|Year : 2016 | Volume
| Issue : 3 | Page : 274-278
Breech deliveries in a secondary health-care facility in South-South Nigeria
ML Kahansim1, LL Changkat2, AE Eya3
1 Department of Obstetrics and Gynaecology, Jos University Teaching Hospital, Jos, Nigeria
2 Department of Obstetrics and Gynaecology, Dalhatu Araf Specialist Hospital, Lafia, Nigeria
3 Maternity Unit, Sacred Heart Catholic Hospital, Obudu, Cross River State, Nigeria
|Date of Web Publication||8-Feb-2017|
M L Kahansim
Department of Obstetrics and Gynaecology, Jos University Teaching Hospital, Jos
Source of Support: None, Conflict of Interest: None
Context: The optimal mode of delivery for breech presentation remains an issue of debate among obstetricians. The care during labor, delivery methods used, and the skills of the birth attendant influence outcome of fetuses in breech presentation.
Objectives: The objective of this study is to determine the incidence, mode of delivery, and outcome of singleton breech deliveries in a secondary health facility in South-South Nigeria.
Materials and Methods: The case notes of all patients who had singleton breech delivery from January 1, 2009, to December 31, 2014, were studied. Data extracted were age, parity, booking status, mode of delivery, indication for cesarean section (CS), birth weight, Apgar score at 5 min and fetal outcome. The data were analyzed using SPSS Version 20 statistical package.P < 0.05 was considered statistically significant.
Results: There were 172 singleton breech deliveries and a total of 5736 deliveries during the study, giving an incidence of 3%. The mean age of the patients was 27 ± 5.4 years. About 36% of the patients were nulliparous, and over half (54.7%) of the patients were booked. About 55.2% of the patients had CS, most (67.4%) of whom were booked. The most common (26%) indication for CS was for breech presentation in primigravida. There were 122 live births (70.9%) and 50 stillbirths of which 36 (20.9%) were fresh stillbirths. The stillbirth rate was 290.7/1000 compared with 54/1000 births for singleton cephalic presentation for the same period. The mean birthweight was 2.96 ± 0.76 kg. Fetuses that weighed ≥3.5 kg had significantly poorer outcomes (P < 0.0001). The babies delivered by CS had better Apgar scores at 5 min compared to those that had vaginal breech delivery.
Conclusion: CS offers a better fetal outcome for singleton breech presentation and fetuses weighing ≥3.5 kg have a poorer outcome at delivery in our facility.
Keywords: Breech deliveries; cesarean section; fetal outcome; secondary care facility.
|How to cite this article:|
Kahansim M L, Changkat L L, Eya A E. Breech deliveries in a secondary health-care facility in South-South Nigeria. Trop J Obstet Gynaecol 2016;33:274-8
|How to cite this URL:|
Kahansim M L, Changkat L L, Eya A E. Breech deliveries in a secondary health-care facility in South-South Nigeria. Trop J Obstet Gynaecol [serial online] 2016 [cited 2020 Sep 25];33:274-8. Available from: http://www.tjogonline.com/text.asp?2016/33/3/274/199814
| Introduction|| |
The incidence of breech presentation decreases from about 20% at 28 weeks of gestation to 3%–5% at term., The majority of babies turn spontaneously to cephalic presentation. There is a higher perinatal mortality and morbidity with breech presentation than cephalic presentation due to congenital anomaly, prematurity, and birth asphyxia.
The optimal mode of delivery for breech presentation remains an issue of debate among obstetricians despite findings from the term breech trial (TBT). The TBT is the largest randomized controlled trial on term breech delivery, however, despite its strength; various authors have questioned and criticized the trial.,, The TBT found that with a policy of planned cesarean section (CS), for every 14 CS done, one neonatal death or serious morbidity will be avoided. Hofmeyr and Hannah suggested that 27 CSs are needed to avoid one case of serious neonatal morbidity. Due to findings of reduced benefit of planned CS in countries with high perinatal mortality rates, Hannah et al. suggested that as many as 39 additional CS have to be done to avoid one perinatal death or severe morbidity. These findings also need to be judged against the background of potential long and short-term risk of CS in low-resource settings. More so that 2 years follow-up of the babies in the TBT did not show a reduction of risk of death or neurodevelopmental delay. Data from the Netherlands suggest that for every infant saved as a result of delivery by CS, one woman will experience a ruptured uterus in a subsequent pregnancy. The maternal morbidity and mortality resulting from this will certainly be more in a low resource country like Nigeria.
A multicenter observational survey in France and Belgium concluded that “in centres where planned vaginal delivery is a common practice and when strict criteria are met, before or during labor, planned vaginal delivery of singleton fetus in breech presentation at term remains a safe option that can be offered to women.” Other studies also suggest that a planned vaginal delivery where appropriate selection criteria are applied would give the same favorable outcome as planned CS, with some studies suggesting that even an undiagnosed breech presentation in labor may be an indication for vaginal breech delivery (VBD) in carefully selected cases., However, most of the studies reporting potential safety of VBD were retrospective in design (either retrospective reviews or retrospective population based studies). Lavin et al. have shown that the number of practitioners with the skills and experience to perform VBD has decreased, even in academic medical centers where faculty support for teaching vaginal delivery for residents remains high. There may be the insufficient volume of vaginal breech deliveries to adequately teach this procedure. We expect this situation to be even worse in facilities that offer obstetric services at a secondary level of care in a developing country like ours, where most of them may not have all that is needed to follow specific protocols set by researchers and clinicians working mainly in academic medical centers supported by necessary workforce and equipment. The fact, however, remains that the care during labor, the delivery methods used and skill of the birth attendant influence outcome of fetuses in breech presentation.
Much has been reported about the incidence and outcome of singleton breech deliveries in tertiary hospitals in Nigeria. Not much has been reported about what happens in our secondary health facilities where possibly most of our breech deliveries take place, usually supervised or conducted by medical officers and midwives. This study set out to determine the incidence, mode of delivery and outcome of singleton breech deliveries at the Sacred Heart Catholic Hospital (SHCH), Obudu, a secondary health-care facility in South-South Nigeria.
| Materials and Methods|| |
The SHCH is a 235-bed capacity hospital with a 44-bed maternity unit including four delivery beds. As of 2014, there were three medical officers and eight trained nurse-midwives that offer maternity services. The hospital is visited once in a year by a consultant obstetrician for 4 weeks, with occasional visits by year three residents from mainly Jos University Teaching Hospital, but sometimes from other parts of the country. Outside those periods, the obstetric services are offered by the medical officers and nurse midwives.
This study was carried out at the maternity unit of the SHCH, Obudu. Obudu is the capital of Obudu local government area; located in the Northern part of Cross River state. It shares a boundary with part of Vandeikya local government area of Benue State in North-central Nigeria. The inhabitants are mainly farmers, traders, and civil servants.
The case notes of all the patients who had singleton breech delivery between January 1, 2009, and December 31, 2014, were studied. The data extracted were the age, booking status, parity, mode of delivery, indication for CS, birthweights, Apgar score at 5 min and fetal outcome. The data were analyzed using SPSS Version 20 statistical package (IBM R SPSS R Statistics 20, IBM Cooperation). P < 0.05 was considered statistically significant.
| Results|| |
There were 172 singleton breech deliveries and a total of 5736 deliveries during the study period, giving an incidence of 3%. The mean age of the patients was 27 (± 5.4) years, (range 16–49 years). About 36% (57) of the patients were nulliparous, while 54.1% (91) were Para 1–4 and the rest were Para 5 and above. Over half (54.7%, n = 94) of the patients were booked. More than half (55.2%, n = 95) of the patients had cesarean delivery while the remaining (44.8%) had VBD. Most (67.4%) of those that had cesarean delivery were booked, compared to 32.6% of unbooked patients. The most common indication for CS was for breech presentation in primigravida in 28 (26.6%) of the women, however, 20 (19%) of the indication was solely due to breech presentation without other obstetric factors. [Table 1] shows the indication for CS.
There were 122 live births (70.9%) and 50 stillbirths, of which 36 (20.9%) were fresh stillbirths and 14 (8.1%) macerated stillbirths. This gave a stillbirth rate of 290.7/1000 births, compared with 54/1000 births for singleton cephalic births over the same period in the hospital. The fetal outcome was better in patients that had cesarean delivery compared with those that had VBD, [Table 2]. This finding remains even after excluding those that had macerated stillbirths assuming these to be possibly antepartum deaths and therefore vaginal delivery was the ultimate goal (χ2 = 31.201, P = 0.0001).
Among those who had vaginal delivery, there was no difference in fetal outcome among patients who were delivered by midwives compared with those delivered by doctors (χ2 = 0.554, P = 0.457), macerated stillbirths were excluded from this study.
The mean birthweight at delivery was 2.96 kg (± 0.76). There was no statistically significant difference in fetal outcomes (live birth or stillbirth rates) among babies <2.5 kg or ≥2.5 kg, (P = 0.109). The study shows that 36% (62) of the fetuses weighed ≥3.5 kg at birth while 64% (110) had birthweight <3.5 kg. There was no statistically significant difference in mode of delivery between those that weighed greater or <3.5 kg at birth (χ2 = 0.058, P = 0.809). However, fetuses weighing ≥3.5 kg had significantly poorer outcome, (χ2 = 16.47, P < 0.0001).
About 79.5% (97) of the live births had Apgar scores at 5 min of 7 and above while 20.5% (25) had Apgar scores <7 at 5 min. The babies delivered through CS had better 5 min Apgar scores (≥7) compared with those delivered vaginally (χ2 = 6.989, P = 0.008), [Table 3]. There were two cases of impacted after-coming head which both ended in fresh stillbirths and three cases of retained placenta among the vaginal delivery group; with one requiring blood transfusion due to postpartum hemorrhage. There were five cases of wound infection and three cases of postpartum hemorrhage (all had obstructed labor) requiring blood transfusion among the CS group.
| Discussion|| |
This review shows that the incidence of breech presentation over the period of review was 3%, and this is within the range of 1.4%–5.7% observed in tertiary centers within the country,,,, indicating that secondary level hospitals may have the same incidence, because patients with breech presentation may not always be referred to tertiary hospitals for care. Even the few that are referred may not present; due to financial and transport constraints.
This study shows a high CS rate for cases of breech presentation. This may possibly be due to less experience with VBD, more so that a high percentage of booked cases had CS compared to the unbooked cases. The study also shows that there was no difference in fetal outcome among vaginal breech deliveries conducted by doctors compared to midwives. The VBD experience among medical officers may not be too different from that of midwives; however, it is also possible that the medical officers are more often called upon for more difficult vaginal breech deliveries, thus resulting in a higher probability of a poorer fetal outcome.
Our study also revealed a relatively high fresh stillbirth rate of 20.9% compared to those observed in most tertiary hospitals in the country., Although this high rate is not surprising, it calls for more urgent need for in service training for doctors and midwives working in secondary care facilities to reduce this high mortality rate. The relatively better fetal outcome seen with CS delivery supported the improved fetal and neonatal outcome with CS compared to VBD reported by other studies in the country., There was, however, more maternal morbidity of wound infection and postpartum hemorrhage with the CS group. The long-term morbidity due to CS in these women in subsequent pregnancies remains unknown; however, in terms of fetal outcome in a secondary care facility, it appears that CS breech delivery offers the best prospect in a secondary health facility like ours.
Unfavorable fetal outcomes were increased in fetuses that weighed >3.5 kg or babies that had VBD. This supports the finding of Abasiattai et al., in a tertiary hospital, where poor perinatal outcome in VBD of fetuses >3.5 kg was shown. The estimated fetal weight is an important factor in most of the criteria for deciding on mode of delivery for breech presentation, however, it's estimation may be challenging; as measurements of the fetal weight before delivery depends much on the skill of the obstetrician; whether clinically or using ultrasound. This also probably explains the reason why there was no difference in the mode of delivery for fetuses weighing greater or <3.5 kg in our facility.
None of the women that were booked had an external cephalic version (ECV), and this is not surprising because of the fact that medical officers/midwives do not have the requisite skills. Even in maternity units supervised by trained obstetricians, it is not a commonly performed procedure., This has led to the poor skills of ECV among medical officers and even young obstetricians.
Transferring patients with breech presentation at term to hospitals where ECV or VBD could be more safely conducted is fraught with social and transport problems, considering the fact that the towns where trained obstetricians are easily accessible are more than 150 km away from our facility. Similarly, advocating a policy of CS for all breech presentation in a secondary level of care hospital is likely to impact negatively in low-resource settings because this will increase the CS rate, and the required resources, both human and material may not be available. This would also further reduce the number of doctors with skills for safe VBD.
So what are then the options for improving the fetal outcome for women with breech presentation in a secondary care facility other than CS? Training in methods and procedures of ECV, as well as education in criteria for selecting women for planned VBD should be instituted in both undergraduate and postgraduate curricula. Second, regular in service training of medical officers and midwives in secondary care hospitals by simulation with mannequins and video demonstrations supported by observation, and practice of VBD by experienced personnel would improve the outcome of fetuses in breech presentation in these facilities and prevent the art of VBD being lost. More so, it is essential because some women always request for VBD and a number of patients seen may be unbooked and present in advanced labor with breech presentation, and there may be no personnel to conduct a safe VBD if indicated.
| Conclusion|| |
That the incidence of breech presentation in our facility is the same with that in most tertiary level facilities, despite our limited workforce and material resources. CS offers a better fetal outcome for singleton breech presentation and fetuses weighing ≥3.5 kg in breech presentation have a poorer outcome at delivery in our facility.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]