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A critical review of selected studies of breech delivery is presented with special attention to the statistical analysis of outcome for low birth weight and term breech delivery. Analysis of the data fails to support the routine use of cesarean birth for all cases of breech delivery except for those with hyperextension of the head. The implication of these findings is discussed.
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Neonatal and maternal outcome in 358 midforceps and 486 cesarean deliveries was compared by retrospective analysis. Neonatal outcome was evaluated on the basis of Apgar score, cord blood gas values, admission to the neonatal intensive care unit, and birth trauma. Maternal outcome was based on intraoperative and postoperative complications, blood loss, and hospital stay. There was no increase in significant short-term neonatal morbidity in the midforceps group, while maternal morbidity was higher in the cesarean delivery group. It is concluded that, in selected cases, midforceps delivery is safe for the neonate and mother.
The outcomes of 54 breech-extracted second twins weighing between 750 and 2000 gm were compared with the outcomes of their siblings and of 43 sets of twins delivered by cesarean section for malpresentation. Vaginally delivered first twins had fewer days of mechanical ventilation and oxygen therapy than their breech-extracted siblings (p = 0.004). There were no significant differences in any measures of neonatal outcome when breech-extracted twins were compared with second twins delivered by cesarean section. We conclude that routine cesarean section is not justified for nonvertex second twins expected to weigh less than 2000 gm.
The Zavanelli maneuver was applied to locked twins. After the first infant was returned into the vagina, an emergency cesarean section was performed. After a not-too-good start, both children did well. The Zavanelli maneuver is presented as a method to reverse the potentially catastrophic situation of locked twins.
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OBJECTIVE: Our purpose was to compare the maternal and perinatal outcomes of twin gestations in which the nonvertex second twin was delivered by total breech extraction versus those delivered by external cephalic version. STUDY DESIGN: The intrapartum courses of 284 consecutive twin gestations were analyzed retrospectively. Once those with actual birth weight < 600 gm, unrecognized multifetal pregnancy, multiple congenital anomalies, cesarean delivery, and/or antepartum intrauterine fetal death were excluded, 23 mothers were delivered by total breech extraction and 21 underwent external cephalic version. RESULTS: The two groups were similar for mean (+/- SD) maternal age, gravidity, parity, gestational age at delivery, ultrasonographic estimate of birth weight for twin B, incidence of breech or transverse presentation for the second fetus, and actual birth weight of the first or second newborn. Suspected fetal distress that led to cesarean delivery occurred significantly more often in parturients who underwent attempted external version (4/21) than total breech extraction (0/23, p = 0.04). The incidence of eventual abdominal delivery was also significantly higher in patients who underwent attempted external cephalic version (10/21) rather than breech extraction (1/23, p = 0.001). For twin B the occurrence of low Apgar scores at 1 minute was significantly higher for infants after attempted external version (7/21) rather than breech extraction (1/23, p = 0.02), but the mean pH, number with Apgar scores < 7 at 5 minutes, and number of neonatal intensive care unit admissions were similar. No perinatal traumatic injury occurred in either group. CONCLUSION: On the basis of our experience, total breech extraction of the nonvertex second twin is preferable to external cephalic version because it appears to be associated with a significantly lower incidence of fetal distress and abdominal delivery with comparable neonatal outcome.
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We have studied the outcome of labor induction in 145 postterm pregnant women in whom gestational age was properly assessed by ultrasound scanning. The induction techniques were adapted to the cervical states of the patients. Seventy-five patients (32 nulliparous and 43 multiparous) with favorable cervical states were successfully induced with intravenous oxytocin. In this group the frequency of Caesarean section was 2%. Seventy patients (45 nulliparous and 25 multiparous) with unripe cervices received 0.5 mg PGE2 in viscous gel intracervically to prime the cervix and to induce labor; 38 (52%) were induced into labor after a single PGE2-gel application whereas 26 (48%) needed labor augmentation with intravenous oxytocin after PGE2-gel obtained cervical ripening. In 6 of the 20 patients the cervix did not ripen and the PGE2-gel application had then to be repeated. The frequency of cesarean sections was 11%. In 5 out of the 145 patients (4%) the fetuses had signs of intrauterine growth retardation (IUGR) as assessed by ultrasound scanning, and postmaturity as verified by pediatric examination at delivery. All these fetuses belonged to nulliparous women with unripe cervices and all had to be delivered instrumentally (3 by cesarean section and 2 by ventouse) indicating the fragility of these children. If postterm pregnancy is complicated by an unfavorable cervical state intracervical application of PGE2-gel seems to be an efficient method to prime the cervix and to induce labor. In most patients an uncomplicated vaginal delivery can be achieved by this procedure. However, nulliparous women with unfavorable cervices and signs of IUGR constitute a high risk group of patients at labor induction.
All cases (70) of failed instrumental deliveries which occurred between 1980 and 1988 at Ramathibodi Hospital, Bangkok, Thailand were critically reviewed. The incidence of failure was 0.5%, and failure occurred more often in primigravidae. Failure to appreciate the true level of the fetal head and too early intervention accounted for failure in 50% of the cases. Failed instrumental delivery can be minimized if the prerequisites for the procedure are strictly adhered to.
OBJECTIVES: To examine whether continuous lumbar epidural analgesia administered in the early phase of labor leads to an increased incidence of instrumental vaginal deliveries. METHODS: In a retrospective analysis we have studied 563 consecutive term cephalic vaginal deliveries where an epidural was given for pain relief in labor. The type of delivery was compared in two groups. In Group 1 epidurals were given when the cervix was 3 cm or less dilated; in Group 2 when they were greater than 3 cm dilated. RESULTS: There was no difference in the incidence of instrumental deliveries in the two groups. Other variables including station of the fetal head, premature rupture of membranes, meconium, and administration of pitocin and pethidine did not effect these results. CONCLUSIONS: There is no justification in delaying epidural analgesia in labor when it is clinically indicated.
In a prospective clinical randomized investigation 487 women had the condition of the fetus during labour supervised by means of stethoscope (AUS), while 482 women went through labour under surveillance of electronic fetal monitoring, cardiotocography (EFM). 349 women refused to participate in the investigation (NAI) and had delivery conducted according to the normal procedures of the department (70% AUS, 30% EFM). Significantly more pathological fetal heart rate patterns (FHR) were found in the EFM group compared to the AUS group in both the first and the second stage of labour. As a result significantly more vacuum extractions were performed in the EFM group than in the AUS group, while no statistical difference was found between the groups in the incidence of acute cesarean sections carried out for asphyxia. One case of intrapartum death occurred in the AUS group. No differences were found in Apgar scores after 1 and 5 min or in neonatal morbidity at examination on the 2nd and 5th days after delivery. A tendency towards more biochemically compromised children was found in the AUS group. The specificity for both methods was found to be acceptably high (80%), while the predictive value for both methods was low (50%). More research is therefore urgently needed to evaluate supplementary investigations and parameters for the evaluation of the intrapartum fetal condition.
This trial compared the termination of early pregnancy (amenorrhoea less than 43 days) by 600 mg orally of the antiprogesteron Mifepristone to the traditional method of vacuum aspiration. Fifty women were randomly assigned to either of the treatments. All the patients treated with vacuum aspiration had a complete abortion. Three of these patients developed pelvic inflammatory diseasae (PID) after the aspiration. Another patient had the uterus perforated during the procedure, and an emergency laparotomy had to be performed. The patients in the evacuation group spent more days in bed and needed longer sick leave after the treatment than the patients in the Mifepristone group. In the Mifepristone group, six patients had incomplete abortions and all were treated by evacuation. Three of the patients developed PID after the evacuation. A decrease of 40% or more in beta hCG from the initial value to the value 1 week later were invariably associated with complete abortion. In both groups the changes in hemoglobin were insignificant and no patients needed blood transfusion or emergency evacuation. The Mifepristone treatment is a simple and safe alternative to vacuum aspiration for termination of early pregnancies.
A total of 400 primiparous patients who were delivered by vacuum extractor were studied. The patients were divided in two groups: Group A included 200 patients who were delivered by metal cup vacuum extractor and Group B consisted of 200 patients who were delivered by rubber cup vacuum extractor. There were no statistically significant differences in the mean maternal age, mean gestational age, mean neonatal birth weight, indications for operative delivery, occipital positions and head stations between the two groups. No differences were found in the rates of birth canal trauma (11% vs. 12.5%), major neonatal scalp trauma (6.5% vs. 5.5%), neonatal jaundice (15.5% vs. 13.5%) and Apgar score. From this study we can conclude that both metal and silicone cups are equally satisfactory for vacuum extraction.
OBJECTIVE: To determine whether continuous epidural analgesia with bupivacaine and fentanyl affects the rate of cervical dilation and myometrial contractility. METHODS: In a 5-week period, 62 consecutive women who received standardized epidural analgesia were matched with the next two groups of 124 consecutive women of the same parity who did not receive epidural analgesia. The outcome variables were uterine activity, rate of cervical dilation, oxytocin therapy, and operative deliveries. RESULTS: Continuous epidural analgesia with bupivacaine and fentanyl did not result in a change in myometrial contractility in the first hour after the initiation of analgesia. However, despite more oxytocin therapy, the rate of cervical dilation was significantly lower in the epidural group than in the nonepidural group (1.9 versus 5.6 cm/hour, P < .001). Operative deliveries were more common in patients with epidural analgesia than in those without it (12 of 62 versus two of 124, P < .001). CONCLUSION: After epidural analgesia, myometrial contractility is maintained with oxytocin, but the ability of the uterus to dilate the cervix is reduced significantly.