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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 1  |  Page : 7-11

A 5-year retrospective review of singleton term breech deliveries seen at a tertiary hospital in northern Nigeria


1 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria
2 Department of Obstetrics and Gynaecology, State Specialist Hospital, Maiduguri, Borno State, Nigeria
3 Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria

Date of Web Publication28-Jul-2016

Correspondence Address:
Dr. Idris Usman Takai
Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, PMB 3011, Kano State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.187203

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  Abstract 

Background: Most singleton breech deliveries in the developing countries are unplanned and therefore, associated with poor perinatal outcome. This is because despite high antenatal attendance, most patients present in advanced labour, coupled with inadequate work force and skill attendants for the management of such cases. This study was undertaken to determine the incidence and outcome of term singleton breech deliveries at the University of Maiduguri Teaching Hospital (UMTH).
Patients and Methods: This is a retrospective study of term singleton breech deliveries at the UMTH, a tertiary health facility in northeastern Nigeria over 5 years from January 1, 2003 to December 31, 2007. The delivery and theater records for all singleton breech deliveries at term were collected while the case notes were retrieved from the central medical records department. Information on age, parity, booking status, type of breech, level of skill of the attendant (accoucheur), Apgar scores, and birth weight were extracted. The main outcome measures were still births, low Apgar scores, birth weight, and accoucheur. Data were analyzed using Statistical Package for the Social Sciences (SPSS) 16.0 statistical computer package.
Results: There were 173 term singleton breech deliveries among the 10,203 patients who delivered during the study period, giving an institutional incidence of 1.69%. The age of the patients ranged 18-44 years; 51.9% of the patients were aged 25-34 years. The likelihood of breech presentation at term increased with increasing parity, being 25.5% among nulliparae, 34.4% in women with 2-4 children, and 40.1% in women who had delivered 5 or more children (P = 0.001). Extended or Frank breech was the most common type of breech presentation, accounting for 54.8%. Most patients (80.3%) were booked. 52.2% were delivered by cesarean section (CS). Only 30.6% of the deliveries were planned despite the large proportion of booked patients in the study. There were 147 live births and two fresh stillbirths. Senior obstetricians or senior midwives were involved in the conduct of almost all the live births. The only two fresh still births resulted from the junior registrars' delivery. Birth asphyxia — Apgar score of less than 6-was more common in the unplanned group than in the planned group (P = 0.01), and all instances were found in the patients delivered by junior registrars.
Conclusion: Despite the high antenatal attendance in the study group, breech deliveries were largely unplanned and the fetal outcome was directly related to the level of skill of the accoucheur. There is a need to plan and have skilled and senior obstetricians in attendance at delivery for this high-risk group.

Keywords: Accoucheur, Apgar score, breech delivery, singleton breech


How to cite this article:
Takai IU, Kwayabura AS, Bukar M, Idrissa A, Obed JY. A 5-year retrospective review of singleton term breech deliveries seen at a tertiary hospital in northern Nigeria. Arch Int Surg 2016;6:7-11

How to cite this URL:
Takai IU, Kwayabura AS, Bukar M, Idrissa A, Obed JY. A 5-year retrospective review of singleton term breech deliveries seen at a tertiary hospital in northern Nigeria. Arch Int Surg [serial online] 2016 [cited 2021 Sep 16];6:7-11. Available from: https://www.archintsurg.org/text.asp?2016/6/1/7/187203


  Introduction Top


The incidence of breech presentation is high before term but most fetuses undergo spontaneous version by term so that the incidence of breech presentation at term is 3-4%.[1],[2],[3],[4] Persistent breech presentation may be a chance occurrence but is often associated with factors such as oligohydramnios, abnormalities of the uterine shape, fetal congenital anomalies, placenta attachment in the lower uterine segment, and cornual implantation.[4],[5] It has been widely recognized that breech delivery is associated with high perinatal morbidity and mortality, which have been linked to the mode of delivery, lethal congenital abnormalities, prematurity, birth asphyxia, and birth trauma.[1],[2],[4] Extrinsic factors such as antecedent antenatal care, socioeconomic status, planned delivery, and the unit of care and skill of the birth attendants, which also influence outcome have received little attention.[4],[6]

The management of breech at term has continued to generate controversies all over the world and several interventions and methods have been employed to improve perinatal outcome. These include routine cesarean section (CS) for all babies with breech presentation, external cephalic version during the antenatal period or in labor before delivery, and x-ray pelvimetry.[1],[2],[7] However, while reports suggest that CS for breech delivery is associated with lower perinatal mortality and morbidity, it is associated with an increased maternal morbidity and mortality.[1],[2],[7],[8] This policy of CS for all breech presentations may increase maternal morbidity and mortality in an environment like ours where women show aversion to CS. Moreover, factors such as the booking status, professional level of care as well as the unit of care have a positive impact on perinatal outcome.[3],[4] Selective assisted vaginal breech delivery may help reduce this additional risk for our women.[9] In most developing countries, many patients with breech present in labor without antenatal preparation and so are only diagnosed in labor.[10] In such patients, parity and/or presence of other obstetric complications constitute risk factors for abdominal delivery.[9],[11] Important investigations such as ultrasound scanning (USS) for fetal weight estimation, diagnosis of overt anomalies, placental localization, and x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) pelvimetry, which influence the choice of delivery route, are not readily available in these areas.[4] External cephalic version has been shown to decrease the incidence of CS in breech deliveries at term without increasing the risk to the baby.[2],[7] Unfortunately, external cephalic version (ECV) is not popular in our environment.[9],[12] This study was undertaken to determine the incidence and outcome of singleton breech deliveries at the University of Maiduguri Teaching Hospital (UMTH).


  Patients and Methods Top


This was a retrospective study of term singleton breech deliveries at UMTH, a tertiary health facility in northeastern Nigeria over a period of 5 years from January 1, 2003 to December 31, 2007. Breech presentation is defined as the entrance of the fetal buttocks or lower extremities into the maternal pelvic inlet while term breech in this series is a pregnancy that lasted 37-42 completed weeks or babies weighing 2.5 kg or more as recorded in the patient's folder. Information on sociodemographic variables of the mother, which included maternal age, parity, and booking status were obtained. The neonatal variables extracted included sex, birth weight, Apgar scores, and neonatal outcome. These information were obtained from labor ward records, theater records, and records from the neonatal intensive care unit. The case notes of these mothers were then retrieved from the Central Medical Records Department and all the relevant data required for the study were extracted and analyzed using Statistical Package for the Social Sciences (SPSS) Statistical software version 16 (SPSS Inc, Chicago, USA, 2006). Descriptive statistics were used for categorical variables and chi-square test was used to test for significance. A P value of ≤0.05 was considered to be significant. We included only women with singleton term breech deliveries as per records because the incidence of breech presentation is high before term and most fetuses undergo spontaneous version by term while those mothers who had preterm deliveries, still births, multiple pregnancies, and gross congenital malformations at birth were excluded from the analysis.

Similarly, the status of the accoucheur and the mode of delivery were noted. The total number of deliveries in the study period was then obtained. Ethical clearance was obtained from the institutional review board of the hospital.


  Results Top


There were 10,203 deliveries during the period of study, out of which 173 women had singleton breech deliveries at term. Of these, 157 case notes were traced and analyzed, giving a retrieval rate of 90.75%. The incidence of singleton breech delivery during the study period was 1.69%. The breech was frank in 86 cases (54.8%), complete in 50 cases (31.8%), and footling in 21 cases (13.4%). Fetal birth weights ranged 2550-4,111 g with a mean of 3,330 ± 784 g. Fetal weight was higher in the group delivered by CS (P = 0.010).

The age of the patients ranged 18-44 years, with half (51.9%) of them aged 25-34 years. The likelihood of breech presentation at term increased with increasing parity (P = 0.001), being 25.5% among nulliparae, 34.4% in women with 2-4 children, and 40.1% in women who have delivered 5 or more children. Most of the patients (80.3%) were booked. These are shown in [Table 1].
Table 1: Sociodemographic characteristics of the patients studied

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[Table 2] shows the mode and type of delivery of the babies. Only 48/157 (30.6%) of the total breech deliveries were planned despite the large proportion of booked patients in the study. Of these, 13 (27.1%) were planned vaginal deliveries and 35 (72.9%) were CS. Only 12 (7.6%) of the patients had breech deliveries in the past, 50% vaginally and 50% via CS. CS was the most common mode of delivery among the patients studied, accounting for 52.2% (82/157).
Table 2: Mode and type of delivery of the babies

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There were 147 live births and two fresh stillbirths. [Table 3] indicated the cadre of the accoucheur and fetal outcome. Registrars conducted most of the deliveries-71/149 (47.7%); senior registrars conducted 61/149 (40.9%) of the deliveries, 11/149 (7.4%) by midwives, and 6/149 (4.0%) by consultants.
Table 3: The cadre of the accoucheur and fetal outcome

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Birth asphyxia — Apgar score of less than 6 was 10 times as common in the unbooked patients compared to the booked patients and seven times more common in the unplanned group when compared to the planned group (P = 0.01). The type of accoucheur also predisposed the newborns to asphyxia where the newborns who had asphyxia belonged to the patients delivered by the registrars. These findings are shown in [Table 4].
Table 4: 5-min Apgar scores by booking status, accoucheur, and type of delivery

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Overall, 363 perinatal deaths occurred during the period under study, with the breech delivery group accounting for 2.75%. There was no neonatal death in the CS group as compared to two fresh stillbirths from the vaginal group; both resulted from the registrars' delivery.


  Discussion Top


The fetus presenting by breech is at an increased risk of perinatal morbidity and mortality, principally due to the higher incidence of birth asphyxia, trauma, and congenital anomalies.[3],[4],[10] The incidence of singleton breech delivery during the study period was 1.69%, which was similar to the findings of other studies [4],[13] but lower than 3.4%,[3] 2.6%,[14] and 3%[15] reported from the southern part of the country and other developing countries and 3-4% generally quoted in the literature.[1],[2],[3],[4],[5] The age of the patients ranged 18-44 years with most (51.9%) aged 25-34 years, a finding similar to the one in Sagamu, Ogun State, Nigeria.[4] In this study, the likelihood of breech presentation at term increased with increasing parity, which was similar to the findings of other studies [2],[3],[6],[9] but the recurrence was low as only 7.6% of the patients had breech deliveries in the past. In this study, successful vaginal breech delivery was found to be 47.8% but this was lower than the 72.3% reported from India.[16] The CS of 52.2% in this study is high when compared to 27.8% reported by Ojiyi et al.[14] but similar to the findings from Ile-Ife [11] and higher than the ordinary rate of about 13% for our center and the findings of others in Nigeria.[4],[8],[9],[17] This high rate may have far-reaching implications for our women who have an aversion to cesarean delivery and where access to CS is not readily available. The leading main indication for CS in our series is a large fetus weighing greater than 3.5 kg, which accounted for 31.7%-a finding similar to other studies.[8],[11],[15] The mode of delivery, and technique and skill of the accoucheur are to some extent related to perinatal outcome [2],[15],[16],[17] in breech deliveries. This was demonstrated in our study as babies delivered by registrars were more likely to have low Apgar scores and perinatal death probably due to low level of training and expertise in vaginal delivery since CS unequivocally improves outcome. There were better Apgar scores and no death in the cesarean group and in those patients delivered by more senior and experienced accoucheurs. Similar results were seen in Nkwabong Elie et al.[18] There is therefore, no doubt that the experience of the accoucheur and the modes of delivery play crucial roles in the outcome of breech deliveries.

Recent findings have shown that planned CS for breech deliveries reduce perinatal morbidity and mortality significantly though maternal morbidity may be increased.[2],[3],[5],[15],[19],[20] Unfortunately, only 30.6% of the deliveries were planned despite the large proportion of booked patients in the study because some of the patients were lost to the planned deliveries for one reason or the other and sadly the poor perinatal outcome in this study was among the unplanned group. In carefully selected patients however, planned vaginal delivery does not differ significantly from CS; rather it is associated with lower maternal morbidity [5],[15],[17],[19],[20] and may be a better option in low-resource settings such as ours with an aversion to and no ready recourse to CS. Moreover, even booked patients tend to present late in labor, as was seen in this study; despite 80.3% antenatal attendance, only 30.6% of the total deliveries were planned thereby making it difficult to stick to a planned delivery protocol although the booked patients were more likely to have planned delivery compared to unbooked patients.[6],[9],[15],[17] Because of the associated high perinatal mortality and morbidity, breech deliveries have always been topical issues in obstetrics practice. This makes room for wide ranges of management policies and/or options with the aim of reducing this perinatal morbidity and mortality. One such option is the external cephalic version, which some advocates believed will improve the outcome.[21] Despite this, such a practice is not routinely performed in our environment because of inadequate facilities and/or manpower to monitor fetuses; thus detection of fetal compromise after external cephalic version may be missed. It is therefore, necessary for our patients to have a planned delivery. Overall, 363 perinatal deaths occurred during the period of study, with the breech delivery group accounting for 2.75%.


  Conclusion Top


In conclusion, most singleton term breech deliveries are unplanned despite the high antenatal attendance among women in this study. CS as well as the experience and level of skill of the accoucheur were associated with a better perinatal outcome; however, the high CS rate is worrisome since our women have an aversion to CS and this may mean improving perinatal outcome in breech deliveries at the expense of increasing maternal morbidity and mortality. There is a need to train and retrain the younger obstetrics residents and midwives as well. Our study is limited by its retrospective nature where some data were not readily available for analysis. Similarly, the socioeconomic status of our patients, which might have impacted the outcome was not determined. Despite these, the findings from this study will allow new and more plans to reduce the fetal morbidity and mortality from breech deliveries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Cunningham GF. Breech presentation and delivery In: Cunningham GF, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY, editors. Williams Obstetrics. 23rd ed. USA: McGraw-Hill Companies; 2010. p. 527-43.  Back to cited text no. 1
    
2.
Adeyemi AS, Adekanle DA, Afolabi AF, Fadero FF. Outcome of breech deliveries at a tertiary health institution in southwestern Nigeria. Niger Hosp Pract 2011;7:3-7.  Back to cited text no. 2
    
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Duke AO, Duke CO, Onyegbule OA, Amajuoyi CC, Madu PI, Enyinnaya EB. Outcome of single breech term deliveries at the Federal Medical Centre, Owerri, South Eastern Nigeria: A five year review. Int J Res Med Sci 2014;2:527-31.   Back to cited text no. 3
    
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Olatunji AO, Sule-Odu AO. Term breech delivery at a university hospital in Nigeria. Niger Postgrad Med J 1999;6:171-4.   Back to cited text no. 4
    
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Glezerman M. Planned vaginal breech delivery: Current status and the need to reconsider. Exp Rev Obstet Gynecol 2012;7:159-66.   Back to cited text no. 5
    
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Aisien AO, Lawson O. Outcome of singleton breech deliveries in a tertiary health care centre. Trop J Obstet Gynaecol 2003;20:129-33.  Back to cited text no. 6
    
7.
Hofmeyr GJ, Kulier R. External Cephalic Version for Breech Presentation at Term (Review). Chichester, UK: The Cochrane Library, John Wiley & Sons Ltd.; 2006.  Back to cited text no. 7
    
8.
Anya SE, Fiebai PO, John CT. An eleven-year review of deliveries for breech presentation in Port Harcourt. Trop J Obstet Gynaecol 2001;18(Suppl 1):31.  Back to cited text no. 8
    
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Adetoro OO, Fakaye OO. Breech presentation: A 3-year survey. Trop J Obstet Gynaecol 1990;8:10-2.  Back to cited text no. 9
    
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Fasubaa OB, Orji EO, Ogunlola O, Kuti O, Shittu SA. Outcome of singleton breech delivery in Wesley Guild Hospital, Ilesha, Nigeria. Trop J Obstet Gynaecol 2003;20:59-62.  Back to cited text no. 10
    
11.
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. 11
    
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Onah HE, Nkwo PO. External cephalic version: A survey of current practice among Nigerian obstetricians. Trop J Obstet Gynaecol 2004;21:24-6.  Back to cited text no. 12
    
13.
Gaikwad S, Rokade R, Banerjee G. A study of maternal and perinatal outcome of breech presentation in vaginal and operative deliveries in a university hospital. MedPulse — Int Med J 2014;1:252-8.  Back to cited text no. 13
    
14.
Ojiyi EE, Dike EI, Okeudo C, Anolue FC, Uzoma O, Uzoma MJ, et al. Outcome of singleton term breech deliveries at a university teaching hospital in Eastern Nigeria. WebmedCent Obstet Gynaecol 2011;2:WMC002543.  Back to cited text no. 14
    
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Pradeep MR, Shivanna L. Route of delivery for term breech presentation; vaginal versus caesarean section; comparative analysis. IOSR J Dent Med Sci (IOSR-JDMS) 2014;13:1-4.  Back to cited text no. 15
    
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Nalliah S, Loh KY, Japaraj RP, Mukudan K. Is there a place for selective vaginal breech delivery in Malaysian hospitals: Experiences from the Ipoh Hospital? J Matern Fetal Neonatal Med 2009;22:129-36.  Back to cited text no. 16
    
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Oboro VO, Dare FO, Ogunniyi SO. Outcome of term breech delivery by intended mode of delivery. Niger J Med 2004;13:106-9.  Back to cited text no. 17
    
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Nkwabong E, Fomulu JN, Kouam L, Ngassa PC. Outcome of breech deliveries in Cameroonian Nulliparous women. J Obstet Gynaecol India 2012;62:531-5.   Back to cited text no. 18
    
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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. 19
    
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Nordtveit TI, Melve KK, Albrechtsen S, Skjaerven R. Maternal and paternal contribution to intergenerational recurrence of breech deliveries: Population based cohort study. BMJ 2008;336:872-6.  Back to cited text no. 20
    
21.
Mohammed K, Serras R, Coulson R. Randomized controlled trial using tocolytics. Br J Obstet Gynaecol 1991;98:8-13.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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