Breech presentation is a longitudinal lie of the fetus with the caudal pole (buttock or lower extremity) occupying the lower part of the uterus and cephalic pole in the uterine fundus [
The breech fetus is at increased risk of harm during delivery because cord compression between the cervix and body must occur as the breech crowns and because the after-coming shoulders, head, and arms are at greater risk of harm from dystocia.
Breech deliveries have always been topical issues in obstetrics because of the very high perinatal mortality and morbidity. These are due to combination of trauma, birth asphyxia, prematurity, and malformation. In addition 19.4% of neonates undergoing term breech deliveries have long-term morbidity up to the school age irrespective of mode of delivery [
The predisposing factors for breech deliveries include maternal factors (foetopelvic disproportion, soft tissue dystocia, uterine anomalies; pelvic tumors (myoma, ovarian neoplasm, etc.), and grand multipara); placenta factors (placenta previa, cornual placenta (it contributes 73 percent)); liquid factors (polyhydramnios, oligohydramnios); and cord factors (very long cord and very short cord). Fetal factors include multiple pregnancies and congenital anomalies (fetal anomalies have been observed in 18 percent of preterm breech and 4–8 percent of term breech deliveries). Other purported risk factors include primiparity, female gender, maternal anticonvulsant therapy, older maternal age, fetal growth restriction, and previous breech presentation [
The wide ranges of management policies have been instituted with the aim of reducing perinatal morbidity and mortality. External cephalic version (ECV) is one of such policies. A successful ECV leads to a more favourable presentation and reduces the incidence of breech deliveries, perinatal morbidity, and mortality. This was the reason the Royal College of Obstetricians and Gynaecologists in 2001 recommended that all women with an uncomplicated breech presentation at term be offered an ECV [
Breech presentation is the most common form of malpresentation, accounting for 3%-4% of all deliveries at term. Persistent breech presentation may be associated with abnormalities of the baby, the amniotic fluid volume, the placental localization, or the uterus. It may be due to an otherwise insignificant factor such as cornual placental position or it may apparently be due to chance [
Morbidity and mortality for breech infants and mothers is most related to inclusion and exclusion criteria adhered to by the hospital for determining mode of delivery, the competence of the attending physician, and the expectation of the mother rather than the mode of delivery. In general countries that perform more vaginal breech births have birth outcomes that are as good as or better than caesarean section outcomes. Countries that perform few vaginal breech births have birth outcomes that are worse than those for caesarean section births. In many countries breech vaginal birth has higher morbidity and mortality risks for babies, but the risk is still relatively low [
From a study done in Scotland on the breech deliveries, there were 11 (28.0 per 10,000 births) delivery related perinatal and neonatal deaths in women who had a vaginal breech delivery. The risk of death (24.3 per 10,000 births) was similar among women having a prelabour caesarean delivery, but only approximately half of these losses were due to asphyxia. There were four (8.1 per 10,000 births) perinatal and neonatal deaths in those who had a postlabour emergency caesarean delivery and two of these were due to asphyxia. There were seven (3.5 per 10,000 births) perinatal and neonatal deaths in women who had a planned caesarean delivery. The absolute risk of asphyxia perinatal death was 25.5 per 10,000 deliveries for women who had a vaginal breech delivery, 12.2 per 10,000 deliveries for women who had a prelabour emergency caesarean delivery, and 4.1 per 10,000 deliveries for women who had a postlabour emergency caesarean delivery [
The total mortality rate in the breech presentation group was 0.92% (
The overall perinatal mortality was significantly (
In one study done in Yekatit 12 Hospital, Addis Ababa, Ethiopia, there was higher perinatal mortality compared to the total number of deliveries; fetuses with low birth weight show a higher mortality rate. There is also a twofold increase in perinatal death in patients without antenatal care [
A study done in Hawassa and Jimma shows that the overall perinatal mortality (intrapartum and early neonatal deaths) in the planned vaginal delivery in term singleton breech was as high as 253 (0.3%). Thus, the risk of perinatal mortality was high in planned vaginal deliveries, 1 in 300 deliveries. The overall rates of birth trauma in the planned vaginal deliveries was as high as 1 in 150 (0.7%); the absolute risk of APGAR score <7 was high in the planned vaginal deliveries groups (2.4%). The absolute risk of neonatal asphyxia in the planned vaginal deliveries was as high as 3.3% [
Factors associated with increased risk of breech delivery in Flanders (Northern Belgium) are low gestational age and low birth weight, increasing maternal age, primiparity, history of caesarean section, female gender, and presence of congenital malformation [
It is important to know prevalence and fetal outcome in singleton breech presentation in reducing perinatal morbidity and mortality in our country and the absence of complete data on the prevalence and fetal outcome in singleton breech presentation at hospital level in our country and geographical variation of factors associated with it, except few studies, in north and central Ethiopia [
The prevalence of singleton term breech deliveries in most of studies was almost similar to what was stated by world health organization which is affected by factors like sociodemographic related factors, maternal and obstetric related factors, and child related factors. In our nation, Ethiopia, early diagnosis and intervention are not equally performed at all setups due to lack of human resources and diagnostic facilities, inadequate transportation facilities, poor ANC visit which might contribute to difficulty of management and increased risk of complications and poor outcomes. It is important to know prevalence in breech presentation and perinatal outcome in our setups. Knowing the prevalence in breech presentation and perinatal outcomes will help as know the most frequent complications in this setup, which in turn helps to develop guidelines on breech presentation and prevention of complications. Therefore, this study fills the existing information gap and will improve existing knowledge.
The aim of this study is to assess prevalence of breach presentation and perinatal outcomes of term singleton breech delivery and its associated factors at Wolisso Hospital, Oromia Region, Southern Ethiopia, in 2016.
The study was conducted from January 1, 2016, to January 30, 2016, on breech delivery of 3 years retrospective data from January 1, 2013, to December 31, 2015, at Wolisso Hospital, Woliso town, which is the Capital Town of Southwest Shewa Zone in Oromia Region, located about 116 km from Addis Ababa in the south west. The zone is one of the eighteen zones of Oromia Region and has eleven districts inhabited by a total of 1,173,363 populations. St. Luke Hospital is one of the two hospitals in the zone and gives clinical services to the population of the zone and nearby regions. It was established and began giving service since January 1, 2001. It is owned by Catholic Church and staffed with expatriates especially by doctors with African, CUUAM, and Italian nongovernmental organization (NGO). It provides outpatient and inpatient service and the average number of daily patients in the hospital is 304 in 2011. It has a total of 200 beds in different wards, two operation theatre complexes, and outpatient departments for all major medical services in addition to psychiatry, ophthalmology, and dentistry, VCT, PMTCT, and ART. There are also Physiotherapy and therapeutic feeding centers and mothers waiting area for pregnant women at risk. In addition, the hospital also provides public health services both at static and outreach sites.
Descriptive and analytic hospital based cross-sectional study was conducted on prevalence and perinatal outcomes of singleton term breech delivery in the past three years at St. Luke Catholic Hospital Southwest Shewa Zone in Oromia Region.
Cards of women who gave birth of breech delivery from January 1, 2013, to December 31, 2015, were obtained.
Mothers with singleton breech presentation who had either vaginal, C/S, or instrumental birth in St. Luke Catholic Hospital from January 1, 2013, to December 31, 2015, were included.
Mothers whose charts were lost. Mothers with preterm breech deliveries. Congenital malformed breech deliveries, because congenital malformed fetus can have reduced survival so that can affect outcome of the fetus.
The sample size was calculated by the single population proportion formulae considering the following assumptions:
First, obstetrics and operative records from obstetric ward and major operation registry book in the operation room were reviewed to identify women who presented with breech presentation and delivered from January 1, 2013 to December 31, 2015. Next, using card number of clients, cards were collected from the card room using simple random sampling method. Finally, based on the inclusion and exclusion criteria of the study, cards were selected.
Perinatal outcomes on singleton breech deliveries (1: died, 0: alive) Prevalence of singleton term breech deliveries.
Sociodemographic related factors include age and address. Maternal and obstetric related factors include gestational age, parity, mode of delivery, cervical dilatation, status of membrane, and antenatal care utilization and child related factors include child weight and IUFD and APGAR score.
Data collection instrument was developed based on patient cards and charts in English. Data was collected from patient record cards, registration books, and anaesthesia charts available in the hospital by checklist questionnaires using trained data collectors. First card number of patients in the study period was identified from registration books (logbooks), and then their chart was retrieved from card office. Data collectors and supervisor were recruited from the health facilities of the study area. The training was given for about five clinical nurses for data collection and one health officer for supervision for two days on data quality, data collection procedure, ethical issues, and confidentiality of information. Pretest was done on 5%. The principal investigators were strictly monitoring data collectors daily to assure the completeness of filled formats. Finally documents from patient cards were entered in to a structured format by five trained nurses.
Data was cleaned and coded with EpiData version 3.2 before being entered into SPSS version 20.0 for analysis. The data was analyzed by SPSS version 20. Frequencies and percentages were used. Chi-square test was performed for categorical variables to check adequacy of cells before performing logistic regression. Bivariate binary logistic regression was used primarily to check crude association of independent variables with prenatal outcome of breech deliveries; then variables found to have
Asphyxiated for APGAR <7 Not asphyxiated for APGAR 7 and above.
Primipara: those who gave birth only once Multipara: those who gave birth above one time Grand-multi: those who gave birth above five times.
During the study period there were 10214 deliveries in Wolisso Hospital in three years. From these deliveries 384 cards were included in the study. Most of the study participants, 141 (36.7%), were within the age group of 25–29 years. Among study subjects 334 (87.0%) were rural, 381 (99.2%) were married, only 3 (0.8%) were single, 382 (99.5%) were attended ANC, 145 (37.8%) had ANC follow-up less than 4 times, 307 (79.9%) did not know their LNMP, 54 (73%) were with 37–42 weeks of GA from LNMP, 266 (69.3%) were with non-fully dilated cervix, 229 (59.6%) were with ruptured membrane, 184 (79.5%) were with rupture of membrane < 8 hours, 281 (73.2%) had assisted vaginal breech delivery, 13 (19.1%) were having indication for CS by footling breech presentation, 362 (94.3%) were with alive intrauterine fetal condition prior to admission, and 322 (83.9%) were alive immediately after delivery.
Among mothers with term breech presentations, 317 (82.6%) of them gave birth vaginally while 67 (17.4%) of mothers gave birth through caesarean delivery. Among mothers who gave birth vaginally, 281 (73.2%) gave birth through assisted breech delivery, 31 (8.1%) through spontaneous breech delivery, 4 (1%) gave birth through destructive deliveries, and 1 (0.3%) through forceps deliveries.
The common reasons caesarean section is indicated for mothers who gave birth in this study were footling breech, 13 (19.1%), failure to progress, 11 (16.2%), previous c/s scar, 11 (16.2%), fetal distress, 9 (13.2%), contracted pelvis, 4 (5.9%), cord prolapse, 4 (5.9%), PROM, 9 (13.2%), and others, 1 (1.5%).
Of the total singleton 384 breech presentations, 22 (5.7%) were IUFD and 362 (94.3%) were alive prior to admission. Regarding neonatal birth weight, 53 (13.8%) neonates were less than 2500 gm, 262 (68.2%) were 2500–3500 gm, and 69 (18%) was greater than 3500 gm.
From the total 384 singleton breech presentations, 62 (16.1%) with (95% CI: 13, 20.3) deliveries had bad outcome (death) within the first 5 minutes. The possible cause of bad outcome (death) in 14 (25.5%) was after-coming head entrapment, in 17 (30.9%) was cord prolapse, in 14 (25.5%) was asphyxia, and in 10 (18.2%) was other, whereas among 322 alive babies within 5 minutes, 253 (79.1%) were healthy looking, 22 (6.9%) were with birth injury, 20 (6.2%) were asphyxiated, and 25 (7.8%) were transferred to NICU. This increased poor fetal outcome and fetal complication could be due to only 31 (8.1%) of mothers giving birth through spontaneous breech delivery and 67 (17.4%) of mothers giving birth through caesarean section delivery. Therefore majority of mothers gave birth through assisted breech delivery (281 (73.2%) and 4 (1%) gave birth through destructive deliveries and 1 (0.3%) through forceps deliveries). This condition could increase the chance of fetal distress and can result in poor fetal outcome and increase fetal complication (see Table
Bivariate logistic regression analysis of associated factors with perinatal outcomes among breech deliveries of Wolisso Hospital (
Variables | Label | Fetal outcome | COR 95% CI |
|
|
---|---|---|---|---|---|
Died | Alive | ||||
Age | 19 or below | 4 (18.2%) | 18 (81.8%) | 1.2 |
0.76 |
20–24 | 10 (12%) | 73 (88%) | 0.74 |
0.46 | |
25–29 | 22 (15.6%) | 119 (84.4%) | 1 | ||
30–34 | 10 (14.9%) | 57 (85.1) | 0.95 |
0.90 | |
35 or above | 16 (22.5%) | 55 (77.5%) | 1.57 |
| |
Residence | Urban | 2 (4%) | 48 (96%) | 0.19 |
|
Rural | 60 (18%) | 274 (82%) | 1 | ||
Parity of women | Primipara | 19 (17.4%) | 90 (82.6%) | 1.36 |
0.38 |
Multipara | 19 (13.5%) | 122 (86.5%) | 1 | ||
Grand multipara | 24 (17.9) | 110 (82.1%) | 1.40 |
0.31 | |
Frequency of ANC follow-up | <4 | 30 (20.7%) | 115 (79.3%) | 1.37 |
0.30 |
≥4 | 23 (16%) | 121 (84%) | 1 | ||
Not mentioned | 9 (9.5%) | 86 (90.5%) | 0.55 |
| |
Women remembered LNMP | Yes | 13 (16.9%) | 64 (83.1%) | 1.1 |
0.84 |
No | 49 (16%) | 258 (84%) | 1 | ||
Cervical dilatation | Fully dilated | 28 (23.7%) | 90 (76.3%) | 1 | |
Not Fully dilated | 34 (12.8%) | 232 (87.2%) | 0.47 |
| |
Condition of membrane | Intact | 9 (5.8%) | 146 (94.2%) | 1 | |
Ruptured | 53 (23.1%) | 176 (76.9%) | 4.89 |
| |
Time duration of membrane rupture | <8 hours | 37 (20.3%) | 145 (79.7%) | 1 | |
≥8 hours | 15 (31.9%) | 32 (68.1%) | 1.84 |
| |
Neonatal birth weight | <2500 gm | 23 (43.4%) | 30 (56.6%) | 5.51 |
|
2500–3500 gm | 32 (12.2%) | 230 (87.8%) | 1 | ||
>3500 gm | 7 (10.1%) | 62 (89.9%) | 0.81 |
0.64 | |
|
|||||
Mode of delivery | Cs | 8 (11.9%) | 59 (88.1%) | 0.66 |
0.31 |
Vaginal delivery | 54 (17%) | 263 (83%) | 1 | ||
Gestational age by fundal height | <37 | 14 (19.7%) | 57 (80.3%) | 0.86 |
0.86 |
37–42 | 33 (14.2%) | 200 (85.8%) | 0.6 |
0.51 | |
>42 | 2 (22.2%) | 7 (77.8%) | 1 |
Mothers of age 35 years and above were 2.62 times more likely to have bad fetal outcome within 5 minutes in singleton breech delivery than mothers within 25–29 years age groups. Those mothers with non-fully dilated cervix were 52% less likely to have bad fetal outcome within 5 minutes in singleton breech delivery when compared with mothers with fully dilated cervix. Mothers with ruptured membrane were nearly five times more likely to have bad fetal outcome within 5 minutes in singleton breech delivery than mothers with intact membrane. Neonates with <2500 gm born from singleton breech presentation were 6.77 times more likely to have bad fetal outcome within 5 minutes when compared with neonatal birth weight of 2500–3500 gm (see Table
Factors associated with perinatal outcome of breech delivery in Wolisso Hospital, 2013–2015.
Variables | Label | Fetal outcome | COR 95% CI | AOR 95% CI |
|
|
---|---|---|---|---|---|---|
Died | alive | |||||
Age | 19 or below | 4 (18.2%) | 18 (81.8%) | 1.2 |
2.66 |
0.15 |
20–24 | 10 (12%) | 73 (88%) | 0.74 |
0.58 |
0.24 | |
25–29 | 22 (15.6%) | 119 (84.4%) | 1 | 1 | ||
30–34 | 10 (14.9%) | 57 (85.1) | 0.95 |
1.45 |
0.42 | |
35 or above | 16 (22.5%) | 55 (77.5%) | 1.57 |
2.62 |
|
|
|
||||||
Residence | Urban | 2 (4%) | 48 (96%) | 0.19 |
0.22 |
0.052 |
Rural | 60 (18%) | 274 (82%) | 1 | 1 | ||
|
||||||
Cervical dilatation | Fully dilated | 28 (23.7%) | 90 (76.3%) | 1 | 1 | |
Not Fully dilated | 34 (12.8%) | 232 (87.2%) | 0.47 |
0.48 |
|
|
|
||||||
Condition of membrane | Intact | 9 (5.8%) | 146 (94.2%) | 1 | 1 | |
Ruptured | 53 (23.1%) | 176 (76.9%) | 4.89 |
5.11 |
|
|
|
||||||
Neonatal birth weight | <2500 gm | 23 (43.4%) | 30 (56.6%) | 5.51 |
6.77 |
|
2500–3500 gm | 32 (12.2%) | 230 (87.8%) | 1 | 1 | ||
>3500 gm | 7 (10.1%) | 62 (89.9%) | 0.81 |
0.78 |
0.598 |
This study assessed prevalence and perinatal bad outcome (death) of singleton breech delivery. This study showed that the prevalence of singleton breech delivery was 3.8%; overall it is comparable with worldwide incidence of 3-4%. This study found that the prevalence of fetal bad outcome (death) in singleton breech delivery was 16.1% with 95% CI: 13, 20.3. This study is in line with study conducted in University Teaching Hospital in Eastern Nigeria whose prevalence was 18.9% [
In this study the perinatal mortality rate is 161 per 1000 term breech presentations. It is higher than study done in ACOG committee; perinatal mortality rate for breech delivery was 66 per 1000 deliveries [
This study revealed that advanced age (≥35 years) of mothers in singleton breech delivery has positive association with fetal death until five minutes of delivery. This finding was in agreement with the study findings of the study conducted in London [
In this study those mothers with non-fully dilated cervix have slight protective effect on adverse perinatal outcomes as compared to fully dilated cervix. This finding was similar to the study finding conducted in Siriraj Hospital [
In this study neonates with <2500 gm born from singleton breech presentation were significantly associated with adverse birth outcomes, consistent with this study conducted in Belgium [
The limitation of the study is that since the study was facility based review, drawing inferences to the wider community can be difficult. The study did not show long-term complications.
In this study entrapment of head, birth asphyxia, and prolapsed cord were the most common causes of perinatal mortality. Factors such as fetal weight <2500 gm, mothers of age 35 years and above, those mothers being with non-fully dilated cervix, and mothers with ruptured membrane were significantly associated with increased perinatal mortality.
Perinatal and intrapartum monitoring and evaluation for fetal presentation, weight, wellbeing, and other parameters must be performed.
Obstetricians, midwives, and other health care personnel conducting deliveries should receive a continuous medical education to be updated on how to conduct vaginal breech deliveries and how to resuscitate asphyxiated newborn.
Professionals should manage breech presentation as soon as possible when labour starts to reduce delays to improve fetal outcome.
Antenatal care
Odds ratio
Relative risk
Confidence interval
External cephalic version
Maternal and child health
Saint
Premature rupture of membrane
Statistical Package for Social Science
Central nervous system
Caesarean section
Intrauterine fetal death
Small for gestational age
Neonatal intensive care unit.
The data was collected by review of the registration books using structured checklists.
The ethical clearance was obtained from Jimma University, College of Health Sciences Ethical Review Board. Formal letter was written from the Ethical Review Committee of Jimma University to Wolisso St. Luke catholic hospital, medical director office, to get permission.
All authors, institutions, and individuals listed here agreed to be listed and acknowledged. Confidentiality of the information was also assured and collected anonymously.
The authors declare that they have no conflicts of interest.
Temesgen Debero Mere designed study, analyzed data, and interpreted the result of the study. Tilahun Beyene Handiso analyzed data, interpreted the result, approved and recommended the study for publication, and prepared manuscript. Abera Beyamo Mekiso analyzed data and interpreted the result of the study. Markos Selamu Jifar contributed to analysis and manuscript writing. Shabeza Aliye Ibrahim contributed to conducting statistical analysis. Temesgen Debero Mere, Tilahun Beyene Handiso, and Abera Beyamo Mekiso contributed equally. Markos Selamu Jifar, Shabeza Aliye Ibrahim, and Degefe Tadele Bilato are second authors.
The authors sincerely thank Jimma University for giving them this opportunity and for funding this study. They would like to extend their genuine thanks to their advisors for their unreserved guidance and comments for this thesis development throughout preparation and completion. They would like also to express their appreciation for Wolisso Hospital administrative, labour ward staff, data collectors, and supervisor for giving relevant information and cooperating for collection of data.