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ORIGINAL ARTICLE
Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 52-55

Breech deliveries in Usmanu Danfodiyo University Teaching Hospital Sokoto, Northwestern Nigeria: A 10-year review


Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital Sokoto, Sokoto, Nigeria

Date of Web Publication19-Jul-2013

Correspondence Address:
Karima Tunau
Usmanu Danfodiyo University Teaching Hospital Sokoto, No. 1 Hospital Road, PMB 2370, Sokoto
Nigeria
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DOI: 10.4103/1118-8561.115257

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  Abstract 

Background: Breech delivery is a major issue in obstetric practice mainly because of the high perinatal morbidity and mortality associated with it. The aims of the study are to determine the prevalence management and perinatal outcome of singleton breech deliveries in our center. Materials and Methods: A retrospective study involving 395 singleton breech deliveries out of 24,160 deliveries conducted at the Usmanu Danfodiyo University Teaching Hospital Sokoto, Sokoto, over a 10-year (2001-2010) period. Results: The prevalence rate of singleton breech delivery was 1.7%. Breech deliveries occurred more in the primigravidae. Most babies (69.1%) had vaginal delivery. There was a high caesarean section (CS) rate of 30.9%. Babies delivered by CS had better Apgar scores than those delivered through the vagina (P < 0.05). The perinatal mortality rate in breech deliveries (410/1000) was significantly higher than that (101.5/10000) in their cephalic counterparts (P < 0.05). Similarly, perinatal deaths were more common in unbooked than in booked patients (P < 0.05). Conclusion: Breech delivery was frequent in the study population. Singleton breech delivered by CS had better outcome than those who were delivered through the vagina.

Keywords: Outcome, prevalence, singleton breech delivery


How to cite this article:
Tunau K, Ahmed Y. Breech deliveries in Usmanu Danfodiyo University Teaching Hospital Sokoto, Northwestern Nigeria: A 10-year review. Sahel Med J 2013;16:52-5

How to cite this URL:
Tunau K, Ahmed Y. Breech deliveries in Usmanu Danfodiyo University Teaching Hospital Sokoto, Northwestern Nigeria: A 10-year review. Sahel Med J [serial online] 2013 [cited 2019 Sep 23];16:52-5. Available from: http://www.smjonline.org/text.asp?2013/16/2/52/115257


  Introduction Top


Breech presentation and breech deliveries have always evoked interest among obstetricians. [1] The optimum mode of delivery for breech fetuses is controversial. [2]

Breech is the most common malpresentation in pregnancy, occurring in 3-4% of the pregnancies at term. [2],[3],[4],[5] However, incidences as low as 1.4% [6] and as high as 5.7% [2] have been documented in Calabar and Ibadan, respectively. The incidence of breech presentation rises with a reduction in gestational age. [3],[4],[5]

At 34 weeks, the incidence is 6.8%, and up to 40% of the fetuses present by the breech at 20 weeks. [3] In Zaria, the preterm breeches constituted about 31% of all breech presentations. [7]

The options on the mode of delivery include external cephalic version (ECV) and cephalic delivery at term, assisted vaginal breech delivery (VBD), breech extraction (BE) and caesarean section (CS). [3] The controversies surrounding the best mode of delivery for breech fetuses were thought to have been resolved by the Term Breech Trial, [8] which concluded that CS was the best mode of delivery for a breech. However, subsequent studies have highlighted that most cases of neonatal death and morbidity in the Term Breech Trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies. [9],[10],[11] Besides, CS may not be applicable in all settings. [11]

VBD is safe where carefully selected criteria are applied antenatally. [3],[4],[5],[11] Furthermore, any other indication for CS should be excluded. In addition, presentation of a mother in advanced labor with no fetomaternal distress, even if CS was originally planned, may also warrant an assisted breech delivery. [3],[5] Bako et al. suggested that even an undiagnosed breech in labor may be an indication for VBD in carefully selected cases. [1],[2],[3] A planned delivery of the term breech has been shown to confer the best advantage in terms of perinatal outcome. [1],[8],[11],[12],[13],[14],[15],[16],[17],[18] Recent evidence suggests that a planned vaginal delivery where appropriate selection criteria are applied would give the same favorable fetomaternal outcome as a planned CS. [9],[10],[11] Besides, in developing countries like ours, despite the decline in the risks associated with CS, a policy of elective CS for all breech presentations may be counterproductive. [1] Apart from an unacceptable rise in CS rates that would occur, the maternal risks following an abdominal delivery are still higher than those following a vaginal delivery. [15],[16] Furthermore, high parity and the challenges of managing a scarred uterus in patients who may not avail themselves for future antenatal care has to be borne in mind in developing nations [14],[15],[16],[17],[18] It has also been noted that difficulty in delivery of the after coming head and birth injuries still occur during a caesarean delivery. [16],[17]

Perinatal mortality (PNM) is higher in breech infants than in their cephalic counterparts even after correcting for gestational age, birth weight and congenital anomalies. [3] It appears therefore that obstetric intervention will not eliminate all mortality and long-term morbidity associated with breech presentation.

The aims of the study are to determine the prevalence, management and outcome of breech deliveries in our center, a tertiary center in northwestern Nigeria.


  Materials and Methods Top


This is a retrospective review and analysis of data obtained from the case notes and labor ward records of all singleton breech deliveries at the Usmanu Danfodiyo University Teaching Hospital between 1 January 2001 and 31 December 2010. Pregnancies less than 28 weeks gestation and twin deliveries were excluded. Data extracted included maternal biodata, parity, booking status, gestational age at delivery, mode of delivery and fetal birth weight. The fetal outcome was measured by the Apgar scores at the 1 st and 5 th minutes of extrauterine life.

The data obtained were analyzed using the EP1-info statistical software version 7:2 of 2007. The chi square test was used to compare proportions where applicable. The level of significance was set at 5%.


  Results Top


A total of 24,160 deliveries were recorded during the study period. Of these, 417were singleton breech deliveries giving a prevalence rate of 1.7%. However, only 395 case notes had sufficient information for detailed analysis. Two hundred and forty-one patients (61.0%) were booked while 154 (39.0%) were unbooked for antenatal care. The age of the mothers ranged between 15 and 41 years, with a mean age of 26.9 ± 6.7 years. Parity ranged from 0 to 12, with a mode of Para 0. There were more breech deliveries in the primigravidae than in the grandmultiparae; however, there was no significant difference in perinatal outcome between the primigravidae and the grandmultiparae (34.2 vs. 22.6; P = 0.82).

Majority of the patients had vaginal delivery irrespective of booking status. The accouchers for the vaginal deliveries in all the booked patients were doctors. Babies who had 5 th minute Apgar scores of 7 and above were significantly higher in Caesarean than in vaginal deliveries (77.3 vs. 44.3%; P < 0.0001).

The main indications for emergency CS were failure to progress in labor (40%), premature rupture of membranes (38%) and eclampsia (16%).

There were 226 perinatal deaths, giving a PNM of 410.5/1000 deliveries, which was significantly higher than that (101.5/1000 deliveries) observed in singleton cephalic deliveries within the study period (P = 0.00001).

The parity distribution of mothers is shown in [Table 1].
Table 1: Parity distribution of mothers with singleton breech presentation

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[Table 2] shows the mode of delivery in breech presentation.
Table 2: Mode of delivery of breech presentation

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[Table 3] shows the Apgar score at 5 min compared with the mode of delivery.
Table 3: Mode of delivery versus 5th minute Apgar scores

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  Discussion Top


From this study, the incidence of breech delivery in Usmanu Danfodiyo University Teaching Hospital Sokoto is 1.7%. This is similar to the 1.4% reported from Calabar [19] and 1.9% reported from Jo. [20] It is however lower than the 2.6% in Ibadan, [21] 2.4% each in Ilesha [22] and Ile-Ife. [23]

The higher incidence of breech deliveries in the primigravidae (34.2%) observed in the current report has similarly been reported by Fawole et al. [21] This is probably due to the tense anterior abdominal wall that reduces the tendency of spontaneous version. [2],[21] Other studies have however observed a higher incidence in the grandmultiparea. [19],[20]

VBD was the most common mode of delivery (76.5%) in the current report. Most of the booked patients had successful assisted vaginal breech deliveries because they were carefully selected and had adequate antenatal preparation. This is in contrast to the unbooked patients who came late in labor and even recourse to CS at that point may not improve fetal outcome. Similar results have been reported in Calabar. [19] The CS rate of 30.9% in breech deliveries is thrice the overall CS rate of 10.3% in our center within the study period. Such high CS rates in breech deliveries have been observed in other centers. [1],[6],[21] Breech delivery is fraught with numerous complications; hence, the frequent recourse to CS. A CS may confer more benefit to the fetus where a vaginal delivery had not been planned. [8],[9],[11] However, in our community, like in many developing societies, women have a strong aversion to CS and an abdominal delivery is seen as a sign of reproductive failure. [1],[20]

Pride in family size and high parity are norms. As such, the inclination to abdominal delivery, especially in the younger age group, may be influenced by the practice and culture of our society without jeopardizing the fetomaternal well being. [16]

The PNM rate in breech deliveries in this study is very high (410/1000). This is about four times the PNM rate among singleton cephalic deliveries during the same period. Forty-five percent of the perinatal deaths were from the unbooked patients, despite their size being just 37% of the entire study population. Most of these patients had an unsupervised pregnancy and labor at home before presentation. These factors have been associated with increased maternal and fetal morbidity and mortality rates. [2]

The 5 th minute Apgar scores of babies born by CS (23%) were significantly better than those delivered by the vaginal route (P < 0.05). This is more so in the elective CS group, where it had already been adjudged that vaginal delivery was unsafe. Similar findings have been made by earlier workers. [1],[2],[17]


  Conclusion Top


In conclusion, this study has shown that breech deliveries were frequent among the primigravidae. The most common mode of delivery was the vaginal route, and this was planned in the booked patients. The short-term outcome appeared to be better in those delivered via CS than in those delivered vaginally. These findings however should be interpreted with caution as determinants of outcome and confounding factors are difficult to determine from this retrospective study.

Prospective studies are recommended to determine the most favorable management strategy of breech presentation in our setting.

 
  References Top

1.Onwudiegwu U, Okonofua FE. Caesarean section in the management of singleton breech deliveries. Trop J Obstet Gynaecol 1993;10:18-20.  Back to cited text no. 1
    
2.Olayemi A, Odukogbe A, Omigbodun A, Odeyemi AS. Effect of caesarean section on the perinatal outcome in singleton breech deliveries in Ibadan. Nig J Clin Pract 2002;5:41-4.  Back to cited text no. 2
    
3.Arulkumaran S. Malpresentation, malposition, cephelopelvic disproportion and obstetric procedures. In: Edmond K, editor. Dewhursts textbook of obstetric and gynaecology. 7 th edn, Vol. 24. USA: Blackwell Sci; 2007. p. 213-26.  Back to cited text no. 3
    
4.John CT, Okpani AO. Breech presentation. In: Kwawukume EY, Emuveyan EE, editors. Comprehensive obstetrics in the tropics. 1 st edn. Accra: Asante and Hittscher Print; 2002. p. 157-61.  Back to cited text no. 4
    
5.Thorpe Beeston JG. Management of breech presentation at term. In: Studd J, editor. Progress in obstetrics and gynaecology. Vol. 9, 13. Philadelphia: Church Livingstone; 1998. p. 87-100.  Back to cited text no. 5
    
6.Abasiattai AM, Bassey EA, Etuk SJ, Udoma EJ, Ekanem AD. Caesarean section in the management of singleton breech delivery in Calabar, Nigeria. Niger J Clin Pract 2006;9:22-5.  Back to cited text no. 6
[PUBMED]    
7.Emombolu J. The preterm breech delivery in Zaria, Northern Nigeria. Int J Gynaecol Obstet 1992;38:287-91.  Back to cited text no. 7
    
8.Hannah ME, Hannah WJ, Hewson SA, Hodne ED, Saigai S, Willan AR. For the term breech trail collaborative group. Planned caesarean section versus planned vaginal birth for breech presentation at term; a randomized multicentre trial. Lancet 2000;356:1375-83.  Back to cited text no. 8
    
9.Krause M. Geburtshilfe Z. The term breech trial: The rise and fall of a randomized controlled trial--a critical survey. Z Geburtshilfe Neonatol 2006;10:121-5.  Back to cited text no. 9
    
10.André B. Lalonde vaginal breech delivery guideline: The time has come. J Obstet Gynaecol Can 2009;31:483-4  Back to cited text no. 10
    
11.Kotaska A, Menticoglou S, Gagnon R. Vaginal delivery of breech presentation. SOGC Clinical Practice Guideline No. 226. J Obstet Gynaecol Can 2009;31:557-66.  Back to cited text no. 11
    
12.Bako AU, Audu LI. Undiagnosed breech in Zaria, Nigeria. J Obstet Gynaecol 2000;20:148-50.  Back to cited text no. 12
[PUBMED]    
13.Nwosu EC, Walkinshaw S, Chia P, Manasse PR, Atlay RD. Undiagnosed breech. Br J Obstet Gynaecol 1993;100:531-5.  Back to cited text no. 13
[PUBMED]    
14.Adeleye JA. A two year assessment of some aspects of breech delivery: Caesarean section in breech presentation and perinatal mortality at the University College Hospital, Ibadan, Nigeria. Trop J Obstet Gynaecol 1985;5:31-4.  Back to cited text no. 14
    
15.Jaiyesinmi RA, Ojo O. Caesarean section. In: Okonofua F, Odunsi K, editors. Contemporary obstetrics and gynaecology for developing countries. 1 st edn, Vol. 32. Benin: WHARC Benin; 2003. p. 592-619.  Back to cited text no. 15
    
16.Sobande AA. Pregnancy outcome in singleton term breeches from a referral hospital in Saudi Arabia. West Afr J Med 2003;1:38-41.  Back to cited text no. 16
    
17.Orji EO, Ajenifuja KO. Planned vaginal delivery version caesarean section for breech presentation in Ile-Ife, Nigeria. East Afr Med J 2003;80:589-91.  Back to cited text no. 17
[PUBMED]    
18.Schutte MF, Van Hamel OJ, van de Berg C, van de Pol A. Perinatal mortality in breech presentation as compared with vertex presentation in singleton pregnancies. An analysis based upon 57, 819 computer registered deliveries in the Netherlands. Eur J Obst Gynaecol Reprod Biol 1985;19:391-400.  Back to cited text no. 18
    
19.Abasiattai AM, Etuk SJ, Asuquo EJ, Ikiaki CO. Perinatal outcome following singleton vaginal breech delivery in the University of Calabar Teaching Hospital, Calabar. A 10-year review. Mary Slessor J Med 2004;4:81-5.  Back to cited text no. 19
    
20.Aisien AO, Lawson O. Outcome of term singleton breech deliveries in a tertiary health care centre. Trop . Obstet Gynaecol 2003;20:121-33.  Back to cited text no. 20
    
21.Fawole A, Adeyemi AS, Adewole IF, Omigbodun AO. A Ten year review of breech deliveries in Ibadan. Afri J Med Sci 2001;30 87-90.  Back to cited text no. 21
    
22.Fasubaa OB, Kuti O, Orji EO Ogunlola O, Shittu S. Outcome of singleton breech delivery in Wesley Guild Hospital Ilesha Nigeria. Trop J Obstet Gynaecol 2003;20:59-62.  Back to cited text no. 22
    
23.Shittu SA, Fasubaa OB, Dare FO, Ogunniyi OS. Five year review of breech presentation at Ile-Ife Nigeria. Trop J Obstet Gynaecol 2001;18:36.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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