The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20

Vaginal breech delivery at term and neonatal

morbidity and mortality – a population-based
cohort study in Sweden

C. Ekéus, M. Norman, K. Åberg, S. Winberg, K. Stolt & A. Aronsson

To cite this article: C. Ekéus, M. Norman, K. Åberg, S. Winberg, K. Stolt & A. Aronsson
(2017): Vaginal breech delivery at term and neonatal morbidity and mortality – a population-
based cohort study in Sweden, The Journal of Maternal-Fetal & Neonatal Medicine, DOI:
10.1080/14767058.2017.1378328

To link to this article: http://dx.doi.org/10.1080/14767058.2017.1378328

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 Vaginal breech delivery at term and neonatal morbidity and mortality – a
population-based cohort study in Sweden

Ekéus C1, Norman M2,4, Åberg K1, Winberg S3, Stolt K1, Aronsson A4

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1 Department of Women’s and Children’s Health, Division of Reproductive Health,
Karolinska Institutet, Stockholm, Sweden
2 Department of Clinical Science, Intervention and Technology, Karolinska Institutet,
Stockholm, Sweden
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3BB Stockholm, Danderyd Hospital, Sweden
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4Karolinska University Hospital, Stockholm, Sweden
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Correspondence: C Ekéus, Division of Reproductive Health, Institution of Women´s and

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Children´s Health, Retzius Väg 13, S-171 77 Stockholm, Sweden. Email:

Cecilia.ekeus@ki.se
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Running headline: Neonatal complications in vaginal breech delivery

 Disclosures of interest
None.

Keywords

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Breech presentation, mode of delivery, intracranial hemorrhage, brachial plexus injury,
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neonatal mortality

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Abbreviations
AOR, adjusted odds ratio; BMI, body mass index; CI, confidence interval; OR, odds ratio;
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CS, cesarean section; ICH, intracranial hemorrhage; SMBR, Swedish Medical Birth Register
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Key message
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Vaginal breech delivery is associated with increased risk for severe neonatal complications.

Funding
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The study was funded by grants from Karolinska Institutet.

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 Abstract

Introduction The routine to deliver almost all term breech cases by elective CS has continued
to be debated due to the risk of maternal and neonatal complications. The aims of the study
were 1) to investigate if mode of delivery impacts on the risk of morbidity and mortality
among term infants in breech presentation and 2) to compare the rates of severe neonatal
complications and mortality in relation to presentation and mode of delivery.

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Methods This population-based cohort study used data from the Swedish Medical Birth
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Register. All women (and their newborn infants) with singleton pregnancies who gave birth
at term to an infant in breech (n=27 357) or cephalic presentation (n=837 494) between 2001
and 2012 were included. Births with vacuum extraction and induced labors were excluded, as
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well as antepartum stillbirths, births with infants diagnosed with congenital malformations
and multiple births.

Results The rates of neonatal complications and mortality were higher among infants born in
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vaginal breech compared to the vaginal cephalic group. On the other hand, after CS the rates
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of all neonatal complications under study and neonatal mortality were lower among infants in
breech presentation than in those in cephalic presentation. After adjustment for confounders,
infants delivered in vaginal breech had 23.8 times higher odds ratio for brachial plexus injury,
13.3 times higher odds ratio for Apgar score <7 at 5 min, 6.7 times higher odds of ICH or
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convulsions and 7.6 higher odds ratio for perinatal mortality than those delivered by elective
CS.
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Conclusion Despite a probable selection of women who before-hand were considered at low
risk and therefore could be recommended vaginal breech delivery, infants delivered in vaginal
breech faced substantially increased risks of severe neonatal complications compared with
infants in breech presentations delivered by elective CS.
 Introduction

In settings where cesarean section is available, the rate of term breech vaginal delivery has
decreased significantly after the publication of the Term Breech Trial in 2000 [1]. In the latest
systematic review [2], the authors reported a reduced (relative risk 0.29; 95% CI 0.10 to 0.86)
perinatal or neonatal mortality among singleton infants delivered by a planned cesarean
section (CS) compared with those planned to be delivered vaginally. Severe neonatal
morbidity was also found to be lower after CS than after vaginal breech in settings with low
perinatal mortality (but not in high mortality settings most likely due to competing outcomes).
On the other hand, at the two-year-follow-up, there were no group differences in the

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combined outcome death or neurodevelopmental delay and maternal outcomes were also
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similar. In fact, more infants who had been allocated to planned CS had medical problems at

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two years [2].

In Sweden the proportion of CSs in singleton breech presentations increased from 14.3% in
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year 1973 to 62% in 1990, and 74% in 1999. After the publication of the Term Breech Trial
[1], the CS-rate for breech presentations increased further. Since 2003, more than 90% of the
women with fetuses in breech position give birth by CS in Sweden [3]. However, national
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data cannot show how many of these CSs that were elective and how many that were
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emergency CSs after onset of labor.

Recommending CS without unambiguous evidence is of major concern due to increased risks

of short-term maternal complications (bleeding, infection, thromboembolism, organ injuries
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and re-operations) and abnormal placentation, obstetric hysterectomy and uterine scar rupture
in subsequent pregnancies [4]. In addition, recent studies indicate that elective CS is
associated with aberrant short-term immune responses in the newborn infant, possibly
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explaining why children and adults born with elective CS exhibit an increased risk of
developing immune diseases [5].

The routine to deliver all term breech cases by elective CS has therefore continued to be
debated. Some researchers suggest that vaginal delivery could be as safe as an elective CS in
selected populations [6,7,8], given that strict criteria are met before and during labor. A study
from Norway concluded that vaginal breech delivery at term constitute a significantly
increased risk of adverse neonatal outcomes. Still, the authors do not recommend planned CS
due to the increased risk of complications of cesarean delivery in subsequent deliveries [9]. In
contrast, other researchers argue that the risk of neonatal complications during vaginal breech
birth is unacceptably high [10,11,12].
 There are only three RTCs that have investigated neonatal outcomes in term breech, by mode
of delivery [1, 13, 14]. Two out of these are old, performed in the 1980-s at one center only,
in the USA. The third RCT; the Term Breech Trial (TBT) was published in the year 2000 and
included a total of 2 083 women from 121 centers in 26 countries. The most recent Cochrane
review [2] on planned cesarean section for term breech delivery included a total of 2,396
women with a fetus in breech presentation. Only 55% of those allocated to a planned vaginal
delivery actually gave birth vaginally raising concern of an underestimation of the true risk
with breech vaginal birth. In addition, there were problems with the methodological design of
the studies as well as systematic errors and the evidence according to GRADE were mostly

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low.

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To be able to study rare but severe complications and to add further support or reject a
continued recommendation of elective CSs in breech delivery, a more contemporary
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population-based study on neonatal outcome after all 27 357 term breech deliveries in Sweden
between 2001 and 2012 is likely to be helpful. Accordingly, the aims of our study were 1) to
investigate if mode of delivery impacts on the risk of morbidity and mortality among term
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infants in breech presentation and 2) to compare the rates of severe neonatal complications
and mortality in relation to presentation and mode of delivery.
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Material and methods

The study was based on data from the Swedish Medical Birth Register (SMBR) held by the
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Swedish National Board of Health and Welfare. The SMBR covers approximately 99 percent
of all births in Sweden and includes prospectively collected information on maternal
characteristics, reproductive history, pregnancy, delivery and infant outcome in the neonatal
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period.

During the period 2001-2012, there were 1 083 683 term births (37+0 - 41+6 gestational
weeks) in Sweden. After the exclusion of multiple births, antepartum stillbirths, births with
congenital malformations, induced labors and births with vacuum extraction, the final cohort
included 864 851 deliveries including elective cesarean sections, unassisted vaginal deliveries
(VD), or emergency cesarean sections.

Information on maternal age, height and body mass index (BMI) was collected. BMI was
categorized into underweight (below 18.5 kg/m2), normal (18.5-24.9 kg/m2), overweight
(25-29.9m2), obese (> 29.9 kg/m2), or missing. Maternal age and height were categorized
 according to Table 1. Parity was categorized as primi- or multiparity. Gestational age was
recorded in weeks based on ultrasound dating of the pregnancy, routinely carried out at
around 17-18 postmenstrual weeks in 97-98% of all pregnant women, and categorized into
gestational week 37-38 or39-41 Infant birthweight was divided into < 3000 gram 3000-3999g
4000-4499g, or >4500g.

Exposure variables
Mode of delivery was categorized as unassisted vaginal delivery, unplanned CS (classified as
cesarean section performed after onset of labor) or elective CS.

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Outcomevariables

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Data on Apgar score <7 at five minutes was collected from the SMBR. Neonatal diagnoses
were identified in the register, using the diagnostic codes classified according to International
Classification of Diseases (ICD), Tenth revision (1997 and onwards). The following
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diagnoses were assessed; convulsions of the newborn (P90), intracranial hemorrhage,
including both intracranial laceration and hemorrhage due to birth injury (P10) and
intracranial non-traumatic hemorrhage of fetus and newborn (P52), and brachial plexus
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injury (P14.0-3) Data on intrapartum stillbirth and neonatal mortality, categorized into early
death; days 0-6 and late; during days 7-27, were also collected from the SMBR.
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Statistical analyses
Frequencies and proportions were used to describe the study population. To study the
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association between mode of delivery and neonatal outcome among infants in breech
presentation, binary logistic regression analysis was used. In the first model we calculated
crude odds ratios (ORs) and 95 % confidence intervals (CIs). In the second model we adjusted
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for possible confounders; parity, year of birth, gestational age, infant birth weight and SGA
newborns, (small for gestational age newborns, defined as a weight equal to or below -2SD
(-22 %) for the gestational age). Statistical analysis was undertaken using SPSS Statistics
22.

Ethical approval for the study was obtained by the Regional Ethical Review Board in
Stockholm, Dnr 2016/2208-32.

Results
During the study period there were 864 851 term singleton births without fetal malformations,
of which 27 357 (3.2%) were in breech presentation. Altogether 1755 (6.4%) of the infants in
 breech presentations were born vaginally while 23.3% were delivered by unplanned CS and
70.2% by an elective CS. The rate of vaginal breech delivery decreased from 10.1% in 2001
to 6.4% in 2012 (figure 1).

Maternal age, height and BMI did only differ slightly with fetal presentation, but 64% of the
women in the breech group were primiparas compared with 36% in the cephalic group. A
higher proportion, 58% of the infant in breech presentation were born in gestational week
37-38, compared with 20% of those in cephalic presentation. One of five infants in the breech
group and one of ten in the cephalic group had a birthweight below 3000 gram. Moreover, the
rate of SGA was twice more common among infants in the breech than the cephalic group,

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2.3% vs 1.4% respectively (Table1).

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Table 2 shows crude and adjusted odds ratios for the neonatal complications among infants in
breech presentation by mode of delivery, with elective CS as the reference group. Here, we
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present convulsions or intracranial hemorrhage (ICH) as one composite outcome and
intrapartum death or neonatal death as another composite. After adjustment for year of birth,
parity, gestational age and infant birthweight and SGA, infants born after a vaginal breech
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delivery had 23.8 times higher odds for brachial plexus injury, 13.3 times higher odds for
Apgar score <7 at 5 min and 6.7 times higher odds of ICH or convulsions and 7.6 times
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higher odds of perinatal mortality compared with those delivered by an elective CS.

Table 3 shows the rate (1/1000) of neonatal complications as well as intrapartum and neonatal
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mortality in relation to fetal presentation and mode of delivery. The rates of all neonatal
complications were higher among infants born in vaginal breech than among those in the
vaginal cephalic group . For instance, the rate of Low Apgar score was 49.6/1000 in the
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vaginal breech group compared with 3.4 in the vaginal cephalic group, and the rate of brachial
plexus injury was 6.3 and 1.4 respectively for infants in the vaginal breech and the vaginal
cephalic group. The rates of all neonatal complications as well as intrapartum death and early
neonatal mortality was lower among infants in breech presentation who were delivered by
unplanned or elective CS than in those in cephalic presentation delivered by CSs. Two infants
(1.1/1000) in the breech vaginal group died during labor. The corresponding rate was 0.1
among infants in the cephalic vaginal group. Infants born in breech vaginal delivery were
also more likely to die in the neonatal period than infants in cephalic presentations - 2.8/1000
infants in the vaginal breech group died 0-6 days after birth compared with 0.1 in the vaginal
cephalic group.
 Discussion
Since only a minority of women with fetuses in breech presentation gives birth vaginally in
Sweden, we hypothesized that they represented a well-selected population with
uncomplicated pregnancies and that the outcome of their infants would be similar or close to
those delivered by elective CS. However, the main finding of the present study was that these
allegedly low-risk breech vaginal deliveries were associated with manifold increased risks of
severe neonatal morbidity and mortality compared with those delivered by elective or
unplanned CS. Our study thereby supports the evidence from previous RCT’s and other more
recent smaller observational studies [15].

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The outcomes we studied are clinically relevant because low Apgar scores, intracranial

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hemorrhages and convulsions can be precursors to long-term physical and neurological
disabilities such as cerebral palsy, epilepsy, and developmental delay. Brachial plexus injury,
caused by excessive, forceful pulling of the infant arm during vaginal breech delivery, can
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cause permanent palsies [16]. In vaginal breech delivery, there is a risk of intrapartum
asphyxia due to cord compression and decreased circulation during the second stage of labor.
The risk of asphyxia depends on the length of the second stage of labor, and is especially high
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after the fetal umbilicus has past the perineum [12,17]. A retrospective observational study
from Helsinki examining risk factors and outcomes in “well-selected” vaginal breech
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deliveries, demonstrated that a second stage of labor <40 minutes protected against adverse
neonatal outcomes [18]). Furthermore, the after-coming head can be trapped and the head
might need to be delivered with forceps [19]. Entrapment of the after-coming head can be a
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result of an incompletely dilated cervix and a fetal head that did not have the time to mould to
the maternal pelvis, which significantly increases the risk of asphyxia [20].
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The significantly increased odd ratios for these rare but severe complications might partly be
attributed to that some vaginal breech births were undetected until second stage of labor.
Since the safety of a vaginal breech birth is dependent on a careful selection process before
onset of labor, cases in which breech presentation run undetected until start of labor challenge
operator skills and intrapartum management with less time for preparation and higher risk of
suboptimal obstetrical care [19]. Few studies have been published on mortality in breech
delivery. A recent Norwegian cohort study including 16 700 breech deliveries found a higher
risk for neonatal mortality in planned vaginal breech deliveries than in planned caesarean
deliveries, which is consistent with our results and the results of the TBT study [21].

The strengths of this study include the large and contemporary study population covering all
 breech births in Sweden during a period of twelve years, and the high quality of the registers,
making it possible to analyze rare diagnoses and unusual events, such as neonatal ICH and
intrapartum stillbirth. collected prospectively and independently from one another, thus
minimizing various types of bias (e.g. selection and recall bias). Moreover, the exclusion of
infants with different kinds of malformations increased the internal validity of the relationship
between fetal presentation, mode of delivery and neonatal complications.

The major limitation of this study is the lack of detailed information about the deliveries and
the decisions leading to the choice of method for delivery. For instance, data from the SMBR
cannot tell whether a vaginal breech delivery was planned as a vaginal birth or not, or if the

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breech presentation was undiagnosed until established labor. Cases of undiagnosed breech

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presentations could lead to an overestimation of neonatal complications among infants in the
breech vaginal group. Nor did we have information about at what stage of labor an unplanned
CS was performed. Thus, an unplanned CS might be due to complications occurring during a
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planned breech delivery or due to an earlier onset of labor than expected for women that was
planned for an elective CS. In addition, these register data do not include information of cause
of death, neither for intrapartum nor neonatal deaths. Therefore, it is not possible to tell if
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death was related to, or caused by, complications that occurred before, during or after labor,
or if it was related to the mode of delivery.
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Moreover, imaging of the neonatal brain for intracranial hemorrhage was performed on
clinical indications in all cases and there was no screening—general or selective based on risk
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factors of asymptomatic infants. Accordingly, detection bias with underestimation of smaller

intracranial hemorrhages cannot be excluded, and a neonatal diagnosis of intracranial
hemorrhage in the medical birth register most likely represents the most severe degrees of
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such a complication. Finally, although recent observational data suggest increased short and
longer term risks for adverse outcome in vaginal breech deliveries occurring also before term
[22] this study as well as previous RCTs were limited to deliveries at term.

Conclusions
Compared with elective CS, vaginal breech delivery is associated with increased risk of
severe neonatal complications including ICH, convulsions, low Apgar score, brachial plexus
injury and intrapartum or neonatal death. Although causality could not be established in this
observational study, it is important to be aware of the increased risk in order to give
evidence-based information about benefits and risks about vaginal breech delivery.
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caesarean section versus planned vaginal birth for breech presentation at term: a
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 Table 1. Mode of delivery, maternal factors, gestational age and infant
birthweight by cephalic or breech presentation of the fetus at term
Total Cephalic Breech
N=864 851 N=837 494 N= 27 357
N (%) (%)
Mode of delivery
Vaginal 732 562 87.3 6.4
Unplanned CS 52 574 5.5 23.3
Elective CS 79 715 7.2 70.2
Maternal age (years)
14–19 14 841 1.7 1.1
20–29 370 485 42.9 40.1
30–34 303 696 35.1 36.5
35–49 175 780 20.3 22.3
Missing 49 .0 .0

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Maternal height (cm)
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130–155 37 596 4.4 4.1

156–160 118 813 13.7 13.6

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161–169 396 731 45.9 45.6
≥ 170 265 702 30.7 31.3
Missning 46 009 5.3 5.5
Maternal BMI
Underweight 13 470 1.5 1.8
Normal
Overweight
Obese
317 382
124 299
51 773
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36.7
14.4
6.0
36.3
13.4
5.8
Missing 357 927 41.3 42.6
Gestational age (weeks)
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37–38 181 851 19.8 58.1
39–41 683 000 80.2 41.9
Parity
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Primipara 347 382 39.4 63.7

Multipara 517 469 60.6 36.3
Birth weight (g)
<3000 87 749 9.8 21.6
3000-4000 621 160 71.9 69.7
4001-4500 126 938 14.9 7.2
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>4500 27 390 3.2 1.4

Missing 1 614 .2 .1
SGA 12 559 1.4 2.3
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Table 2.Frequencies and crude and adjusted Odds Ratios for low Apgar score, intracranial hemorrhage
and/or convulsions and neonatal mortality (including intrapartum death). Breech delivery only.

N Breech n 1/1 000 Unadjusted OR, Adjusted OR

presentation (95% CI)
Apgar score <7 at 5 min

Elective CS 19 215 81 4.2 1.0 1.0

Vaginal 1 755 87 49.6 12.32 (9.07-16.74) 13.32 (9.61-18.47)
Unplanned CS 6 387 40 6.3 1.49 (1.02-2.18) 1.52 (1.04-2.23)
Total 27 357 208 7.6
Intracranial hemorrhages or
convulsions
Elective CS 19 215 17 0.9 1.0 1.0
Vaginal 1 755 10 5.7 6.47 (2.96-14.15) 6.75 (2.96-15.40)
 Unplanned CS 6 387 8 1.3 1.42 (0.61-3.28) 1.41 (0.61-3.28)
Total 27 357 35 1.3
Brachial plexus
injury
Elective CS 19 215 5 0.3 1.0 1.0
Vaginal 1 755 11 6.3 24.2 (8.4-69.8) 23.8 (7.77-72.89)
Unplanned CS 6 387 1 0.2 0.60 (0.07-5.15) 0.58 (0.07-4.94)
Total 27 357 17 0.6
Intrapartum or Neonatal
mortality
Elective CS 19 215 11 0.6 1.0 1.0
Vaginal 1 755 8 4.6 7.99 (3.21-19.90) 7.61 (2.88-20.10)
Unplanned CS 6 387 3 0.5 0.82 (0.23-2.94) 0.84 (0.23-3.04)
Total 27 357 22 0.8

Adjusted for year of birth, parity, gestational age and infant birthweight and SGA

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 Table 3. Frequencies and crude rates (1/1000 ) of neonatal complications and mortality by fetal
presentation and mode of delivery

Neonatal CEPHALIC BREECH

outcome

Vaginal Unplanned Elective CS Vaginal Unplanned Elective CS

CS CS

N n 1/1000 n 1/1000 n 1/1000 n 1/1000 n 1/1000 n 1/1000

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Apgar score <7

4784 2481 (3.4) 1495 (32.4) 600 (9.9) 87 (49.6) 40 (6.3) 81 (4.2)
at 5 min

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Convulsions 840 472 (0.6) 220 (4.8) 117 (1.9) 8 (4.6) 8 (1.3) 15 (0.8)

Intracranial

hemorrhage
203 146 (0.2) 28 (0.6) EP
22 (0.4) 3 (1.7) 2 (0.3) 2 (0.1)
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Brachial plexus 1035 996 (1.4) 13 (0.3) 9 (0.1) 11 (6.3) 1 (0.2) 5 (0.3)

injury
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Intrapartum 99 45 (0.1) 45 (1.0) 7 (0.1) 2 (1.1) 0 0 0 0

death
6
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Death days 0-6 197 86 (0.1) 66 (1.4) 32 (0.5) 5 (2.8) 2 (0.3) (0.3)

1 5 (0.3)
Death days 7-27 123 83 (0.1) 19 (0.4) 14 (0.2) 1 (0.6) (0.2)
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AC
Figure 1: Mode of delivery in breech position between 2001-12
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EP
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