Avoid labor augmentation in breech deliveries if a Cesarean delivery is impossible

OB/GYN News, April 15, 2003 by Sherry Boschert

SAN FRANCISCO--If a breech fetus cannot be delivered by Cesarean section before ,the onset of labor, there are still some strategies that can be used to decrease the risk of perinatal complications, Dr. Mm Su said at the annual meeting of the Society for Maternal-Fetal Medicine.

Secondary analysis of the 1,889-patient Term Breech Trial found that avoiding labor. induction and a long active phase of the second stage of labor, as well as involvement of an obstetrician experienced in breech deliveries, reduced the risk of perinatal problems, said Dr. Su of the University of Toronto.

The primary results of the Term Breech Trial showed that a policy of planned C-section delivery of term breech fetuses was safer for babies than plannedvaginal delivery. Perinatal problems occurred in 2% after planned C-section and 5% after vaginal delivery (Lancet 356:1375-1383, 2000).

The current analysis looked at baseline antepartum characteristics and intrapartum events in 1,384 patients who delivered after some form of labor to determine which factors were associated with an increased risk for an adverse perinatal outcome.

Compared with vaginal birth, which conferred the highest risk, C-section before labor reduced the risk by 90%, and C-section during early labor reduced the risk by 80%. A 40% reduction in risk with C-section during active labor was not statistically significant.

Babies weighing less than 2,800 g were nearly twice as likely as babies weighing 2,800-3,500 g to develop complications.

Labor augmentation more than doubled the risk for perinatal complications, compared with women who experienced some form of labor but without labor augmentation.

An active phase of the second stage of labor--from pushing to the delivery phase- increased the risk for perinatal problems in a dose-response fashion. The longer the pushing, the higher the risk; the greatest risk was in women who pushed for at least 1 hour, Undergoing C-section before any pushing reduced that risk by 80%.

Compared with pushing for at least 60 minutes, pushing for no more than 30 minutes reduced risk by 70%. Pushing for 30-60 minutes was associated with a 30% reduction in risk, which was not statistically significant.

Having an experienced obstetrician assist in the delivery also helped, but only when "experienced" was defined as the clinician's personal opinion of self-expertise with confirmation from the department chair. When experience was defined by years of practice or being licensed to practice obstetrics, the risk for perinatal complications was not reduced, she said.

"Breech babies at term are best delivered by prelabor C-section. If that's not possible, adverse perinatal outcomes may be reduced by 'avoiding active labor, avoiding and minimizing the duration from pushing to delivery, avoiding labor augmentation, and having an experienced clinician," Dr. Su said.