When any part of the foetus occupies lower pole of uterus other than vertex it is called malpresentation. Breech presentation is defined as the fetus in longitudinal presentation and the podalic pole presents at the pelvic brim. Breech presentation is the common form of malpresentation accounting to 3 to 4% of all deliveries at term1. In India, the incidence of breech presentation is 2.1%. ¹

The most common reason for breech presentation in labor is preterm delivery. Breech presentation may be caused by the prevention of the fetal rotation (tight nuchal cord, uterine anomalies, cornual fundal location of placenta, oligohydramnios), an outstanding fetal rotation ( preterm pregnancy), undue mobility of the fetus (hydramnios, multipara with lax abdominal wall). Many clinical factors beside preterm gestation are most commonly associated with breech presentation such as breech presentation in a previous pregnancy, primi, congenital fetal anomalies, oligohydramnios, fetal growth restriction, placenta previa and maternal uterine anomalies. Maternal complications include increased operative vaginal delivery, perineal trauma, anaesthesia complications and increased risk of sepsis. ^2-4

The best mode of delivering breech presentation is still debatable. Malpresentation of fetus is one of the main indication for primary caesarean section. The term Breech trial² in 2000 showed a bad perinatal outcome and maternal outcome after vaginal birth delivery. After that study, the number of caesarean deliveries increased rapidly. However, planned caesarean section group show significantly lower perinatal and neonatal mortality or neonatal morbidity as compared to planned vaginal delivery group. ⁵

The study is done to compare the mode of delivery in breech presentation and its perinatal outcome. The present study is conducted at tertiary care centre , government medical college associated with government hospital, Kadapa . On an average around 10000- 12000 pregnant woman attending the antenatal out patient department and around 9000 – 10000 deliveries were conducted at this hospital per year. Infrastructure for providing proper antenatal checkups, safe institutional deliveries, and satisfactory postoperative and postnatal services, including radiological, laboratory, good NICU facilities, and well-trained staff, and good contraception and sterilization facilities are available in this institution in which the study was taken up.

AIMS AND OBJECTIVES

AIM OF THE STUDY:

To study the mode of delivery in breech presentation from 28 weeeks of gestation and its perinatal outome.

OBJECTIVES OF THE STUDY:

1. To determine the perinatal outcome of breech presentation at different gestational age in relation to mode of delivery.
2. To study the factors favouring the breech vaginal
3. To correlate the perinatal outcome with gestational age, birth weight, APGAR SCORE in neonates delivered by

        vaginal delivery.

4. To study the factors associated with breech

PATIENTS AND METHODS

Place of study-- Government General Hospital, Kadapa. Period of study – February 2021 to July 2022.

Study design: Quantative observational analytical prospective cross sectional study . Study population :                100 study population.

Source of data -- Cases of singleton breech presentation admitted in labour ward of GGH Kadapa confirmed by clinical examination and confirmed by ultrasound are selected for this study

INCLUSION CRITERIA :

1. Singleton

EXCLUSION CRITERIA:

1. Multiple gestation. Intrauterine death 3.Congenital anomaly

Name, age, unit, registration number and address of the patients are noted. Detailed obstetric history is taken. The time of admission is noted down. History of present pregnancy about last menstrual period taken and gestational age is calculated. A per abdomen examination is done to access the presentation and position of the fetus. Estimated foetal weight is calculated. Per vaginal examination is done to confirm the presentation, assess the pelvis, rule out gross feto-pelvic disproportion and assess the Bishop's score.

USG is done in all cases to confirm the gestational age, presentation, type of breech, position of placenta, liquor status, gestational age, hyperextension of neck and to rule out anomaly.

In those admitted in labour ward the presumptive mode of delivery either vaginal or abdominal is based upon the obstetric history, parity, type of breech, estimated foetal weight, pelvis assessment, progress of labour, foetal condition in utero and associated maternal complication.

TABLE 1: AGE WISE DISTRIBUTION

Table 1 shows 42% belonged to age group of 20-24 years, 38% belonged to 25-29

years, 9% belonged to 30-34 years, 8% belonged to 18-19 yrs.

TABLE 2: PARITY DISTRIBUTION

Table 2: shows 54% in the study were multigravida and 46% were primigravida.

TABLE 3: GESTATIONAL AGE DISTRIBUTION

Table 3 shows that 77% cases are among gestational age of >36 weeks and 14% are in between 33-36 weeks gestation and 9% are in between <32 weeks gestation.

TABLE 4: BOOKING STATUS

Table 4 shows 58% are booked and 42% are unbooked.

TABLE 5: ANTENATAL COMPLICATIONS DISTRIBUTION

Table 5 shows that in this study,breech is more commonly associated with oligohydramnios and PIH followed by PROM, IUGR.

TABLE 6: H/O PREVIOUS BREECH

Table 6 shows 6% had history of previous breech.

TABLE 7: MODE OF DELIVERY DISTRIBUTION

Table 7 shows out of 100, 16 delivered by assisted breech delivery and 84 delivered by cesarean section among which 4 were delivery by elective and 80 were delivered by emergency cesarean section.

TABLE 8: INDICATION OF CESAREAN SECTION

Table 8 shows that in this study, most common indication for LSCS is fetopelvic disproportion, oligohydramnios followed by fetal distress and footling.

Table 9.: TYPE OF BREECH DISTRIBUTION

Table 9 shows 51% belonged to frank breech, followed by 33% flexed and 16% footling breech.

TABLE 10: COMPLICATIONS DURING LABOR

Table 10 shows that in this study 1% had postpartum haemorrhage and 1% had abruption and remaining 98% were without any complications.

TABLE 11: UTERINE ANOMALY DISTRIBUTION

Table 11 shows 21 cases had uterine anomaly among which 8 were of unicornate uterus, 6 were septate uterus, 3 were arcuate uterus and 2 each were bicornuate and subsepate uterus.

TABLE 12: POSTPARTUM COMPLICATIONS DISTRIBUTION

Table 12 shows 2 patients required blood transfusion, remaining 95% are without any complications.

TABLE 13:BIRTH WEIGHT DISTRIBUTION

Table 13 shows 39 babies were in birth weight of 2.6-3 kgs and 26 cases were in birth weight of 2-2.5 kgs,16 babies were in a range of 1.2-1.9 kgs, 13 babies in a range of 3.1-3.5 kgs and 6 babies in a range of 3.6-4 kgs.

TABLE 14: APGAR SCORE DISTRIBUTION

Table 14 shows 90 cases had apgar score of 8-10, 9 babies with a score of 6-8 and only 1% with an apgar score of 2-4.

TABLE 15:NICU ADMISSION

Table 15 shows 15 cases had NICU admissions.

TABLE 16:NEONATAL COMPLICATIONS

Table 16 shows that 5 had perinatal mortality.

TABLE 17: COMPARISION OF GESTATIONAL AGE AND MODE OF DELIVERY

Table 17 shows in <32 weeks gestation,out of 9 cases, 3.6% were delivered by LSCS and 37.5% were delivered by vaginal route. In 33-36 weeks gestation, 18.8% were delivered vaginally and 13.1% by cesarean section. In >36 weeks gestation, 43.8% were delivered by vaginal route and 83.3% were delivered by LSCS.

TABLE 18: COMPARISION OF TYPE OF BREECH AND MODE OF DELIVERY

Table 18 shows 33% were flexed breech in which 62.5% were delivered by vaginal route and 27.4% by LSCS. 16% were of footling and all were delivered by LSCS and 51% were of frank in which 37.5% were delivered by vaginal route and remaining by cesarean section.

TABLE 19: COMPARISION OF COMPLICATIONS DURING LABOR AND MODE OF DELIVERY

TABLE 20: COMPARISION OF POSTPARTUM COMPLICATIONS AND DELIVERY

TABLE 21 : COMPARISION OF BIRTH WEIGHT AND MODE OF DELIVERY

Table 21 shows 39% delivered were in birth weight range of 2.6-3 kgs among which 25% were delivered vaginally and 41.7%(35) by LSCS,26%were in birth weight range of 2-2.5 kgs in which 31.3% were delivered by vaginal route and 25% by cesarean section.

TABLE 22: COMPARISION OF APGAR SCORE AND MODE OF DELIVERY

Table 22 shows 90% babies were born with an apgar score of 8-10 in 78 babies(92.9%) were delivered by LSCS and remaining(12 babies i.e 75%) by vaginal route, 9% cases had a score of 6-8 out of which 6 were delivered by LSCS and remaining vaginally. 1% case had a score of 2-4 and delivered by ABD.

TABLE 23: COMPARISION OF NICU ADMISSION AND MODE OF DELIVERY

Table 23 shows that 15% babies were admitted in NICU among which 10.7%(9 babies) admitted were delivered by LSCS and 37.5%(6 babies) were by vaginal delivery.

TABLE 24: COMPARISION OF NEONATAL COMPLICATIONS AND MODE OF DELIVERY

Table 24 shows total 5 babies(5%) had perinatal mortality among which 3(18.8%) were delivered by vaginal route and 2(2.4%) by cesarean section.

AGE DISTRIBUTION

In this study, 42% belonged to 20-24 yrs of age group, followed by 38% in age group of 25-29 yrs and 9% in 30-34 yrs age group, 8% belonged to <19 yrs. According to Shradha et a7 study, 61% cases belonged to 20-24 yrs, followed by 31% in 25-30 yrs. According to Kothapally et al⁸ study, 37% cases belonged to 20-24 yrs.

PARITY

In this study, incidence of primigravida was 46% and multigravida was 54%. According to Bhavesh B Airao et al⁹ study, incidence of primigravida was 47% and multigravida was 53%. According to Andal et al¹⁰ study, incidence of primigravida was 46% and multigravida was 54%.

Present study correlated well with other studies which too showed higher incidence of breech presentation in Multigravida than in primigravidae. This is probably because of relative low tone of uterine musculature in multigravida favouring malrotation and subsequent breech presentation.

ANTENATAL COMPLICATIONS

In this study, most commonly associated with oligohydramnios, and gestational hypertension each constituting 9% which is comparable to a study done by Kavitha Kothapally⁸.

In study by Kavitha, breech is associated with oligohydramnios, uterine anomalies, short cord, fetal anomalies. Karning et al¹¹ showed that breech presentation is associated with PIH, oligohydramnios, IUGR.

H/O PREVIOUS BREECH

In this study, 6% cases had recurrent breech. This is comparable with a study done by Kavitha²⁴ in which recurrent breech is seen in 6%.

MODE OF DELIVERY

In this study, 16% of cases underwent assisted breech delivery (ABD) and 84% underwent LSCS. In a study done by Shradha⁷ , 92% underwent LSCS and 8% ABD. In study by Kavitha²⁴, 96% underwent LSCS and 4% ABD. A positive correlation was observed with previous studies, that in majority of the studies, caesarean section was more common as a mode of delivery than vaginal route.

In this study, the most common indications for LSCS are FPD – 20%, Oligohydramnios- 17%, footling- 12%, fetal distress- 12%, prior LSCS- 10%. This can be compared with the studies done by Shradha⁷, Karning⁸. In karning²⁴ study, most common indications are FPD, prior lscs, oligohydramnios.

TYPE OF BREECH

In this study, majority of cases presented as Frank breech of about 51%, followed by flexed- 33%, and then footling- 16%. This can be compared with other studies.

Present study correlates with previous studies, it favors incidence of extended (frank) breech more than complete breech. This is most probably because of a favorable engaging diameter in extended breech (bistrochanteric) and less space occupied by the narrow lower pole.

MATERNAL COMPLICATIONS

In this study, 2% cases complications in which 1 had abruption and 1 had postpartum haemorrhage and remaining 98% had no complications during labour. This is in accordance with other studies. In study by kavitha⁸, maternal complications is seen in 5%, in which 4% had postpartum haemorrhage and 1% had premature rupture of membranes and remaining 45% had no complications.

In a study by Shradha et al⁷, incidence of maternal complications was 4%, Karning RK et al¹¹ 5.8%, term breech trial 3.5% and Moodley et al¹² 4.72% and Rauf et al 6%. ¹³

UTERINE ANOMALY

In this study, incidence of uterine anomaly is 21%,which includes unicornuate- 8%, septate- 6%, arcuate- 3%, bicornuate- 2% and subseptate- 2%. It is similar to the other studies done by Shradha⁷ and Karning⁸.

POSTPARTUM COMPLICATIONS

In this study, 2% required blood transfusions.

BIRTH WEIGHT

In this study, 39% cases had birth weight of 2.6-3.0 kg, 26% cases had weight of 2-2.5 kgs. This is comparable to a study by Kavitha Kothapally²⁴, in which 56% had birth weight of 2.6-3 kgs and 14% had 3.1-3.5 kgs.

APGAR SCORE

In this study, 90% babies were born with an APGAR score of 8-10, 9% with an apgar score of 6-8 and in 1% the score is 2--4.

NICU ADMISSION

In this study, 15% cases required NICU admission. In a study by Karning²⁵, 38% cases needed NICU admission.

NEONATAL COMPLICATIONS

In this study, incidence of perinatal mortality was 5%, compared to Shradha et al⁷ – 4% and term breech trial² - 0.3%.

COMPARISION OF GESTATIONAL AGE AND MODE OF DELIVERY

In this study, in <32 weeks of gestation, out of 9 deliveries, 6 are ABD and 3 are LSCS i.e 37.5% and 3.6% respectively. In between 33- 36 weeks of gestation, in total 14 cases, 3 are ABD and 11 are LSCS i.e 18.8% and 13.1% respectively. In >36 weeks gestation, out of 77 cases, 7 cases are ABD and 70 cases are LSCS corresponding to 43.8% and 83.3% respectively.

In a study by M Andal²⁰, in <32 weeks gestation 100% delivered by vaginal route and in 33-34 weeks gestation, 96.3% delivered by vaginal route and 3.7% by LSCS. In 35-37 weeks gestation, 46.5% delivered by vaginal route and 53.6% by LSCS.

COMPARISION OF TYPE OF BREECH AND MODE OF DELIVERY

In this study, in frank breech, the incidence of vaginal delivery is 37.5% and LSCS is 53.6%, whereas in non-frank, vaginal delivery is seen in 62.5% and LSCS is 46.4%

In a study by M Andal¹⁰, In frank Breech, delivery by vaginal route was seen in 30.3% and incidence of LSCS was 69.6% and in non- frank breech the incidence was 5%.In a study by Bhavesh⁹ also, the incidence of vaginal delivery is more in frank breech when in comparision to complete breech.

Type of breech is a significant factor affecting the method of delivery. So,in cases of frank breech presentation irrespective of gravidity, trial of vaginal delivery should be given.

This difference is may be due to difference in study population taken.

COMPARISION OF MATERNAL COMPLICATIONS AND MODE OF DELIVERY

In this study, 2% had maternal complications and they underwent LSCS.

COMPARISION OF BIRTH WEIGHT AND MODE OF DELIVERY

In this study, 39% cases delivered were of birth weight of 2.6-3 kgs in which 41.7% delivered by LSCS and 25% by ABD. 26% cases delivered were of birth weight of 2-2.5 kgs, in which 21 cases were by LSCS and 5 were delivered by

ABD. 13% delivered were of birth weight 3.1-3.5 kgs in which 13 were delivered by LSCS.

In Andal et al¹⁰ study, 13.6% cases were delivered by vaginal delivery and 86.4% underwent LSCS in birth weight of 2.5-2.9 kgs.6.7% were delivered by vaginal route and 93.3% delivered by LSCS in birth weight of 3-3.4 kgs.

COMPARISION OF APGAR SCORE AND MODE OF DELIVERY

In this study, out of 16 vaginal deliveries, 75% had a score of 8-10, 18.8% had a score of 6-8 and 6.3% had a score of 2-4. Out of 84 LSCS, 92.9% had a score of 8-10, 7.1% had a score of 6-8.

In Karning¹¹ study, in patients delivered by vaginal route (21.4%). the APGAR score was found to be less than 7. The same results were seen in Pradhan et al¹⁴, Term Breech Trial², Alarab et al¹⁵, where Apgar score < 7 were more commonly seen in babies delivered vaginally.

COMPARISION OF NICU ADMISSIONS AND MODE OF DELIVERY

In this study, 15 babies were admitted in NICU, among which 6 were delivered by vaginal route and 9 were delivered by cesarean section corresponding to 37.5% and 10.7% respectively. In Karning study¹¹, 21.64% of vaginally delivered babies and 16.5% of fetuses delivered by LSCS were admitted in neonatal unit.

COMPARISION OF PERINATAL MORTALITY AND MODE OF DELIVERY

In this study, out of 100 babies 5 babies had perinatal mortality accounting to 5% in which 3 were delivered by vaginal route and 2 were delivered by LSCS corresponding to 18.8% and 2.4% respectively.

This is in accordance with other studies. In Karning et al¹¹ study, the perinatal mortality was higher among vaginally delivered patients which was 1.6% (8 cases) and in patients delivered by LSCS, it was 0.8% (4 cases).

Caesarean section reduces risk of perinatal outcome at term during both labour and delivery for singleton breech presentation compared with vaginal delivery. Fetal morbidity was lower and Apgar scores are better in fetuses delivered by lower segment cesarean section. Perinatal mortality was more in fetuses delivered by vaginal route. Hence, it can be stated that vaginal mode of delivery is not always a completely safe option but may be considered as a safe mode for babies in breech as long as the selection criteria is fulfilled and delivery is done by a skilled and trained   obstetrician with continuous fetal monitoring.. Though caesarean section gives good perinatal outcome, present recommendations are for vaginal breech delivery so that the vaginal delivery does not become obsolete. Therefore, it is concluded that a balanced decision to be taken about the mode of delivery on a case by case basis as it differs from case to case and gestational age as well as training of assisted breech delivery will go on a long term basis to optimise the outcome of breech presentation

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