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Obstetrics & Gynecology 2003;102:911-917
© 2003 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Vaginal Versus Cesarean Delivery for Breech Presentation in California: A Population-Based Study

William M. Gilbert, MD, Shauna M. Hicks, MD, Nina M. Boe, MD and Beate Danielsen, PhD

From the Department of Obstetrics and Gynecology, University of California, Davis, Sacramento; and Health and Information Solutions, Rocklin, California.

Address reprint requests to: William M. Gilbert, MD, 4860 Y Street, Suite 2500, Sacramento, CA 95817; E-mail: wmgilbert{at}ucdavis.edu.


   ABSTRACT
TOP
ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: To examine the population-based pregnancy outcomes associated with vaginal breech delivery.

METHODS: A retrospective, population-based cohort study of all term (greater than 37 weeks’ gestation), normal birth weight (2.5–3.8 kg), nonanomalous newborns in California, from January 1, 1991 to December 31, 1999 was performed. Neonatal mortality and major neonatal morbidity were compared by route of delivery for cephalic (3,271,092) and breech (100,730) presentations.

RESULTS: More than 3.2 million singleton term newborns were identified during the study period, with 100,667 (3%) in breech presentation at the time of delivery. Of these, 4952 women (4.9%) had vaginal breech delivery, whereas 60,418 women delivered by cesarean without labor, and 35,297 women underwent cesarean in labor. Breech vaginal delivery in nulliparous women was associated with increased neonatal mortality (odds ratio [OR] 9.2, 95% confidence interval [CI] 3.3, 25.6) and morbidity (asphyxia: OR 5.7, 95% CI 4.5, 7.3; brachial plexus injury: OR 33.9, 95% CI 15.2, 76.1; and birth trauma: OR 5.8, 95% CI 4.7, 7.1) compared with breech delivery by prelabor cesarean in nulliparous women. In breech-presenting women with one prior vaginal delivery, neonatal mortality was not different between groups, but morbidities (asphyxia: OR 3.9, 95% CI 3.0, 5.1; brachial plexus injury: OR 22.4, 95% CI 9.9, 50.5; and birth trauma: OR 4.2, 95% CI 3.4, 5.3) remained increased for vaginal compared with cesarean delivery.

CONCLUSION: The "normal" term breech fetus, when delivered vaginally, had significantly increased neonatal mortality (in nulliparous women) and morbidity (all breech deliveries), when compared with the breech fetus delivered by cesarean, which suggests that these patients might best be delivered by cesarean to avoid these adverse outcomes.

It has long been thought that vaginal breech delivery is associated with increased neonatal morbidity and mortality compared with elective cesarean delivery. This observation has been a topic of considerable debate over the past few years, and retrospective studies of the subject have yielded conflicting data.1–6 Overall, breech presentation occurs in approximately 3% of term deliveries in the United States.7 The controversy over appropriate management of breech presentation, as well as considerable disagreement regarding appropriate candidates for a trial of vaginal breech delivery, has made it a difficult phenomenon to study prospectively. Only three prospective, randomized, controlled studies have examined maternal and newborn outcomes associated with breech vaginal delivery.8–10 The first two were published more than 20 years ago and found minimal increased risk to the fetus in a carefully selected group of vaginal breech deliveries.8,9 In these two older studies, however, maternal morbidity was significantly increased (49%) with cesarean delivery, thus influencing decisions to undergo a trial of labor for breech presentation.8,9

More recently, in the Term Breech Trial, Hannah et al10 conducted a large, multicenter, prospective, randomized, controlled trial of intention-to-treat for vaginal breech delivery as compared with planned cesarean delivery. In their study, they found a lower rate of perinatal and neonatal mortality and serious neonatal morbidity (1.6% for planned cesarean delivery compared with 5.0% in planned vaginal birth) without significant differences in maternal morbidity or mortality. Their follow-up study examining maternal morbidity at 3 months found less urinary incontinence in the cesarean group, but otherwise there was no difference.11 The first Hannah et al study prompted the American College of Obstetricians and Gynecologists to recommend planned cesarean delivery for term singleton breech presentations.12 Some have argued that the design of the Term Breech Trial is flawed, and the debate continues.13 A large, retrospective, population-based study over a 9-year period in California was undertaken to help clarify this controversial subject.


   MATERIALS AND METHODS
TOP
ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
This project was approved by our institutional review board committee and the California Office of Statewide Health Planning and Development. All maternal and newborn hospital discharge records and birth and death certificates were linked for all hospitals, which report to the Office of Statewide Health Planning and Development (98% of all California deliveries). The computer linkage has been found to be 97.8% accurate for linkage of the three databases.14 The database was searched for demographic information, parity, and discharge diagnoses with use of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic and procedural codes.

We selected all term (37 or more weeks) live-born singleton neonates who weighed between 2500 and 3800 g at birth. These weight criteria were based on the original criteria of Collea et al.8 The study period was from January 1, 1991, until December 31, 1999. Infants with congenital malformations were excluded, as were those with all malpresentations except breech. We included all infants who survived to be discharged, as well as neonatal or infant deaths. Neonates were grouped and analyzed according to presentation, mode of delivery, maternal parity, maternal history of prior cesarean delivery, and the presence or absence of labor.15 Breech deliveries were identified by ICD-9-CM code 652.2, which excludes footling and incomplete breech presentations. Our database could not further differentiate the different types of breech presentation or the level of skill of the care provider at delivery. Neonatal morbidity included any birth trauma, asphyxia, need for continuous mechanical ventilation, and brachial plexus injury.

The data were analyzed by determining odds ratios (ORs) and 95% confidence intervals for adverse outcomes for each group. The ORs were adjusted for birth weight, maternal age, race or ethnicity, and maternal educational level. The control group consisted of infants in vertex presentation that were delivered vaginally. Comparisons were then made between groups of infants stratified by presentation, mode of delivery, maternal parity, and presence or absence of labor. To ease the comparisons within the group of breech-delivered infants only, adjusted ORs are also presented for which breech deliveries via elective cesarean in nulliparous woman are used as the reference group.


   RESULTS
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
A total of 3,371,822 deliveries were included in the study period. Of these, 100,667 fetuses (3%) presented in breech position, with 4952 (4.9%) delivering vaginally. The demographic data are presented in Table 1Go. Nulliparous women and women with a previous cesarean delivery were more likely to have a cesarean delivery with both cephalic and breech presentations than were their parous counterparts. Non-Hispanic whites were less likely than other ethnic groups (black, Hispanic, Asian, or other) to have a vaginal breech delivery. In addition, patients who were self-pay, uninsured, or insured with MediCal (California’s version of Medicaid) had a vaginal breech delivery rate of 6.9–7.3%, compared with only 3.1–3.4% of women with private insurance or managed care. Maternal educational level was inversely proportional to the rate of vaginal breech birth. Only 3.2% of women with a college degree had a vaginal breech delivery, compared with 7.6% of women who did not complete high school.


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  		Table 1. Birth Demographics
 
Time trends in cesarean delivery rates for both cephalic and breech presentations are presented in Table 2Go. Clearly, the overall cesarean delivery rate has increased for breech presentation from 1991 (93%) to 1999 (97%). Cesarean deliveries in cephalic presentation (both overall and planned) dropped slightly in the early to mid-1990s, then trended back toward a level in 1999 that was slightly less than the rate in 1991.


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  		Table 2. Total Births, Cesarean Delivery Rates, and Planned Cesarean Delivery Rates by Presentation, 1991–1999
 
Significant adverse neonatal outcomes (birth trauma, asphyxia, brachial plexus injury, continuous mechanical ventilation, and neonatal death) for breech vaginal compared with breech cesarean deliveries are presented in Table 3Go. Distinct neonatal morbidities and mortality are separated into groups based on parity, the presence or absence of a prior cesarean delivery, and whether or not the breech cesarean delivery was performed before or during labor. For the nulliparous women, neonatal mortality was increased with vaginal breech delivery when compared with breech cesarean deliveries, whether performed in labor or not (Table 3Go). In the multiparous patients, neonatal mortality was not greater for vaginal breech deliveries; however, most of the major neonatal morbidities were increased in both nulliparous and multiparous women when comparing vaginal and cesarean breech delivery.


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  		Table 3. Adverse Outcomes by Parity, Presence of Previous Cesarean Delivery, and Presence or Absence of Labor for Breech Deliveries Compared With Breech Cesarean
 
In Table 4Go, all of the breech fetuses are compared with a control group comprising all cephalic vaginal deliveries. The ORs are controlled for maternal age, race or ethnicity, and educational level, and they are displayed relative to all cephalic vaginal deliveries (n = 2,773,886). With increasing parity, the adverse neonatal outcomes associated with vaginal breech delivery decreased compared with nulliparous women but remained significantly increased compared with both cephalic vaginal delivery and breech cesarean delivery.


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  		Table 4. Adverse Outcomes by Parity, Presence of Previous Cesarean Delivery, and Presence or Absence of Labor for Breech Deliveries Compared With Cephalic Vaginal Deliveries
 
Of special note, the risk of brachial plexus injury was high for all vaginal breech deliveries (0.9%) when compared with cephalic vaginal deliveries (0.1%). The risk of brachial plexus injury for breech cesarean delivery was equal to or less than that for cephalic vaginal delivery. This suggests that vaginal breech delivery subjects the newborn to a significant risk of brachial plexus injury.


   DISCUSSION
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Our population-based study of nearly 5000 vaginal breech deliveries in California supports the view that vaginal breech delivery is associated with significant neonatal morbidity and mortality. Furthermore, these increases in morbidity and mortality are found in a select group of patients (term gestation, birthweight 2.5–3.8 kg, and no congenital malformations) for whom a trial of labor is recommended.8,9 Neonatal mortality was increased in vaginal breech delivery owing to a significantly increased risk in nulliparous women (Table 3Go). The three prospective studies on breech vaginal delivery did not find a difference in neonatal mortality related to parity, but this might be because of study design, considering that the effect of parity was not a primary outcome in their studies.8–10 Our study would suggest that it is important to inform patients who are considering undergoing a breech vaginal delivery that mortality seems to be increased only in those women in their first pregnancy.

Overall, there were nine neonatal deaths in the 4952 vaginal breech deliveries, 25 neonatal deaths in 60,481 prelabor cesarean breech deliveries, and 22 neonatal deaths in 35,297 in-labor cesarean breech deliveries, giving neonatal mortality rates of 1.8, 0.41, and 0.62 per 1000 births, respectively (0.55 per 1000 for all breech). This was in comparison with the rate of 0.3 per 1000 in the cephalic vaginal delivery group. Our neonatal mortality rate of 1.8 per 1000 births for vaginal breech delivery is less than that previously reported (9.8 per 1000 births) in a meta-analysis by Cheng and Hannah.16 They excluded congenital malformations in 7675 vaginal breech deliveries from 24 studies.16 Interestingly, their neonatal mortality rate for breech cesarean deliveries was similar to ours at 0.5 per 1000 births. In the Term Breech trial, there were six neonatal deaths in the planned vaginal delivery group, for a neonatal mortality rate of 5.8 per 1000.10 Clearly, our results suggest an improvement in neonatal mortality, but not enough to recommend that vaginal breech delivery be pursued.

All major neonatal morbidity was increased with vaginal breech delivery. Most striking was the finding of an increased risk of brachial plexus injury associated with breech vaginal delivery throughout the entire population (Tables 3Go and 4Go). In contrast, cesarean delivery of the breech fetus was protective against brachial plexus injury, when compared with both breech and cephalic vaginal delivery (Tables 3Go and 4Go). Collea et al8 found that two out of 60 vaginal breech deliveries (3.3%) had brachial plexus injury. This was a major cause of injury from breech vaginal delivery in their study.8 Based on their finding of high maternal morbidity (49%) and minimal neonatal morbidity, they encouraged vaginal delivery in appropriately selected breech fetuses.8 The risk of brachial plexus injury in cephalic presentation increases with increasing birth weight, operative vaginal delivery, and gestational diabetes.17 In our study with infants between 2.5 and 3.8 kg, the risk of brachial plexus injury in breech vaginal delivery was 0.9%, which is nine-fold greater than that found with cephalic vaginal delivery (0.1%). In perspective, this rate of 0.9% is still five times greater than a cephalic vaginal delivery of a macrosomic infant weighing 4 kg at birth.17 Our data suggest that vaginal breech delivery might have an unacceptably high risk of brachial plexus injury, and vaginal delivery should not be recommended.

When breech delivery by cesarean is separated into "prelabor" and "in-labor" groups, there are differences in neonatal outcome. Both birth trauma (60%) and asphyxia (250%) are increased in newborns delivered to nulliparous women who had a cesarean delivery during labor as compared with prelabor (Table 3Go). In multiparous women, the risk of asphyxia remains increased for in-labor as compared with prelabor cesarean delivery, suggesting that the process of labor carries inherent risks as well. Our database cannot determine at what stage in labor the cesarean deliveries occurred, so any recommendations for delivery before the onset of labor should be made cautiously, if at all.

The large and diverse population of the state of California gave us an excellent look at the demographics of breech deliveries. Our calculated incidence of 3% breech presentation might not be representative of the entire population, because our study was limited to term infants with birth weights between 2.5 and 3.8 kg, and infants with congenital malformations were excluded. We found that women who were of an ethnic minority, with less education, or who were uninsured were more likely to deliver a breech infant vaginally than were women who were white, college educated, and privately insured. It is possible that women in lower socioeconomic groups were more likely to be delivered in large teaching institutions, where vaginal breech delivery was more actively pursued. Cultural or educational biases could also be present, but this study could not address their possible influences on outcomes.

This study’s main strength is the power in its large number of subjects. This large, population-based study group also allowed us to further define risks based on categories such as parity and history of previous cesarean delivery. Another strength of the study is that birth certificates in the state of California have been shown to be valid resources for obtaining information.18 Our study has several of the limitations inherent to a retrospective study. Women who underwent a vaginal breech delivery could very well have been different from those who underwent a cesarean delivery; these differences cannot be determined from our database, and might have been a cause for the differences in outcome. In addition, the use of maternal and neonatal hospital discharge and birth certificate data has limitations related to ICD-9-CM hospital abstractors and coders. Finally, patterns of medical management and practice change over time. We have no information on patient or physician biases regarding route of delivery in breech presentation.

In summary, nulliparous vaginal breech delivery carries a greater than nine-fold increase in the risk of neonatal mortality when compared with delivery by cesarean (Table 3Go). Infants of nulliparous women were also found to have significantly increased risk of birth trauma, asphyxia, brachial plexus injury, and continuous mechanical ventilation. All vaginally delivered breech newborns showed a small but significant increase in birth trauma compared with cephalic newborns who delivered vaginally.


   Footnotes
 
doi:10.1016/S0029-7844(03)00809-3

Received May 28, 2003. Received in revised form July 3, 2003. Accepted July 10, 2003.


   REFERENCES
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
1. Sanchez-Ramos L, Wells TL, Adair CD, Arcelin G, Kaunitz AM, Wells DS. Route of breech delivery and maternal and neonatal outcomes. Int J Gynaecol Obstet 2001;73:7–14.[Medline]

2. Irion O, Almagbaly PH, Morabia A. Planned vaginal delivery versus elective caesarean section: A study of 705 singleton term breech presentations. Br J Obstet Gynaecol 1998;105:710–7.[Medline]

3. Thorpe-Beeston JG, Banfield PJ, Saunders NJ. Outcome of breech delivery at term. BMJ 1992;305:746–7.[Medline]

4. Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by mode of delivery among term breech births: Swedish experience 1987-1993. Obstet Gynecol 1998;92:945–50.[Abstract]

5. Brenner WE, Bruce RD, Hendricks CH. The characteristics and perils of breech presentation. Am J Obstet Gynecol 1974;118:700–5.[Medline]

6. Confino E, Gleicher N, Elrad H, Ismajovich B, David MP. The breech dilemma. A review. Obstet Gynecol Surv 1985;40:332–9.

7. Hickok DE, Gordon DC, Milberg JA, Williams MA, Daling JR. The frequency of breech presentation by getational age at birth: A large population-based study. Am J Obstet Gynecol 1992;166:851–6.[Medline]

8. Collea JV, Chein C, Quilligan EJ. The randomized management of term frank breech presentation: A study of 208 cases. Am J Obstet Gynecol 1980;137:235–44.[Medline]

9. Gimovsky ML, Wallace RL, Schifrin BS, Paul RH. Randomized management of the nonfrank breech presentation at term: A preliminary report. 1983;146:34–40.

10. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: A randomized multicentre trial. Lancet 2000;356:1375–83.[Medline]

11. Hannah ME, Hannah WJ, Hodnet ED, Chalmers B, Kung R, Willan AR, et al. Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term. JAMA 2002;287:1822–31.[Abstract/Free Full Text]

12. American College of Obstetricians and Gynecologists. Mode of term singleton breech delivery. ACOG committee opinion no. 265. Washington: American College of Obstetricians and Gynecologists, 2001.

13. Hauth JC, Cunningham FG. Vaginal breech delivery is still justified. Obstet Gynecol 2002;99:1115–6.[Free Full Text]

14. Gilbert WM, Nesbitt TS, Danielsen B. Childbearing beyond age 40: Pregnancy outcome in 24,032 cases. Obstet Gynecol 1999;93:9–14.[Abstract/Free Full Text]

15. Towner D, Castro MA, Eby-Wilkins E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999;341:1709–14.[Abstract/Free Full Text]

16. Cheng M, Hannah M. Breech delivery at term: A critical review of the literature. Obstet Gynecol 1993;82:605–18.[Medline]

17. Gilbert WM, Nesbitt NS, Danielsen B. Associated factors in 1611 cases of brachial plexus injury. Obstet Gynecol 1999;93:536–40.[Abstract/Free Full Text]

18. Braveman P, Pearl M, Egerter S, Marchi K, Williams R. Validity of insurance information of California birth certificates. Am J Public Health 1998;88:813–6.[Abstract/Free Full Text]




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