Management of breech presentation at term: a retrospective cohort study of 10 years of experience.

OBJECTIVE: To evaluate the impact of management of childbirth (external cephalic version (ECV) plus planned vaginal delivery (PVD)) of breech presentation at term (⩾37 weeks of gestation). STUDY DESIGN: This retrospective cohort study was based on data collected of singleton breech presentations at term in the Obstetrics and Gynaecology Service, Cruces University Hospital (Biscay, Spain), from January 2003 to December 2012. RESULT: We attended 2377 singleton breech pregnancies at term. We attended 1684 singleton breech term deliveries, attempting vaginal delivery after selection in 52.9% of cases and were successful in 57.5% of attempts. A total of 1360 ECV were attempted, with a success rate of 50.3% of those attempted. The use of ECV has decreased the rate of breech presentation at delivery by 39.0%, the rate of breech presentation as a caesarean section (CS) indication by 47.1% (CS due to breech presentation/total of CS) and the rate of CS for breech presentation out of the total of deliveries by 39.1% (CS due to breech presentation/total of deliveries). Early postnatal parameters (5-min Apgar score, umbilical cord arterial pH and acid-base analysis) were significantly lower following PVD compared with planned CS for breech presentation. However, we did not find any differences in the rates of admissions to the neonatal unit or neonatal mortality. CONCLUSION: Management of breech presentation with a protocol that includes ECV, careful selection criteria and active management of vaginal delivery achieve a great decrease in the rate of CS for breech presentation.

Is external cephalic version at term contraindicated in previous caesarean section? A prospective comparative cohort study.

OBJECTIVE: To determine if external cephalic version (ECV) can be performed with safety and efficacy in women with previous caesarean section. DESIGN: Prospective comparative cohort study. SETTING: Cruces University Hospital (Spain). POPULATION: Single pregnancy with breech presentation at term. METHODS: We compared 70 ECV performed in women with previous caesarean section with 387 ECV performed in multiparous women (March 2002 to June 2012). MAIN OUTCOME MEASURES: Success rate, complications of the ECV and caesarean section rate. RESULTS: The success rate of ECV in women after previous caesarean section was 67.1% versus 66.1% in multiparous women (P = 0.87). The logistic regression analysis confirmed this result (odds ratio 0.93, 95% CI 0.52-1.68; P = 0.82) adjusted by the variables associated with success of ECV. There were no complications in the previous caesarean section cohort. The vaginal delivery rate in the previous caesarean section cohort was 52.8% versus 74.9% in the multiparous cohort (P < 0.01). There were no cases of uterine rupture. CONCLUSION: Based on our data, we conclude that complications are uncommon with ECV in women with previous caesarean section, with a success rate comparable to that of multiparous women. Uterine scar should not be considered a contraindication and ECV should be offered to women with previous caesarean section with breech presentation at term.

Inserción velamentosa de cordón umbilical. Rotura intraparto / Velamentous insertion of umbilical cord. Intrapartum rupture

La inserción velamentosa de cordón es aquella situación en la que los vasos umbilicales se separan en las membranas a cierta distancia del margen placentario, que alcanzan rodeados sólo por un pliegue del amnios. Su desgarro o rotura suponen una urgencia obstétrica. Ante la sospecha diagnóstica se debe realizar una extracción fetal inmediata. Presentamos un caso de rotura intraparto de vasos umbilicales en una inserción velamentosa de cordón, con buen resultado perinatal (AU)

Umbilical cord insertion in the placenta is considered normal if it occurs inside the placental tissue. When this insertion is just in the edge (marginal) or beyond (velamentous), the umbilical cord is connected to the placenta only through its blood vessels, coated by the amniotic membrane, without the protection of Wharton's gelatin. Because of this lack of protection, the umbilical vessels may tear before or during delivery, provoking an obstetric emergency. We present a case of velamentous insertion of umbilical vessels and rupture during delivery with a favorable perinatal outcome (AU)

Conversion of atrial fibrillation with ajmaline in a pregnant woman with Wolff-Parkinson-White syndrome.

Pregnancy is related to an increased frequency of arrhythmias in asymptomatic patients with Wolff-Parkinson-White syndrome, which might lead to sudden death. A 40-year-old woman, with Wolff-Parkinson-White syndrome which was not diagnosed until pregnancy, presented in the 34th week with an atrial fibrillation, with high risk criteria for ventricular fibrillation. Intravenous ajmaline was given to convert the tachyarrhythmia to sinus rhythm. We obtained an excellent maternal control with no maternal or fetal adverse effects.

Early neonatal sudden death or near death syndrome. An epidemiological study of 29 cases.

Early neonatal sudden death syndrome (SIDS) is a rare but well known disease entity. Between January 1975 and December 1991, 29 full-term newborn infants delivered in our maternity unit and, considered healthy at birth, suffered early SIDS (n = 15) or early apparent life threatening events (ALTE) (n = 14). Data from the whole population of live full-term infants born in our hospital during the past five years have been used as a reference (n = 27,841). The general rate of early SIDS was 0.14 per 1000 (15/107,263). Combining early ALTE cases, the overall rate was 0.27 per 1000 (29/107,263). A postmortem examination was performed for all infants who died (20/29): no cause of death could be determined, and we did not observe a single case with evident sequelae. There were 9 deaths (31%) within the first hour after delivery and 12 deaths occurred in the early morning hours (04:00-08:00; RR = 3.76; p = 0.0008). The lowest incidence was in the spring (RR = 0.21; p = 0.03). There was a tendency for an increased incidence during the weekend and the summer. No influence of sex, maternal age, gestational age, infant weight presentation, delivery, anesthesia or presence of meconium-stained fluid was found. In our opinion, SIDS can take place even during the first hour of life and it is not possible to predict when a baby might be affected. Pediatrically trained caregivers, close observation by the mother during the first few days and resuscitation facilities in maternity wards may be the most important preventive measures to reduce the risk of early SIDS and the consequences of ALTE in the early newborn period.

Delayed childbearing and pregnancy outcome.

This study is to analyze the effect of delayed childbearing on pregnancy outcome among nulliparous women. A hospital-based study was conducted with prospectively collected data from the computerized perinatal data base that includes information about all patients delivered in our Hospital. We studied 17,230 nulliparous women who were > or = 20 years of age with a singleton gestation delivered between 1987 and 1992. We assessed the rates of low birth weight (< 2500 g), preterm delivery (< 37 weeks), small for gestational age, perinatal death (> 500 g and 28 days of life), and selected complications of pregnancy and delivery (ante partum complications, meconium, labor abnormal fetal heart rate, cesarean section, breech presentation, Apgar score, umbilical cord-pH, and rates of neonatal admission). Compared with women aged 20-29 years, women aged > or = 35 years had no significantly higher odds ratio (OR) of low birth weight < 2500 g (OR = 1.3); preterm delivery < 37 weeks (OR = 1.2); small for gestational age (OR = 1.0); and perinatal death (OR = 1.7). In contrast, we found a significantly higher rates of specific antepartal complications (OR = 1.9); cesarean section (OR = 2.5); breech presentation (OR = 1.4); and higher rates of admission to the newborn intensive care unit (OR = 1.4); but excluding infants delivered before 37 weeks of gestation, we found no significantly higher odds ratio of neonatal admission (OR = 1.4). Delayed childbearing is associated with an increased risk of complications of pregnancy and delivery although neonatal outcomes were not appreciably different from those among infants of younger women.

Perinatal outcome of very low birthweight infants by mode of delivery.

In order to evaluate the influence of mode of delivery on perinatal morbidity and mortality in vertex infants weighing less than 1500 g (VLBW), we made a retrospective study of 152 singleton newborns, in vertex presentation, with a birthweight of less than 1500 g, delivered in the Cruces Hospital (Vizcaya, Spain), a major perinatal referral center, between 1 January 1987 and 31 December 1989. Twins and infants with lethal congenital anomalies or gross intrauterine growth deviations were excluded from the study (n = 71). Of the infants studied (n = 81), 37 were delivered by cesarean section (mean weight 1120 +/- 206 g, range: 680-1495 g) and 44 were delivered vaginally (mean weight 1029 +/- 283 g, range: 530-1475 g). The patients were divided into four groups: Group A: 500-749 g (n = 10); Group B: 750-999 g (n = 21); Group C: 1000-1249 g (n = 27); and Group D: 1250-1499 g (n = 23). The percentages of cesarean sections in each group were 10%, 42%, 66% and 39%, respectively. A comparison within each group of immediate perinatal outcome (Apgar score and umbilical vein cord pH), as well as mortality and sequelae up to 1 year of age did not yield any significant differences between cesarean and vaginal birth. We conclude that cesarean delivery does not appear to offer improved outcome over vaginal delivery in live births without congenital anomalies. For this reason, we believe that fetal weight should not be the only obstetrical variable considered when deciding whether or not to perform a cesarean section in these circumstances.

[Comparative study of peridural anesthesia with bupivacaine alone and combined with fentanyl during vaginal delivery]. / Estudio comparativo entre la anestesia peridural con bupivacaína sola o asociada a fentanilo durante el parto vaginal.

Two groups of primiparous women with single fetus in cephalic presentation were prospectively randomized at the end of pregnancy to receive epidural analgesia with 0.25% bupivacaine, either single (n = 102) or associated with 0.05 mg of phentanyl (n = 102). Phentanyl significantly reduces the period of development of analgesia and increases the interdose period. The quality of analgesia is significantly better when fentanyl is associated with bupivacaine. The evolution of delivery (dilatation and expulsion) and the perinatal results (cord pH and vitality of the newborn as assessed by the Apgar test) were similar in both groups. We conclude that the association of phentanyl with bupivacaine has advantages for epidural analgesia during delivery, as the quality of analgesia is improved, its duration is prolonged and there are no adverse effects on the evolution of delivery or on the newborn.