Morbidity and mortality associated with mode of delivery for breech periviable deliveries.
OBJECTIVE
The purpose of this study was to estimate the odds of morbidity and death that are associated with cesarean delivery, compared with vaginal delivery, for breech fetuses who are delivered from 23-24 6/7 weeks' gestational age.


METHODS
We conducted a retrospective cohort study of state-level maternal and infant hospital discharge data that were linked to vital statistics for breech deliveries that occurred from 23-24 6/7 weeks' gestation in California, Missouri, and Pennsylvania from 2000-2009 (N = 1854). Analyses were stratified by gestational age (23-23 6/7 vs 24-24 6/7 weeks' gestation).


RESULTS
Cesarean delivery was performed for 46% (335 fetuses) and 77% (856 fetuses) of 23- and 24-week breech fetuses. In multivariable analyses, overall survival was greater for cesarean-born neonates (adjusted odds ratio [AOR], 3.98; 95% confidence interval [CI], 2.24-7.06; AOR, 2.91; 95% CI, 1.76-4.81, respectively). When delivered for nonemergent indications, cesarean-born survivors were more than twice as likely to experience major morbidity (intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, asphyxia composite; AOR, 2.83; 95% CI, 1.37-5.84; AOR, 2.07; 95% CI, 1.11-3.86 at 23 and 24 weeks' gestation, respectively). Among intubated neonates, despite a short-term survival advantage, there was no difference in survival to >6-month corrected age (AOR, 1.77; 95% CI, 0.83-3.74; AOR, 1.50; 95% CI, 0.81-2.76, respectively). There was no difference in survival for intubated 23-week neonates who were delivered by cesarean for nonemergent indications or cesarean-born neonates who weighed <500 g.


CONCLUSIONS
Cesarean delivery increased overall survival and major morbidity for breech periviable neonates. However, among intubated neonates, despite a short-term survival advantage, there was no difference in 6-month survival. Also, cesarean delivery did not increase survival for neonates who weighed <500 g. Patients and providers should discuss explicitly the trade-offs related to neonatal death and morbidity, maternal morbidity, and implications for future pregnancies.
Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN. Electronic address: btuckere@iupui.edu.
Brownsyne
B
Tucker Edmonds
Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN.
Fatima
F
McKenzie
Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA.
Michelle
M
Macheras
Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Sindhu K
SK
Srinivas
Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.
Scott A
SA
Lorch
D000293:Adolescent; D000328:Adult; D001238:Asphyxia Neonatorum / Q000453:epidemiology; D001946:Breech Presentation / Q000453:epidemiology* / Q000401:mortality / Q000601:surgery; D001997:Bronchopulmonary Dysplasia / Q000453:epidemiology; D002543:Cerebral Hemorrhage / Q000453:epidemiology; D002585:Cesarean Section; D036861:Delivery, Obstetric; D020345:Enterocolitis, Necrotizing / Q000453:epidemiology; D005260:Female; D005313:Fetal Death; D006801:Humans; D007231:Infant, Newborn; D009017:Morbidity; D011247:Pregnancy; D016019:Survival Analysis; D055815:Young Adult
breech; mode of delivery; outcome; periviable birth