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For A Singleton Breech Presentation Vaginal Delivery Should Be an Option A Review Over One Year in A Tertiary Hospital

1 Professor and Head of Department, 2 Senior Resident Department of Obstetrics and Gynaecology, ESIC Hospital, Kalaburgi ABSTRACT Introduction: Breech is commonest malpresentation, with incidence ranging from 3 to 4% in term gestations. Perinatal mortality is increased 2-4 fold with breech presentation regardless of mode of delivery. Offering a trial of vaginal breech delivery to a well counselled strictly selected patients remains an appropriate option. Aims and Objectives 1. To study the maternal complications like genital tract trauma after term breech delivered vaginally. 2. To study the neonatal complications in terms of perinatal mortality, apgar score at 5 minutes, and neonatal trauma in all singleton term breech delivered vaginally. Material and Methods: Hundred patients with singleton term breech presentation delivered vaginally during the year 2015, were studied retrospectively, for maternal and neonatal complications. maternal complications include genital tract trauma and neonatal complications include perinatal mortality, apgar score at 5 minutes, and neonatal trauma Results: Hundred patients with singleton term breech presentation admitted and delivered vaginally were studied retrospectively. All were unbooked cases in labour. 90% were multigravidae and 10 % were primigravidae. An apgar score of >\=8 at 5 minutes was observed in 91% of cases while 4% had apgar score <8 at 5 minutes. there were 5 still births and 2 neonatal deaths. None of the baby had birth trauma. Only 2% of mothers had genital tract trauma (cervical tears). Conclusion: Offering a trial of vaginal breech delivery to selected and well counselled women is an appropriate option without compromising perinatal and maternal outcome. Thus contributing in decreasing the rising caesarean section rate.


Introduction
Breech is commonest malpresentation, with incidence ranging from 3 to 4% in term gestations. It is a condition in which the baby, at the time of birth, exits the mother's pelvis buttocksor feetfirst. Based on the relation between the baby's lower limbs and the bottom, breech presentation can be classified as: complete (the baby's hips and knees are flexed so that the baby is sitting with feet beside the bottom), and incomplete breech (the baby's legs are folded flat up against the chest); most breech babies are in the incomplete breech position, with bottom coming first. Other types of incomplete breech presentation are the kneeling breech and footling breech. Factors that have been associated with breech presentation include nulliparity, uterine abnormallities, low insertion of placenta, polyhydramnios, oligohydramnios, multiple pregnancy, prematurity, decreased fetal activity, fetal abnormalities and fetal death. Moreover, there is increased risk of recurrence of this type of presentation in subsequent pregnancies. Management of breech presentation remains an area of intense controversy. Various options available are external cephalic version (ECV), Planned caesarean section and planned vaginal delivery. Perinatal mortality is increased 2-4 fold with breech presentation regardless of mode of delivery. The higher perinatal mortality and morbidity associated with breech presentation is principally due to prematurity, congenital malformations, birth asphyxia and trauma. In 2000, the results of a randomized multicenter trial, theTerm Breech Trial (TBT) were published in the Lancet. The trial reported significantly lower perinatal mortality, neonatal mortality, or serious neonatal morbidity in the planned caesarean section arm (1.6%) versus in the planned vaginal delivery arm (5.0%). After this the ACOG Committee on Obstetric practice in2001 recommended that planned vaginal delivery of a term singleton breech was no longer appropriate. Offering a trial of vaginal breech delivery to a well counselled strictly selected patients remains an appropriate option. Vigorous intra partum monitoring and proper technique of breech delivery have been established as the most important determinant for successful outcome without compromising fetomaternal wellbeing and decreasing the caesarean section rate. Aim of this study is to determine the maternal and neonatal complications in terms of genital tr act trauma to the mother, perinatal mortality, APGAR SCORE at 5 mins and neonatal trauma in all term breech cases delivered vaginally.

Aims and Objectives
1) To study the maternal complications like genital tract trauma after term breech delivered vaginally.
2) To study the neonatal complications in terms of perinatal mortality, apgar score at 5 minutes, and neonatal trauma in all singleton term breech delivered vaginally.

Material and Methods
Hundred patients with singleton term breech presentation admitted and delivered vaginally at our hospital during the year 2015 were studied retrospectively, for maternal and neonatal complications.

Results
There were total of 5975 deliveries during the year 2015, Of which there were 186 vaginal breech delivery (incidence is 3.11%). 100cases were analysed retrospectively for the study. All were unbooked cases, 90% of were multigravidae and 10% were primi, most between 21 to 30 years of age. Gesrtational age of Most of the women who delivered vaginally were between 39-40 weeks. The mean birth weight was 2.75kg. Ninety one percentage of the babies that were born had an APGAR SCORE of >/8 and 5% had < 8. There were 5 still births and 2 neonatal deaths. None of the babies had Birth trauma. Maternal genital tract trauma was seen in 4%. 1 lateral vaginal wall tear, 2 cervical tears, 1 had third degree perineal tear.

Discussion
Incidence of breech delivery in our study was 3.1% , which is comparable to Ile-Ife 3 and Ilesha 2 studies but incidence is more as compared to sokoto 4 study(1.7%) and calabar 1 studies ( 1.4%). Mean age group was 21-30 years in our study which is in comparasion with sokoto 4 study which is 26.9 years. Fawole 6 and Usmanu Sokoto 4 studies reported incidence of breech presentation more among primigravida but in our study incidence of breech is more among multigravida (90%) which is comparable to Abasiattai AM 1 , Aisien AO 5 studies. In our study there were 5 / 100 perinatal mortality where as in sokoto 4 16 has also shown that the AR of birth traumain vaginal breech delivery was <1%, which was comparableto the AR of birth trauma in vaginal cephalic deliveries ofbabies who had shoulder dystocia, a birthweight >3.5 kgand instrumental delivery. [12][13][14][15] Hannah et al. found that planned CD for breech presentation did not reduce serious morbidity in newborns in high-PMR countries as much as in low-PMR countries. They recognized thepossibility of the caregivers being more experienced inbreech deliveries in the low-PMR countries, which traditionally have low CD rates 11 . The data reflected in our study have shown that with careful selection of patients, incidence of caesarean section can be reduced in breech presentation without increasing perinatal morbi-dity and mortality Experienced obstetrician, care full assessment of events in labor careful fetomaternal assessment, monitoring of fetal wellbeing, experienced paediartician provides comparable fetal outcome by elective caesarean section

Conclusion
We conclude that in proper assessment of indivisual case and selection and in well managed cases the risk to the fetus is minimal following vaginal breech delivery. Offering a trial of vaginal breech delivery to selected and well counselled women is an appropriate option without compromising perinatal and maternal outcome. Thus contributing in decreasing the rising caesarean section rate.

Implication
Experienced obstetrician, care full assessment of events in labor careful feto-maternal assessment, monitoring of fetal well-being, experienced paediartician provides comparable fetal outcome by elective caesarean section . For vaginal breech delivery to guide best practice it is necessary to set eligibility criteria at the national level. A comparative study on vaginal cephalic and vaginal breech delivery & with comparision caesarean section for breech is recommended.