Reduction of maternal and neonatal harm through prevention of the primary Cesarean section

While there are clear life-saving indications for Cesarean section (C-section), rates of this procedure have seen a continued rise without a concomitant improvement in maternal or neonatal outcomes. There is some evidence that outcomes may actually be worse for low-risk C-sections versus vaginal delivery. However, this is not necessarily common knowledge for healthcare providers, and therefore, their patients. Measures to safely reduce the C-section rate target management of labour arrest and specific indications for progression to C-section. In the active phase of the first stage of labour, C-section should be considered only in cases of failure to progress after 4 hours of adequate uterine contraction, or 6 hours of inadequate contraction. In the second stage of labour, expectant management of 3 hours of pushing in nulliparous women and 2 hours in multiparous women is safe and appropriate. Furthermore, manual rotation and operative vaginal delivery in the second stage are reasonable alternatives to C-section. Expectant management is also appropriate for certain non-reassuring fetal heart rate tracings. In post-dates pregnancies, induction of labour reduces both rates of C-section and neonatal mortality. Finally, evidence supports the use of external cephalic version in breech presentation as well as a more conservative approach to suspected macrosomia and multiple pregnancy. Taken together, these measures target the most common indications for progression to C-section and can allow us to safely reduce the C-section rate. Educating patients and physicians on the risks of the procedure and reasonable alternatives can improve outcomes for mothers and neonates.

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Sonographic assessment of fetal head deflexion using occiput: spine angle measured during first stage of labour and its role in predicting the mode of delivery among nulliparous women

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20193147 ◽

2019 ◽

Vol 8 (8) ◽

pp. 3025

Author(s):

Keerthi Somu ◽

Sujatha B. S. ◽

Shripad Hebbar ◽

Shyamala G. ◽

Muralidhar V. Pai

Keyword(s):

Cesarean Section ◽

Vaginal Delivery ◽

Mode Of Delivery ◽

Active Phase ◽

Mean Value ◽

Fetal Head ◽

Nulliparous Women ◽

Active Labour ◽

Study Population ◽

The Mean

Background: The attitude of the fetal head during labour significantly influences the progress and outcome of delivery and is mainly diagnosed by vaginal examination during labour. The aim of the study was to quantify the extent of deflexion of the fetal head by measuring the fetal occiput spine angle (OSA) through transabdominal ultrasonography in the first stage of labour and to determine whether the fetal OSA can predict the mode of delivery.Methods: We conducted a prospective observational study on 145 nulliparous uncomplicated singleton pregnant women without occiput-posterior position of the fetus during active labour. The OSA was measured as the angle between the two tangential lines to the occipital bone and the vertebral body of the first cervical spine, during active labour and monitored until delivery. Intra- and interobserver reproducibility of the OSA measurement and the correlation between the OSA and mode of delivery were also evaluated.Results: For the study population, the mean value of the OSA measured in the active phase of the first stage was 124.2±11.5⁰. The OSA measurement showed excellent intraobserver agreement (r = 0.82; 95% confidence interval [95% CI] 0.70-0.80) and fair-to-good interobserver agreement (r = 0.62; 95% CI 0.51-0.71). The mean OSA was significantly less for the group of patients who required conversion to cesarean section due to labour arrest (n=32) as compared to those who had vaginal delivery (n=113) (116.25±9.2⁰ versus 126.53±11.1⁰, P<0.01). An OSA of ≥121° was associated with vaginal delivery in 80.5% (91/113) of women, whereas 87.5% (28/32) of the women who delivered by cesarean section had an OSA <121⁰.Conclusions: Measurement of the OSA, by sonography is feasible, reproducible and an objective tool to assess the degree of fetal head deflexion during labour and to predict the mode of delivery.

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Fetal Malpresentation in Pregnancy

10.2310/obg.19071 ◽

2020 ◽

Author(s):

Afshin Azimirad ◽

Errol R. Norwitz

Keyword(s):

Vaginal Delivery ◽

Medical Center ◽

Breech Presentation ◽

Obstetric Care ◽

External Cephalic Version ◽

Breech Delivery ◽

Advantages And Disadvantages ◽

Ultrasound Evaluation ◽

Elective Repeat Cesarean ◽

Anatomical Part

Fetal presentation refers to that anatomical part of the fetus that presents at the maternal pelvic inlet. The most common and most desirable fetal presentation is cephalic (head first). Any presentation other than cephalic is referred to as a malpresentation. Breech is the most common fetal malpresentation. The prevalence of breech presentation varies with gestational age (25% at 28 weeks and 3-5% of at term). Ultrasound evaluation is the gold standard for the diagnosis of fetal presentation. External cephalic version (ECV) refers to a series of manual manipulations designed to convert a malpresenting fetus to cephalic to promote vaginal delivery. There are two strategies around the timing of ECV; at 36-37 weeks and/or at or shortly after 39 weeks’ gestation. Each has advantages and disadvantages. Currently, most breech pregnancies at term are delivered by cesarean at 39 weeks prior to the onset of labor. Malpresentation is the second most common indication for planned cesarean (behind elective repeat cesarean). Vaginal delivery for a breech fetus at term should only be attempted if the mother is strongly motivated, if the obstetric care provider is experienced, and if the medical center has the requisite facilities to manage any and all complications. This review contains 3 figures, 2 tables, and 66 references. Keywords: fetal presentation, malpresentation, breech presentation, ultrasound evaluation, external cephalic version (ECV), cesarean delivery, vaginal breech delivery

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Predictive Factors for Successful Vaginal Delivery after a Trial of External Cephalic Version: A Retrospective Cohort Study of 946 Women

American Journal of Perinatology ◽

10.1055/s-0041-1739505 ◽

2021 ◽

Author(s):

Asaf Bilgory ◽

Olena Minich ◽

Maria Shvaikovsky ◽

Genady Gurevich ◽

Joseph B. Lessing ◽

...

Keyword(s):

Cohort Study ◽

Vaginal Delivery ◽

Predictive Factors ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Goodness Of Fit ◽

External Cephalic Version ◽

Nulliparous Women ◽

Tertiary Center ◽

Vertex Presentation

Objective Our aim was to find the factors which predict a vertex presentation of vaginal delivery (VD) in women who are admitted for a trial of external cephalic version (ECV). Study Design This is a retrospective cohort study of women who underwent a trial of ECV and delivered between November 2011 and December 2018 in a single tertiary center. The main outcome measure was successful VD of a fetus in the vertex presentation. Women who achieved VD in the vertex presentation or underwent cesarean delivery were compared on the basis of variety of predictive factors. Adverse neonatal and maternal outcomes were reported. Logistic regression was used for the multivariate analysis. Results A total of 946 women were included; 717 (75.8%) women had a successful ECV and 663 (70.1%) women had a VD in the vertex presentation. Parous women had 79.3% VD rate (570/719) and nulliparous women had 41.0% VD rate (93/227). Women with an amniotic fluid index (AFI) of 50 to 79, 80 to 200, and >200 mm had 34.8, 71.0, and 83.1% VD rate, respectively. Parous versus nulliparous women had an adjusted odds ratio (aOR) of 5.42 (95% confidence interval [CI] 3.90–7.52, p < 0.001), women with AFI 50 to 79 mm compared with AFI 80 to 200 mm had an aOR of 0.21 (95% CI 0.12–0.37, p < 0.001), and women with an AFI >200 mm compared with AFI 80 to 200 mm had an aOR of 1.74 (95% CI 1.03–2.92, p = 0.037) to achieve VD. The final prediction model for the chances of a VD based on data on admission for ECV was reported. The Hosmer-Lemeshow test was used to evaluate the goodness of fit of the model (p = 0.836). Conclusion Being parous and having an AFI >200 mm are positive independent predictive factors for achieving VD of a vertex presenting fetus after ECV. Whereas AFI 50 to 79 mm is a negative independent predictive factor. Key Points

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External Cephalic Version for Breech Presentation With or Without Spinal Analgesia in Nulliparous Women at Term: A Randomized Controlled Trial

Obstetrics and Gynecology ◽

10.1097/aog.0b013e318166e905 ◽

2008 ◽

Vol 111 (3) ◽

pp. 776 ◽

Cited By ~ 2

Author(s):

Mladen Predanic

Keyword(s):

Randomized Controlled Trial ◽

Controlled Trial ◽

Breech Presentation ◽

External Cephalic Version ◽

Spinal Analgesia ◽

Randomized Controlled ◽

Nulliparous Women

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Cesarean Section Poses Fewer Risks Than Vaginal Delivery for Term Infants in Breech Presentation

Family Planning Perspectives ◽

10.2307/2673758 ◽

2001 ◽

Vol 33 (2) ◽

pp. 92

Author(s):

F. Althaus

Keyword(s):

Cesarean Section ◽

Vaginal Delivery ◽

Breech Presentation ◽

Term Infants

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Prematurity, multiple gestation, and abnormal presentation

10.1093/med/9780198713333.003.0033 ◽

2016 ◽

Author(s):

Oonagh Keag ◽

E. Sarah Cooper

Keyword(s):

Preterm Labour ◽

Multiple Pregnancy ◽

Breech Presentation ◽

Neonatal Morbidity ◽

External Cephalic Version ◽

Multiple Gestation ◽

Antenatal Corticosteroids ◽

Breech Delivery ◽

Vaginal Breech Delivery ◽

Maternal Risks

Preterm labour is a common cause of neonatal morbidity and mortality. This chapter describes the definition, aetiology, diagnosis, and management of preterm labour and delivery with a focus on tocolytic therapy, the use of antenatal corticosteroids, and of magnesium sulphate. Anaesthesia for preterm delivery is discussed. The section on multiple pregnancy details the recommended antenatal careplan for dichorionic and monochorionic twin pregnancies, the fetal and maternal risks and potential complications, and the management of labour and delivery of twins, as well as the anaesthetist’s role in managing these high-risk pregnancies. There are a number of abnormal presentations managed by obstetricians, including abnormal cephalic presentations such as occiputo-posterior positions, breech, transverse, and compound presentations. This chapter focuses specifically on breech presentation, comparing the evidence for vaginal breech delivery versus planned caesarean delivery. It also discusses external cephalic version and vaginal breech delivery itself.

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