Sheila Hewson

Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial

BACKGROUND For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies. METHODS At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat. FINDINGS Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35). INTERPRETATION Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

International Multicentre Term Prelabor Rupture of Membranes Study: Evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term

OBJECTIVES Our purpose was to determine significant predictors for the development of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. STUDY DESIGN Logistic regression analysis with odds ratios and 95% confidence intervals was used to determine the significant predictors of clinical chorioamnionitis and postpartum fever in women with prelabor rupture of membranes at term enrolled in this study. The study recently compared in a randomized controlled trial four strategies of management: induction with oxytocin, induction with prostaglandin, expectant management, and, if failed, induction with oxytocin or prostaglandin. RESULTS The following variables were significantly associated with clinical chorioamnionitis: (1) number of digital vaginal examinations: > 8, 7 to 8, 5 to 6, 3 to 4 (vs 0 to 2) (odds ratio 5.07, 3.80, 2.62, 2.06); (2) duration of active labor: > or = 12, 9 to < 12, 6 to < 9 hours (vs < 3 hours) (odds ratio 4.12, 2.94, 1.97); (3) meconium-stained amniotic fluid (odds ratio 2.28); (4) parity of 0 (odds ratio 1.80); (5) time from membrane rupture to active labor: > or = 48, 24 to < 48 hours (vs < 12 hours) (odds ratio 1.76, 1.77); and (6) group B streptococcal colonization (odds ratio 1.71). Variables significantly associated with postpartum fever were (1) clinical chorioamnionitis (odds ratio 5.37), (2) duration of active labor: > or = 12, 9 to < 12, 6 to < 9, 2 to < 6 hours (vs < 3 hours) (odds ratio 4.86, 3.53, 3.46, 3.04), (3) cesarean section, operative vaginal delivery (odds ratio 3.97, 1.86), (4) group B streptococcal colonization (odds ratio 1.88), and (5) maternal antibiotics before delivery (odds ratio 1.94). CONCLUSIONS Increasing numbers of digital vaginal examinations, longer duration of active labor, and meconium staining of the amniotic fluid were the most important risk factors for the development of clinical chorioamnionitis in women with prelabor rupture of membranes at term. The most important risk factors for the development of postpartum fever were clinical chorioamnionitis, increasing duration of active labor, and cesarean section delivery.

Impact of the International Term Breech Trial on Clinical Practice and Concerns: A Survey of Centre Collaborators

OBJECTIVE The purpose of this study was to determine what impact the International Term Breech Trial had had in different settings and to elicit any concerns among collaborators regarding the implementation of a policy of planned Caesarean section for term breech babies. METHODS We mailed a questionnaire to all Term Breech Trial collaborators. The questionnaire asked 3 open-ended questions about the impact of the trial, about concerns with implementing planned Caesarean section for term breech babies, and about whether information as to the relative costs of planned Caesarean section versus planned vaginal birth would be helpful. Frequencies of responses were calculated for centres in countries classified as having a low or a high national perinatal mortality rate (< or = 20/1000 vs. > 20/1000, respectively) according to the figures published by the World Health Organization in 1996. RESULTS We received responses from 80 centres in 23 countries. Most centres (92.5%) stated that clinical practice had changed to planned Caesarean section for most or all term breech babies. The majority of centres (66.3%) had no difficulties or concerns with implementing a policy of planned Caesarean section for term breech babies. Most centres (85.0%) indicated that an analysis of relative costs would not affect clinical practice in their setting. CONCLUSION Clinical practice has changed to planned Caesarean section in most collaborating centres, given the results of the Term Breech Trial.

Factors associated with adverse perinatal outcome in the Term Breech Trial

BACKGROUND In the Term Breech Trial, the risk of adverse perinatal outcome was lower with planned cesarean section versus planned vaginal birth. We undertook secondary analyses to determine factors associated with adverse perinatal outcome. STUDY DESIGN By using multiple logistic regression analyses, we determined the effect of prelabor cesarean section, cesarean section during early labor, cesarean section during active labor versus vaginal birth, and other factors, on adverse perinatal outcome. For 1384 fetuses delivered after labor, we determined the effect of variables associated with labor on adverse perinatal outcome. RESULTS The risk of adverse perinatal outcome was lowest with prelabor cesarean section (odds ratio [OR]=0.13) and highest with vaginal birth. For those delivered after labor, labor augmentation (P=.007), birth weight less than 2.8 kg (P=.003), and longer time between pushing and delivery (P<.001) increased the risk, whereas the presence of an experienced clinician at delivery (P=.004) reduced the risk of adverse perinatal outcome. CONCLUSION Breech infants at term are best delivered by prelabor cesarean section.

The Control of Hypertension In Pregnancy Study pilot trial

Objective  To determine whether ‘less tight’ (versus ‘tight’) control of nonsevere hypertension results in a difference in diastolic blood pressure (dBP) between groups.

The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial

Background: The Term Breech Trial compared the safety of planned cesarean and planned vaginal birth for breech presentations at term. The combined outcome of perinatal or neonatal death and serious neonatal morbidity was found to be significantly lower among babies delivered by planned cesarean section. In this study we conducted a cost analysis of the 2 approaches to breech presentations at delivery. Methods: We used a third-party–payer (i.e., Ministry of Health) perspective. We included all costs for physician services and all hospital-related costs incurred by both the mother and the infant. We collected health care utilization and outcomes for all study participants during the trial. We used only the utilization data from countries with low national rates of perinatal death (≤ 20/1000). Seven hospitals across Canada (4 teaching and 3 community centres) were selected for unit cost calculations. Results: The estimated mean cost of a planned cesarean was significantly lower than that of a planned vaginal birth (

Factors Associated with Maternal Morbidity in the Term Breech Trial

7165 v.

Crossing international boundaries: Implications for the Term Breech Trial data coordinating centre

8042 per mother and infant; mean difference –

Cerclage for the Short Cervix Demonstrated by Transvaginal Ultrasound: Current Practice and Opinion

877, 95% credible interval –

Original articleCrossing international boundaries: implications for the Term Breech Trial Data Coordinating Centre

1286 to –