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Extremely Preterm Vaginal Breech Delivery en Caul

From the Department of Obstetrics and Gynecology, McGill University, Women’s Pavilion, Royal Victoria Hospital, Montreal, Canada.

Address reprint requests to: Jane R. Richmond, MD, McGill University, Department of Obstetrics and Gynecology, Women’s Pavilion (F4.46), Royal Victoria Hospital, 687 Pine Avenue West, Montreal H3A 1A1, Canada; E-mail: jane.richmond{at}muhc.mcgill.ca.

OBJECTIVE: To describe an alternative method of vaginal birth to the conventional assisted delivery for extremely preterm breech infants within intact amnions, and to compare the immediate neonatal outcomes with those delivered by cesarean.

METHODS: Retrospective review of singleton breech deliveries under 26 weeks’ gestation after spontaneous labor with intact membranes. Nine "en caul" vaginal births after tocolysis and six cesarean deliveries performed for the sole indication of preterm labor were identified between 1996 and 2001.

RESULTS: The vaginal group’s mean gestation and cervical dilatation on admission were 23⁺⁶ weeks and 3.2 cm, respectively, and 24⁺⁶ weeks and 2.8 cm in the cesarean group. Vaginal delivery occurred an average of 4 days after admission and 1 day for cesarean delivery. Mean time interval between the first corticosteroid injection and delivery was greater in the vaginal group (90 versus 22 hours). Failure to start or complete a steroid course was more likely in the operative group (67% versus 11%). Mean birth weights were comparable. Five-minute Apgar scores and cord pHs were 6 and 7.41, respectively, for vaginal births, and 5.5 and 7.32 after cesarean deliveries. Fifty-five percent of vaginally delivered infants had a 5-minute Apgar score less than 7, with 22% of the whole group dying during the first week of life. This compared with 66% and 50%, respectively, for cesarean infants. Of the survivors, average age at discharge was 121 days for both groups.

CONCLUSION: Vaginal birth can be effected in extremely preterm breech pregnancies with intact membranes by adopting the "en caul" delivery method.