title: Maternal outcomes of term breech presentation delivery: impact of successful external cephalic version in a nationwide sample of delivery admissions in the United States.
abstract: We aimed to define the frequency and predictors of successful external cephalic version in a nationally-representative cohort of women with breech presentations and to compare maternal outcomes associated with successful external cephalic version versus persistent breech presentation.
  
  
  
  Using the Nationwide Inpatient Sample, a United States healthcare utilization database, we identified delivery admissions between 1998 and 2011 for women who had successful external cephalic version or persistent breech presentation (including unsuccessful or no external cephalic version attempt) at term. Multivariable logistic regression identified patient and hospital-level factors associated with successful external cephalic version. Maternal outcomes were compared between women who had successful external cephalic version versus persistent breech.
  
  
  
  Our study cohort comprised 1,079,576 delivery admissions with breech presentation; 56,409 (5.2 %) women underwent successful external cephalic version and 1,023,167 (94.8 %) women had persistent breech presentation at the time of delivery. The rate of cesarean delivery was lower among women who had successful external cephalic version compared to those with persistent breech (20.2 % vs. 94.9 %; p < 0.001). Compared to women with persistent breech at the time of delivery, women with successful external cephalic version were also less likely to experience several measures of significant maternal morbidity including endometritis (adjusted Odds Ratio (aOR) = 0.36, 95 % Confidence Interval (CI) 0.24-0.52), sepsis (aOR = 0.35, 95 % CI 0.24-0.51) and length of stay > 7 days (aOR = 0.53, 95 % CI 0.40-0.70), but had a higher risk of chorioamnionitis (aOR = 1.83, 95 % CI 1.54-2.17).
  
  
  
  Overall a low proportion of women with breech presentation undergo successful external cephalic version, and it is associated with significant reduction in the frequency of cesarean delivery and a number of measures of maternal morbidity. Increased external cephalic version use may be an important approach to mitigate the high rate of cesarean delivery observed in the United States.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, POB 12000, Israel. carolynfweiniger@gmail.com.
authors.forename: Carolyn F
authors.initials: CF
authors.lastname: Weiniger
authors.affiliation: Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Deirdre J
authors.initials: DJ
authors.lastname: Lyell
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Lawrence C
authors.initials: LC
authors.lastname: Tsen
authors.affiliation: Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Butwick
authors.affiliation: Maternal-Fetal Medicine Unit, Department of Obstetrics & Gynecology, Sheba Met & March of Dimes Prematurity Research Center, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: BatZion
authors.initials: B
authors.lastname: Shachar
authors.affiliation: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: William M
authors.initials: WM
authors.lastname: Callaghan
authors.affiliation: Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, USA.
authors.forename: Andreea A
authors.initials: AA
authors.lastname: Creanga
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.|Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Bateman
mesh_terms: D000293:Adolescent; D000328:Adult; D001946:Breech Presentation / Q000628:therapy*; D002585:Cesarean Section / Q000706:statistics & numerical data*; D002821:Chorioamnionitis / Q000453:epidemiology*; D004716:Endometritis / Q000453:epidemiology*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D010343:Patient Admission; D011247:Pregnancy; D018805:Sepsis / Q000453:epidemiology*; D017211:Treatment Failure; D014481:United States / Q000453:epidemiology; D014710:Version, Fetal; D055815:Young Adult
keywords: Breech; Cesarean delivery; External cephalic version; Maternal morbidity