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The Preterm Breech Vaginal Versus. Abdominal Delivery PowerPoint Presentation
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The Preterm Breech Vaginal Versus. Abdominal Delivery

The Preterm Breech Vaginal Versus. Abdominal Delivery

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The Preterm Breech Vaginal Versus. Abdominal Delivery

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    1. 1 The Preterm Breech Vaginal Versus. Abdominal Delivery Mohamed Kandeel M.B.B.Ch., M.Sc.(Ob/Gyn), M.D.(Ob/Gyn) Professor of Obstetrics and Gynecology Menofyia University Egypt

    2. Introduction The literature on this subject shows varied conflicting data. On one side, there are reports stating that vaginal delivery does not increase morbidity/mortality for preterm breech. On the other hand, there are many investigators reporting that the method of choice for delivering these babies would be caesarean section in order to improve the perinatal outcome for such babies. This dilemma has influenced many Obstetricians to consider preterm breech delivery as a high risk situation.

    3. Definition and Incidence Although the term preterm delivery simply means delivery before completed 37 weeks gestation; I was not able to find a standard definition for preterm breech delivery among the English literature which I reviewed. Some used a definition of < 26 gestational weeks; others used definitions between 28-36, 30-36 or between 26-36 weeks. Many researchers considered a preterm breech is that breech weighing < 1500 grams. Breech presentation occurs in 25% of births prior to 28 weeks' gestation, 7% of births at 32 weeks' gestation and 1-3% of births at term.

    4. Types of Breech 1- Complete breech: Fetus is in flexion attitude. Hips and knees are flexed with the buttocks and knees at the same level. 2-Incomplete breech: A-Frank breech: Fetal hips are flexed and knees extended B-Footling: Hip and knee joint; on one or both sides, are partially extended. C-Knee presentation: Hip is partially extended and knee is flexed on one or both sides.

    5. Aetiology Causes which favor preterm breech are not different than those for term breech. They include: 1-Uterine Malformations. E.g. septate or bicornuate uterus. 2-Fibroids in the lower part of the uterus. 3-Polyhydramnios. 4-Fetal abnormalities: e.g. malformations of brain, neck masses & aneuploidy

    6. Aetiology (Cont.) 5-Multiple gestations: due to the limited space in the uterus 6-Grand multiparity 7-Short umbilical cord 8-Placenta previa

    7. Complications Of Preterm Breech Delivery 1-Entrapment of the aftercoming head through an incompletely dilated cervix. 2-Cord Prolapse 3-Intrapartum Hypoxia 4-Inco-ordinate Labor 5-Aspiration Pneumonia 6-Traumatic Injuries

    8. Outcome of Breech delivery Gestational Age < 26 Weeks

    9. Outcome of Breech delivery Getational Age 26 -32 Weeks

    10. Outcome of Breech delivery Gestational Age < 32 Weeks Emembolu (1992) claimed that a CS would be an important morbidity consideration in his sample population. Garcia (2002) claimed that when low vertical C.S. is performed to reduce maternal morbidity and avoids head entrapment during vag delivery, neonatal morbidity still occurs at the same rate. He reported 3 breeches < 32 weeks who had femoral fractures among 26 CS.

    11. Outcome of Breech delivery Gestational Age 26 -36 Weeks

    12. Outcome of Breech delivery Gestational age 30-36 weeks

    13. Outcome of Breech delivery Gestational Age 28-36 Weeks

    14. Outcome According To Birth Weight

    15. Outcome According To Birth Weight

    16. Outcome According To Birth Weight

    17. Outcome According To Birth Weight Robilio et al 2007, based on a retrospective study which included singleton breech pregnancies < 37 weeks and birthweight <2.5 Kg. claimed that vaginal delivery was associated with more neonatal mortality compared to delivery by C.S. there was increased birth trauma and asphyxia with vaginal delivery.

    18. Comments on outcome of preterm breech delivery-Review articles Vasilj et al 2007, suggested that the decision regarding mode of delivery for preterm breech should be individualized according to clinical situation as there is no clear evidence to favor one mode of delivery over another. Yamamura et al 2007, stated that the Term Breech Trial (TBT) showed that C.S. have better outcome compared to vaginal delivery. However; they claimed that the long term follow up contradicted the TBT initial findings and they questioned whether the untoward complications of C.S. are warranted given the uncertain minimal increase in neonatal survival and improvement in neurologic outcome with planned C.S.

    19. Conclusions An honest discussion with the parents should take place to clarify the lack of data regarding the ideal mode of delivery for preterm breech. Vaginal delivery should be considered For fetuses < 26 weeks within intact membranes (en ceul). Should membranes rupture, C.S. offers the best favorable outcome only if good NICU facilities exist. Vaginal delivery should be considered for pregnancies between 26-36 gestational weeks, after a discussion of risks and benefits with the parents.

    20. Conclusions The major body of evidence; regardless of birthweight whether less or equal or more than 1500 gm, supports vaginal delivery for the preterm breech. Most studies showed no difference in morbidity and mortality between both modes of deliveries. Regardless of GA or birthweight, CS should be performed whenever C.S. for associated indications such as abnormal pelvis, failure of labor to progress, hyperextension of fetal head etc.

    21. Limitations Of Conclusions I-The best evidence comes from RCTs. To date, only 2 incomplete RCTs are available. Zlatink in 1993 recruited 38 women with GA between 28-36 weeks in the period between 1978-1983. He terminated the study because of difficulties in randomization and mode of delivery. Penn et al in 1996 surveyed 26 English hospital to determine willingness to participate. Only 6 hospitals were actively recruiting participants for the study. They cited reasons for termination as difficulty with obtaining consent, concerns over the availability of skilled personnel and medicolegal concerns.

    22. Limitations Of Conclusions II-The reviewed studies lacked the following: 1- There was no standard definition for gestational age between studies. 2- The choice of the route of delivery for the LBWt fetuses may reflect judgment on their viability. 3- No studies reported on maternal morbidity. 4- Not all studies specified the type of breech delivery whether simple breech, assisted breech or breech extraction. 5- No data were given in any of the studies regarding any attempted cephalic version or a trial of labor before a decision for CS was made.

    23. Therefore Until such time when a properly conducted RCT or a meta-analysis which include properly designed studies, controversy will continue and the mode of delivery of a preterm breech will remain one of the delivering obstetrician preference.