Audit of breech presentation delivered vaginally at Chris Hani Baragwanath Hospital
Uzabakiriho, Dr Bernard
Background Vaginal breech delivery can be a difficult obstetric procedure. The well-known Term Breech Trial concluded that planned elective caesarean section at term was safer for the babies than planned vaginal birth. This resulted in widespread adoption of protocols favouring planned caesarean section for breech presentation. However, daily experience shows that vaginal breech deliveries are still conducted in our hospitals. Objectives and methods This study was done to: 1) determine the reasons why vaginal breech deliveries still occur with live babies at Chris Hani Baragwanath hospital, despite the adoption of a protocol for elective caesarean section for breech presentation at term; 2) to audit the quality of clinical notes given the potential medicolegal hazards associated with breech delivery; and 3) to describe neonatal morbidity and mortality associated with vaginal breech delivery. This was a retrospective descriptive study and audit of vaginal breech deliveries, using a period sample of vaginal breech births of babies alive at the onset of the second stage of labour, and weighing 800 g or more at birth. Data collection was by review of maternal and neonatal case notes. Results Results There were 90 women with eligible vaginal breech deliveries. Four (4%) were referred from midwife-run antenatal clinics for breech presentation. External cephalic version was not attempted on any of these women. Five (6%) had been booked for elective caesarean section. On admission in labour, 26 (29%) of these breech presentations were missed, and 23 (26%) had emergency caesarean sections booked. The vaginal deliveries were conducted by registrars in 55 cases (61%) and by midwives in 22 (24%). At delivery, the fetal heart was noted to be present in 28 cases (31%). The method of delivery of the head was stated in 23 deliveries (26%). The median birthweight was 2370 g (interquartile range 1730-3000 g). There were eight babies weighing less than 1000 g (9%). There were eight perinatal deaths (9%), of whom four weighed more than 2500 g. There was one where the aftercoming head could not be delivered with the baby eventually born as a fresh stillbirth. Conclusion There may be a problem with clinical skill in detecting breech presentation, and with supervision of vaginal breech deliveries by senior obstetric staff. Note-keeping, with a view to preventing medicolegal risks, was generally poor. However, the majority of vaginal breech deliveries occurred without warning even in the presence of standard antenatal and intrapartum care. This means that vaginal breech deliveries will continue to occur in this institution. Clinicians must remain skilled in vaginal breech delivery and understand the importance of following standard protocols and operating procedures, especially in note-keeping, to prevent poor clinical outcomes and associated medico-legal hazards.