cephalic presentation gestational age

Fetal Presentation, Position, and Lie (Including Breech Presentation)

Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies

Lionel Carbillon ORCID: orcid.org/0000-0001-6367-4828 1 , 2 ,
Amelie Benbara 2 ,
Ahmed Tigaizin 2 ,
Rouba Murtada 2 ,
Marion Fermaut 2 ,
Fatma Belmaghni 2 ,
Alexandre Bricou 2 &
Jeremy Boujenah 2

BMC Pregnancy and Childbirth volume 20 , Article number: 263 ( 2020 ) Cite this article

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The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies.

In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed.

The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

Peer Review reports

The ideal management of women with term breech presentation remains a matter of intense debate. The rate of vaginal delivery has steadily declined in the last decades of the last century [ 1 ]. In 2000, the Term Breech Trial (TBT) Collaborative Group concluded that a composite variable combining perinatal and neonatal mortality or serious neonatal morbidity was significantly lower in the planned caesarean section (CS) group than in the planned vaginal birth group [ 2 ], which marked an apparent turning point in this controversy. Based on the short-term outcomes presented in the TBT study, the Royal College of Obstetricians and Gynaecologists (RCOG) [ 3 ] and the American College of Obstetricians and Gynecologists (ACOG) [ 4 ] recommended over the next few years that all women with persistent singleton breech presentation at term should undergo a planned CS delivery. An important and almost immediate impact on the practice was also observed in some countries that previously had a high proportion of vaginal breech deliveries [ 5 ]. TBT was the largest randomized trial ever published on the term breech mode of delivery. However, despite its undeniable strengths, a number of weaknesses have been identified. Specifically, there was a lack of adherence to strict criteria for vaginal birth in an important proportion of the included patients and nonoptimal methods of labour management as recognized by the TBT group itself [ 6 , 7 , 8 ]. In addition, when the TBT Collaborative Group published the 2-year analysis of paediatric outcomes, despite a large (greater than 50%) post-randomization loss to follow-up [ 9 ], these researchers found no reduction in the risk of death or neurodevelopmental delay in children at 2 years of age, thus raising questions regarding the real lessons to be drawn from this trial. Using multiple logistic regression analyses, the TBT group also reported [ 10 ] that the risk of maternal morbidity was lowest following vaginal birth (odds ratio [OR] 1.0) and highest following CS after active labour (36.1% in the TBT) (OR 3.33; 95% CI 1.75–6.33, P < 0.001), particularly after a short second stage < 30 min (OR 0.25; 95% CI 0.11–0.57, P < 0.001) [ 9 ].

Later, population-based retrospective studies helped refine the consequences of applying recommendations of systematically planned CS for women with term breech presentation at the population level. Hartnack Tharin et al. [ 11 ] found that the rate of CS for term breech deliveries increased from 79.6 to 94.2% between 1997 and 2008 in Denmark, while intrapartum or early neonatal mortality decreased from 0.13 to 0.05% [relative risk (RR) 0.38 (95% CI 0.15–0.98)], which was a significant but lower reduction than the difference reported in the TBT. Using the Dutch National Perinatal Registry from 1999 to 2007, Vlemmix et al. [ 12 ] stated that after publication of the TBT, the elective CS rate increased from 24 to 60%, and overall perinatal mortality and short-term morbidity decreased. In contrast, these outcomes remained stable in the planned vaginal birth group. However, the authors estimated that 338 CS deliveries would need to be performed to prevent one perinatal death, and Schutte et al. [ 13 ] estimated the perinatal case fatality rate for elective CS for breech presentation in 2000–2002 at 0.47/1000 operations. At the same time, in the Netherlands the incidence of severe maternal morbidity (SMM) was estimated at 6.4/1000 during an elective CS compared with 3.9/1000 during an attempted vaginal delivery (OR 1.7; 95% CI 1.4–2.0), with an increased risk for SMM in the next pregnancy (OR 3.0; 95% CI 2.7–3.3) [ 14 ], despite the numerous facilities and adequate resources allocated to perinatal care in such a high-income country.

On the other hand, new guidelines were published in 2009 by the Society of Obstetricians and Gynaecologists of Canada (SOGC) stating that “planned vaginal delivery is reasonable in selected women with a term singleton breech foetus”. Afterwards, a study [ 15 ] including 52,671 breech deliveries in Canada (2003–2011) reported in 2011 that vaginal deliveries increased from 2.7% in 2003 to 3.9%. In this study, a concomitant increase in composite neonatal mortality and morbidity rates was observed with an adjusted rate ratio of 3.60 (95% CI 2.50–5.15), compared with CS without labour [ 15 ]. Moreover, CS with labour also increased from 8.7 to 9.8%, highlighting the particular difficulty in returning to previous practices after the clinical skills required to conduct a vaginal breech delivery have declined [ 15 , 16 ].

Some authors recently considered that “the TBT recommendations should be withdrawn” [ 6 ], while others still consider that the “results (of the TBT) are generalizable” [ 16 , 17 ]. Nevertheless, national guideline bodies have partially reversed their recommendations based on these discussions [ 18 , 19 , 20 ]. However, as rightly noted by Joseph et al. [ 16 ], the availability of clinical skills has declined in some of these countries, raising concerns from a pedagogic resident education and training standpoint [ 16 ]. In this regard, a meaningful role could be given to the possibility of training by simulation in building and maintaining specific skills and competencies for vaginal breech delivery.

A new meta-analysis [ 21 ] and several large-scale epidemiologic datasets from medical birth registries [ 22 , 23 , 24 ] recently evaluated risk factors associated with adverse perinatal outcomes in planned vaginal breech labours at term. These investigations were conducted in countries that have not abruptly modified their policies and that have continuously applied similar strict criteria over the last several decades for individual decision-making in cases of term breech presentation. We believe that the time has come to go beyond the sole question of delivery mode in the management of these situations.

Term breech presentation: are we asking the right questions?

It now appears time to expand our thinking and, considering recent important data that help elucidate the underlying significance of persistent breech presentation at term, to offer more dynamic and multidisciplinary insight into the management of these cases.

Indeed, similar to some older studies [ 25 , 26 , 27 ], several recent population-based studies [ 22 , 23 ] strongly suggest that the increased risk observed in foetuses that remain in the breech presentation at term is closely linked to antenatal or underlying disorders that may be associated with the breech presentation and is not solely due to the mode of delivery. Because adverse outcomes can be caused by underlying or gestational disorders, any discussion that is limited to delivery mode seems too restrictive and does not address the whole issue.

Most recent large-scale data

Deterministic or accidental breech presentation.

In a recent Finnish population-based case-control study including all singleton deliveries from 1 January 2005 to 31 December 2014 and excluding preterm deliveries, antepartum-diagnosed stillbirths, placenta previa and infants with congenital malformations (499,206 foetuses at term), Macharey et al. [ 22 ] evaluated the antenatal risk factors associated with adverse perinatal outcomes in planned vaginal breech labour at term. They found that the stillbirth rate was significantly higher in cases of planned vaginal breech labour than in cases of cephalic presentation (0.2 vs 0.1%, respectively), which was correlated with foetal growth restriction, oligohydramnios, gestational diabetes mellitus (GDM) and a history of CS. Furthermore, in another recent survey based on the same cohort of mother-neonate dyads that also excluded congenital malformations, placenta previa and prelabour stillbirths [ 23 ], this same group showed that breech presentation at term was significantly associated with antenatal stillbirth and a number of individual obstetric risk factors for adverse perinatal outcomes, including oligohydramnios, foetal growth restriction, gestational diabetes, history of CS section and congenital anomalies. Among all planned singleton vaginal deliveries with the foetus in the breech presentation at term, a composite adverse perinatal outcome defined as umbilical arterial pH < 7.00, 5-min Apgar score below 7 and/or neonatal mortality during the first 6 days of life (excluding stillbirth) was associated with foetal growth restriction (aOR 2.94 [1.30–6.67]), oligohydramnios (adjusted OR 2.94 [1.15–7.81]), gestational diabetes (aOR 2.89[1.54–5.40]), and a history of CS (aOR 2.94 [1.28–6.77]).

In another recent population-based study based on perinatal data of all (650,968) children born in Norway from 1999 to 2009 [ 24 ], the authors recognized the limitations of most registry-based studies, as the selection of women with breech presentation and planned vaginal delivery was based on criteria that might have identified pregnancies with a lower risk of adverse outcomes compared with those selected for CS delivery. Moreover, in this study [ 24 ], the intrapartum conversion of some of the planned vaginal deliveries to an emergency CS delivery may have increased the risk for adverse outcome in the CS group. However, Bjellmo et al. [ 24 ] conducted an innovative analysis comparing breech deliveries to vaginal cephalic births. Thus, they showed that singleton children born at term without congenital malformations had a higher risk for stillbirth and neonatal mortality if they were born in the breech presentation “regardless of whether they were born vaginally or by CS delivery” (0.9 per 1000 in those actually delivered vaginally and 0.8 per 1000 in those actually born by CS delivery) compared with those born by vaginal cephalic delivery (0.3 per 1000). Of note, among those children born in the breech rather than in the cephalic presentation, these authors [ 24 ] found that a higher proportion of infants were born small for gestational age (SGA). However, these authors [ 23 ] did not distinguish foetal growth restriction among SGA neonates. In their interpretation, Bjellmo et al. [ 23 ] considered that “the overall higher risk for stillbirth and the higher proportion of infants born SGA among children born in the breech than in the cephalic presentation may suggest that foetuses with antenatal acquired risk factors for adverse outcomes are more likely to present in the breech than in the cephalic presentation at birth.” According to these authors, the findings were most likely explained by a combination of antenatal acquired risk factors for neonatal death with increased vulnerability to the birth process. Of note, in the TBT group, birth weights of less than 2.8 kg were also associated with adverse perinatal outcomes ( P = 0.003) [ 10 ]. In fact, a limitation in the Norwegian study [ 24 ] was that, unlike Macharey et al., the authors did not distinguish foetal growth restriction among these SGA neonates. Indeed, in a large cohort study conducted with the National Health Service region in England through a multivariable analysis of 92,218 normally formed singletons delivered during 2009–2011 from 24 weeks of gestation, including 389 stillbirths, Gardosi et al. [ 25 ] showed that foetal growth restriction had the largest population attributable risk for stillbirth which was fivefold greater if it was not detected antenatally than when it was (32.0% v 6.2%). The above data suggest that some antenatal features associated with term breech presentation, notably foetal growth restriction, and some gestational disorders (such as uncontrolled gestational diabetes mellitus) could affect the prognosis in term breech cases. Previous data also support this conclusion; Luterkort M et al. [ 26 ] had previously reported in a prospective follow-up of 228 pregnancies with the foetus in the breech presentation in the 33rd gestational week that the 96 foetuses (42%) who remained in the breech presentation at delivery weighed 4.9% less than their vertex controls after adjustments were made for gestational age and had an increased frequency of oligohydramnios. Krebs et al. [ 27 ] later confirmed this association between breech presentation and foetal growth restriction from a register-based, case-control cohort of infants with cerebral palsy born between 1979 and 1986 in East Denmark.

In fact, as reported by Fox and Chapman [ 28 ], up to 21% of all foetuses adopt a noncephalic presentation at 28–29 weeks of gestation, and this proportion progressively decreases to 5% from 37 to 38 weeks [ 28 ]. Certain conditions, such as uterine malformation, can disturb both this continuous process of spontaneous cephalic version and normal foetal growth, thereby leading to increased term breech presentation rates in these cases [ 29 ]. This point highlights the importance of estimating foetal weight and well-being in cases of persistent breech presentation at term. Furthermore, even some cases of controlled GDM may be associated with excess foetal weight during the last weeks of pregnancy, leading to possible dystocia due to this overgrowth, or with other GDM-related complications, such as preeclampsia; thus, foetal weight estimates should be monitored closely beginning in the 37th week of gestation, with regular reassessment as long as the patient has not delivered.

The impact of strict criteria on the selection of vaginal delivery

From a broad perspective, in the most recent meta-analysis investigating the risks of planned vaginal breech delivery versus planned CS for term breech birth [ 21 ], the overall heterogeneity (I 2 = 36%) was informative. The variability of neonatal mortality among 14 studies accounting for 74,094 breech vaginal deliveries was low (ranging from 0.08 to 0.37%). On the other hand, neonatal mortality was markedly higher in only 2 studies authored by Singh et al. [ 30 ] and Hannah et al. [ 2 ] (the TBT). These two studies [ 2 , 30 ] accounted for 1099 breech vaginal deliveries (1.5% of births) and had perinatal mortality rates as high as 21 and 1.3%, respectively, for planned vaginal births (25.6% of perinatal deaths). The same was true for neurological morbidity, which was 3.4 and 1%, respectively, in the studies by Singh et al. [ 30 ] and TBT [ 2 ], while it ranged from 0.07 to 0.2% in the 14 other studies encompassing 74,094 breech vaginal deliveries conducted with the implementation of more stringent exclusion criteria for vaginal breech delivery.

In these 14 studies accounting for 74,094 breech vaginal deliveries, the retrospective observational cohort study from the Finnish Medical Birth Register [ 31 ] and the prospective observational study PREMODA [ 32 ] (as well as the more recent Norwegian Medical Birth Registry study) applied similar pre-established exclusion criteria for planned vaginal birth. In the PREMODA study, an increased absolute rate of perinatal death or serious neonatal morbidity was observed in both the planned vaginal group (1.60, 95% CI 1.14–2.17) and planned CS delivery group (1.45 [1.16–1.81]) with breech presentation among the total population of 264,105 births, but the planned vaginal group and the planned CS delivery group with breech presentation did not differ significantly for the combined outcome of foetal/neonatal mortality or serious morbidity (odds ratio [OR] = 1.10, 95% CI [0.75–1.61]). The Royal College of Obstetricians and Gynaecologists proposes comparable pre-established criteria for the management of term breech presentation, recommending that “women should be informed that a higher risk of planned vaginal breech birth is expected where there are independent indications for CS section and in circumstances such as a hyperextended neck on ultrasound, high estimated foetal weight (more than 3,800 g), low estimated weight (less than tenth centile), footling presentation, [and] evidence of antenatal foetal compromise” but considers that “the role of pelvimetry is unclear” [ 20 ]. Of note concerning this last point, Van Loon et al. showed in a randomized controlled trial [ 33 ] that the adequacy of pelvis size, as assessed by pelvimetry, improved the selection of delivery route. In line with them, two recent studies support this view [ 34 , 35 ]. Other authors also included criteria for the adequate management and continuous monitoring of foetal heart rate during labour (which is common in maternity wards of most high-income countries but could be monitored intermittently in the TBT). Indeed, decreased variability and late decelerations are more prevalent during breech deliveries than vertex deliveries [ 36 ], and good labour progress is a predictor of better neonatal outcomes [ 37 ]. In the Finnish Medical Birth Register [ 31 ], 1270 women (43.6%) were selected as candidates for vaginal breech delivery, and the selection quality was confirmed by the low conversion rate of vaginal to CS breech delivery (11.4%). This rate was higher (36.1%) in the TBT [ 30 ].

As noted by methodologists [ 38 ], real-world prenatal patient care is subject to decision-making based on the continuous evaluation of risk factors, medical history, comorbidities, behavioural aspects, and other factors that indeed cannot be strictly reproduced in randomized controlled trials. For example, in the TBT [ 2 ], an upper limit of 4000–4500 g was given for estimated foetal weight. However, as the duration between randomization and delivery inevitably lengthened in the planned vaginal delivery group, a significantly higher number of macrosomic neonates were born in the planned vaginal delivery group ( P = 0.002). In actuality, an informed woman who opts for vaginal delivery at 36 or 37 weeks of gestation usually changes her mind if she has not delivered several weeks later and if the clinician tells her that the birthweight will probably exceed 3800–4000 g, with an associated increased risk of adverse perinatal outcomes. Thus, in cases of even minor glycaemic disorder, special attention should be paid in the 37th week of gestation to foetal weight estimates and the possible occurrence of preeclampsia or associated gestational disorders; moreover, cases of SGA foetuses with possible foetal growth restriction should be closely followed, regardless of the delivery mode chosen by the patient [ 26 , 39 ].

How might we maximize patient benefit from a safe external cephalic version attempt?

With the restrictive practice of breech vaginal delivery in the last 15 years, national colleges of obstetricians (RCOG, ACOG, SOGC and RANZCOG) and FIGO updated their guidelines and recommended external cephalic version (ECV) at term to limit the increase in elective CS rate for cases of term breech presentation. However, recent data urge us to develop a broader perspective and an accurate assessment of the real impact of various ECV policies.

Indeed, the true impact of ECV may first be limited by the timely detection of breech presentation. In a retrospective cohort study of 394 consecutive cases of breech presentation at term, Hemelaar et al. [ 40 ] found that over two periods separated by 10 years (1998–1999 and 2008–2009), the proportion of breech presentations not diagnosed antenatally increased from 23.2 to 32.5% ( P = 0.04), causing 52.8% of women who were eligible for ECV to miss an attempt in 2008–2009. The authors also reported that the proportion of women who declined ECV during the same period decreased significantly from 19.1 to 9.0%.

Eligibility is a second limitation. In Australia, a large-scale survey [ 41 ] showed that 22.3% of 32,321 singleton breech pregnancies were considered ineligible (due to oligohydramnios, antepartum haemorrhage or abruption, previous CS or pelvic abnormality, placenta previa, placenta accreta, or an infant with major congenital anomalies). In this survey [ 41 ], only 10.5% of the singleton breech pregnancies had an ECV. In a systematic review, Rosman et al. [ 42 ] identified 60 studies that reported 39 different contraindications and five guidelines with 18 contraindications (varying from five to 13 contraindications per guideline), with oligohydramnios being the only contraindication that was consistently mentioned in all guidelines. Thus, there was no general consensus on the eligibility of patients for ECV, but contraindications generally include all conditions in which this procedure may be associated with a particular risk for the foetus or mother. These conditions include the following: severe intrauterine growth restriction, abnormal umbilical artery Doppler index and/or nonreassuring foetal heart rate, which may require an emergency CS birth; foetuses with a hyperextended head and significant foetal or uterine malformations, which may carry a particular foetal risk; rhesus alloimmunization, which might be reactivated by the procedure; and recent vaginal bleeding or ruptured membranes, which were associated with cord prolapse in 33% of reported cases after ECV attempt [ 43 ].

If CS or rapid delivery is indicated for another obstetric condition, ECV is also contraindicated, notably in cases of placenta previa, severe preeclampsia, and increased risk of placental abruption. Other situations, such as maternal obesity, nonsevere SGA foetuses, and nonsevere oligohydramnios, merely decrease the likelihood of ECV success. In contexts such as severe oligohydramnios or multiple gestations, ECV is simply impracticable, except for a second twin after delivery of the first. Furthermore, previous uterine surgery (CS delivery, myomectomy, or hysteroplasty) is considered a relative contraindication for ECV by some but not all authors [ 44 ]. On the other hand, in patients with gestational diabetes mellitus, incomplete or uncontrolled glucose levels are associated with an increased risk of foetal macrosomia in late pregnancy, and even if the estimated foetal weight seems compatible with a planned vaginal delivery when the mode of delivery is discussed, rapid foetal growth during the last weeks may lead to major difficulties during delivery. Therefore, in such a context, we believe there is potential for a particular benefit from successful ECV at 36 weeks.

Predictors of successful ECV

Pinard previously observed that unengaged breech presentation is an important predictor of successful ECV [ 45 ]; the same observation was made by Lau et al. [ 46 ], Aisenbrey et al. [ 47 ], and Hutton et al. [ 48 ]. In the large series of 1776 ECVs published by Hutton et al. [ 48 ], descent and impaction of the breech foetus were the most discriminating factors for predicting successful ECV, regardless of parity. Other predictors of success include parity [ 45 , 47 , 49 , 50 ], abundant amniotic fluid [ 49 , 50 , 51 ], nonfrank breech presentation [ 47 ], gestational age under 38 weeks [ 43 ], and posterior placenta [ 50 ]. In contrast, nulliparity and tense uterus are associated with a lower likelihood of success [ 44 , 48 , 52 ].

Velzel et al. [ 53 ] recently reviewed prediction models, most of which were developed without any external validation, and found that the most reliable predictors of successful ECV were nonimpacted breech presentation, parity and uterine softness (which usually go hand in hand), normal amniotic fluid index, posterior placental location, and, as noted by Pinard [ 45 ], foetal head in a palpable situation. These criteria might be used to support patient counselling and decision-making about ECV and to reduce the proportion of women declining ECV, particularly in the most favourable situations for ECV.

Obstetric outcomes after an ECV attempt

De Hundt et al. [ 54 ] conducted a systematic review and meta-analysis and showed that women who have had a successful ECV for breech presentation are at increased risk for CS delivery (OR 2.2; 95% CI 1.6–3.0) and instrumental vaginal delivery (OR 1.4; 95% CI 1.1–1.7) compared with women with spontaneous cephalic presentation. Interestingly, stratification by time delay between successful ECV and delivery revealed a trend for increased risk of CS during the first week after ECV [ 55 ]. Furthermore, in a cohort of 301 women with successful ECV, De Hundt et al. [ 56 ] found that nulliparity was the only of seven factors that predicted the risk of CS and instrumental vaginal delivery (OR 2.7; 95% CI 1.2–6.1). Based on a retrospective, population-based cohort study using the CDC’s birth data files from the US in 2006, Balayla et al. [ 57 ] also showed that relative to breech controls without an ECV attempt, cases of ECV failure with persistent breech presentation and labour attempts were associated with increased odds of CS delivery (adjusted OR 1.38; 95% CI 1.21–1.57), assisted ventilation at birth (aOR 1.50; 95% CI 1.27–1.78), 5-min Apgar score < 7 (aOR 1.35; 95% CI 1.20–1.51), and neonatal intensive care unit admission (aOR 1.48; 95% CI 1.20–1.82).

This information should also be considered in the dialog with women regarding the way in which late pregnancy and delivery should be managed based on existing data, their own situations and their wishes.

The true benefit of an active and systematic ECV policy is widely appreciated [ 58 , 59 ], and such evaluation may be subject to bias. Burgos et al. [ 58 ] found that their policy decreased the rate of breech presentation at delivery by 39.0% and decreased the CS rate for cases of breech presentation at term from 59 to 44%. On the other hand, Coppola et al. [ 59 ] reported that their CS rate was not significantly reduced in the planned ECV group, even after adjustments were made for age, parity and previous CS delivery. Thus, each perinatal centre should implement an appropriate and coherent policy in accordance with the prevalence of pathologies in the population.

Towards a consensus for a global shared vision and management of term breech presentation that could include the following

A policy of breech presentation screening at 36 weeks of gestation is efficient and cost effective [ 60 ].

Such screening should allow timely ECV and a careful evaluation of potential underlying antenatal risks, considering obstetric history, estimated foetal weight/growth and potential gestational disorders [ 23 , 24 , 25 , 26 , 27 , 29 ].

Foetal weight estimates based on clinical and ultrasound examinations are essential, despite the large confidence interval of all available algorithms for producing such estimates. Vaginal birth may be excluded when the estimated foetal weight approximates the upper limit used for selection in most national guidelines (3800 g) [ 18 , 19 , 20 ], particularly in the absence of previous successful vaginal delivery.

Before vaginal delivery is considered, clinical pelvic examination is universally recommended to rule out pathological pelvic contraction. Radiologic or magnetic resonance imaging (MRI) pelvimetry is not universally conducted [ 20 , 23 , 24 , 31 , 32 ]. However, Van Loon et al. [ 33 ] demonstrated in a randomized controlled trial that the use of MRI pelvimetry in breech presentation at term allowed better selection of delivery route, with a significantly lower emergency CS rate. More specifically, several recent studies [ 34 , 35 ] have evaluated the contribution of pelvimetry and found that MRI pelvimetry provided useful criteria for the preselection and counselling of women with breech presentation and the desire for vaginal delivery. Therefore, pelvimetry is diversely used in Europe for the preselection and counselling of women (particularly nulliparous women) with breech presentation and is specifically used in regions where vaginal delivery is still considered an option [ 35 ].

In cases of failed ECV with persistent breech presentation, this policy should allow customized care tailored to each situation in the last weeks of pregnancy.

A discussion with the informed patient is essential. One must thoroughly consider the experience of the health care team/the availability of clinical skills required for conducting a vaginal breech delivery and carefully select women who are eligible for planned vaginal delivery (considering obstetric history and the criteria described above for the choice between planned vaginal and CS deliveries) [ 20 , 23 , 24 , 26 , 28 ].

Regardless of the planned mode of delivery [ 22 ], adequate follow-up during the last weeks of pregnancy is mandatory, with particular consideration of possible associated underlying disorders (particularly foetal growth restriction or excessive foetal weight in cases of gestational diabetes mellitus) [ 24 , 25 , 26 ]. Thus, the foetal weight estimation should be carefully considered in the 37th week of gestation, even in cases of minor glycaemic disorder, with regular reassessments and a plan for CS delivery if the patient remains pregnant for many more weeks and if foetal weight estimates reach approximately 3600–3800 g.

If vaginal delivery is planned, careful labour management by a skilled team is needed, accompanied by continuous foetal heart rate monitoring [ 36 ] and a particular focus on the rate of progress in the second delivery stage [ 37 ]. When such conditions are not or cannot be fulfilled, a planned CS may be the best choice.

When a CS has been planned, adequate follow-up during the last weeks of pregnancy and careful calculation of the delivery date are needed, taking into account possible comorbidities and gestational disorders.

Term breech presentation is a condition for which personalized obstetrical care is particularly needed. The best way is likely to be as follows: first, efficiently screen for breech presentation at 36–37 weeks of gestation; second, thoroughly evaluate the maternal/foetal condition, foetal weight and growth potential, and the type (frank, complete, or footling) and mobility of breech presentation; and three, consider the obstetric history and pelvic size/conformation. The management plan, including ECV and follow-up during the last weeks, should then be organized taking into account antenatal risk factors on a case-by-case basis by a skilled team after informing the woman, discussing her personal situation and criteria and helping her make a rational decision. Foetal overgrowth or growth restriction and/or oligohydramnios may necessitate timely CS, and the mode of delivery should be re-evaluated as necessary according to obstetric conditions (e.g., estimated foetal weight and Bishop score).

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Abbreviations

American College of Obstetricians and Gynecologists

Caesarean section

External cephalic version

International Federation of Gynecology and Obstetrics

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Royal College of Obstetricians and Gynaecologists

Severe maternal morbidity

Society of Obstetricians and Gynaecologists of Canada

Term breech trial

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Department of Obstetrics and Gynecology, Sorbonne Paris Nord University, Assistance Publique – Hopitaux de Paris, Avenue du 14 juillet, Hôpital Jean Verdier, 93140, Bondy Cedex, France

Lionel Carbillon

Department of Obstetrics and Gynecology, Assistance Publique – Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France

Lionel Carbillon, Amelie Benbara, Ahmed Tigaizin, Rouba Murtada, Marion Fermaut, Fatma Belmaghni, Alexandre Bricou & Jeremy Boujenah

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Study conception and design: LC, AB, JB, AT, FB, AB. Analysis and interpretation of data: LC, JB. Drafting of manuscript: LC. Critical revision: LC, JB, RM, MF. The authors read and approved the final manuscript.

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Carbillon, L., Benbara, A., Tigaizin, A. et al. Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies. BMC Pregnancy Childbirth 20 , 263 (2020). https://doi.org/10.1186/s12884-020-2831-4

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Term breech delivery
Small-for-gestational-age
Foetal growth restriction
Oligohydramnios
Delivery route
Perinatal mortality
Perinatal morbidity

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A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case–control study

Maternal-Fetal Medicine
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Published: 18 November 2019
Volume 301 , pages 393–403, ( 2020 )

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Anna E. Toijonen ORCID: orcid.org/0000-0002-4812-2766 1 , 3 ,
Seppo T. Heinonen 1 ,
Mika V. M. Gissler 2 &
Georg Macharey 1

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To determine if the common risks for breech presentation at term labor are also eligible in preterm labor.

A Finnish cross-sectional study included 737,788 singleton births (24–42 gestational weeks) during 2004–2014. A multivariable logistic regression analysis was used to calculate the risks of breech presentation.

The incidence of breech presentation at delivery decreased from 23.5% in pregnancy weeks 24–27 to 2.5% in term pregnancies. In gestational weeks 24–27, preterm premature rupture of membranes was associated with breech presentation. In 28–31 gestational weeks, breech presentation was associated with maternal pre-eclampsia/hypertension, preterm premature rupture of membranes, and fetal birth weight below the tenth percentile. In gestational weeks 32–36, the risks were advanced maternal age, nulliparity, previous cesarean section, preterm premature rupture of membranes, oligohydramnios, birth weight below the tenth percentile, female sex, and congenital anomaly. In term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, premature rupture of membranes, oligohydramnios, congenital anomaly, female sex, and birth weight below the tenth percentile.

Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in extremely preterm deliveries has, with the exception of preterm premature rupture of membranes, similar clinical risk profiles as in cephalic presentation.

Risk factors for adverse outcomes in vaginal preterm breech labor

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Introduction

The prevalence of breech presentation at delivery decreases with increasing gestational age. At 28 pregnancy weeks, every fifth fetus lies in the breech presentation and in term pregnancies, less than 4% of all singleton fetuses are in breech presentation at delivery [ 1 , 2 ]. Most likely this is due to a lack of fetal movements [ 3 ] or an incomplete fetal rotation, since the possibility of a spontaneous rotation declines with increasing gestational age. Consequently, preterm labor itself is often associated with breech presentation at delivery, since the fetus was not yet able to rotate [ 4 , 5 , 6 , 7 , 8 , 9 ]. This fact makes preterm labor as one of the strongest risk factors for breech presentation.

Vaginal breech delivery in term pregnancies is not only associated with poorer perinatal outcomes compared to vaginal delivery with a fetus in cephalic presentation [ 6 , 10 , 11 ], but also it is debated whether the cause of breech presentation itself is a risk for adverse peri- and neonatal outcomes [ 3 , 12 , 13 ]. Several fetal and maternal features, such as fetal growth restriction, congenital anomaly, oligohydramnios, gestational diabetes, and previous cesarean section, are linked to a higher risk of breech presentation at term, and, furthermore, are associated with an increased risk for adverse perinatal outcomes [ 3 , 4 , 5 , 8 , 9 , 14 , 15 , 16 , 17 ].

The literature lacks studies on the risk factors of breech presentation in preterm pregnancies. It remains unclear whether breech presentation at preterm labor is only caused by the incomplete fetal rotation, or whether breech presentation in preterm labor is also associated with other obstetric risk factors. Most of the studies reviewing risk factors for breech presentation focus on term pregnancies. Our hypothesis is that breech presentation in preterm deliveries is, besides preterm pregnancy itself, associated with other risk factors similar to breech presentation at term. We aim to compare the risks of preterm breech presentation to those in cephalic presentation by gestational age. Such information would be valuable in the risk stratification of breech deliveries by gestational age.

Materials and methods

We conducted a retrospective population-based cross-sectional study. The population included all the singleton preterm and term births, from January 2004 to December 2014 in Finland. The data were collected from the national medical birth register and the hospital discharge register, maintained by the National Institute for Health and Welfare. All Finnish maternity hospitals are obligated to contribute clinical data on births from 22 weeks or birth weight of 500 g to the register. All newborn infants are examined by a pediatrician and given a personal identification number that can be traced in the case of perinatal mortality or morbidity. The hospital discharge register contains information on all surgical procedures and diagnoses (International Statistical Classification of Diseases and Related Health Problems 10th Revision, ICD-10) in all inpatient care and outpatient care in public hospitals.

Authorization to use the data was obtained from the National Institute for Health and Welfare as required by the national data protection law in Finland (reference number THL/652/5.05.00/2017).

The study population included all the women with a singleton fetus in breech presentation at the time of delivery. The control group included all the women with a singleton fetus in cephalic presentation at delivery. Other presentations were excluded from the study ( N = 1671) (Fig. 1 ). Gestational age was determined according to early ultrasonographic measurement which is routinely performed in Finland and it encompasses over 95% of the mothers, or if not available, to the last menstrual period. We excluded neonates delivered before 24 weeks of gestation and birth weight of less than 500 g, because the lower viability may have influenced the mode of the delivery or the outcome. The study population was divided into four categories according to the World Health Organization (WHO) definitions of preterm and term deliveries. WHO defines preterm birth as a fetus born alive before 37 completed weeks of pregnancy. WHO recommends sub-categories of preterm birth, based on gestational age, as extremely preterm (less than 28 pregnancy weeks), very preterm (28–32 pregnancy weeks), and moderate to late preterm (32–37 pregnancy weeks).

Breech presentation for singleton pregnancies during the period of 2004–2014 in Finland

In our study, we assessed four factors that may be associated with breech presentation based on prior reports [ 3 , 4 , 5 , 14 , 17 , 18 , 19 , 20 ]. These factors were: maternal age below 25 and 35 years or more, smoking, pre-pregnancy body mass index (BMI) over 30, and in vitro fertilization. The following factors were also analyzed: nulliparity, more than three previous deliveries, and history of cesarean section. The obstetric risk factors including maternal hypo- or hyperthyroidism (ICD-10 E03, E05), gestational diabetes (ICD-10 O24.4) and other diabetes treated with insulin (ICD-10 O24.0), arterial hypertension or pre-eclampsia (ICD-10 O13, O14), and maternal care for (suspected) damage to fetus by alcohol or drugs (ICD-10 O35.4, O35.5) were assessed in the analysis. The variables that were also included in the analysis were: oligohydramnios (ICD-10 O41.0), placenta praevia (ICD-10 O44), placental abruption (ICD-10 O45), preterm premature rupture of membranes (PPROM) (ICD-10 O42), infant sex, fetal birth weight below the tenth percentile, fetuses with birth weight above the 97th percentile, and fetal congenital anomalies as defined in the register of congenital malformations.

The babies born in breech presentation from the four study groups were compared with the babies born in cephalic presentation with the equal gestational age, according to WHO classification. The calculations were performed using SPSS 19. Statistical differences in categorical variables were evaluated with the Chi-squared test or Fisher’s exact test when appropriate. We calculated odds ratios (ORs) with corresponding 95% confidence intervals (CIs) using binary logistic regression. Each study group was separately adjusted, according to gestational age at delivery, defined by WHO. The adjustment for the risk factors was done by multivariable logistic regression model for all variables. Differences were deemed to be statistically significant with P value < 0.05.

This analysis includes 737,788 singleton births, from these 20,086 were in breech presentation at the time of delivery. Out of all deliveries, 33,489 infants were born preterm. The prevalence of breech presentation at delivery decreased with the increase of the gestational age: 23.5% in extremely preterm delivery, 15.4% very preterm deliveries, and 6.7% in moderate to late preterm deliveries. At term, the prevalence of breech presentation at delivery was 2.5% (Fig. 1 ).

From all deliveries, 2056 fetuses were born extremely preterm (24 + 0 to 27 + 6 gestational weeks). The differences in the possible risk factors for breech presentation at delivery were higher odds of PPROM (aOR 1.39, 95% CI 1.08–1.79, P = 0.010) and a lower risk of placental abruption (aOR 0.59, 95% CI 0.36–0.98, P = 0.040). No statistically significant differences were observed for the other factors (Table 1 , Figs. 1 , 2 , 3 , 4 ).

Prevalence of obstetric risk factors for breech presentation compared to cephalic by gestational age. PPROM preterm premature rupture of membranes, PROM premature rupture of membranes

Obstetric risk factors for breech presentation with adjusted odds ratios by gestational age. PPROM preterm premature rupture of membranes, PROM premature rupture of membranes, aOR adjusted odds ratio

The determinants of breech presentation by gestational age. PPROM preterm premature rupture of membranes, PROM premature rupture of membranes

The group of very preterm deliveries (28 + 0 to 31 + 6 gestational weeks) included 4582 singleton newborns. Breech presentation at delivery was associated with PPROM (aOR 1.61, 95% CI 1.32–1.96, P < 0.001), oligohydramnios (aOR 1.65, 95% CI 1.03–2.64, P = 0.038), fetal birth weight below the tenth percentile (aOR 1.57, 95% CI 1.19–2.08, P = 0.002), and maternal pre-eclampsia and arterial hypertension (aOR 1.31, 95% CI 1.04–1.66, P = 0.023). Details of risk factors in very preterm breech deliveries are described in Table 2 . The risk of placenta praevia as well as having a birth weight above the 97th percentile was lower in pregnancies with fetuses in breech rather than in cephalic presentation (Table 2 , Figs. 2 , 3 , 4 ).

The moderate to late preterm delivery group (32 + 0 to 36 + 6 gestational weeks) included 26,851 deliveries. Breech presentation in moderate to late preterm deliveries was associated with older maternal age (maternal age 35 years or more aOR 1.24, 95% CI 1.10–1.39, P < 0.001), nullipara (aOR 1.43, 95% CI 1.27–1.60, P < 0.001), maternal BMI less than 25 (maternal BMI ≥ 25 aOR 0.75, 95% CI 0.62–0.91, P = 0.004), previous cesarean section (aOR 1.31, 95% CI 1.12–1.53, P < 0.001), female sex (aOR 1.22, 95% CI 1.11–1.34, P < 0.001), congenital anomaly (aOR 1.37, 95% CI 1.22–1.55, P < 0.001), fetal birth weight below the tenth percentile (aOR 1.31, 95% CI 1.10–1.56, P = 0.003), oligohydramnios (aOR 3.60, 95% CI 2.63–4.92, P < 0.001), and PPROM (aOR 1.58, 95% CI 1.41–1.78, P < 0.001). Breech presentation decreased the odds of having a fetus with birth weight above the 97th percentile (aOR 0.60, 95% CI 0.42–0.85, P = 0.004) (Table 3 , Figs. 2 , 3 , 4 ).

The term and post-term group included 704,299 deliveries, among them 17,044 fetuses in breech presentation. The factors associated with breech presentation amongst these were: maternal age of 35 years or more (aOR 1.24, 95% CI 1.19–1.29, P < 0.001), nullipara (aOR 2.46, 95% CI 2.37–2.55, P < 0.001), maternal BMI less than 25 (BMI ≥ 25 aOR 0.90, 95% CI 0.85–0.96, P < 0.001), maternal hypothyroidism (aOR 1.53, 95% CI 1.28–1.82, P < 0.001), pre-gestational diabetes treated with insulin (aOR 1.24, 95% CI 1.00–1.53, P = 0.049), placenta praevia (aOR 1.45, 95% CI 1.11–1.91, P = 0.007), premature rupture of membranes (PROM) (aOR 1.58, 95% CI 1.45–1.72, P < 0.001), oligohydramnios (aOR 2.02, 95% CI 1.83–2.22, P < 0.001), congenital anomaly (aOR 1.97, 95% CI 1.89–2.06, P < 0.001), female sex (aOR 1.28, 95% CI 1.24–1.32, P < 0.001), and birth weight below the tenth percentile (aOR 1.18, 95% CI 1.12–1.24, P < 0.001) Table 4 includes details for risk factors of term and post-term group (Figs. 2 , 3 , 4 ).

The main novel finding of our study was that the risk associations increase with each gestational age group after 28 weeks of gestation. With the exception of PPROM, the extremely preterm breech deliveries have similar clinical risk profiles as in cephalic presentation when matched for gestational age. However, as gestation proceeds, the risks start to cluster. In moderate to late preterm pregnancies as in term pregnancies, the breech presentation is a high-risk state being associated with several risk factors: PPROM, oligohydramnios, advanced maternal age, nulliparity, previous cesarean section, fetal birth weight below the tenth percentile, female sex, and fetal congenital anomalies. These are in line with the findings of previous studies [ 3 , 5 , 7 , 8 ], that associated breech presentation at term with obstetric risk factors. The prevalence of breech presentation was negatively correlated with the gestational age with a decline from 23.5% in extremely preterm pregnancies to 2.5% at term. The prevalence of breech presentation in preterm pregnancies observed in our trial is similar to that of comparable studies [ 1 , 2 ].

In extremely preterm deliveries, PPROM was the only risk factor for breech presentation and it stayed as a risk for breech presentation through the gestational weeks. This finding is comparable to the previous literature suggesting that PPROM occurs more often at earlier gestational age in pregnancies with the fetus in breech presentation compared with cephalic [ 21 , 22 ]. PPROM might prevent the fetus to change into cephalic presentation. Furthermore, Goodman and colleagues (2013) reported that in pregnancies with a fetus in a presentation other than cephalic had more complications such as oligohydramnios, infections, placental abruption, and even stillbirths. In our study, surprisingly, placental abruption seemed to have a negative correlation with breech presentation among extremely preterm deliveries. This inconsistency between our results and the literature might be due to the small number of cases. Many of the obstetric complications, for example gestational diabetes, late pre-eclampsia, and late intrauterine growth restriction develop during the second or the third trimester of the pregnancy which explains partially why the risk factors for breech presentation are rarer in extremely preterm deliveries.

In very preterm delivery, breech presentation was associated with PPROM, pre-eclampsia, and fetal birth weight below the tenth percentile. Fetal growth restriction is a known risk factor for breech presentation at term, since it is associated with reduced fetal movements due to diminished resources [ 23 , 24 , 25 ]. Furthermore, fetal growth restriction is known to be the single largest factor for stillbirth and neonatal mortality [ 26 , 27 , 28 , 29 , 30 ]. Maternal arterial hypertension disturbs placental function which might cause low birth weight [ 31 , 32 ]. Arterial hypertension and pre-eclampsia increased the risk for breech presentation in very preterm births, but not in earlier or later preterm pregnancies. This finding may be due to the bias that pre-eclampsia is a well-described risk factor for PPROM, fetal growth restriction, and preterm deliveries which are also independent markers for breech presentation itself [ 4 , 5 , 31 , 33 , 34 ]. The severity of early pre-eclampsia might affect the fetal wellbeing, reduce fetal movements and growth, which might reduce the spontaneous fetal rotation to the cephalic position [ 35 ]. In addition, the most severe cases might not reach older gestational age before the delivery.

The risk factor for breech presentation in moderate to late preterm breech delivery was PPROM, oligohydramnios, advanced maternal age, nulliparity, previous cesarean section, fetal birth weight below the tenth percentile, female sex, and fetal congenital anomalies. Oligohydramnios is a known significant risk factor for term breech pregnancies [ 25 ] and it is linked to the reduced fetal movements partly due to a restricted intrauterine space [ 24 , 35 ] and nuchal cords [ 35 ]. Additionally, oligohydramnios is associated with placental dysfunction, which might reduce fetal resources and thus has a progressive effect on the fetal movements and prevent the fetus from turning into cephalic presentation [ 3 , 4 , 18 ]. Fetal female sex in moderate to late preterm breech pregnancies remained as a risk factor, as identified previously for term pregnancies [ 3 , 4 , 5 ]. It has been debated whether this risk is due to a smaller fetal size or that female fetuses tend to move less [ 9 , 20 ]. The mothers of infants born in breech presentation in moderate to late preterm and term and post-term pregnancies seemed to be older and had an increased risk of having a fetus with a congenital anomaly. The advanced maternal age is associated with negative effects on vascular health, which may have an influence on the developing fetus and increase the incidence of congenital anomalies [ 19 , 34 , 36 ]. Furthermore, congenital anomalies may have a negative influence on fetal movements [ 19 , 35 ]. Whereas, the low birth weight was found as a risk for breech presentation, a birth weight above the 97th percentile was, coherently a protective factor for breech presentation in very to term and post-term pregnancies.

We found that in term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, PROM, oligohydramnios, fetal congenital anomaly, female sex of the fetus, and birth weight below the tenth percentile. A previous cesarean section is known to be positively related to the odds of having a fetus in breech presentation at term [ 5 , 14 ], and in our study, this risk factor started to show already in moderate to late preterm pregnancies. Instead of the scar being the cause of breech presentation, it is more likely that the women with a history of breech cesarean section have, during subsequent pregnancies, a fetus in breech presentation again or have a cesarean section for another reason [ 3 , 5 , 37 ]. Our data suggest that the advanced maternal age and nulliparity are the risks for breech presentation at term, but as well as in moderate to late preterm pregnancies. The tight wall of the abdomen and the uterus of nulliparous women might inhibit the fetus from rotating to cephalic presentation [ 9 ]. In a meta-analysis from 2017, older maternal age has been considered to increase the risk of placental dysfunction such as pre-eclampsia and preterm birth [ 36 ] that are also common risk factors for breech presentation [ 4 , 5 ]. Bearing the first child in older maternal age and giving birth by cesarean section may affect the decision not to have another child and might explain the higher rate of nulliparity among moderate to late preterm and term deliveries [ 1 ]. Our study found correlation between maternal hypothyroidism and breech presentation at term. Some studies have demonstrated an association between maternal thyroid hypofunction and adverse pregnancy outcomes such as pre-eclampsia and low birth weight which are, furthermore, risks for breech presentation and may explain partly the higher prevalence of maternal hypothyroidism in term breech deliveries [ 38 , 39 , 40 ]. However, the absence of screening of, for example, thyroid diseases may cause bias in the diagnoses.

Our study demonstrated that as gestation proceeds, more obstetric risk factors can be found associating with breech presentation. In the earlier gestation and excluding PPROM, breech deliveries did not differ in obstetric risk factors compared to cephalic. The risk factors in 32 weeks of gestational age are comparable to those in term pregnancy, and several of these factors, such as low birth weight, congenital anomalies and history of cesarean section, are associated with adverse fetal outcomes [ 1 , 4 , 5 , 8 , 14 , 17 ] and must be taken into account when treating breech pregnancies. Risk factors should be evaluated prior to offering a patient an external cephalic version, as the presence of some of these risks may increase the change of failed version or fetal intolerance of the procedure. This study had adequate power to show differences between the risk profiles of breech and cephalic presentations in different gestational phase. Further research, however, is needed for improving the identification of patients at risk for preterm breech labor and elucidating the optimal route for delivery in preterm breech pregnancies.

Our study is unique since it is the first study, to our knowledge, that compares the risks for breech presentation in preterm and term deliveries. The analysis is based on a large nationwide population, which is the major strength of our study. The study population included nearly 34,000 preterm births over 11 years in Finland and 737,788 deliveries overall. The medical treatment of pregnancies is homogenous, since there are no private hospitals treating deliveries. A further strength relates to the important information on the characteristics of the mother, for example smoking during pregnancy and pre-pregnancy body mass index. The retrospective approach is a limitation of the study, another one is the design as a record linkage study, due to which the variables were restricted to the data availability. Therefore, we were not able to assess, for example uterine anomalies or previous breech deliveries to the analysis.

Our results show that the factors associated with breech presentation in very late preterm breech deliveries resemble those in term pregnancies. However, breech presentation in extremely preterm breech birth has similar clinical risk profiles as in cephalic presentation.

Abbreviations

International Statistical Classification of Diseases and Related Health Problems 10th Revision

World Health Organization; BMI, body mass index

Preterm premature rupture of membranes

Crude odds ratio

Confidence interval

Adjusted odds ratio

Premature rupture of membranes

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Acknowledgements

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

This study was supported by Helsinki University Hospital Research Grants. Authorization to use of the data was obtained from the National Institute for Health and Welfare as required by the national data protection legislation in Finland (reference number THL/652/5.05.00/2017).

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AT: Project development, manuscript writing. SH: Project development. MG: Data collection and analysis, manuscript editing. GM: Project development, manuscript editing.

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Toijonen, A.E., Heinonen, S.T., Gissler, M.V.M. et al. A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case–control study. Arch Gynecol Obstet 301 , 393–403 (2020). https://doi.org/10.1007/s00404-019-05385-5

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DOI : https://doi.org/10.1007/s00404-019-05385-5

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A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study

Affiliations.

1 Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland. [email protected].
2 School of Medicine, University of Helsinki, Helsinki, Finland. [email protected].
3 Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland.
4 National Institute for Health and Welfare (THL), Helsinki, Finland.
PMID: 31741046
PMCID: PMC7033046
DOI: 10.1007/s00404-019-05385-5

Purpose: To determine if the common risks for breech presentation at term labor are also eligible in preterm labor.

Methods: A Finnish cross-sectional study included 737,788 singleton births (24-42 gestational weeks) during 2004-2014. A multivariable logistic regression analysis was used to calculate the risks of breech presentation.

Results: The incidence of breech presentation at delivery decreased from 23.5% in pregnancy weeks 24-27 to 2.5% in term pregnancies. In gestational weeks 24-27, preterm premature rupture of membranes was associated with breech presentation. In 28-31 gestational weeks, breech presentation was associated with maternal pre-eclampsia/hypertension, preterm premature rupture of membranes, and fetal birth weight below the tenth percentile. In gestational weeks 32-36, the risks were advanced maternal age, nulliparity, previous cesarean section, preterm premature rupture of membranes, oligohydramnios, birth weight below the tenth percentile, female sex, and congenital anomaly. In term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, premature rupture of membranes, oligohydramnios, congenital anomaly, female sex, and birth weight below the tenth percentile.

Conclusion: Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in extremely preterm deliveries has, with the exception of preterm premature rupture of membranes, similar clinical risk profiles as in cephalic presentation.

Keywords: Breech presentation; Preterm delivery; Preterm labor; Risk factor.

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Obstetric Labor, Premature / epidemiology*
Premature Birth / epidemiology*
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Maternal and fetal characteristics to predict c-section delivery: A scoring system for pregnant women

Rima irwinda.

1 Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology, Faculty of Medicine Universitas Indonesia and Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Rabbania Hiksas

2 Faculty of Medicine Universitas Indonesia and Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Angga Wiratama Lokeswara

Noroyono wibowo, introduction:.

Cesarean section is one of the most common obstetrical interventions that has been performed at an increasing rate globally, due to both medical and non-medical reasons. This study aims to develop a prediction tool for pregnant women potentially needing c-section, such that necessary preparations from the mothers, families, and health providers can be made.

A total of 603 pregnant women were recruited in the first phase of c-section prediction tool development. The association between the maternal and fetal factors on the risk of c-section were analyzed, followed by a stepwise multivariate regression analysis. In the next phase, 61 pregnant women were enrolled for external validation. Discrimination was assessed using area under the curve. The calibration plot was then made and assessed using the Hosmer–Lemeshow test.

There were 251 (41.6%) cases of vaginal delivery and 352 (58.4%) of c-section assessed. Multivariate analysis showed that gestational age < 37 wg (OR: 1.66, 95% CI: 1.10–2.51), pre-pregnancy body mass index (underweight) (OR: 0.40, 95% CI: 0.22–0.76), no history of vaginal delivery (OR: 2.66, 95% CI: 1.76–4.02), history of uterine surgery (OR: 8.34, 95% CI: 4.54–15.30), obstetrical complications (OR: 5.61, 95% CI: 3.53–8.90), birthweight ⩾ 3500 g (OR: 4.28, 95% CI: 2.16–8.47), and non-cephalic presentation (OR: 2.74, 95% CI: 1.53–4.89) were independently associated with c-section delivery. Those parameters were included in a 7-item scoring tool, with consecutive predictive scores of 1,–1,2,3,3,2,2,1. The area under the curve result was 0.813 (95% CI: 0.779–0.847), indicating a good predictive ability. The external validation showed AUC: 0.806, 95% CI: 0.694–0.917, Hosmer–Lemeshow test p = 0.666 and calibration plot coefficient of r = 0.939.

Conclusion:

A total of 7 maternal-fetal factors were found to be strongly associated with c-section delivery, including gestational age < 37, maternal underweight body mass index, previous uterine surgery, obstetrical complications, birthweight ⩾ 3500, history of vaginal delivery, and non-cephalic presentation. Using these factors, a prediction tool was developed and validated with good quality.

Introduction

Cesarean section, or more commonly known as c-section, has become the main alternative delivery method in pregnancy with life-threatening complications. 1 The decision to perform c-section should be made under conditions where vaginal delivery is impossible, or poses more risks, and is therefore taken only with certain maternal or fetal indications. 2

Based on the Statement on Cesarean Section Rates by the WHO, 3 a systematic review and ecological analysis have found that a population-based c-section rates above 10% does not correlate with reductions in maternal and neonatal mortality, thus is considered non-optimal, considering the adverse complications in future pregnancies. 4 , 5 Nevertheless, in the last decade, WHO found that the rates of c-section has dramatically increased from 7% in 1990 to more than 1 in 5 childbirths (21%) in 2021, and is projected to reach 29% in 2030, globally. If the trend continues, Eastern Asia and Latin America are projected to reach the highest rates at 63% and 54% respectively. 6

Although c-section can be an imperative, lifesaving surgery in certain cases, one concerning reason behind the trend is the increasing c-section by maternal request, without any medical indications. 7 A systematic review by Begum et al. 8 in 2020 found that c-section by maternal request makes up 0.2%–42% of all childbirths, and 0.9%–60% of all c-sections, with 11-fold increase in c-section by maternal request in upper middle-income countries compared with either high or lower-middle income countries.

In Indonesia, the rate of c-section mimics the global trend, as it increased from 9.8% in 2013 to 17.6% in 2018, with the highest rate found in Jakarta (31.1%). 9 In recent years, the rate of c-section in Cipto Mangunkusumo National Referral Hospital alone reached almost 50%. Despite advanced surgical techniques, c-section poses short-term and long-term complications. Several risks are associated with c-section, including miscarriage and stillbirth, placenta previa, and placenta accreta in the following pregnancy, as well as development of childhood asthma. 10 In Cipto Mangunkusumo hospital, the cases of placenta accreta was found to be at 76 out of 2660 c-section deliveries (2.86%) in 2019. 11 A multi-country survey has also found that c-section performed without medical indications increases risks for severe maternal outcome. 12

Furthermore, in Indonesia, the high maternal morbidity and mortality rates were highly influenced by the poor infrastructure of the healthcare system in remote areas as well as poor awareness of the pregnant mothers, resulting in delayed referrals. 13 In developing countries like Indonesia, poor awareness of the early signs of obstetrical complications also contributes to late consultation to obstetricians. This could eventually delay the c-section, resulting in life-threatening conditions. Therefore, by educating pregnant women with regards to their risks of c-section, maternal and fetal outcomes could potentially be improved.

With varying trends in c-section and its medical and non-medical reasons, the medical risk factors behind today’s trend of c-section becomes unclear. Numbers of scoring system related maternal and fetal characteristics to predict the risk of c-sections have been developed for obstetricians in order to ensure the procedure was done only if indicated. 14 , 15 However, the existing scoring systems were built for obstetrician, hence are too difficult for pregnant women in general population to comprehend, thus many pregnant women remain unaware of their obstetrical condition. Therefore, this study aims to assess the maternal and fetal risk factors of c-section and develop a prediction tool for mothers potentially needing c-section. Hence, necessary preparations from the mothers and families, especially in third trimester, and health providers can be made.

Study setting

The study was carried out at Cipto Mangunkusumo Hospital, Fatmawati Hospital, and Tangerang General hospital, located in Jakarta-Tangerang, Indonesia. All of the hospitals are tertiary referral hospital, which receive and treat referred cases from primary and secondary healthcare facilities. Moreover, Cipto Mangunkusumo Hospital is a national referral hospital in Indonesia, handling patients not only from Jakarta, Indonesia, but also other referred patients from other provinces in Indonesia, mainly the ones with adverse pregnancy complications. These hospitals are also teaching hospitals, where examination and procedures were performed by residents of the Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Indonesia, under close supervision by highly qualified Obstetrics and Gynecology subspecialists and consultants.

Study design and sample recruitment

This was a retrospective cohort study using data from the hospital’s medical records. The first phase of the study was development of a scoring system, which took place in Cipto Mangunkusumo Hospital and Fatmawati Hospital. The minimum sample size calculated was 273; on the basis incidence of c-section rate in Jakarta, 2018 (31.1%), 9 along with 95% confidence interval (CI), and 80% power. 16 The study was restricted to women delivered in those two hospitals from January to April 2019, with gestational age of 22–42 weeks. A total of 753 cases met the criteria. We excluded deliveries with babies weighing 500 g or less (n = 13), cases of intrauterine fetal death at less than 28 weeks (n = 28), and cases with incomplete antenatal data (n = 109). After exclusions, a total of 603 cases complied our eligibility criteria and were put to analysis.

The next phase was a validation of the scoring system, which took place in Tangerang General Hospital. The minimum sample size was also calculated with 95% CI and 80% power. 16 With the effect size 0.26 (low-risk and high-risk difference from the first part of study), the minimum sample requirement for the external validation was 46. Applying similar inclusion and exclusion criteria, the study was restricted to women delivered in the hospital from July to August 2021, with gestational age of 22–42 weeks. Within the period of study, a total 89 cases met the criteria. We excluded deliveries with babies weighing 500 g or less (n = 5), cases of intrauterine fetal death at less than 28 weeks (n = 4), and cases with incomplete antenatal data (n = 19). We continued the external validation using 61 samples. Figure 1 shows the workflow diagram.

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The workflow diagram.

This study has been approved by The Ethical Committee for Research in Humans from The Faculty of Medicine, Universitas Indonesia (KET-1491/UN2.F1/ETIK/PPM.00.02/2020). Since this was a retrospective study, we extracted only clinically relevant information from medical records with ensuring patient’s privacy protection. This study also did not affect patients treatment and health, thus written informed consent from all participants was waived by the Ethical Committee.

Outcome measures

All data extracted from medical records were classified into demographic characteristics, pregnancy history, current pregnancy characteristics, and neonatal features. Demographic characteristics; maternal age, gestational age, body height, body weight before pregnancy and during last trimester, body mass index (BMI) before pregnancy and during last trimester which was categorized based on Asia-Pacific BMI criteria including underweight (< 18.5), normal (18.5–22.9), overweight (23–24.9), and obese (⩾ 25). Pregnancy history; gravidity, parity, previous uterine surgery (c-section or myomectomy), history of vaginal delivery. Current pregnancy characteristics; antenatal care (ANC) visit, types of pregnancy (single or twin), pregnancy program, presence of chronic diseases (diabetes, hypertension, heart disease, kidney disease, autoimmune diseases, infections including syphilis, human immunodeficiency virus (HIV), or hepatitis B, and cancer), obstetrical complications [hypertensive disorder in pregnancy, 17 gestational diabetes mellitus (severe hyperglycaemia in pregnancy), 18 intrauterine growth restriction (i.e. estimated fetal weight or abdominal circumference below the 10th percentile, abnormal doppler/amniotic fluid index/biophysical profile), 19 placenta previa, and placental abruption], and the presence of premature rupture of membrane (later than 6 or 12 h). Neonatal features: birth weight, and fetal presentation at the last trimester.

All women were classified into two groups: vaginal delivery and c-section. C-section included both emergency and elective c-section. Vaginal delivery included spontaneous delivery, with or without induction, vacuum extraction, or forceps delivery. The primary outcome of this study was to identify the possible independent factors associated with c-section, which are comprehensible for both non-health care workers and health-care providers.

Statistical analysis

Data analysis was performed using SPSS statistics, version 25 (SPSS Inc, Chicago, Illinois, USA). Mean and standard deviation were used to describe continuous variables with normal distribution, while median and interquartile range for non-normal distribution data. Comparison of proportions was performed by Pearson’s chi-square (χ 2 ) for categorial variables. Variables with p-value < 0.250 in bivariate analysis were put into logistic regression analysis. Each odds ratio (OR) with multivariable log-binomial regression models was estimated with 95% confidence intervals (CIs). A p-value of less than 5% was considered statistically significant.

A predictive scoring tool was developed through stepwise calculations: (1) dividing each prognostic factor’s coefficient B by its standard error (coefficient B/SE); (2) choosing the lowest B/SE value as a reference (3) dividing each B/SE value by the reference value; and (4) picking the rounded number nearest to the result from step 3. In order to evaluate the performance of our scoring system, we analyzed calibration score using the Hosmer–Lemeshow test and discrimination score using receiver operating characteristic (ROC) and area under receiver operating characteristic curve (AUC). These were followed by internal validation using repeated backward logistic regression model for each of predictors with 1000 bootstrap resampling. Finally, the result of external validation of the scoring system were evaluated using repeated discrimination and calibration test using the same method.

Characteristics of study population

There were 603 cases assessed in this study, including 251 (41.6%) cases with vaginal delivery and 352 (58.4%) with c-section delivery. The characteristics of study population is shown in Table 1 . Bivariate and multivariate analysis were performed to evaluate the significances of variables associated with mode of delivery. Among the 18 variables which were analyzed for their association with the risk of c-section, 11 variables found to be significant ( Table 2 ). These 11 variables were then included in the logistic regression analysis, resulting in 7 variables found to be significantly associated with c-section delivery (p < 0.05). The odds ratio of the 11 variables are showed in Table 3 .

Baseline characteristics of study population.

IQR: interquartile range; BMI: body mass index; BP: blood pressure.

Bivariate analysis of factors associated with c-section.

OR: odds ratio; CI: confidence interval; BMI: body mass index; ANC: antenatal care.

Odds ratio for independent variables in multivariate logistic regression analysis.

OR: odds ratio; CI: confidence interval; wg: weeks of gestation; BMI: body mass index.

Development of c-section scoring system

There were seven variables identified in development of scoring system for the final model ( Table 4 ), including gestational age < 37 weeks, underweight pre-pregnancy BMI, previous uterine surgery, obstetrical complications, birth weight ⩾ 3500 g, no history of vaginal delivery, and non-cephalic presentation. Following that, a 7-item scoring system was developed (gestational age < 37 weeks = 1, underweight pre-pregnancy BMI = –1, non-cephalic presentation = 1, no history of vaginal delivery = 2, birthweight ⩾ 3500 g = 2, previous uterine surgery = 3, and obstetrical complications = 3), with a total score 11. The full scoring system is shown in Table 5 .

Derivation of 7-point scoring system to the risk of c-section from stepwise multivariate analysis.

SE: standard error; OR: odds ratio; CI: confidence interval; wg: weeks of gestation; BMI: body mass index.

Sensitivity, specificity, and probability analysis of the scoring system.

Furthermore, the area of AUC was 0.813 (95% CI: 0.779–0.847). ( Figure 2 ). This was considered good as sensitivity of 81% were shown when the score ⩾3 was categorized as high risk for c-section, with a probability score of 53.13% ( Table 5 ). Calibration using Hosmer–Lemeshow showed a good calibration score with p = 0.555 (p > 0.05). An internal validation using 1000× boostraping also showed the same p value (p = 0.555). As the p values of before and after bootstrapping are the same, the scoring system can likely be expected to have similar results in a bigger population.

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The ROC curve of the scoring system development the AUC = 0.813, 95% CI: 0.779–0.847.

External validation

We then enrolled 61 subjects for external validation of the scoring tool. Among them, 24 subjects underwent vaginal delivery and 37 subjects underwent c-section delivery. The performance of c-section risk scoring tool was assessed for calibration and discrimination results. As the calibration plot showed a coefficient of r = 0.939 ( Figure 3 ), and the Hosmer–Lemeshow test showed p = 0.624, the scoring system was considered to have a good calibration. In Figure 4 , The AUC was 0.806, with 95% CI (0.694–0.917), showing an excellent discrimination with no big difference from the first part of the study.

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The plot calibration diagram of the scoring system in external validation (r = 0.939).

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The ROC curve of the scoring system in external validation. The AUC = 0.806, 95% CI: 0.694–0.917.

There were seven variables identified to be independently associated with c-section delivery, including gestational age < 37 weeks, maternal underweight pre-pregnancy, previous uterine surgery, obstetrical complications, no history of vaginal delivery, birth weight ⩾ 3500 g, and non-cephalic presentation. From these variables, a scoring system for the risk of c-section has been developed. Since this scoring system was intended for those without medical background, certain variables which were deemed too technical for general population to understand were not included in the analysis. Therefore, variables such as characteristics of amniotic fluid or umbilical cord were not included in the analysis despite their known associations with the risk of c-section based on previous studies. 14

Among the maternal demographical characteristics, maternal underweight BMI pre-pregnancy was the only variable to independently reduce the risk of c-section by OR: 0.40, 95% CI: 0.22–0.76. This finding was consistent with numbers of study from Asia to Europe, where pre-pregnancy underweight BMI were found to lower the risk of cesarean delivery by almost half, with OR: 0.45–0.66. 20 – 22 In contrast, obese patients who were thought to have increased risks for c-section, showed no significant difference in our study. This was surprising as a previous study had suggested that nulliparous obese pregnant women might have increased risk of c-section. 23 A different cut off value for BMI category between the two criteria, Asian-Pacific and WHO criteria, might have influenced the differing results.

In terms of the obstetrical history, the history of uterine surgery and no history of vaginal delivery were found to be highly associated with c-section. Our study found that the history of uterine surgery was one of two variables with the highest scores in predicting c-section. This finding is in agreement with previous studies which found that a history of c-section in previous births increased the risk of c-section in the following pregnancy, with RR 4.30 (4.24–4.36) and OR: 3.5 (3.4–3.6). 15 , 24 This value may also be increased in deliveries with a history of previous c-section with a gestational distance of less than 19 months. 25 , 26 Although a history of previous c-section is not an absolute indication of c-section in subsequent pregnancies, vaginal birth after cesarean (VBAC) might cause numerous adverse effects including uterine rupture, fetal death, or fetal brain damage due to hypoxia. In addition, other previous uterine surgeries such as myomectomy or resection of adenomyosis were also known as a risk factor for c-section, and are considered indications for c-section in subsequent deliveries. 27 Moreover, history of vaginal delivery also affects the risk of c-section. Mothers in their first pregnancy have a greater risk of having a cesarean delivery compared to those who have already had a vaginal delivery before. This is because the pelvic of multiparous women with previous vaginal delivery was considered to be more flexible and easier to undergo vaginal delivery in the following pregnancies. 15 , 23 , 28

Furthermore, obstetrical complications are also well-established major risk factors of c-section procedure. In this study, we included preeclampsia/eclampsia, gestational diabetes mellitus, IUGR, placenta previa, and placental abruption, since those are the most common pregnancy problems in Indonesia. 9 Previous studies have suggested that those complications of pregnancy had relative risk of around 1.45–1.75 for c-section. 14 , 15 , 24 Our study found that preterm birth (gestational age < 37 wg) increased the risk of c-section. This was consistent with another previous study which showed that birth at < 37 wg increased the risk of c-section with an OR: 1.45, 95% CI: 1.16–1.72. 29 This findings imply that pregnant women who felt the signs of labor such as uterine contractions, bloody mucous discharge or water breaking before 37 weeks of gestation, were predicted to had increased risk of c-section.

The characteristics of the fetus during pregnancy may also affect the risk of c-section delivery, especially during the third trimester. Our study found that birthweight ⩾ 3500 g had OR of 4.28 (95% CI: 2.16–8.47), thus is given a score of “2” in our prediction tool. This is in agreement with a previous study which found that heavier fetal weight was associated with the increased risk of c-section. 14 , 30 Another previous study also supports our finding, suggesting that a total of 60.7% of pregnancies with a fetal weight more than 3500 were delivered by c-section, compared to 39.3% for a fetus weighing < 3500 g. 28 Although our study used the clinical birthweight rather than the estimated fetal weight, previous studies have found that there was no significant difference between estimated fetal weight and actual birth weight in normal weight population. 31 Significant difference of fetal weight usually found in small for gestational age fetus, with differences up to 200 g. 32 Thus, a clinically-determined estimated fetal weight of ⩾ 3500 g, can still be a predictive factor for an increased risk of c-section. In addition, our study also found that non-cephalic presentation is associated with increased risk of c-section. This was not surprising, as numbers of studies have also found its association with increased risk of c-section. A previous study found that the incidence of c-section in non-cephalic presentation was 93.3% (p < 0.001) compared to head presentation, the incidence of which is 37.3%. 28 Nevertheless, studies have suggested that non-cephalic presentation was best diagnosed at 36 weeks of gestational age. 33 Therefore, pregnant women who uses our scoring tool with diagnosed fetal presentation before 36 weeks of gestation, is recommended to repeat the examination in the subsequent weeks of pregnancy. Moreover, interestingly, in our first part of study, we also found 37.18 per 1000 rate of early fetal death. This high number was due to the fact that our study was conducted in tertiary and national referral hospitals, thus the number of cases of adverse pregnancy complications was higher than the national data. 9

To the best of our knowledge, this is the first study to propose a scoring system in the risk of c-section for both non-medical and medical personnel, with variables which were considered simple and easy to evaluate. The internal and external validations have reflected satisfactory calibration and discrimination values of the scoring system. Nevertheless, there were certain limitations of the study. Pregnant women that could confidently use this scoring were the ones with late trimester, as most of variables could only be evaluated during the last trimester. Also, this was a retrospective study, thus the conclusions were limited by the results of this present study. Further studies should explore the application of this predictive scoring tool in a wider range of population with a prospective cohort design.

There were seven independent factors found to be highly associated with c-section delivery, including gestational age < 37, underweight pre-pregnancy BMI, previous uterine surgery, no history of vaginal delivery, obstetrical complications, birthweight ⩾ 3500, and non-cephalic presentation. A predictive scoring tool has been developed and validated with a good quality. Pregnant women were expected to use this scoring tool as a self-administered questionnaire so they are able to self-assess their risks of c-section. High risk of c-section results would encourage mothers, families, and healthcare professionals to arrange for early consultations with obstetricians and make better preparations for the mothers to deliver at the hospitals.

Acknowledgments

We thank Danone Specialized Nutrition Indonesia for supporting this research, as they will further create an online application for the tools.

Author contributions: R.I. and N.W. designed the study. R.H. and A.W.L. conducted the research, performed the analysis, interpretation of data, and wrote the manuscript. R.I. validated the data, revised the paper, and had primary responsibility for the final content. All authors agreed to the published version of the manuscript.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Object name is 10.1177_17455065211061969-img1.jpg

Data availability: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Fetal Presentation, Position, and Lie (Including Breech Presentation
Head first (called vertex or cephalic presentation) Facing backward (occiput anterior position) Spine parallel to mother's spine (longitudinal lie) Neck bent forward with chin tucked. Arms folded across the chest . If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not ...
The evolution of fetal presentation during pregnancy: a retrospective
Introduction. Cephalic presentation is the most physiologic and frequent fetal presentation and is associated with the highest rate of successful vaginal delivery as well as with the lowest frequency of complications 1.Studies on the frequency of breech presentation by gestational age (GA) were published more than 20 years ago 2, 3, and it has been known that the prevalence of breech ...
Fetal Positions For Birth: Presentation, Types & Function
Occiput or cephalic anterior: This is the best fetal position for childbirth. It means the fetus is head down, facing the birth parent's spine (facing backward). Its chin is tucked towards its chest. The fetus will also be slightly off-center, with the back of its head facing the right or left. This is called left occiput anterior or right ...
Leopold Maneuvers
The first maneuver aims to determine the gestational age and the fetal lie. Gestational age can be evaluated using fundal height or McDonald's rule. The uterine fundus reaches: ... In the cephalic presentation, the hand is placed flat on the pubic symphysis, and the palpation could delineate the fetal head portion that can be reached above the ...
Your Guide to Fetal Positions before Childbirth
Head Down, Facing Down (Cephalic Presentation) This is the most common position for babies in-utero. In the cephalic presentation, the baby is head down, chin tucked to chest, facing their mother's back. This position typically allows for the smoothest delivery, as baby's head can easily move down the birth canal and under the pubic bone ...
Cephalic presentation
A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; ... Factors that influence this positioning include the gestational age (earlier in gestation breech presentations are more common as the head is relatively bigger), ...
External Cephalic Version
The global cesarean section rate has increased from approximately 23% to 34% in the past decade. Fetal malpresentation is now the third-most common indication for cesarean delivery, encompassing nearly 17% of cases. Almost one-fourth of all fetuses are in a breech presentation at 28 weeks gestational age; this number decreases to between 3% and 4% at term. In current clinical practice, most ...
A comparison of risk factors for breech presentation in preterm and
Introduction. The prevalence of breech presentation at delivery decreases with increasing gestational age. At 28 pregnancy weeks, every fifth fetus lies in the breech presentation and in term pregnancies, less than 4% of all singleton fetuses are in breech presentation at delivery [1, 2].Most likely this is due to a lack of fetal movements [] or an incomplete fetal rotation, since the ...
Breech Presentation: Overview, Vaginal Breech Delivery ...
Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks' gestation to 3-4% of births at term.
Revisiting the management of term breech presentation: a proposal for
Of note, among those children born in the breech rather than in the cephalic presentation, these authors found that a higher proportion of infants were born small for gestational age (SGA). However, these authors did ... [49,50,51], nonfrank breech presentation , gestational age under 38 weeks , and posterior placenta . In ...
External Cephalic Version: Overview, Technique, Periprocedural Care
Successful version of a breech into cephalic presentation allows women to avoid cesarean delivery, which is currently the largest contributing factor to the incidence of postpartum maternal morbidity. ... Williams MA, Daling JR. The frequency of breech presentation by gestational age at birth: a large population-based study. Am J Obstet Gynecol ...
A comparison of risk factors for breech presentation in ...
Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery.
Delivery in breech presentation: Perinatal outcome and
For each newborn with a breech presentation, the first child born after the case in a cephalic presentation with a gestational age variation of 1 week was selected. Pregnant women with twins or those giving birth in another site, deliveries with an estimated foetal weight less than 1500 g or ≤32 weeks gestational age, stillborn children, and ...
Breech presentation induction compared to cephalic presentation
After adjustment for maternal age, gestational age, and Bishop score, there was no significant difference between the two groups (OR 0.67 [95 % CI 0.38-1.18]). The percentages of women undergoing cesarean section were higher in the cephalic group for failed induction (32.7 % vs 17.6 %) and latent phase dystocia (42.3 % vs 11.8 %).
External cephalic version
Following the term breech trial (TBT), the incidence of Caesarean section secondary to breech presentations increased, from 76.9 % to 89.7 %. External Cephalic Version (ECV) is a safe effective method to reduce non-cephalic presentation at time of delivery.
External cephalic version at 38 weeks' gestation at a specialized
Moreover, 28 fetuses had spontaneously turned into cephalic presentation prior to the procedure. A flowchart of outpatient consultations for birth planning with breech presentation is shown in Fig 2. Open in a separate window. ... the median gestational age at ECV was 37+5 weeks, and the majority were nulliparous (70.8%). Most fetuses were in ...
Breech presentation: its predictors and consequences. An analysis of
The Tauffer database contains a three-level variable describing birth presentation (cephalic/breech/oblique) that was used to define our variable of interest (cephalic versus breech presentation). ... Furthermore, newborns with breech presentation had a lower gestational age at delivery (by 0.3 weeks, 95% CI 0.25-0.27) (Tables 1 and 2).
A comparison of risk factors for breech presentation in ...
Conclusion: Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery.
External Cephalic Version—A Chance for Vaginal Delivery at Breech
The mean gestational age at ECV was 261.82 days (SD = 4.98). The minimum gestational age at ECV in our cohort was 35 + 2 weeks of pregnancy and the latest performed ECV was at 40 + 0 weeks of pregnancy. In 12 cases (10.6%), ECV was performed under 37 weeks of gestation because of medical necessity and with informed patient consent.
Full article: Changes in fetal presentation in the preterm period and
Non-cephalic presentation at birth comprises 3-4% of total pregnancies [1]. ... (4.4%). Non-cephalic presentation in later half of the gestational period was associated with low incidence of spontaneous cephalic version. ... Milberg JA, et al. The frequency of breech presentation by gestational age at birth: a large population-based study. Am ...
External Cephalic Version in Cases of Imminent Delivery at Preterm
Inclusion criteria were gestational age between 23 and 36 weeks, live fetus or fetuses, presentation other than cephalic (breech, transverse, or oblique), category I or II fetal heart rate monitoring, indication for delivery being (1) labor, (2) preterm prelabor rupture of membranes (with deepest vertical pocket ≥2 cm and cervix dilated ≤2 ...
Maternal and fetal characteristics to predict c-section delivery: A
A previous study found that the incidence of c-section in non-cephalic presentation was 93.3% (p < 0.001) compared to head presentation, the incidence of which is 37.3%. 28 Nevertheless, studies have suggested that non-cephalic presentation was best diagnosed at 36 weeks of gestational age. 33 Therefore, pregnant women who uses our scoring tool ...

Fetal Presentation, Position, and Lie (Including Breech Presentation)

Position and Presentation of the Fetus

Occiput posterior position

Breech presentation

Other presentations

Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies

Term breech presentation: are we asking the right questions?

Most recent large-scale data

The impact of strict criteria on the selection of vaginal delivery

How might we maximize patient benefit from a safe external cephalic version attempt?

Predictors of successful ECV

Obstetric outcomes after an ECV attempt

Towards a consensus for a global shared vision and management of term breech presentation that could include the following

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A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case–control study

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A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study

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Maternal and fetal characteristics to predict c-section delivery: A scoring system for pregnant women

Rabbania Hiksas

Angga Wiratama Lokeswara

Conclusion:

Introduction

Study setting

Study design and sample recruitment

Outcome measures

Statistical analysis

Characteristics of study population

Development of c-section scoring system

External validation

Acknowledgments

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