy compared to cephalic presentation after exclusion of fetuses with congenital malformations (LE3).
Worldwide, mode of delivery of breech presentation has undergone profound changes since the publication of the TBT (Term Breech Trial). There are intrinsic factors associated with breech presentation, which should not be overlooked when interpreting the increased perinatal morbidity and mortality observed in case of breech presentation.
Cost effectiveness of using moxibustion to correct non-vertex presentation
2016, Revista Internacional de Acupuntura
Analizar el coste-efectividad de la utilización de la técnica de moxibustión para corregir la posición fetal no-cefálica y disminuir el número de cesáreas realizadas a término de embarazo.
Se elaboró un modelo determinista de análisis de decisión para analizar el coste del tratamiento de aplicación de calor mediante la combustión de Artemisia vulgaris (moxibustión) en el punto de acupuntura Vejiga 67 (V 67), en mujeres embarazadas con feto en posición no-cefálica entre las 33-35 semanas de gestación. Esta aproximación se comparó con el tratamiento convencional de recomendaciones de manejo de técnica postural genupectoral. Los costes se obtuvieron fundamentalmente de los datos suministrados por el Sistema Sanitario Público Andaluz. Los datos de efectividad parten, en el análisis basal, de un ensayo clínico realizado y publicado previamente. Para hacer los resultados generalizables a otros ámbitos de la salud, se realizó un análisis secundario basado en un metaanálisis llevado a cabo mediante análisis de efectos aleatorios de los estudios publicados en las últimas revisiones sistemáticas de moxibustión frente a tratamiento convencional. Se realizaron análisis de sensibilidad determinísticos y probabilísticos bajo diversos supuestos para evaluar la incertidumbre del resultado.
El análisis basal muestra que la aplicación de la moxibustión previene el 8,92% de los partos con presentación no-cefálica en comparación con el tratamiento convencional, con un ahorro promedio de 107,11 € por parto, principalmente por el ahorro de evitar la necesidad de realizar una cesárea. El metaanálisis reveló un riesgo relativo de la versión de la presentación no-cefálica a término de 0,34 (intervalo de confianza del 95%, 0,16-0,76). El análisis de sensibilidad demostró que la moxibustión puede evitar 0,34 cesáreas, con un coste incremental por parto que va desde 68 a –640 € para la moxibustión frente al tratamiento convencional.
El tratamiento con moxibustión aplicado en el punto de acupuntura V 67 puede evitar la necesidad de cesárea y lograr ahorro de costes para el sistema de salud en comparación con el tratamiento convencional.
To analyse the cost effectiveness of using the moxibustion technique to correct non-vertex presentation and to reduce the number of caesarean sections performed at term.
A deterministic model of decision analysis has been developed to analyse the cost of treatment in which heat is applied by moxibustion (the combustion of Artemisia vulgaris) at acupuncture point BL 67 for pregnant women with non-vertex fetal position at 33-35 weeks’ gestation. This approach was compared with conventional treatment recommendations based on the knee-chest posture technique. The costs were obtained mainly from data provided by the Andalusian Public Health System. Effectiveness data for the baseline analysis were taken from a previous clinical study. A secondary analysis was performed based on a meta-analysis conducted using random effects analysis, by reference to studies published in recent systematic reviews of moxibustion versus conventional treatment, in order to make the results generalisable to other healthcare settings. Deterministic and probabilistic sensitivity analyses were performed under diverse assumptions to assess the uncertainty of the result.
The baseline analysis shows that the application of moxibustion prevents 8.92% of deliveries with non-vertex presentation compared with conventional treatment, with an average cost saving of 107.11 € per delivery, mainly due to the cost saving from avoiding the need for caesarean section. The meta-analysis revealed a relative risk of the version of non-vertex presentation at term of 0.34 (95%CI, 0.16-0.76). The sensitivity analysis showed that moxibustion can avoid 0.34 caesarean sections, with an incremental cost per delivery ranging from 68 to –640 € for moxibustion versus conventional treatment.
Moxibustion treatment applied at acupuncture point BL 67 can avoid the need for caesarean section and achieve cost savings for the healthcare system in comparison with conventional treatment.
Cost effectiveness of using moxibustion to correct nonvertex presentation
2015, Acupuncture in Medicine
Using moxibustion in primary healthcare to correct non-vertex presentation: A multicentre randomised controlled trial
2014, Revista Internacional de Acupuntura
Comparar la efectividad de la moxibustión adicional en el punto de 67 V con la moxibustión en un punto no específico de acupuntura, y con el tratamiento habitual exclusivamente para corregir la presentación no cefálica.
Se realizó un ensayo multicéntrico, controlado, aleatorizado en el que 406 embarazadas de bajo riesgo con un feto en presentación no cefálica, comprobado por ecografía, con una edad gestacional de 33-35 semanas, fueron asignadas a: a) moxibustión verdadera en el punto 67 V más tratamiento habitual; b) moxibustión en el punto 1B, un punto de acupuntura no específico (moxibustión falsa), además del tratamiento habitual, o c) el tratamiento habitual exclusivamente. La medida principal de resultado fue la presentación cefálica al nacimiento. Las mujeres fueron reclutadas en centros de atención primaria de salud.
En el grupo moxibustión verdadera, el 58,1% de las presentaciones a término fueron cefálicas en comparación con un 43,4% en el grupo de moxibustión falsa (riesgo relativo [RR]: 1,34; intervalo de confianza del 95% [IC95%], 1,05-1,70) y un 44,8% en el grupo de tratamiento habitual (RR: 1,29; IC95%, 1,2-1,64). La reducción del RR de la variable principal de resultado en las mujeres asignadas al grupo moxibustión verdadera en comparación con el grupo de tratamiento habitual fue del 29,7% (IC95%, 3,1-55,2) y el número necesario a tratar fue de 8 (IC95%, 4-72). No hubo efectos adversos graves durante el tratamiento.
La moxibustión en el punto de acupuntura 67 V es efectiva y segura para corregir la presentación no cefálica cuando se utiliza entre las 33 y 35 semanas de gestación. Creemos que la moxibustión representa una opción terapéutica a tener en cuenta para conseguir la versión no cefálica del feto.
To compare the effectiveness of additional moxibustion at point BL 67 with moxibustion at a non-specific acupuncture point and with usual care alone to correct non-vertex presentation.
This was a multicentre randomised controlled trial in which 406 low-risk pregnant women with a fetus in ultrasound breech presentation, with a gestational age of 33-35 weeks, were assigned to: a) true moxibustión at point BL 67 plus usual care; b) moxibustion at SP 1, a non-specific acupuncture point (sham moxibustion) plus usual care; or c) usual care alone. The primary outcome was cephalic presentation at birth. Women were recruited at health centres in primary healthcare.
In the true moxibustion group, 58.1% of the full-term presentations were cephalic compared with 43.4% in the sham moxibustion group (relative risk [RR]: 1.34; 95% confidence interval [95%CI], 1.05-1.70) and 44.8% of those in the usual care group (RR: 1.29; 95%CI, 1.02-1.64). The reduction in RR of the primary outcome in women allocated to the true moxibustion group compared with the usual care group was 29.7% (95%CI, 3.1-55.2) and the number needed to treat was 8 (95%CI, 4-72). There were no severe adverse effects during the treatment.
Moxibustion at acupuncture point BL 67 is effective and safe to correct non-vertex presentation when used between 33 and 35 weeks of gestation. We believe that moxibustion represents a treatment option that should be considered to achieve version of the non-vertex fetus.

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Obstetrics and prenatal diagnosisBreech presentation in Spain, 1992: a collaborative study

Abstract

Eur J Obstet Gynecol Reprod Biol

Eur J Obstet Gynecol Reprod Biol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Eur J Obstet Gynecol Reprod Biol

Mode of delivery and neonatal death in 17 587 infants presenting by the breech

Br J Obstet Gynecol

Outcome of breech delivery at term

Br Med J

Reduction of perinatal mortality and morbidity in breech delivery through routine use of cesarean section

Obstet Gynecol

Obstetrics and prenatal diagnosis
Breech presentation in Spain, 1992: a collaborative study