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CHAPTER 22:  Normal Labor

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Fetal orientation.

• MECHANISMS OF LABOR
• NORMAL LABOR CHARACTERISTICS
• MANAGEMENT OF NORMAL LABOR
• LABOR MANAGEMENT PROTOCOLS
• Full Chapter
• Supplementary Content

Labor is the process that leads to childbirth. It begins with the onset of regular uterine contractions and ends with delivery of the newborn and expulsion of the placenta. Pregnancy and birth are physiological processes. Thus, labor and delivery should be considered normal for most women.

Fetal position within the birth canal is critical to labor progress and to the delivery route. It should be determined in early labor, and sonography can be implemented for unclear cases. Important relationships include fetal lie, presentation, attitude, and position.

Of these, fetal lie describes the relationship of the fetal long axis to that of the mother. In more than 99 percent of labors at term, the fetal lie is longitudinal . A transverse lie is less frequent. Occasionally, the fetal and maternal axes may cross at a 45-degree angle to form an oblique lie . This is unstable and becomes longitudinal or transverse during labor.

Fetal Presentation

The presenting part is the portion of the fetal body either within or in closest proximity to the birth canal. It usually can be felt through the cervix on vaginal examination. In longitudinal lies, the presenting part is either the fetal head or the breech, creating cephalic and breech presentations, respectively. When the fetus lies with the long axis transversely, the shoulder is considered the presenting part.

Cephalic presentations are subclassified according to the relationship between the head and body of the fetus ( Fig. 22-1 ). Ordinarily, the head is flexed sharply so that the chin contacts the thorax. The occipital fontanel is the presenting part, and this presentation is referred to as a vertex or occiput presentation . Much less often, the fetal neck may be sharply extended so that the occiput and back come into contact, and the face is foremost in the birth canal— face presentation . The fetal head may assume a position between these extremes. When the neck is only partly flexed, the anterior (large) fontanel may present— sinciput presentation . When the neck is only partially extended, the brow may emerge— brow presentation . These latter two are usually transient. As labor progresses, sinciput and brow presentations almost always convert into occiput or face presentations by neck flexion or extension, respectively. If not, dystocia can develop ( Chap. 23 , p. 441).

FIGURE 22-1

Longitudinal lie, cephalic presentation. Differences in attitude of the fetal body in (A) occiput, (B) sinciput, (C) brow, and (D) face presentations. Note changes in fetal attitude as the fetal head becomes less flexed.

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Breech Position and Breech Birth

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• Condition Basics

What is breech position?

During most of pregnancy, there is enough room in the uterus for the baby (fetus) to change position. By 36 weeks of pregnancy, most babies turn into a head-down position. This is the normal and safest fetal position for birth.

But in about 4 out of 100 births, the baby doesn't naturally turn head-down. Instead, the baby is in a breech position. footnote 1 Babies in breech position usually must be delivered by C-section .

There are three main breech positions :

The buttocks are in place to come out first during delivery. The legs are straight up in front of the body, with the feet near the head. This is the most common type of breech position.

The buttocks are down near the birth canal. The knees are bent, and the feet are near the buttocks.

One leg or both legs are stretched out below the buttocks. The leg or legs are in place to come out first during delivery.

What causes it?

Most of the time, there is no clear reason why the baby did not turn head-down.

In some cases, breech position may be linked to early labor, twins or more, problems with the uterus, or problems with the baby. footnote 2

What are the signs?

You probably won't be able to feel whether your baby is breech. But if you are 36 or more weeks pregnant and think you feel the baby's head pressing high up in your belly or you feel kicking in your lower belly, see your doctor for an exam.

How is it diagnosed?

During a routine exam late in your pregnancy, your doctor will feel your upper and lower belly and may do a fetal ultrasound to find out if your baby is breech. Your doctor may also learn that your baby is breech when he or she checks your cervix .

How is breech position treated?

Sometimes a doctor can turn a baby from a breech position to a head-down position by using a procedure called an external cephalic version. (If you are using a midwife and your baby is in breech position, your midwife will refer you to a doctor for this procedure.) If the baby can be turned head-down before labor starts, you may be able to have a vaginal birth.

You also can ask your doctor if you can try certain positions at home that may help turn your baby. This is called postural management. There is no research to prove that this works, but it's not harmful. It may work for you.

It's normal to feel disappointed and worried about a breech pregnancy, especially if the doctor has tried to turn the baby without success. But most breech babies are healthy and don't have problems after birth. Talk to your doctor if you're concerned about your baby's health.

How is a breech baby delivered safely?

In most cases, a planned cesarean delivery (C-section) is safest for the baby. If your fetus is still in a breech position near your due date, your doctor will likely schedule a cesarean. If you are using a midwife, your midwife will refer you to a doctor for a scheduled cesarean.

In rare cases, a cesarean breech birth may not be recommended or even possible. For instance, if a breech labor progresses too quickly, a vaginal birth may be the only option. During a twin birth in which the first twin is head-down and the second twin is breech, both babies may best be delivered vaginally. footnote 3

No matter what position a baby is in, every labor and delivery is unique. Even though you and your doctor have a birth plan for labor and delivery, plans can change. If something unexpected happens, your doctor may need to make some quick decisions to keep you and your baby safe.

• Related Information
• Cesarean Section
• Labor and Delivery
• Multiple Pregnancy: Twins or More
• Vaginal Birth After Cesarean (VBAC)

Citations American College of Obstetricians and Gynecologists (2000, reaffirmed 2012). External cephalic version. ACOG Practice Bulletin No. 13. Obstetrics and Gynecology , 95(2): 1–7. Cunningham FG, et al. (2010). Breech presentation and delivery. In Williams Obstetrics , 23rd ed., pp. 527–543. New York: McGraw-Hill. American College of Obstetricians and Gynecologists (2006, reaffirmed 2012). Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. Obstetrics and Gynecology , 108: 235–237.

Current as of: July 10, 2023

Author: Healthwise Staff Clinical Review Board All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

Author: Healthwise Staff

Clinical Review Board All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

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Breech presentation

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency cesarean section and placenta previa; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned cesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned cesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. [1] Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997. [2] Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned cesarean section.

History and exam

Key diagnostic factors.

• buttocks or feet as the presenting part
• fetal head under costal margin
• fetal heartbeat above the maternal umbilicus

Other diagnostic factors

• subcostal tenderness
• pelvic or bladder pain

Risk factors

• premature fetus
• small for gestational age fetus
• nulliparity
• fetal congenital anomalies
• previous breech delivery
• uterine abnormalities
• abnormal amniotic fluid volume
• placental abnormalities
• female fetus

Diagnostic investigations

1st investigations to order.

• transabdominal/transvaginal ultrasound

Treatment algorithm

<37 weeks' gestation, ≥37 weeks' gestation not in labor, ≥37 weeks' gestation in labor: no imminent delivery, ≥37 weeks' gestation in labor: imminent delivery, contributors, natasha nassar, phd.

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Disclosures

NN has received salary support from Australian National Health and a Medical Research Council Career Development Fellowship; she is an author of a number of references cited in this topic.

Christine L. Roberts, MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

CLR declares that she has no competing interests.

Jonathan Morris, MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

JM declares that he has no competing interests.

Peer reviewers

John w. bachman, md.

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

JWB declares that he has no competing interests.

Rhona Hughes, MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

RH declares that she has no competing interests.

Brian Peat, MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

BP declares that he has no competing interests.

Lelia Duley, MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

LD declares that she has no competing interests.

Justus Hofmeyr, MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

JH is an author of a number of references cited in this topic.

Differentials

• Transverse lie
• Antenatal corticosteroids to reduce neonatal morbidity and mortality
• Caesarean birth

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Practical Guide to Simulation in Delivery Room Emergencies pp 363–379 Cite as

Breech Delivery and Updates in Simulation for Breech Vaginal Delivery

• Joseph Bouganim 4 ,
• Fatima Estrada Trejo 5 , 6 &
• Kfier Kuba 4  
• First Online: 14 June 2023

524 Accesses

The incidence of breech presentation at term is approximately 3–4%. In the United States, more than 85% of pregnant women with persistent breech presentation are delivered by cesarean delivery. The Term Breech Trial, published in 2000, reported an increased risk of short-term complications in singleton breech vaginal deliveries. More recent evidence, however, has refuted these findings. In select patients, planned vaginal delivery of the breech-presenting fetus is encouraged by several professional societies today. The aim of this chapter is to provide an evidence-based overview of breech vaginal delivery in both term and preterm pregnancies, including a comprehensive review of the Term Breech Trial and its impact worldwide. Technique for breech vaginal delivery is discussed in detail, as well as current trends in obstetrics simulation for breech delivery.

• Breech vaginal delivery
• Term breech trial
• Breech delivery simulation
• Breech presentation
• Breech technique
• Vaginal breech

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Albert Einstein College of Medicine, New York, NY, USA

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Bouganim, J., Trejo, F.E., Kuba, K. (2023). Breech Delivery and Updates in Simulation for Breech Vaginal Delivery. In: Cinnella, G., Beck, R., Malvasi, A. (eds) Practical Guide to Simulation in Delivery Room Emergencies. Springer, Cham. https://doi.org/10.1007/978-3-031-10067-3_20

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Breech Position and Breech Birth

Topic contents, condition basics, related information, what is breech position.

During most of pregnancy, there is enough room in the uterus for the baby (fetus) to change position. By 36 weeks of pregnancy, most babies turn into a head-down position. This is the normal and safest fetal position for birth.

But in about 4 out of 100 births, the baby doesn't naturally turn head-down. Instead, the baby is in a breech position. footnote 1 Babies in breech position usually must be delivered by C-section .

There are three main breech positions :

The buttocks are in place to come out first during delivery. The legs are straight up in front of the body, with the feet near the head. This is the most common type of breech position.

The buttocks are down near the birth canal. The knees are bent, and the feet are near the buttocks.

One leg or both legs are stretched out below the buttocks. The leg or legs are in place to come out first during delivery.

What causes it?

Most of the time, there is no clear reason why the baby did not turn head-down.

In some cases, breech position may be linked to early labour, twins or more, problems with the uterus, or problems with the baby. footnote 2

What are the signs?

You probably won't be able to feel whether your baby is breech. But if you are 36 or more weeks pregnant and think you feel the baby's head pressing high up in your belly or you feel kicking in your lower belly, see your doctor for an examination.

How is it diagnosed?

During a routine examination late in your pregnancy, your doctor will feel your upper and lower belly and may do a fetal ultrasound to find out if your baby is breech. Your doctor may also learn that your baby is breech when he or she checks your cervix .

How is breech position treated?

Sometimes a doctor can turn a baby from a breech position to a head-down position by using a procedure called an external cephalic version. (If you are using a midwife and your baby is in breech position, your midwife will refer you to a doctor for this procedure.) If the baby can be turned head-down before labour starts, you may be able to have a vaginal birth.

You also can ask your doctor if you can try certain positions at home that may help turn your baby. This is called postural management. There is no research to prove that this works, but it's not harmful. It may work for you.

It's normal to feel disappointed and worried about a breech pregnancy, especially if the doctor has tried to turn the baby without success. But most breech babies are healthy and don't have problems after birth. Talk to your doctor if you're concerned about your baby's health.

How is a breech baby delivered safely?

In most cases, a planned caesarean delivery (C-section) is safest for the baby. If your fetus is still in a breech position near your due date, your doctor will likely schedule a caesarean. If you are using a midwife, your midwife will refer you to a doctor for a scheduled caesarean.

In rare cases, a caesarean breech birth may not be recommended or even possible. For instance, if a breech labour progresses too quickly, a vaginal birth may be the only option. During a twin birth in which the first twin is head-down and the second twin is breech, both babies may best be delivered vaginally. footnote 3

No matter what position a baby is in, every labour and delivery is unique. Even though you and your doctor have a birth plan for labour and delivery, plans can change. If something unexpected happens, your doctor may need to make some quick decisions to keep you and your baby safe.

• Caesarean Section
• Labour and Delivery
• Multiple Pregnancy: Twins or More
• Vaginal Birth After Caesarean (VBAC)

Citations American College of Obstetricians and Gynecologists (2000, reaffirmed 2012). External cephalic version. ACOG Practice Bulletin No. 13. Obstetrics and Gynecology , 95(2): 1–7. Cunningham FG, et al. (2010). Breech presentation and delivery. In Williams Obstetrics , 23rd ed., pp. 527–543. New York: McGraw-Hill. American College of Obstetricians and Gynecologists (2006, reaffirmed 2012). Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. Obstetrics and Gynecology , 108: 235–237.

Current as of: November 9, 2022

Author: Healthwise Staff Medical Review: Sarah Marshall MD - Family Medicine Adam Husney MD - Family Medicine Kathleen Romito MD - Family Medicine William Gilbert MD - Maternal and Fetal Medicine

Author: Healthwise Staff

Medical Review: Sarah Marshall MD - Family Medicine & Adam Husney MD - Family Medicine & Kathleen Romito MD - Family Medicine & William Gilbert MD - Maternal and Fetal Medicine

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Cardini F , Weixin H. Moxibustion for Correction of Breech Presentation : A Randomized Controlled Trial . JAMA. 1998;280(18):1580–1584. doi:10.1001/jama.280.18.1580

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Moxibustion for Correction of Breech Presentation : A Randomized Controlled Trial

From the Jiangxi Women's Hospital, Nanchang, People's Republic of China (Dr Weixin). Dr Cardini is in private practice in Verona, Italy.

Context.—  Traditional Chinese medicine uses moxibustion (burning herbs to stimulate acupuncture points) of acupoint BL 67 (Zhiyin, located beside the outer corner of the fifth toenail), to promote version of fetuses in breech presentation. Its effect may be through increasing fetal activity. However, no randomized controlled trial has evaluated the efficacy of this therapy.

Objective.—  To evaluate the efficacy and safety of moxibustion on acupoint BL 67 to increase fetal activity and correct breech presentation.

Design.—  Randomized, controlled, open clinical trial.

Setting.—  Outpatient departments of the Women's Hospital of Jiangxi Province, Nanchang, and Jiujiang Women's and Children's Hospital in the People's Republic of China.

Patients.—  Primigravidas in the 33rd week of gestation with normal pregnancy and an ultrasound diagnosis of breech presentation.

Interventions.—  The 130 subjects randomized to the intervention group received stimulation of acupoint BL 67 by moxa (Japanese term for Artemisia vulgaris ) rolls for 7 days, with treatment for an additional 7 days if the fetus persisted in the breech presentation. The 130 subjects randomized to the control group received routine care but no interventions for breech presentation. Subjects with persistent breech presentation after 2 weeks of treatment could undergo external cephalic version anytime between 35 weeks' gestation and delivery.

Main Outcome Measures.—  Fetal movements counted by the mother during 1 hour each day for 1 week; number of cephalic presentations during the 35th week and at delivery.

Results.—  The intervention group experienced a mean of 48.45 fetal movements vs 35.35 in the control group ( P <.001; 95% confidence interval [CI] for difference, 10.56-15.60). During the 35th week of gestation, 98 (75.4%) of 130 fetuses in the intervention group were cephalic vs 62 (47.7%) of 130 fetuses in the control group ( P <.001; relative risk [RR], 1.58; 95% CI, 1.29-1.94). Despite the fact that 24 subjects in the control group and 1 subject in the intervention group underwent external cephalic version, 98 (75.4%) of the 130 fetuses in the intervention group were cephalic at birth vs 81 (62.3%) of the 130 fetuses in the control group ( P =.02; RR, 1.21; 95% CI, 1.02-1.43).

Conclusion.—  Among primigravidas with breech presentation during the 33rd week of gestation, moxibustion for 1 to 2 weeks increased fetal activity during the treatment period and cephalic presentation after the treatment period and at delivery.

IN CASES OF BREECH presentation at the onset of labor, delivery is associated with additional risks: for the mother, cesarean delivery and for the neonate, physical injury. Breech presentation is common in the midtrimester pregnancy and the incidence decreases as the pregnancy approaches term because of spontaneous version. 1 - 4 It is reasonable to assume (although not firmly established) that fetal activity plays an important role in spontaneous version. 5 - 9 The incidence of breech presentation at delivery can be reduced, but not eliminated, by the use of external cephalic version (ECV). 10

Since ancient times, traditional Chinese medicine has proposed moxibustion of acupoint BL 67 (Zhiyin) to promote version of fetuses in breech presentation. Moxibustion is a traditional Chinese method that uses the heat generated by burning herbal preparations containing Artemisia vulgaris (mugwort) (the Japanese name is moxa ) to stimulate acupuncture points. Acupoint BL 67 is beside the outer corner of the fifth toenail.

At present, there are no randomized, controlled clinical trials to evaluate the efficacy of this therapy. The 2 published Chinese studies 11 , 12 are not randomized and are based on a mixed population of primipara and multipara subjects stimulated at varying times between the 28th and 38th weeks of pregnancy. Although both studies give encouraging results and stimulate reflection regarding possible mechanisms of action, they do not allow definitive conclusions regarding efficacy because they are not randomized, little information is provided about the population sample, and the times at which stimulation is applied are wide ranging.

Cardini et al 13 identified the stage of pregnancy at which stimulation should commence and the parity status of the groups studied as primary factors to ensure the reliability of a clinical trial concerning spontaneous or induced correction of breech presentation.

Data in the literature concerning the probability of spontaneous correction indicate that correcting breech presentation before the 32nd week is useless. 14 - 16 There is also a sharp differentiation between multigravidas (high likelihood of spontaneous correction of breech presentation, even between the 32nd and 35th weeks) and primigravidas or multigravidas with a previous breech presentation at term (low probability of spontaneous version after the 32nd week). 15 - 17

Gottlicher and Madjaric, 15 , 16 by ultrasound examination of 4066 pregnant women, defined the likelihood of spontaneous correction of breech presentation from the 33rd week of pregnancy as 15.5% (95% confidence interval [CI], 2.8%-28.2%) for primigravidas and 57.5% (95% CI, 36.3%-78.7%) for multigravidas.

Westgren et al, 17 by ultrasound screening of 4600 women in the 32nd week of pregnancy, identified 310 cases (6.7%) of breech presentation, which were prospectively studied until birth. Rates of spontaneous cephalic version varied, according to whether subjects were primigravida (46%), multigravida with a previous breech presentation (32%), or multigravida with no previous breech presentation (78%). All the studies available report data relating to Western populations and we have been unable to retrieve any information regarding the spontaneous version rate from the 33rd week to term among Chinese pregnant women.

Given this background, Cardini and Marcolongo, 18 in a retrospectively controlled clinical trial, compared 23 primigravidas treated for breech presentation by moxibustion in the 32nd and 33rd week with a retrospective, untreated group at the same stage of pregnancy. The difference in prevalence of breech presentation showed borderline statistical significance ( P =.05). Thus, the subgroup of primigravidas with breech presentation at the 33rd week of pregnancy seemed to be the ideal population for a randomized, controlled clinical trial.

We undertook this study to evaluate the efficacy and safety of moxibustion on acupoint BL 67 in correcting breech presentation in a population of primigravidas treated since the 33rd week of pregnancy and to evaluate the efficacy of this technique in increasing active fetal movements (AFMs).

These 2 main objectives are consistent with the hypothesis that the use of moxibustion in women whose fetuses are breech in the 33rd week of pregnancy will (1) increase fetal activity; (2) reduce the proportion of fetuses that remain in a nonvertex presentation and, hence, decrease the need for ECV; and (3) decrease the incidence of breech presentation at birth. A secondary aim of the study was to assess the efficacy of 2 different dosages of moxibustion.

This was a randomized, controlled, open clinical trial of subjects treated by moxibustion since the 33rd week of pregnancy (intervention group) vs untreated subjects (control group). Subjects with persistent breech presentation after 2 weeks' treatment (intervention group) or observation (control group) could undergo ECV. Moxibustion in the early third trimester and ECV in late pregnancy are the standard care for breech presentation in both the centers involved in the trial. Thus (and also for ethical reasons), the availability of ECV was maintained for all subjects recruited.

Subjects were included if they were primigravidas, in the 33rd week of gestation (from 32 weeks + 1 day to 33 complete weeks, based on the last menstruation date and ultrasound data), with breech presentation diagnosed by ultrasound within 24 hours of randomization, and with normal fetal biometry (biparietal diameter and abdominal circumference between the 10th and 90th percentiles). Subjects were excluded if they had pelvic defects, previous uterine surgery, uterine malformation or fibromyoma of diameter greater than 4 cm, fetal malformation, twin gestation, tocolytic therapy during pregnancy, risk of premature birth (uterine hypercontractility and/or initial shortening or dilatation of the neck, with a Bishop score ≥4), or pathological pregnancy (eg, intrauterine growth retardation, gestosis, serious infections, placenta previa, polyhydramnios, oligohydramnios) judged by the investigator to contraindicate inclusion in the study. Subjects refusing to undergo treatment were also excluded.

The trial was conducted from April 1995 through August 1996 in the Women's Hospital of Jiangxi Province, Nanchang, People's Republic of China. A few subjects (23) were recruited in the nearby Jiujiang Women's and Children's Hospital, also in Jiangxi Province. The subjects were recruited during the routine management of normal pregnancies in the outpatient department. All procedures were executed by midwives (with the supervision of physicians) except ultrasound examinations and ECVs. The protocol followed the ethical standards of the Declaration of Helsinki.

Pregnant women fulfilling all criteria of the study were asked to participate. Interested subjects gave oral informed consent. Subjects had an ultrasound scan at the 33rd week. On the day of the ultrasound scan by which breech presentation was confirmed, the selected subject was randomly assigned to 1 of the 2 groups. The sample was randomly allocated by numbered envelopes (randomized in groups of 10 by the computer program PACT, Version 2.0 [Glaxo-Wellcome, London, England], in Italy). Once randomized, subjects and investigators were aware of group assignment. All subjects recruited were advised to avoid or, at least, to ask the investigators about other interventions or therapies that could contaminate the results of the trial.

All subjects were asked to return after 2 weeks for an ultrasound check on presentation. If breech presentation persisted at this time, the subject (after giving informed consent) could undergo ECV in the following weeks.

All subjects were also asked to complete 2 record forms for AFMs, 1 for each of the 2 weeks subsequent to recruitment. These 2 forms were returned at the time of the ultrasound examination. Each record form had to be completed once daily for 7 days, reporting the number of AFMs counted in 1 hour (if possible, between 5 and 8 PM) and times of starting and finishing the count.

Finally, each subject was asked to report all significant details of her pregnancy and delivery during a personal or telephone appointment after she had given birth. The following specific information was collected: date of birth, place of birth, name and address of the obstetrician normally consulted, and name and address of the obstetrician present at birth. In this way, it was possible to consult other sources of information (obstetrician normally consulted, obstetrician present at birth, patient record forms) if the subject provided incomplete or unreliable information. Because almost all the enrolled subjects gave birth in the same hospital where they had been studied, information about delivery was reliable and easy to check.

If the subject belonged to the intervention group, she was admitted to the hospital to attend an instruction session within 24 hours of randomization, alone or with her partner or the person who was actually going to help administer the treatment. Teaching the technique for applying moxibustion at home included presenting the moxibustion material (cigar-shaped rolls containing Artemisia ), locating of acupoint BL 67, and explaining the technique for stimulation of acupoint BL 67. During the therapy the subject relaxed in the sitting or semisupine position, with the partner sitting comfortably. The therapy was executed for 30 minutes (15 minutes per side) daily for 7 days in the first 87 subjects, and twice daily in the last 43 subjects. The subjects were allowed to choose the time, ensuring no interruptions in the therapy (if possible, between 5 and 8 PM). The intensity of moxibustion was just below the individual tolerability threshold, causing hyperemia from local vasodilatation but not burn blisters.

Reasons for discontinuing stimulation and consulting the investigator (abdominal pain, other suspected adverse effects, sensation that version had occurred before completion of 7 days' treatment) were explained to the subject, together with symptoms suggesting that version had occurred (decreased pressure in the epigastrium or hypochondrium, increased pressure in the hypogastrium, pollakiuria, a "different feeling" in the abdomen). The first stimulation session was executed in the hospital and the necessary materials for the following 6 days' stimulation were dispensed, together with the AFM record forms.

Last, an examination after 1 week's treatment (visit 2) was scheduled. Visit 2 included a check on presentation and collection of the AFM record form. The presentation check was by localization of fetal heartbeats and abdominal palpation (Leopold maneuvers). Ultrasound examination was performed only in the event that the techniques described herein failed or yielded uncertain findings. 19 This was to avoid an excess of ultrasound examinations, given that an ultrasound examination was scheduled for the 35th week in all subjects. If cephalic version had not occurred, another week's treatment was advised if there were no adverse effects and the subject agreed to continue. Further moxa rolls were therefore dispensed to the subject with a second AFM record form. The frequency of the treatment was the same as in the first week. Visit 3 was scheduled and executed after a further week; the procedure was the same for all treated and untreated subjects as described herein ( Figure 1 ).

The primary outcomes were number of cephalic presentations at the 35th week and at birth and fetal motor activity. Secondary outcomes were compliance with treatment, observation of possible adverse effects in the intervention group and adverse events in both groups, number of cephalic versions after 1 and 2 weeks of treatment (ie, 34th and 35th weeks' gestation), number of cephalic versions with 2 different dosages of moxibustion (once or twice daily), number and causes of cesarean deliveries, spontaneous and induced vaginal deliveries, and Apgar score at 5 minutes.

On the basis of the study by Cardini and Marcolongo, 18 for primigravidas it seemed possible to identify a 30% difference in the number of cephalic presentations at the 35th week and at term between the intervention and control groups, with an α significance level of .05 and greater than 90% power if 60 subjects per group completed the study. Given that the reliability of the preliminary study was limited because it was based on retrospective data and that we decided to assess the efficacy of 2 different dosages of moxibustion, the number of enrolled subjects was increased to 130 per group.

Even if not attributable to 1 of the causes specified in the research protocol, discontinuation of treatment did not entail the subject's exclusion from the study. Outcomes of all subjects recruited were analyzed on the basis of intention to treat. Every possible effort was made to ascertain the reason for withdrawal.

The statistical processing was performed using Epi Info, Version 6.04 (Centers for Disease Control and Prevention, Atlanta, Ga). The χ 2 test (supplemented, where necessary, by the Fisher exact test) and the t test were used for comparing qualitative and continuous variables, respectively. The measurement of effects was also described in terms of relative risk (RR) with 95% confidence intervals (CIs).

The total number of subjects was 260 (130 subjects per group), recruited, randomized, observed, or treated and followed up to delivery. No significant differences emerged between the intervention group and the control group ( Table 1 ). Neither the placental localization and grading nor the amount of amniotic fluid at the 33rd week showed significant differences between the 2 groups.

The main results of the trial are summarized in Table 2 . At the ultrasound check at the 35th week of gestation (2 weeks after the first visit), 98 (75.4%) of 130 fetuses in the intervention group were cephalic compared with 62 (47.7%) of 130 in the control group ( P <.001; RR, 1.58; 95% CI, 1.29-1.94).

After 35 weeks of pregnancy, only 1 subject in the intervention group agreed to undergo ECV, but version was not obtained. Twenty-four subjects in the control group agreed to undergo ECV and in 19 subjects cephalic version was obtained. Despite this, the number of cephalic presentations at birth was still significantly different in the 2 groups: 98 (75.4%) of 130 in the intervention group compared with 81 (62.3%) of 130 in the control group ( P =.02; RR, 1.21; 95% CI, 1.02-1.43). The results obtained excluding subjects treated with ECV are shown in Table 2 .

Of the 98 cephalic versions obtained in the intervention group, 82 occurred during the first week and 16 during the second week of treatment. The cephalic or breech presentations observed at the second visit (35th week of pregnancy) remained unchanged up to term in all subjects treated and observed, except for those successfully treated with ECV.

The only intervention allowed for the subjects in the control group was ECV during the last 5 weeks of pregnancy. They were specifically questioned at the 35th week and after delivery and none reported having been treated with moxibustion or other therapies.

Among the intervention group only 1 subject failed to comply with the treatment schedule prescribed and discontinued the therapy. At the end of the first week of treatment 8 subjects withdrew from therapy, 3 on the advice of the obstetrician (for Braxton Hicks contractions, breech engagement, and maternal tachycardia and atrial sinus arrhythmia, respectively) and 5 subjects for unspecified reasons. All 9 subjects maintained the breech presentations of their fetuses to term and none of them were excluded from the statistical analysis.

The form of discomfort most frequently reported by both groups was a sense of tenderness and pressure in the epigastric region or in one of the hypochondria (epigastric crushing) attributable to the head of the breech fetus pressing against the maternal organs.

No adverse events occurred in the intervention group during treatment. After treatment, 2 premature births occurred (both at 37 weeks), 1 of which was preceded by premature rupture of the membranes (PROM). There were 4 PROMs in the intervention group.

Adverse events occurring in the control group included 3 premature births at 34, 35, and 37 weeks (the third was preceded by placental detachment with fetal distress) and 1 intrauterine fetal death (intrauterine growth retardation and oligohydramnios, spontaneous delivery at 38 weeks; growth was within normal limits at ultrasound examination at 35 weeks). The total number of PROMs in the control group was 12.

Regarding the efficacy of the moxibustion treatment in producing an increase in fetal motility, comparison between the 2 groups proved possible for only the first week of treatment (or observation) because all the subjects in the intervention group who achieved cephalic version in the first week of treatment filled in only the first of the 2 record forms used for the weekly AFM counts. The mean value for fetal movements recorded during a 1-hour observation period for 7 days was 48.45 for the subjects in the intervention group and 35.35 for the subjects in the control group (difference, 13.08; 95% CI, 10.56-15.60; t test, 10.215; P <.001).

In the intervention group, the first 87 subjects received 1 stimulation per day, lasting 30 minutes, for 7 or 14 days (QD [ quaque die ] group). The last 47 subjects received 2 30-minute stimulations per day for 7 or 14 days (BID [ bis in die ] group). The 2 subgroups showed no significant differences in amount of amniotic fluid during the 33rd week, frequency of straight or bent leg position during the 33rd week, placental localization, neonatal sex, treatment compliance, or adverse effects attributable to the treatment.

At the end of the first week of treatment in the BID group, 34 (79.1%) of 43 cephalic versions were obtained compared with 48 (55.2%) of 87 in the QD group ( P =.007; RR, 1.43; 95% CI, 1.12-1.83).

During the second week of treatment, 15 additional cephalic versions were obtained in the QD group and only 1 additional version in the BID group. Thus, the following cephalic presentation results were observed on ultrasound examination at the end of the second week of treatment: 63 (72.4%) of 87 in the QD group and 35 (81.4%) of 43 in the BID group (nonsignificant difference). The same percentages were maintained to term.

No statistically significant differences were found in the number of cesarean deliveries performed. In the intervention group, 46 cesarean deliveries (35.4% of births) were performed, 20 of which were with cephalic presentations and 26 of which were with breech presentations. The 20 cesarean deliveries in the cephalic presentations were performed for fetopelvic disproportion (14 cases), postterm pregnancy (3 cases), or fetal distress (3 cases). The 26 cesarean deliveries in the breech presentations were performed for PROM after week 37 (10 cases), large fetus (2 cases), fetal distress (1 case), oligohydramnios (2 cases), and unspecified causes (11 cases).

In the control group, 47 cesarean deliveries (36.2%) were performed, 21 of which were with cephalic presentations and 26 of which were with breech presentations. Indications for cesarean delivery in the subjects with cephalic fetuses included fetopelvic disproportion (11 cases, 1 of which was with oligohydramnios), fetal distress (4 cases, 1 of which was in a subject with toxemia of pregnancy), sacral rotation of the occiput (2 cases), placental insufficiency (1 case), toxemia of pregnancy (1 case), PROM (1 case), and deep transverse arrest (1 case). Cesarean deliveries in the breech presentations were performed for PROM after 37 weeks (8 cases, 1 of which was with prolapse of the cord), oligohydramnios (3 cases), fetal distress (2 cases), large fetus (1 case), and unspecified causes (12 cases).

In both the intervention and control groups, cesarean delivery revealed 1 case of previously undiagnosed bicornuate uterus. In both cases, the presentation at birth was breech. Because they had been randomized, both cases were included in the statistical analysis of the data despite uterine malformations being exclusion criterion.

In regard to vaginal deliveries, the only significant difference between the 2 groups relates to the use of oxytocin, given to 7 (8.6%) of 81 subjects in the intervention group vs 25 (31.3%) of 80 in the control group (RR, 1.33 [95% CI, 1.13-1.56]; P <.001) before or during labor. In the intervention group, 2 vacuum-extractor and 1 forceps deliveries were performed and in the control group, 2 vacuum-extractor and 3 forceps deliveries were performed.

No neonates in the intervention group, but 7 in the control group, had Apgar scores of less than 7 at 5 minutes (Fisher exact test, P =.006). On grouping Apgar scores in the traditional manner, in the intervention group no neonates had Apgar scores less than 4 and 4 had scores 4 to 7; in the control group, 2 neonates had Apgar scores less than 4 and 12 had scores 4 to 7.

Moxibustion is a popular and much appreciated therapy for breech presentation in the People's Republic of China; thus, it would have been impossible to propose a "sham moxibustion" as a placebo for the control group.

Furthermore, moxibustion is a typical cheap, self-administered home therapy. This made blinding practically impossible. It was very difficult for investigators to persuade subjects to accept randomization and the consequent risk of having to do without the therapy. Consent was often obtained because of the availability of ECV later in pregnancy, but this is a much less popular and somewhat feared therapy; thus, only a few subjects, mostly belonging to the control group, opted for this solution.

Because the main results of the trial are of a qualitative type and were measured objectively (ultrasound), we believe that the lack of blinding and a placebo does not undermine the validity of the results. This is not entirely the case when considering fetal movement count, which was subjectively assessed.

The choice of sample (primigravidas at the 33rd week of gestation) appears to have been appropriate because the presentation did not change after the 35th week in any of the subjects (except for those undergoing ECV). This confirms the rarity of spontaneous fetal version (to either breech or cephalic presentation) among primigravidas after the 35th week. 16

Two half-hour stimulations per day proved more effective in producing cephalic version than a single stimulation. On prolonging the therapy by 1 week in those cases in which cephalic version was not achieved, this difference in efficacy was partly, although not entirely, annulled. Of the 2 dosages, then, twice-daily stimulation is recommended because it did not reduce treatment compliance and had no adverse effects. Compliance with the treatment was by and large good.

In 2 cases, disorders serious enough to prompt discontinuation were observed during treatment. It was not clear whether these were adverse effects of the treatment.

No severe adverse events attributable to the treatment were observed and, in particular, there were no cases of intrauterine death or placental detachment. No cases of severe fetal anemia attributable to fetomaternal transfusion 20 were reported. The number of PROMs was similar in both groups and the number of premature births was lower in the intervention group.

Moxibustion treatment did not reduce the rate of cesarean deliveries in a population in which elective cesarean delivery is not envisaged for breech presentations. On the other hand, it is possible that the significantly higher number of breech presentations at birth in the control group may have been a factor in bringing about worse Apgar scores.

The mechanism of action of moxibustion appears to be through increased AFMs, which proved significantly stronger in the treated subjects. Although a number of studies in China 11 , 12 , 21 have investigated the neurologic path of stimulation by moxibustion and have shown evidence of its effect on maternal plasma cortisol and prostaglandins, we think that the mechanism of action of moxibustion is not entirely clear and warrants further research.

Further studies 22 are needed to establish the efficacy and safety of moxibustion at more advanced gestational ages than those considered in this trial, as well as in second pregnancies or multigravidas and populations other than Chinese. Moreover, it is not clear whether moxibustion is more or less efficacious than ECV at term for obtaining cephalic presentation given the small number of subjects (nearly all belonging to the control group) who underwent ECV. Furthermore, since moxibustion and ECV must be performed at different gestational ages, we may regard them as complementary therapies to be used in succession. As we see it, if the results of this trial are confirmed, moxibustion should be extensively used on account of its noninvasiveness, low cost, and ease of execution. In fact, it is easy to train expectant mothers (either alone or with their partners) to administer the therapy at home. Further studies are also necessary to establish whether moxibustion treatment can reduce the rate of cesarean deliveries where these are used electively for breech presentation at birth.

Additional results regarding the effects of family history, fetal sex, cranial circumference, and leg position on the likelihood of cephalic version will be presented in a subsequent article.

On the basis of the results of the trial, moxibustion, when performed in primigravidas for 1 or 2 weeks starting in the 33rd week of pregnancy, has proved to be an effective therapy for inducing a significant increase in cephalic versions within 2 weeks of the start of therapy and in cephalic presentations at birth.

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Risk factors for adverse outcomes in vaginal preterm breech labor

Anna toijonen.

1 Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290 Helsinki, Finland

Seppo Heinonen

Mika gissler.

2 National Institute for Health and Welfare (THL), Helsinki, Finland

Georg Macharey

Associated data.

The Finnish register data have been given for this specific study, and the data cannot be shared without authorization from the register keepers. More information on the authorization application to researchers who meet the criteria for access to confidential data can be found at Findata, the Health and Social Data Permit Authority: https://www.findata.fi/en/ .

To assess the risk factors for adverse outcomes in attempted vaginal preterm breech deliveries.

A retrospective case–control study, including 2312 preterm breech deliveries (24 + 0 to 36 + 6 gestational weeks) from 2004 to 2018 in Finland. The preterm breech fetuses with adverse outcomes born vaginally or by emergency cesarean section were compared with the fetuses without adverse outcomes with the same gestational age. A multivariable logistic regression analysis was used to calculate the risk factors for adverse outcomes (umbilical arterial pH below 7, 5-min Apgar score below 4, intrapartum stillbirth and neonatal death < 28 days of age).

Adverse outcome in vaginal preterm breech delivery was associated with maternal obesity (aOR 32.19, CI 2.97–348.65), smoking (aOR 2.29, CI 1.12–4.72), congenital anomalies (aOR 4.50, 1.56–12.96), preterm premature rupture of membranes (aOR 1.87, CI 1.00–3.49), oligohydramnios (28–32 weeks of gestation: aOR 6.50, CI 2.00–21.11, 33–36 weeks of gestation: aOR 19.06, CI 7.15–50.85), epidural anesthesia in vaginal birth (aOR 2.44, CI 1.19–5.01), and fetal growth below the second standard deviation (28–32 weeks of gestation: aOR 5.89, CI 1.00–34.74, 33–36 weeks of gestation: aOR 12.27, CI 2.81–53.66).

The study shows that for each subcategory of preterm birth, there are different risk factors for adverse neonatal outcomes in planned vaginal breech delivery. Due to the extraordinary increased risk of adverse outcomes, we would recommend a planned cesarean section in very preterm breech presentation (28 + 0 to 32 + 6 weeks) with severe maternal obesity, oligohydramnios, or fetal growth restriction and in moderate to late preterm breech presentation (33 + 0 to 36 + 6 weeks) with oligohydramnios or fetal growth restriction.

Introduction

Around 4% of all fetuses are in breech presentation at birth [ 1 , 2 ]. In preterm labor breech presentation is more common than in term and every fourth of all fetuses born extremely preterm are in breech presentation at birth [ 3 – 6 ]. Breech presentation in preterm and term pregnancies is associated with obstetric risk factors for adverse neonatal outcomes, such as oligohydramnios, fetal growth restriction, and congenital anomalies [ 7 – 9 ]. Vaginal breech delivery at term is a risk factor for short-term neonatal morbidity [ 10 ], and therefore, vaginal breech delivery is feasible only for well-selected patients [ 11 – 15 ]. In vaginal preterm breech delivery, the situation is still unclear in which cases a vaginal delivery is associated with an increased adverse neonatal outcome. The royal college of obstetricians and gynaecologists stated in their breech delivery guidelines that a spontaneous vaginal breech labor in preterm pregnancies is not contraindicated if an immediate cesarean delivery is not needed for maternal or fetal reasons [ 16 ]. In many countries, cesarean section is the most common way of delivery for preterm breech fetuses as several studies have suggested that preterm breech fetuses delivered by a primary cesarean section have a significantly lower risk of neonatal mortality compared with those delivered vaginally [ 17 – 19 ]. Cochrane review 2013 could not recommend the mode of birth instead of another in preterm deliveries irrespectively of fetal presentation [ 20 ].

Earlier studies were able to identify risk factors for adverse neonatal outcome in vaginal term breech deliveries [ 8 , 11 , 21 ], but there is no research available regarding risk factors for adverse neonatal outcome in vaginal preterm breech delivery. Our study aims to identify risk factors for adverse neonatal outcomes in vaginal preterm delivery. This information is needed, since every tenth baby is born preterm [ 20 ] and many of them are in a breech position. Obstetricians need adequate information to identify those women who should give birth by cesarean section in any case.

Materials and methods

The study is a population-based case–control study, including all singleton breech deliveries from 24 to 36 completed weeks of gestation that were delivered vaginally or by emergency cesarean section in Finland. The study period ranged from January 1st, 2004 to December 31st, 2018. The population included altogether 2312 preterm breech deliveries.

We utilized the data of the national medical birth register and the hospital discharge register maintained by the Finnish Institute for Health and Welfare. The authorization to use the data was obtained from the Finnish Institute for Health and Welfare as required by the national data protection law in Finland (reference number THL/652/5.05.00/2017). All maternity hospitals are obligated to report clinical data on national registers. The national medical birth register includes all live births and stillbirths from 22 weeks or from 500 grams. The hospital discharge register contains information on all inpatient and outpatient care in public hospitals including data from maternal, obstetric, and neonatal care. International Statistical Classification of Diseases and Related Health Problems 10th Revision, ICD-10, is used to code the information.

We limited the study population to the fetuses born vaginally or by emergency cesarean section, as we wanted to research intrapartum risk factors of preterm breech deliveries. We excluded multiple gestations, antepartum stillbirths, deliveries before 24 weeks of gestation, and term pregnancies from our study. The deliveries complicated with uterus rupture (ICD-10 O71.0, O71.1), placental abruption, and severe congenital anomalies such as chromosomal and heart defects diagnosed at birth hospital (ICD-10 Q90–Q99, Q20, Q22, Q28) that might have affected on the newborns surviving, were excluded from the study.

The primary outcome of the study was an adverse outcome defined as the following: umbilical arterial pH below 7, a 5-min Apgar score below 4, intrapartum stillbirth or neonatal death between 0 and 27 days of age. The following maternal variables were included in the analysis: age, parity, pre-pregnancy body mass index (BMI), smoking, in vitro fertilization, history of cesarean section, and maternal hypo- or hyperthyroidism (ICD-10 E03, E05). The obstetric risk factors assessed in the analysis were: maternal gestational diabetes (ICD-10 O24.4) and other diabetes treated with insulin (ICD-10 O24.0), arterial high blood pressure or preeclampsia (ICD-10 O13, O14), oligohydramnios (ICD-10 O41.0), and preterm premature rupture of membranes (PPROM) (ICD-10 O42). Induction of labor and the use of epidural anesthesia during labor were also included in the variables. The fetal factors such as sex, fetal birthweight below the second standard deviation (SD), and congenital fetal anomalies, as defined in the register of congenital malformations, were included in the analysis.

We divided the study population into three groups according to the World Health Organization (WHO) definitions of preterm deliveries. A fetus born alive before 37 completed weeks of pregnancy is defined as preterm birth, according to WHO. WHOs recommended subcategories based on gestational age were used in the division of the groups: extremely preterm (less than 28 pregnancy weeks), very preterm (28 to 32 pregnancy weeks), and moderate to late preterm (32 to 37 pregnancy weeks).

The preterm breech fetuses with adverse outcomes were compared with the fetuses without adverse outcomes with the same gestational age. Each study group, divided according to WHO classification, was separately adjusted.

We used SPSS for 19 to perform the statistical analyses. The adjustments with a binary logistic regression model were calculated for the study population. A Chi squared test or Fisher’s exact test was used when appropriate. Odds ratio (ORs) and corresponding 95% confidence interval (CIs) for each risk factor for adverse outcomes were calculated, and p values below ≤ 0.05 were considered statistically significant.

Our study included 2312 singleton preterm breech deliveries born between 24 + 0 and 36 + 6 gestational weeks in 2004–2018 in Finland. Out of these deliveries, 7.4% (172 fetuses) had adverse outcomes. The risk of having adverse outcomes was over tenfold in the fetuses born in 24 + 0 to 27 + 6 weeks of gestation and threefold in 28 + 0 to 32 + 6 weeks of gestation, compared to the late preterm breech deliveries (Fig.  1 ).

Breech presentation and adverse outcomes during the period of 2004–2018 in Finland

In 24 to 28 weeks of gestational age, 78 out of 250 breech deliveries (31.2%) had an adverse outcome. In these gestational weeks, the only significant risk factor in a trial of vaginal breech labor emerging from our study was PPROM (aOR 1.87, CI 1.00–3.49) (Table  1 ).

Table 1

Unadjusted and adjusted odds ratios for risk factors for adverse outcomes in 24 + 0 to 27 + 6 weeks of gestational age fetuses in breech presentations 2004–2018 in Finland

BMI body mass index, PPROM preterm premature rupture of membranes

Among very preterm breech deliveries (28 + 0 to 32 + 6 weeks of gestation), nearly one out of ten fetuses (47/518, 9.1%) had adverse outcomes. Severe maternal obesity (aOR 32.19, CI 2.97–348.65), oligohydramnios (aOR 6.50, CI 2.00–21.11), congenital anomalies (aOR 4.50, 1.56–12.96), and fetal growth restriction (aOR 5.89, CI 1.00–34.74) increased the risks for adverse outcomes in these gestational weeks. Nulliparity (aOR 0.43, CI 0.18–0.99) and maternal preeclampsia or high blood pressure (aOR 0.21, CI 0.05–0.96) were associated with a decreased risk of adverse outcome (Table  2 ).

Table 2

Unadjusted and adjusted odds ratios for risk factors for adverse outcomes in 28 + 0 to 32 + 6 weeks of gestational age fetuses in breech presentations 2004–2018 in Finland

In late preterm deliveries, the adverse outcomes became less frequent, as in 33 to 36 gestational weeks, only 47 out of 1544 deliveries (3.0%) had an adverse outcome. Significant risk factors for adverse outcomes in late preterm breech deliveries in our study were maternal smoking (aOR 2.29, CI 1.12–4.72), oligohydramnios (aOR 19.06, CI 7.15–50.85), epidural anesthesia in vaginal birth (aOR 2.44, CI 1.19–5.01), and fetal growth restriction (aOR 12.27, CI 2.81–53.66) (Table  3 ).

Table 3

Unadjusted and adjusted odds ratios for risk factors for adverse outcomes in 33 + 0 to 36 + 6 weeks of gestational age fetuses in breech presentations 2004–2018 in Finland

Our study shows that for each subcategory of preterm birth, there are different risk factors for adverse neonatal outcomes in planned vaginal preterm breech delivery. In extremely preterm breech deliveries (24 + 0 to 27 + 6 weeks) PPROM was associated with adverse neonatal outcomes. In very preterm breech deliveries (28 + 0 to 32 + 6 weeks) severe maternal obesity, oligohydramnios, congenital anomalies, and fetal growth restriction were associated with a higher risk of adverse neonatal outcome. In moderate to late preterm breech deliveries (33 + 0 to 36 + 6 weeks) maternal smoking, oligohydramnios, epidural anesthesia, and fetal growth restriction were identified as risk factors.

Oligohydramnios was found to increase the adverse outcomes 6.5-fold for very preterm and 19-fold for moderate to late preterm breech deliveries in our study. The results are supported by the previous literature that has shown oligohydramnios to be a risk factor for adverse perinatal outcomes in term breech pregnancies [ 8 ]. Oligohydramnios is linked to diminished fetal movements, compression of the umbilical cord, insufficiency of the placental as well as fetal aspiration of meconium [ 8 , 22 , 23 ]. Besides, previous studies have shown that a low amniotic fluid amount is linked with lower Apgar scores, a higher risk of neonatal acidosis and cesarean section as the mode of delivery due to fetal distress [ 22 ].

Fetal growth restriction in term is a well-known contraindication for vaginal breech delivery, since it is indisputably linked to severe adverse perinatal outcomes such as hypoxic injuries and even neonatal death [ 8 , 21 ]. Our results were coherent; fetal growth restriction (< − 2SD/IUGR) in planned vaginal breech delivery increased remarkably the risk for perinatal morbidity also in very preterm (sixfold) and in moderate to late preterm (12-fold) deliveries. Growth restricted fetuses might suffer more easily from distress during labor, and potential entrapment of the head during vaginal labor might increase the risks. Our study showed that smoking increased adverse outcomes in 33 to 36 weeks of gestation. Smoking is a major risk factor for intrauterine growth restriction and it is associated with obstetric complications such as placental abruption and placenta previa, as well as preterm birth itself [ 24 , 25 ].

Maternal obesity was shown as a risk for neonatal health in very preterm breech deliveries. The risk for adverse outcome increased 32-fold, if women with a BMI above 35 attempted a trial of vaginal delivery among very preterm pregnancies. Antenatal and intrapartum obstetric complications, as well as perinatal morbidity and mortality, are known to be increased in obese mothers [ 7 , 26 , 27 ]. Maternal obesity is associated with preterm delivery itself, instrumental delivery, and cesarean section as a mode of birth [ 26 , 27 ]. Also, evaluation of fetal wellbeing might be more difficult in obese women [ 26 ]. Our personal opinion is that the massive obesity has an effect on the birth channel and that a very preterm fetus is not able to path through the birth channel smoothly, through excessive soft tissue resistance.

One of the essential findings of our study was that the induction of labor did not increase the risks in preterm breech deliveries (24–27 weeks of gestation: aOR 0.50, p value 0.787, 28–32 weeks of gestation: aOR 2.13, p value 0.103, 33–36 weeks of gestation: aOR 1.38, p value 0.105). Contrary findings were found in a recent meta-analysis (2018) as induction of term breech labor was found to increase the risk of perinatal morbidity and cesarean sections [ 28 ]. However, Macharey et al. found no association between induction of term breech labor and neonatal morbidity, but the rate of vaginal deliveries was remarkably lower if term breech labor was induced compared to the spontaneous breech deliveries [ 29 ]. Induction of term labor in breech presentation was established as safe as planned cesarean delivery also in observational prospective study 2019 [ 30 ].

Our results showed a connection between epidural anesthesia in vaginal breech labor and adverse outcomes in moderate to late preterm deliveries. Earlier studies have already shown a connection between epidural anesthesia and prolonged labor in term breech deliveries [ 31 ]. Furthermore, epidural anesthesia during labor is associated with increased augmentation with oxytocin and over twofold higher risk of adverse outcomes in term breech deliveries [ 8 , 31 ]. It has been speculated whether adverse outcomes are due to the fact that epidural anesthesia is more used in prolonged labors or epidural anesthesia itself increases the duration of labor [ 8 , 31 ].

Interestingly, in our study pre-eclampsia or high blood pressure decreased the odds of adverse outcomes in very preterm breech deliveries. However, pre-eclampsia is a well-identified risk factor for maternal and neonatal mortality and morbidity [ 32 ]. Pre-eclampsia is associated with intrauterine growth restriction and congenital anomalies [ 32 – 34 ], in which both conditions increased the adverse perinatal outcomes in our study among very preterm deliveries. Our contradictory results might be explained by the fact that the small number of cases may not have had enough power to detect differences between the groups. Besides, maternal obstetric risk factors such as pre-eclampsia or high blood pressure may be considered as a contraindication for vaginal delivery and thus these women have more often a planned cesarean section as mode of delivery. These circumstances might cause bias in the results [ 35 ].

Other authors have shown primiparous women to have more adverse perinatal outcomes [ 36 ]. Furthermore, primiparity is linked to low birth weight in term pregnancies [ 37 ], and in our results, fetal growth restriction in preterm breech deliveries seemed to increase the risks. Nevertheless, primiparity in preterm breech deliveries was not found as a risk for perinatal morbidity in our study, and in contrary, primiparity appeared as a protective factor in very preterm vaginal breech delivery. This finding may partly be explained that the mode of birth is more likely primary cesarean section in nulliparous women when the fetus is in a breech position.

Congenital anomalies in term breech pregnancies are known risks for perinatal morbidity and mortality [ 7 , 9 , 38 ], and our study showed similar results among very preterm breech fetuses. In addition, other studies have linked oligohydramnios, fetal growth restriction, maternal obesity, and high blood pressure to increased congenital anomalies [ 24 , 27 , 39 ], and as shown before, these factors were risks for adverse outcomes in our study as well. However, in many cases of severe congenital anomalies, vaginal delivery is favorable also in breech deliveries to minimize maternal morbidity [ 40 ].

In extremely preterm breech deliveries over 30% had adverse outcomes. In this group the only risk factor found for adverse outcomes was PPROM. The extremely preterm delivery itself is a major risk for short-term neonatal morbidity [ 41 ], and this fact may be the reason why we could not identify more risk factors. Sephton S showed PPROM to be associated with a significant risk of neonatal morbidity partly due to infections and placental abruptions [ 42 – 44 ]. Preterm fetuses with PPROM and born vaginally may not tolerate the contractions during labor or the compression when descending in the birth canal [ 45 ]. Preterm breech deliveries complicated with PPROM may also have more difficulties with the delivery of the aftercoming head [ 46 ]. In a Cochrane review (2017) Bond and colleagues pointed out that despite PPROM before 37 weeks’ gestation and without contraindications, expectant management in careful evaluation is associated with good neonatal outcomes [ 47 ].

Our study offers essential information about the risks of adverse outcomes in preterm breech deliveries. This is the first study that was able to identify risk factors for adverse neonatal outcomes in planned vaginal preterm breech delivery. Understanding the risks for adverse outcomes is essential for the decision-making on the mode of delivery when treating preterm breech deliveries. Obstetricians can now select for preterm breech presentation those women who should give birth by cesarean section in any case. Some of the risk factors like oligohydramnios, congenital anomalies, and fetal growth restriction were similar as in planned vaginal breech delivery at term [ 8 , 21 ], but others, like severe maternal obesity and PPROM, were not known as risk factors for breech deliveries overall. This study is a unique population-based case–control study of the subject and offers valuable information for decision-making when treating preterm breech deliveries.

There are, however, few limitations in our study. Designed as a retrospective trial, we are exposed to the possibility of a typical bias of retrospective case–control studies. Additionally, data were restricted to the information of the data bank. In a few risk factors, we might have lacked statistical power to detect the risks of adverse outcomes, as there were only a few patients in the group. Nevertheless, our study was population-based and included over 2300 vaginal preterm breech deliveries from 14 years. Because there are no private birth hospitals in Finland, the treatment of the deliveries are homogenous and comparative.

We recommend a planned cesarean section for women with severe maternal obesity (BMI > 35), oligohydramnios, or fetal growth restriction in very preterm breech deliveries (28 + 0 to 32 + 6 weeks) and for women with oligohydramnios or a fetus with fetal growth restriction (< 2 SD) in moderate to late preterm breech deliveries (33 + 0 to 36 + 6 weeks).

Acknowledgements

Open access funding provided by University of Helsinki including Helsinki University Central Hospital.

Abbreviations

Author contribution.

AT: Project development, manuscript writing. SH: Project development, manuscript editing. MG: Data management and analysis, manuscript editing. GM: Project development, manuscript editing. All authors read and approved the final manuscript.

This study was funded by Helsinki University Hospital Research Grants.

Data availability

Compliance with ethical standards.

The author A. Toijonen declares that she has no conflict of interest. The author S. Heinonen declares that he has no conflict of interest. The author M. Gissler declares that he has no conflict of interest. The author G. Macharey declares that he has no conflict of interest.

This article does not contain any studies with human participants performed by any of the authors.

The register keeping organizations gave their permission to use their confidential health data in this study. No registered persons were contacted and thus, no consent for participant was needed. The Finnish Institute for Health and Welfare authorized to use the data (reference number THL/652/5.05.00/2017).

SAS custom code cannot be shared publicly, but it is available on request from Mika Gissler ([email protected]).

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Anna Toijonen, Email: [email protected] , Email: [email protected] .

Seppo Heinonen, Email: [email protected] .

Mika Gissler, Email: [email protected] .

Georg Macharey, Email: [email protected] .

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The Chicago Bears ' 2024 offseason has been interesting to say the least. It's going to get even more interesting with the upcoming draft. 

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