Association of free maternal and fetal ropivacaine after epidural analgesia for intrapartum caesarean delivery: a prospective observational trial.

BACKGROUND: Ropivacaine is present in plasma in both protein-bound and free forms. The free form is responsible for the occurrence of toxic side effects. During obstetric epidural analgesia, free ropivacaine enters the fetal circulation depending on various factors. The aim of this study was to analyse a potential association between ropivacaine concentrations in maternal and fetal plasma and hence the extent of fetal exposure to ropivacaine. METHODS: In this prospective monocentre study, parturients who met the following criteria were included in the study: 1. epidural administration as part of obstetric anaesthesia, and 2. subsequent intrapartum caesarean delivery, which 3. was performed after an epidural bolus administration of ropivacaine within the existing epidural analgesia. Total and free ropivacaine concentrations were analysed in maternal blood at baseline, prior to epidural bolus administration for caesarean delivery, and in maternal and fetal (umbilical venous, oxygenated) blood at delivery. The results are presented as mean ±â€¯SD or median (25/75th percentile). RESULTS: We screened 128 parturients who went into labour at term and requested epidural analgesia, of whom 39 were ultimately included in the study. An intrapartum caesarean delivery was performed after the epidural application of 207 (166/276) mg ropivacaine during an epidural treatment period of 577 (360/1010) min. Total and free ropivacaine concentrations were 1402 ±â€¯357 ng/ml and 53 ±â€¯46 ng/ml, respectively, in maternal venous blood and 457 ±â€¯243 ng/ml and 43 ±â€¯27 ng/ml, respectively, in fetal blood. The maternal total and free ropivacaine concentrations were significantly correlated (r = 0.873; P < 0.0001). CONCLUSION: The results of the present study suggest that determining the concentration of free ropivacaine in maternal blood may be a feasible option for estimating neonatal exposure to ropivacaine.

Maternal and neonatal outcome after vaginal breech delivery at term after cesarean section - a prospective cohort study of the Frankfurt breech at term cohort (FRABAT).

OBJECTIVE: To compare the neonatal and maternal outcomes as well as the mode of delivery of intended vaginal breech deliveries in women with a prior cesarean section to primiparous patients. STUDY DESIGN: The prospective monocenter cohort study was conducted among 604 women who presented for an intended vaginal singleton breech delivery at term between January 2007 and December 2016. RESULTS: Out of 37 women with a prior cesarean 19 had a successful vaginal delivery. 344 of 567 primiparous women had a successful vaginal delivery. Neonatal morbidity and mortality as well as maternal outcome were not significantly different in successful vaginal deliveries of women with prior cesarean compared to primiparous patients. The cesarean section rate was not significantly higher in the group of women with a prior cesarean (49%) compared to the group of primipara (39%). CONCLUSION: A prior cesarean should not be taken as an exclusion criterion for a planned vaginal delivery out of a breech presentation at term. Large multicenter, case-controlled studies are necessary to implement international guidelines.

Deficient primary cilia in obese adipose-derived mesenchymal stem cells: obesity, a secondary ciliopathy?

Obesity alters the composition, structure and function of adipose tissue, characterized by chronic inflammation, insulin resistance and metabolic dysfunction. Adipose-derived mesenchymal stem cells (ASCs) are responsible for cell renewal, spontaneous repair and immunomodulation in adipose tissue. Increasing evidence highlights that ASCs are deficient in obesity, and the underlying mechanisms are not well understood. We have recently shown that obese ASCs have defective primary cilia, which are shortened and unable to properly respond to stimuli. Impaired cilia compromise ASC functions. This work suggests an intertwined connection of obesity, defective cilia and dysfunctional ASCs. We have here discussed the current data regarding defective cilia in various cell types in obesity. Based on these observations, we hypothesize that obesity, a systemic chronic metainflammation, could impair cilia in diverse ciliated cells, like pancreatic islet cells, stem cells and hypothalamic neurons, making these critical cells dysfunctional by shutting down their signal sensors and transducers. In this context, obesity may represent a secondary form of ciliopathy induced by obesity-related inflammation and metabolic dysfunction. Reactivation of ciliated cells might be an alternative strategy to combat obesity and its associated diseases.

[Physiological changes during pregnancy]. / Physiologische Veränderungen in der Schwangerschaft.

The physiological state of a woman experiences multiple changes in the body during pregnancy. These alterations could be of particular importance in the medical care of pregnant women. This review article highlights the physiological developments of various organ systems throughout gestation with a focus on endocrinology, the cardiovascular system, hematology, the respiratory system and water balance.

Insight into the development of obesity: functional alterations of adipose-derived mesenchymal stem cells.

Obesity is associated with a variety of disorders including cardiovascular diseases, diabetes mellitus and cancer. Obesity changes the composition and structure of adipose tissue, linked to pro-inflammatory environment, endocrine/metabolic dysfunction, insulin resistance and oxidative stress. Adipose-derived mesenchymal stem cells (ASCs) have multiple functions like cell renewal, spontaneous repair and homeostasis in adipose tissue. In this review article, we have summarized the recent data highlighting that ASCs in obesity are defective in various functionalities and properties including differentiation, angiogenesis, motility, multipotent state, metabolism and immunomodulation. Inflammatory milieu, hypoxia and abnormal metabolites in obese tissue are crucial for impairing the functions of ASCs. Further work is required to explore the precise molecular mechanisms underlying its alterations and impairments. Based on these data, we suggest that deregulated ASCs, possibly also other mesenchymal stem cells, are important in promoting the development of obesity. Restoration of ASCs/mesenchymal stem cells might be an additional strategy to combat obesity and its associated diseases.

Mode of birth in twins: data and reflections.

Our primary objective was to compare neonatal and maternal outcomes in women with twin pregnancies, beyond 32 weeks, having a planned vaginal birth or a planned caesarean section (CS). This was a retrospective cohort study from a single tertiary centre over nine years. 534 sets of twins ≥32 + 0 weeks of gestation were included. 401 sets were planned vaginally and 133 sets were planned by CS. We compared a composite adverse perinatal outcome (perinatal mortality or serious neonatal morbidity; five minute APGAR score ≤4, neurological abnormality and need for intubation) and a composite maternal adverse outcome (major haemorrhage, trauma or infection) between the groups. There were no significant differences. Given the similarity of these results with several other larger studies of twin birth, we sought to look at reasons why there is still a rising rate of CS for twin births. We further make suggestions for keeping this rate to a sensible minimum. Impact statement What is already known on this subject? The largest randomised controlled study comparing planned vaginal birth with planned CSs for lower risk twins between 32 and 39 weeks of gestation, showed no added safety from planned CS. However, in most of the Western countries this conclusion has failed to increase the number of planned vaginal births for lower risk twins. What do the results of this study add? This observational study from a single tertiary centre provides external validation of the twin trial results in a practical day-to-day setting. It also provides insights as to how planned vaginal birth can be developed and maintained, with a key focus on safety and maternal participation in decision making. It does focus on consent and providing accurate data. What are the implications of these findings for clinical practice and/or further research? There are good grounds to encourage vaginal birth for low-risk twin pregnancies. The trend of rising caesarean rates in low-risk twin pregnancies worldwide will erode important skills for the conduct of vaginal births without any clear benefit for mothers or babies. The current situation demands careful thought about implementing innovative training opportunities for younger obstetricians. Finally, we need intelligent responses to many non-evidence-based factors which can drive clinical practice.

Deficiency of RITA results in multiple mitotic defects by affecting microtubule dynamics.

Deregulation of mitotic microtubule (MT) dynamics results in defective spindle assembly and chromosome missegregation, leading further to chromosome instability, a hallmark of tumor cells. RBP-J interacting and tubulin-associated protein (RITA) has been identified as a negative regulator of the Notch signaling pathway. Intriguingly, deregulated RITA is involved in primary hepatocellular carcinoma and other malignant entities. We were interested in the potential molecular mechanisms behind its involvement. We show here that RITA binds to tubulin and localizes to various mitotic MT structures. RITA coats MTs and affects their structures in vitro as well as in vivo. Tumor cell lines deficient of RITA display increased acetylated α-tubulin, enhanced MT stability and reduced MT dynamics, accompanied by multiple mitotic defects, including chromosome misalignment and segregation errors. Re-expression of wild-type RITA, but not RITA Δtub ineffectively binding to tubulin, restores the phenotypes, suggesting that the role of RITA in MT modulation is mediated via its interaction with tubulin. Mechanistically, RITA interacts with tubulin/histone deacetylase 6 (HDAC6) and its suppression decreases the binding of the deacetylase HDAC6 to tubulin/MTs. Furthermore, the mitotic defects and increased MT stability are also observed in RITA-/- mouse embryonic fibroblasts. RITA has thus a novel role in modulating MT dynamics and its deregulation results in erroneous chromosome segregation, one of the major reasons for chromosome instability in tumor cells.

Maternal CD4+ microchimerism in HIV-exposed newborns after spontaneous vaginal delivery or caesarean section.

BACKGROUND: Maternal CD4+ cell microchimerism may be greater after caesarean section compared to spontaneous vaginal delivery and could cause mother-to-child transmission (MTCT) in HIV-exposed newborns. AIMS: To evaluate maternal CD4+ cell microchimerism in HIV-exposed newborns after spontaneous vaginal delivery or caesarean section. STUDY DESIGN AND SUBJECTS: In this prospective single-centre study, neonates whose mothers were infected with HIV and had normal MTCT risk according to the German Austrian Guidelines were considered for study enrolment. Maternal CD4+ cell microchimerism in the newborns' umbilical cord blood was measured and compared by mode of delivery. RESULTS: Thirty-seven HIV-infected mothers and their 39 newborns were included in the study. None of the 17 (0.0%) newborns delivered vaginally had quantifiable maternal CD4+ cells (95% confidence interval (CI): 0.00-0.00) in their circulation at birth compared with four of 16 (25.0%) newborns delivered via planned caesarean section, who showed 0.01-0.66% maternal cells (95% CI: -0.06-0.16; P=0.02) in their circulation. The intention to treat analysis, which included six additional newborns delivered by unplanned caesarean section, showed quantifiable maternal CD4+ cells in one (0.05%; 95% CI: -0.02-0.04) of 23 (4.3%) newborn at birth compared to four of 16 (25.0%) born via planned caesarean section (95% CI: -0.06-0.16; P=0.04). There was no MTCT in any of the newborns. CONCLUSION: In this small cohort, spontaneous vaginal delivery in HIV-infected women with normal MTCT risk was associated with lower maternal CD4+ cell transfer to newborns compared to planned caesarean section.

[CAMIC Recommendations for Surgical Laparoscopy in Non-Obstetric Indications during Pregnancy]. / CAMIC-Empfehlungen zur chirurgischen Laparoskopie aus nicht geburtshilflicher Indikation während der Schwangerschaft.

In the operative surgical primary care, the laparoscopic surgical technique has firmly established itself in recent years. Meanwhile, in the normal population over 90 % of all cholecystectomies and over 80 % of all appendectomies are performed in a minimally invasive manner. The proven benefits of the laparoscopic surgical technique, compared with conventional open surgery, are a comparatively rapid early postoperative recovery with early resumption of the general physical and occupational activity. As these benefits are equally applicable for necessary interventions during pregnancy, in recent years laparoscopy has become the preferred treatment for non-obstetric indications in the gravid patient. Overall, it can be assumed that such interventions have to be performed in approximately 2 % of all pregnant patients. Numerous studies have proven here that the use of laparoscopic techniques, in particular for the expectant mother, is safe and not associated with an increased risk. On the other hand, the current pregnancy makes necessary an adapted approach to the solution of surgical problems to ensure the protection of the unborn child. On the basis of currently available data situation, recommendations are formulated which can be used as a decision-making support for a variety of clinical situations.

Clinical Study: Change in Outlook Towards Birth After a Midwife Led Antenatal Education Programme Versus Hypnoreflexogenous Self-Hypnosis Training for Childbirth.

Aim: To compare the change of maternal outlook towards birth due to a midwife led antenatal education programme versus hypnoreflexogenous self-hypnosis training for childbirth. Method: Before beginning of the classes and after the last class maternal perception on birth was evaluated using Osgood semantic differential questionnaire. The Gießen personality score was evaluated once. Results: 213 patients were enrolled in this study. 155 were in the midwife led education programme and 58 in the self-hypnosis training programme. There was no statistically significant difference between the two groups in regard of participants' characteristics, Gießen personality score and initial Osgood semantic differential scores. After the midwife led course childbirth was emotionally more negatively scored (displeasure, tarnishing, dimension evaluation [p < 0.05]), whereas after the hypnosis course childbirth was emotionally more positively evaluated (pleasure, harmony, dimension evaluation [p < 0.01] and brightness [p < 0.05]). Summary: In this study hypnoreflexogenous self-hypnosis training resulted in a positive maternal outlook towards childbirth, in comparison to the midwife led course. Further prospective randomised studies are required to test these initial results.

Less understood issues: p21(Cip1) in mitosis and its therapeutic potential.

p21(Cip1) is a multifunctional protein and a key player in regulating different cellular processes. The transcription of p21 is regulated by p53-dependent and -independent pathways. The expression of p21 is increased in response to various cellular stresses to arrest the cell cycle and ensure genomic stability. p21 has been shown to be a tumor suppressor and an oncogene as well. The function of p21 in mitosis has been proposed but not systematically studied. We have recently shown that p21 binds to and inhibits the activity of Cdk1/cyclin B1, and is important for a fine-tuned mitotic progression. Loss of p21 prolongs the duration of mitosis and results in severe mitotic defects like chromosome segregation and cytokinesis failures promoting consequently genomic instability. Moreover, p21 is dramatically stabilized in mitotic tumor cells upon treatment with mitotic agents like paclitaxel or mitotic kinase inhibitors. Increased p21 is mainly localized in the cytoplasm and associates with cell survival indicating a crucial role of p21 in susceptibility to mitotic agents in tumor cells. In this review we will briefly summarize the structure and general physiological functions as well as regulation of p21, discuss in detail its role in mitosis and its potential to serve as a therapeutic target.

Intrapartum ST segment analyses (STAN) using simultaneous invasive and non-invasive fetal electrocardiography: a report of 6 cases.

The objective of this study was to analyze ST segment analyses (STAN) using simultaneous traditional - gold standard invasive (fetal scalp electrode) and newly available non-invasive abdominal fetal electrocardiography (fECG) during delivery.This was a prospective observational study of non-invasive fetal ECG using 5 abdominally sited electrodes (Monica AN24) against the traditional fetal scalp electrodes (STAN S31) on 6 patients. Data were analyzed when the STAN S31 found the baseline and when there was a baseline rise.Successful fECG signal acquisition was achieved in 6/6 (100%) patients. Using the non-invasive fECG, P and QRS waves were seen in all cases, and T waves in 3/6 (50%). ST segment analysis analysis was possible in 6/6 (100%) and 3/6 (50%) using invasive and non-invasive fECG, respectively.This study demonstrates that ST segment analysis is feasible using invasive and non-invasive fECG. Further studies are warranted to confirm the preliminary results and improve ECG morphology of non-invasive fECG.

Gestational diabetes outcome in a single center study: higher BMI in children after six months.

The aim of the study was to examine obstetric outcomes and metabolic disorders in patients with gestational diabetes mellitus (GDM) and their offspring compared to mothers without GDM and their offspring. We performed a retrospective single center cohort study of mothers with GDM using a questionnaire with items concerning the maternal medical history, neonatal complications, and child development. Mothers with gestational diabetes (GDM; n=130) and those with normal glucose tolerance (NGT; n=77) were recruited. GDM mothers were older (37.58 years vs. 34.32 years, p<0.0001) and had a greater body mass index (25.18 kg/m² vs. 23.37 kg/m², p<0.01). There were no significant differences regarding the mean birth weight, the frequency of Cesarean sections, and the prevalence of macrosomia (> 4 000 g). At follow-up (pediatric U5 screening visit after 6 months of birth) children of mothers with GDM had significantly higher BMI than the children of the NGT group (17.07 kg/m² vs. 16.59 kg/m², p=0.042). GDM women in need of insulin therapy during pregnancy had higher BMI than dieting GDM mothers and experienced more frequently an operative vaginal delivery (17.95% vs. 6.17%, OR 3.23, p=0.04). We found less significant differences between GDM mothers with treatment of impaired glucose tolerance and NGT mothers concerning the neonatal outcome than expected. Despite higher BMI of the GDM group's offspring at follow-up U5 visit, the children did not show any other development disorder. In conclusion treatment of GDM could minimize the frequency of obstetric and neonatal complications in this risk group.

Pregnancy complications in HIV-positive women: 11-year data from the Frankfurt HIV Cohort.

OBJECTIVES: The aim of the study was to assess pregnancy complications in HIV-positive women and changes in the rates of such complications over 11 years in the Frankfurt HIV Cohort. METHODS: There were 330 pregnancies in HIV-positive women between 1 January 2002 and 31 December 2012. The rate of pregnancy-related complications, such as gestational diabetes mellitus (GDM), pre-eclampsia and preterm delivery, the mode of delivery and obstetric history were analysed. Maternal and neonatal morbidity/mortality as well as HIV mother-to-child transmission (MTCT) were evaluated. RESULTS: In our cohort, GDM was diagnosed in 38 of 330 women (11.4%). Five women (1.5%) developed pre-eclamspia or hypertension. In 16 women (4.8%), premature rupture of membranes (PROM) occurred and 46 women (13.7%) were admitted with preterm contractions. The preterm delivery rate was 36.5% (n = 122), and 26.9% of deliveries (n = 90) were between 34+0 and 36+6 weeks of gestation. Over the observation period, the percentage of women with undetectable HIV viral load (VL) increased significantly (P < 0.001), from 26.1% to 75%, leading to obstetric changes, including an increase in the rate of vaginal deliveries (P < 0.001), from no vaginal births to 50%. The preterm delivery rate decreased significantly (P < 0.001), from 79.2% to 8.3%. There were no significant changes in the rate of GDM, pre-eclampsia, PROM or preterm contractions. CONCLUSIONS: In the 11 years of our analysis, there was a significant reduction in the rate of preterm deliveries and an increase in the vaginal delivery rate, possibly reflecting changes in treatment policies in the same period and the availability of more effective antiretroviral therapy options. The rates of complications such as GDM, pre-eclampsia, preterm contractions, PROM and postnatal complications were stable over the 11 years, but were still increased compared with the general population.

p21Waf1/Cip1 deficiency causes multiple mitotic defects in tumor cells.

As a multifaceted molecule, p21 plays multiple critical roles in cell cycle regulation, differentiation, apoptosis, DNA repair, senescence, aging and stem cell reprogramming. The important roles of p21 in the interphase of the cell cycle have been intensively investigated. The function of p21 in mitosis has been proposed but not systematically studied. We show here that p21 is abundant in mitosis and binds to and inhibits the activity of Cdk1/cyclin B1. Deficiency of p21 prolongs the duration of mitosis by extending metaphase, anaphase and cytokinesis. The activity of Aurora B is reduced and the localization of Aurora B on the central spindle is disturbed in anaphase cells without p21. Moreover, HCT116 p21-/-, HeLa and Saos-2 cells depleted of p21 encounter problems in chromosome segregation and cytokinesis. Gently inhibiting the mitotic Cdk1 or add-back of p21 rescues segregation defect in HCT116 p21-/- cells. Our data demonstrate that p21 is important for a fine-tuned control of the Cdk1 activity in mitosis, and its proper function facilitates a smooth mitotic progression. Given that p21 is downregulated in the majority of tumors, either by the loss of tumor suppressors like p53 or by hyperactive oncogenes such as c-myc, this finding also sheds new light on the molecular mechanisms by which p21 functions as a tumor suppressor.

Outcome in single and twin pregnancies at 20 to 24 weeks gestation: ten years experience in one perinatal center.

OBJECTIVE: The aim of this investigation was to evaluate the outcome at 20 to 24 weeks gestation of twin and singleton extremely low birth weight infants. STUDY DESIGN: The authors conducted a retrospective cohort study of live newborns at 20 to 24 weeks gestation admitted to one neonatal intensive care unit (NICU) from 2000 to 2009. Outcome mortality and predictors of outcome were evaluated. Results were compared for twin and singleton infants. RESULTS: The cohort of infants consisted of 60 singleton infants and 17 twins. The results suggest an increased risk of death for twins when compared with singletons. A correlation between neonatal C-reactive protein (CRP) and bacterial culture positive results on admission to NICU might be a predictor of neonatal outcome. CONCLUSION: In extremely low birth weight infants, twin delivery is associated with an independent increased risk of death. Both first- and second-born twins are at increased risk.

Prenatal ultrasound screening for fetal anomalies and outcomes in high-risk pregnancies due to maternal HIV infection: a retrospective study.

OBJECTIVE: To assess the prevalence of prenatal screening and of adverse outcome in high-risk pregnancies due to maternal HIV infection. STUDY DESIGN: The prevalence of prenatal screening in 330 pregnancies of HIV-positive women attending the department for prenatal screening and/or during labour between January 1, 2002 and December 31, 2012, was recorded. Screening results were compared with the postnatal outcome and maternal morbidity, and mother-to-child transmission (MTCT) was evaluated. RESULTS: One hundred of 330 women (30.5%) had an early anomaly scan, 252 (74.5%) had a detailed scan at 20-22 weeks, 18 (5.5%) had a detailed scan prior to birth, and three (0.9%) had an amniocentesis. In seven cases (2.12%), a fetal anomaly was detected prenatally and confirmed postnatally, while in eight (2.42%) an anomaly was only detected postnatally, even though a prenatal scan was performed. There were no anomalies in the unscreened group. MTCT occurred in three cases (0.9%) and seven fetal and neonatal deaths (2.1%) were reported. CONCLUSION: The overall prevalence of prenatal ultrasound screening in our cohort is 74.5%, but often the opportunity for prenatal ultrasonography in the first trimester is missed. In general, the aim should be to offer prenatal ultrasonography in the first trimester in all pregnancies. This allows early reassurance or if fetal disease is suspected, further steps can be taken.

Prevalence, Spectrum and Antibiotic Susceptibility of Bacterial and Candida Colonization between the 21st and 33rd Week of Gestation in Women with PPROM - 5 Years' Experience in 1 Perinatal Center.

Objective: The aim of this study was to evaluate the prevalence, spectrum and antibiotic susceptibility of bacterial and Candida colonization of the vagina between the 21st and the 33rd week of gestation in women who had preterm premature rupture of membranes (PPROM). Study design: High vaginal swabs from 245 subjects with PPROM were analyzed in a retrospective cohort study using cultivation-dependent methods. Patients were additionally divided into two groups: women with PPROM between the 21st and 27th week of gestation (group A) and women with PPROM between the 28th and 33rd week of gestation (group B). A subgroup analysis comparing the two groups was done. Results: The prevalence of pathological bacterial colonization was similar in both study groups (40.8 vs. 41.4 %; p > 0.05), however, a difference in antibiotic susceptibility was noted, which did not reach statistical significance (resistance to ampicillin 71.4 vs. 52.5 %; cefuroxime 9.5 vs. 11.7 %; gentamicin 28.6 vs. 16.4 %; ciprofloxacin 5.0 vs. 5.4 %). In group A there was a statistically significant lower rate of Candida colonization (11.1 vs. 24.3 %; p = 0.04). Conclusion: In patients with early PPROM, the rate of Candida colonization (group A) is lower and there are indications of a difference in antibiotic susceptibility of the colonizing bacteria depending on gestational age. Larger study groups are required to confirm these preliminary results.

Neonatal Transfer Rate and Mode of Delivery from 37th Week of Gestation in a German Perinatal Center Level 1.

Introduction: Rates for caesarean section are on the rise and the reasons for this are being discussed worldwide. As the data is unclear, the identification of additional predictive factors for caesarean section is important as caesarean sections are closely linked to maternal and neonatal morbidity. The aim of the study was to identify predictive factors for the transfer of the neonate to a neonatal intensive care unit (NICU) depending on the mode of delivery. The study investigated the neonatal transfer rates for singleton and twin pregnancies delivered at ≥ 36 + 0 weeks of gestation. Material and Methods: The data of all singleton (n = 4181) and twin pregnancies (n = 305 neonates), delivered between 1 January 2009 and 31 March 2012 in the OB/Gyn Department of the University Hospital Frankfurt/M, Germany, (perinatal center level 1) were evaluated. The indications for transfer to the NICU and possible predictive factors were evaluated. Results: Our study found a two times lower neonatal transfer rate for vaginal deliveries of pregnant women without risk factors compared to women with risk factors. The following neonatal transfer rates to the NICU were noted for singleton pregnancies: 4.7 % without risk factors, 8.3 % high-risk pregnancy, 6.2 % vaginal breech delivery, 9.3 % forceps delivery, 10 % elective primary caesarean section and 14 % secondary caesarean section. There was a statistically signific.

[Breech presentation - more than just caesarean vs. spontaneous birth]. / Beckenendlagengeburt - mehr als Sectio vs. Spontangeburt.

The cesarean section rate and the associated complications are still rising in Germany. An important indication is term breech in singletons. Not significant data concerning a higher morbidity or mortality in vaginal breech birth indicate the cesarean but a deficit in education and experience.