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J Matern Fetal Neonatal Med, Early Online: 1–5

! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2015.1067768

ORIGINAL ARTICLE

Vaginal delivery or cesarean section at term breech delivery – chance or

risk?
Ivana Babović, Milica Arandjelović, Snežana Plešinac, and Radmila Sparić

Department of Gynecology and Obstetrics, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
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Abstract Keywords
Aim: The aim of the study was to examine maternal age, parity, and estimated neonatal birth Cesarean section, neonatal outcome,
weight (BW) depending on the mode of a full-term breech presentation (BP) birth delivery and term breech delivery, vaginal delivery
neonatal outcomes.
Material and methods: One hundred and forty-six singleton term breech presentation History
pregnancies were included in a retrospective study conducted at the Department of
Gynecology/Obstetrics, Clinical Center of Serbia in Belgrade in 2013. Statistical analysis: Received 8 April 2015
Student’s-t test, 2 likelihood ratio, and the Fisher’s exact test. The level of statistical Revised 19 June 2015
significance was set at p50.05. Accepted 27 June 2015
Results: An ECS was the most common mode of delivery in (81.2%) nulliparous older than Published online 28 July 2015
35 years and most of the neonates (66.67%) with an estimated birth weight (BW) above
3500 grams were delivered by elective cesarean section (ECS). Perinatal asphyxia remained
For personal use only.

increased in the successful vaginal delivery (SVD) group (23.8%) compared with the urgent CS
(UCS) group (13.3%) (p ¼ 0.035). Birth asphyxia was the most common in neonates were
delivered by SVD (23.8%). There were no cases of perinatal deaths.
Conclusion: ECS remained the recommended mode of breech term delivery in
nulliparous women older than 35 years, as well as in neonates with an estimated BW above
3500 grams.

Introduction Over the past decade, there has been an increasing trend in
the United States to perform cesarean delivery for full-term
According to previous research, the incidence of a breech
singleton fetuses in a breech presentation. In 2002, the rate of
presentation during a full-term pregnancy is 7%, while the
cesarean deliveries for women in labor with a breech
incidence during a full-term delivery is 3–4% [1]. The failure
presentation was 86.9% [4].
to change from a breech presentation during pregnancy results
Perinatal mortality (Mt) increases 2 - to 4-fold during a
from endogenous and exogenous factors. Endogenous factors
breech presentation, regardless of the mode of delivery. Vaginal
involve the inability of the fetus to adequately move, whereas
delivery (VD) may lead to several complications (e.g. umbilical
exogenous factors include insufficient intrauterine space
cord prolapse and dystocia) and higher early neonatal morbidity
available for fetal movements. The incidence of a breech
(Mb), including intrapartum-related hypoxia (formerly called
presentation at delivery includes various exogenous factors,
‘‘birth asphyxia’’), intra-cranial hemorrhage, birth injuries
such as maternal and medical factors. Maternal constitutional
(e.g. spinal cord injury, injury of plexus brachialis, and
factors include nulliparity, grand multiparity, contracted
clavicula fracture). VD is a potential recommended option for
pelvis, older maternal age and uterine anomalies such as
properly selected patient. The initial criteria used in these
fibroma. Pregnancy complications include fetal malforma-
reports were similar, as follows: gestational age greater than
tions, fetal growth retardation, hydramnion, oligohydramnion,
37 weeks, frank or complete breech presentation, no fetal
placenta previa, and a short umbilical cord [2].
anomalies on ultrasound examination, adequate maternal
An ultrasound examination is the most common diagnostic
pelvis, and estimated fetal weight between 2500 g and 4000 g,
procedure for determining the breech presentation for term
excluding fetopelvic disproportion (as any clinically significant
births, such as complete breeches, frank breeches, footling
mismatch between the size or shape of the presenting breech of
breeches and finally, kneeling breeches [3].
the fetus and the size or shape of the maternal pelvis and soft
tissue). In addition, the protocol involved a fetal head flexion,
ultrasound examination for adequate amniotic fluid volume,
defined as a 3-cm vertical pocket. Oxytocin induction or
Address for correspondence: Ivana Babović, Department of Gynecology
and Obstetrics, Clinical Center of Serbia, School of Medicine, University augmentation was not offered, and strict criteria were estab-
of Belgrade, Belgrade, Serbia. E-mail: [email protected] lished for a normal labor progress [5,6].
 2 I. Babović et al. J Matern Fetal Neonatal Med, Early Online: 1–5

The aim of the study multiparous and younger than 35 years of age (Table 1). The
study did not confirm a statistically significant correlation
The aim of study was to examine maternal age, parity, and
between parity and the mode of delivery in patients who were
estimated neonatal birth weight (BW) depending on the mode
younger than 35 years of age (p ¼ 0.213).
of a full-term breech presentation birth delivery and neonatal
In a group of patients older than 35 years of age,
outcomes.
16 (45.7%) were nulliparous and 19 (54.2%) were multipar-
Material and methods ous. In group of nulliparous women, only three patients
delivered vaginally, but an ECS was the most common mode
One hundred and forty-six singleton term breech presentation of delivery in 13 (81.2%) patients. In the group of multiparous
pregnancies were included in a retrospective study conducted women, 10 (52.6%) were older than 35 years of age; in these
at the Department of Gyn/Obstet, Clinical Center of Serbia in women, ECS was the most common mode of delivery.
Belgrade in 2013. We evaluated the influence of maternal age An ECS was more frequently performed than VD in
and parity as well as, the duration and mode of delivery on nulliparous women older than 35 years of age (p ¼ 0.034).
neonatal outcomes (BW), Apgar score at the 5th min (Ap5), Fetopelvic disproportion was the most common indication
duration in neonatal intensive care unit (NICU), early for ECS in 24 (32.4%) deliveries.
neonatal Mb and Mt. The following groups were included The mean body weight (BW) of neonates was
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based on their mode of delivery: group A – elective cesarean 3225.42 ± 584.5 g in the PVD group and 3168.24 ± 553.1 g
section group (ECS group) and group B – planned vaginal in the ECS group. There was no statistically difference in the
delivery group (PVD group). Group B was sub-divided into neonatal BW between the two groups (p ¼ 0.545).
the following two groups: group B1 – successful vaginal Most of the neonates (10, 55.5%) with an estimated BW
delivery (SVD group) and group B2 – urgent (emergency) below 2500 g were delivered by ECS, and 8 (44.4%) neonates
cesarean section group (UCS group). with an estimated BW below 2500 g were delivered by PVD.
The most prevalent indication for ESC was: fetopelvic dis- Finally, most of the neonates 34(66.67%) with an estimated
proportion for an UCS. In addition to, the fetopelvic BW above 3500 g were delivered by ECS, but 17 (33.3%) of
disproportion, the other indication for UCS was fetal distress. these neonates had PVD (Table 2). There was a statistically
For the statistical analysis, we used descriptive analyses significant difference between the estimated BW and the
Student’s-t test, 2 likelihood ratio, and the Fisher’s exact test. mode of delivery (p ¼ 0.008). Most neonates had an estimated
The level of statistical significance was set at p50.05.
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The following exclusion criteria were used in this study:

fetuses or neonates with severe malformations determined Table 1. The mode of delivery, maternal age and parity.
before or after birth, neonates with hemolytic disease, as well
as cases of intrauterine fetal death. Parity
A computer database search was performed to identify all Nulliparous Multiparous
full-term breech presentations and neonatal outcomes.
535 years 435 years 535 years 435 years
Our study missed dates of neonatal outcomes for seven
(7/146; 4.79%) neonates. Mode of
delivery n % n % n % n %
Patients were informed of the potential risks and benefits
to the mother and babies of both vaginal breech deliveries A (ECS)* 36 (52.17) 13 (81.25) 15 (35.71) 10 (52.63)
and cesarean delivery and they provided signed informed B (PVD)y 33 (47.83) 3 (18.75) 27 (64.29) 9 (47.37)
Total 69 100 16 100 42 100 19 100
consent.
*ECS, elective cesarean section.
Results yPVD, planned vaginal delivery.
An ECS was more frequently performed than VD in nulliparous women
A retrospective study of neonatal outcomes of 146 full-terms older than 35 years of age (p ¼ 0.034).
breech deliveries found that 74 (50.7%) planned ECS
deliveries and 72 (49.3%) had PVD.
The mean age of the patients in the PVD group was
Table 2. The mode of delivery and neonatal birth weight.
30.4 ± 4.53 years and 31.8 ± 4.61 years in the ECS group.
Student’s-t test did not identify a statistically significant Neonatal birth weight
difference in the mother’s ages between the groups
52500 g 2500 g–3500 g 43500 g
(p ¼ 0.053).
In the PVD group, 36 mothers (50%) were nulliparous, but Mode of
in 49 (66.2%) nulliparous mothers, an ESC was performed. In delivery n % n % n %
the PVD group, 50% (36/72) were multiparous, but an ESC A (ECS)* 10 (55.56) 30 (38.96) 34 (66.67)
was performed in 25 multiparous mothers (33.8%). The study B (PVD)y 8 (44.44) 47 (61.04) 17 (33.33)
Total 18 100 77 100 51 100
confirmed that more nulliparous mothers were delivered by
ESC than multiparous mothers (p ¼ 0.047). *ECS, elective cesarean section.
In the PVD group, 33 mothers (47.8%) were nulliparous, yPVD, planned vaginal delivery.
and 27 mothers (64.2%) were multiparous and younger than There was a statistically significant difference between the estimated BW
and the mode of delivery (p ¼ 0.008).
35 years of age. An ECS were performed in 36 (52.2%) Most neonates had an estimated BW below 2500 g, because neonates
nulliparous women and in 15 (35.7%) mothers who were with an estimated BW above 3500 g were delivered by ESC.
 DOI: 10.3109/14767058.2015.1067768 Vaginal delivery or cesarean section at term breech delivery 3

BW below 2500 g, because neonates with an estimated BW A UCS was performed in 18 (54.6%) nulliparous women
above 3500 g were delivered by ESC. who were younger than 35 years, but 21 (77.7%) multiparous
An Apgar score at the 5th min 8 was observed in mothers were delivered by SVD. The mode of delivery was
62 (86.1%) of the neonates in the PVD group and in not determined by the mother’s age in patients younger than
66 (89.1%) of the neonates in the ECS group. The mode of 35 years of age (p ¼ 0.585).
delivery was not correlated with an neonatal Apgar score at Only one patient delivered vaginally among the nulliparous
the 5th min (p ¼ 0.597). women who were older than 35 years of age, and UCS was
Neonatal macrosomia (estimated BW above the 90th more frequent mode of delivery for the other two women in
percentile for gestational age) was diagnosed in 4 (5.4%) of this group of patients. In a group of nine multiparous women,
the neonates in the ECS group, but in 7 (9.4%) neonates in this older than 35 years of age, five (55.7%) delivered by
group had neonatal hypotrophia (BW below the 10th percentile SVD (Table 4). This study did not confirm that the mode of
for estimated GW). A sonographic finding, such as fetal delivery was determined by the mother’s age among these
macrosomia or intrauterine growth restriction (IUGR), patients (p ¼ 0.193).
required further meticulous consideration for term breech Fetopelvic disproportion was the most common indication
delivery by ECS. Early neonatal well-being was diagnosed in for UCS (11women, 36.7%) and distocia [failure to progress
54 (72.9%) of the neonates in the ECS group and in 41 (56.9%) in labor, either because the cervix will not dilate (expand)
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of the neonates in the PVD group (Table 3). For those with a further or (after full dilation) the breech does not descend
breech presentation, perinatal asphyxia increased in the PVD through the mother’s pelvis] occurred in nine women (30%).
group (19.4%) compared with the ECS group. There was a In addition to the fetopelvic disproportion, an indication for
statistically significant correlation between the structure of UCS was an acute increase in maternal blood of pressure
perinatal Mb and the mode of delivery (p ¼ 0.042). above 140 mmHg in six (20%) and fetal distress in four
The duration of being in a NICU was significantly shorter (13.3%) deliveries.
after PVD compared with ECS (4.08 ± 3.1 d versus Spontaneous VD occurred in 11 of 42 women (26.2%) with
5.66 ± 5.3 d; p ¼ 0.033). a mean duration of 4.49 ± 2.1 h, and was augmented by
Group B was sub-divided into the following two groups: Syntocinon in 31 deliveries (73.8%), with a mean duration of
group B1 – SVD group and group B2 – UCS group 6.13 ± 1.7 h. Oxytocin augmentation of VD was associated
(emergency). There were 42 (58.3%) patients in group B1 with the duration of labor (p ¼ 0.015).
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and 30 (41.6%) patients in group B2. The Lövset maneuver was most frequently performed in
In the SVD group, 31 mothers (75.60%) were assisted and 34 (80.9%) of the SVD cases. The Bracht maneuver
11 (26.82%) were spontaneous deliveries. The mean age of was performed in six women (14%) and the Smellie–Veit
patients in the SVD group was 30.14 ± 4.6 years and maneuver was performed in 2 (4.76%) of the women
30.77 ± 4.49 years in the UCS group. In Student’s-t test, undergoing SVD.
there was no statistically significant difference in the mother’s The mean BW of the neonates was 3107 ± 384 g in the
age between the groups (p ¼ 0.568). SVD group and 3165 ± 621 g in the UCS group. There was no
Sixteen nulliparous neonates (38.1%) were delivered by statistically significant difference in neonatal BW between the
SVD and 20 (66.7%) were delivered by UCS. Of the most two groups (p ¼ 0.627).
multiparous neonates, 26 (61.9%) were delivered by SVD. There were similar number of neonates with an estimated
In 10 multiparous mothers (33.3%), an UCS was per- BW below 2500 g who were delivered by UCS and SVD (4/8;
formed. The study confirmed that a significantly higher 50%). Neonates with an estimated BW above 3500 g delivered
number of nulliparous neonates were delivered by UCS by UCS in 9/17 (52, 9%) cases, but 8/17 (47, 06%) neonates
than by SVD, and a significantly higher number of were delivered by SVD. The study did not report a difference
multiparous women were delivered by SVD than by UCS. between the groups (p ¼ 0.429).
The mode of delivery was determined by parity in our The Apgar score at the 5th min (8) was observed in 35
study (p ¼ 0.017). (83.3%) of the neonates in the SVD group and in 27(90%) of
the neonates in the UCS group. The mode of delivery was not
Table 3. The mode of delivery and neonatal outcome.

The mode of delivery Table 4. The mode of delivery and neonatal outcome.

A (ECS)* B (PVD)y The mode of delivery

Neonatal morbidity n % n % B1 (SVD)* B2 (UCS)y
Neonatal well-being 54 (72, 9) 41 (56, 9) Neonatal morbidity n % n %
Birth asphyxia 9 (12, 1) 14 (19, 4)
Intrauterine growth restriction 7 (9, 4) 6 (8, 3) Neonatal well-being 20 (46, 6) 21 (70)
Neonatal macrosomia 4 (5, 4) 4 (5, 5) Birth asphyxia 10 (23, 8) 4 (13, 3)
Intrauterine growth restriction 3 (7, 1) 3 (1)
*ECS, elective cesarean section. Neonatal macrosomia 2 (4, 7) 2 (6, 6)
yPVD, planned vaginal delivery (missed dates of neonatal outcome for
seven neonates). *SVD, successful vaginal delivery.
There was a statistically significant correlation between the structure of yUCS, urgent cesarean section (missed dates of neonatal outcome for
perinatal Mb and the mode of delivery (p ¼ 0.042). seven neonates).
Birth asphyxia increased in the VD group (19.4%) compared with the In breech presentation, birth asphyxia remained increased in the SVD
ECS group (12.1%). group (23.8%) compared with the UCS group (13.3%) (p ¼ 0.035).
 4 I. Babović et al. J Matern Fetal Neonatal Med, Early Online: 1–5

associated with the early neonatal Apgar score at the 5th min confirmed that vaginally delivered neonates had significantly
(p ¼ 0.416). shorter stays in NICU compared with neonates delivered by
Neonatal macrosomia was diagnosed in two (6.67%) of the ECS or UCR, as has been seen in previous studies [10].
neonates in the UCS group. Hypotrophic neonates 3(10%) Superimposed intrapartal asphyxia on chronic fetal hypoxia or
were delivered by UCS. Early neonatal well-being was acute hypoxic insult (e.g. abruptio placentae, prolapse of the
diagnosed in 21 (70%) of the neonates in the UCS group umbilical cord) were the most common indications for UCS
and in 20 (46.62%) of the neonates in the SVD (Table 4). and caused lower Apgar scores at the 5th min [11].
In breech presentation, perinatal asphyxia remained increased Early neonatal well-being was diagnosed in 70% neonates
in the SVD group (23.8%) compared with the UCS group in the UCS group, which was similar to the 72.9% seen among
(13.3%) (p ¼ 0.035). the neonates in the ECS group. The results of our study do not
The duration of stay in the NICU was significantly support the results of other research. The similar number of
shorter after VD compared with UCS (3.12 ± 1.9 d versus patients in each group (UCS and ECS group) in our study
5.43 ± 3.9 d; p ¼ 0.002). could be an explanation for observed results. We used
There were no neonatal deaths in each of the groups. oxytocin augmentation only for dysfunctional labor. Oxytocin
augmentation was used in more than half of the VDs and was
the main reason for the study, unexpectedly shorter duration
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Discussion
of spontaneous VD that was observed in our study. In our
Before Hannah et al. published a study in the Lancet about the study, birth asphyxia, increased twice in the VD group
neonatal outcomes of term breech presentation, VD was compared with the UCS and ECS, groups, as was observed in
commonly used in clinical practice (October 2000) [5]. This the study of Al-Mulhim et al. [12]. The most often cited
international randomized study found a significant decline in etiological factor for that in our study was failure to progress
neonatal Mb after planned cesarean section compared with into labor or prolonged expulsion phases.
PVD. In our study, more than 50% of term breech deliveries The Löwset maneuver was applied because it significantly
were completed by ECS [6]. reduces the risk of birth injuries, which occur frequently in
From 2007 to 2008, a similar study observed that ECS breech VDs compared with the cephalic presentation of
remained the recommended mode of delivery in nulliparous the fetus [13].
women older than 35 years of age. VD in term breech
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presentation was considered to be an optional mode of

delivery in multiparous women younger than 35 years of age
Conclusion
[7]. Five years later, this study confirmed a continuing trend VD can be considered as safe option especially in multiparous
observed in previous research. We found approximately the women younger than 35 years of age as well as in neonates
same number of nulliparous women who were delivered by with an estimated BW of 2500–3500 g. ECS remained the
ECS (73.9%/66.2), as was reported by Babović et al. [7]. recommended mode of breech term delivery in nulliparous
Parity is one of the most important factors of the mode of women older than 35 years, as well as in neonates with an
delivery in breech term presentation as well as estimated fetal estimated BW above 3500 g. Early neonatal well-being is
BW by an ultrasound examination. The only documented risk more frequently diagnosed in neonates born by ECS. Finally,
related to parity is cord prolapse, which was 2-fold higher in the decision-making process for handling a term breech
parous women than in primigravidas [8]. presentation is very controversial. The most frequent compli-
More recent studies have documented that estimated fetal cation for these neonates in such cases is birth asphyxia and a
BW above 3500 g is an absolute indication for ECS. VD was longer duration of stay in NICU; thus, we should ascertain
controversial for term neonates in breech presentation with an that our decision is correct.
estimated BW below 2500 g. Most term breech presentation
neonates with an estimated BW below 2500 g in our study
Declaration of interest
were delivered almost by ECS (55.5%). Our study also
confirmed that fetal macrosomia, especially after sonographic The authors report no declarations of interest.
examination or adequately diagnosed feto–maternal etio-
logical factors of IUGR in fetuses (e.g. chronic hypertension,
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