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​Cihat Şen, ​Nicola Volpe

Cecilia Villalain, Daniel Rolnik, M. Mar Gil

Managing Editors
Murat Yayla

Statistics Editor
Resul Arısoy

Article info

The impact of delivery mode on the Apgar scores in term and preterm breech delivery. Perinatal Journal 2011;19(3):103-107

Author(s) Information

Muhammet Erdal Sak1,
Mehmet Sıddık Evsen1,
Hatice Ender Soydinç1,
Sibel Sak2,
Ahmet Yalınkaya1,
Mehmet Zeki Taner1,
Sezin Vural1,
Yılmaz Palancı3

  1. Dicle Üniversitesi Tıp Fakültesi, Kadın Hastalıkları ve Doğum Anabilim Dalı- Diyarbakır TR
  2. Kadın Doğum Hastalıkları ve Çocuk Hastanesi, Kadın Hastalıkları ve Doğum Bölümü- Diyarbakır TR
  3. Dicle Üniversitesi Tıp Fakültesi, Biyoistatistik Anabilim Dalı- Diyarbakır TR
Publication History
Conflicts of Interest

No conflicts declared.

In this study, Apgar scores were evaluated in patients with term and preterm breech delivery according to forms of delivery.
Patients data with breech delivery were retrospectively reviewed between January 2003 and December 2010 in Obstetrics and Gynecology Clinic.
Total number of delivery was 22,666, 3.72% of them (850 cases) was breech delivery. Patients with breech delivery, mean age was 29.0±6.9, while 23.8%, were over age 35. The average age of vaginal breech delivery group was 30.6±7.2, when the cesarean breech delivery group was 28.6±6.7. 29% of the patients was primigravid, 71%of the patients was multigravid that delivered breech. Cesarean and vaginal breech delivery rate were found 76.8%, 23.2%, respectively. Average birth weights of nulliparous was 2,536±768 gr, while the multiparous was 2,750±943 gr. Uterine anomaly were detected 3.1% of the cases. The most common uterine anomaly was uterus septus. First and fifth minute Apgar scores of cesarean breech delivery were higher than vaginal breech delivery.
In our study, Apgar scores in preterm and term breech vaginal delivery group was significantly higher than cesarean delivery group. 

Term, preterm breech delivery, Apgar scores, cesarean section, vaginal delivery

Breech deliveries occur  in approximately %2 to 4% of all deliveries. Breech presentation has many risks for fetus and mother when compared to cephalic presentation. Increased morbidity and mortality in preterm birth is associated to congenital anomalies, birth trauma and cord compression).[1-3]
Deciding the type of delivery in breech presentations is still an ongoing debate nowadays Especially , this debate usually focus on whether the type of delivery decided in preterm or term breech deliveries in the literature Pregnancy status, gestational age, the clinicians experience are the important parameters while deciding to the delivery from as long as last three decades.[2-5]
In this study, Apgar scores were compared in patients with term and preterm breech delivery according to the type of delivery.
Data of the patients who admitted to the Dicle University, School of Medicine, Department of Obstetricsand Gynecology between January 2003 and December 2010 with breech delivery were retrospectively investigated from their patient charts. The patients with gestation week over 24 weeks were included in the study. When determining the gestation week last menstrual date and ultrasonographic examinations were used. Uterine anomaly was diagnosed during the ultrasonography or cesarean section. Conditions like lethal congenital anomalies, fetal death, fetal distress, preeclampsia, eclampsia, HELLP syndrome, placenta previa, hydrocephaly, cordon prolapsus, and abruptio placenta were excluded. Tocolytic treatment was administered to the patients with preterm labor and steroid treatment was given for maturation of lungs of fetuses. All patients were monitorized by fetal electronic heart monitorization devices during labor. In this study Apgar scoring was used to determine early perinatal morbidity. The Apgar scores in the first and fifth minutes of after delivery, birth weight of the child and their systemic examinations were assessed by a pediatrician in all participants.
Obtained data were analyzed by using Statistical Package for Social Sciences 11.5 version (SPSS Inc., Chicago, IL, USA). Descriptive analyses were presented as means and frequencies. For comparison of the variables that were normally distributed, student t test was used. Results are presented in the 95% confidence interval and statistically significance level was set as the any p value <0.05.
The total number of births in our clinic was 22,666 between the dates of this study and 850 (3.75%) cases were births with breech presentation. The mean age of cases who delivered breech presentation was 29.0±6.9 and 23.8% of these were over 35 years old (Table 1). 71% of cases were primigravida and 29% were multigravida. The average age of delivered with vaginal and cesarean section was 30.6±7.2, 28.5±6.7, respectively. When average birth weight was 2,536±768 in cases of nulliparous, it was 2,750±943 in cases of multiparous, and there was significant difference between two groups. This birth rate with cesarean section of breech birth cases was 76.8% and birth rate with vaginal of those were 23.2%. The distributions of cases according to indications for cesarean section are given in table 2. The most common indication was breech presentation and it was to follow with indication for repeated cesarean section. The uterine anomaly was found in 3.1% of the cases (Table 3). The most common anomaly was uterine septus.
There was significant difference between the scores of the first and fifth minutes that Term and preterm in cases of breech presentation delivered with caesarean section and vaginal delivery. The first and fifth minute Apgar scores of delivered cases with cesarean section were higher than vaginal births (Table 4). According to birth weight, the first and fifth minute Apgar scores of delivered cases with cesarean section were higher than vaginal births (Table 5).
Deciding the type of delivery in breech presentations is still an ongoing debate. This debate usually focus on whether the type of delivery decided in preterm or term breech deliveries is an important factor in increased fetal morbidity and mortality or not.[2-5] Although Apgar scoring is not a decisive method in the evaluation of fetal asphyxia it is widely used in the clinic due to its simple and easy use.[6] According to the retrospective and prospective studies perinatal mortality and early neonatal morbidity is reported to be increased in term vaginal breech deliveries when compared to those of cesarean breech deliveries.[2-7-10] However, early neonatal results of term vaginal deliveries were reported to be similar with the results of the term cesarean breech deliveries in selected and well managed cases. Among these cases perinatal mortality was reported in 2 of every 1000 deliveries, and early neonatal morbidity was 2%.[2] When deciding vaginal delivery for the patients with breech presentation absence of intrauterine growth restriction, cord prolapsus and mocrosomic fetus, and the presence of appropriate pelvic structure and fetal weight between 2,500 and 4,000 grams are important criteria.[2] In this study, mean Apgar score of the children with term breech cesarian delivery were higher than that of children with term breech vaginal delivery.
The type of delivery in preterm breech presentation is an ongoing discussion of the clinicians in during the last 3 decades. In some studies elective cesarian delivery is recommended for early preterm breech deliveries, however, some other studies have suggested no superiority of it to preterm vaginal breech delivery after arguing against the former studies given their methodological mistakes, small and heterogenous sample sizes.[7,9,10,3,4] Supporting their suggestion Kayem et al.reported no increase of neonatal mortality risk in planned vaginal breech delivery.[3] In our study, mean Apgar scores were higher in the cesarian olmalı breech delivery group than the scores of vaginal breech delivery group when the patients were grouped according to their gestational age or birth weight. Mullerian anomalies may cause obstetric complications like malpresentation.[11] Uterine anomaly was detected in 3.1% of our cases, septateuterus being the most frequent one.
Neonatal morbidity and mortality were observed to be higher in vaginal breech deliveries in the studies conducted in our country.[12,13] Our findings are consistent with those previous studies from our country.
Large randomized studies comparing term cesarian and vaginal breech deliveries concluded that rate of mortality and neurodevelopmental delay were similar in children who have reached to their 2 years of age in both groups.[5] The studies are limited in the literature about preterm breech delivery. In fact, there are some authors who have suggested re-examination of these studies and their methodological errors.[3]
In conclusion, Apgar scores of the children with term and preterm cesarean breech delivery are found to be higher than those of vaginal breech delivery. This difference seemsto persist when the cases were grouped according to their gestational ages and birth weights.
1. Brenner WE, Bruce RD, Hendricks CH. The characteristics and the perils of breech presentation. Am J Obstet Gynecol 1974;118:700-12.
2. Kotaska A, Menticoglu S, Gagnon R. Vaginal delivery of breech presentation. J Obstet Gynaecol Can 2009;31:557-66.
3. Kayem G, Baumann R, Goffinet F, El Abiad S, Ville Y, Cabrol D, et al. Early Preterm breech delivery: is a policy of planned vaginal delivery associated with increased risk of neonatal death? Am J Obstet Gynecol 2008;198:289.e1-6.
4. Malloy MH, Onstad L, Wright E. The effect of cesarean delivery on birth outcome in very low birth weight infants. Obstet and Gynecol 1991;77:498-503.
5. Whyte H, Hannah ME, Saigal S. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the international randomized term breech trial. Am J Obstet Gynecol 2004;191:864-71.
6. Moster D, Lie RT, Irgens LM, Bjerkedal T, Markestad T. The association of Apgar score with subsequent death and cerebral palsy: a population-based study in term infants. J Pediatr 2001;138:798-803.
7. Demol S, Bashiri A, Furman B. Breech presentation is a risk factor for intrapartum and neonatal death in preterm delivery. Eur J Obstet Gynecol Reprod Biol 2000;93:47-51.
8. Hannah ME, Whyte H, Hannah WJ, Hewson S. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized term breech trial. Am J Obstet Gynecol 2004;191:917-27.
9. Van Eyk EA, Huisjes HJ. Neonatal mortality and morbidity associated with preterm breech presentation. Eur J Obstet Gynecol Reprod Biol 1983;15:17-23.
10. Karp LE, Doney JR, McCarthy T, Meis PJ, Hall M. The premature breech: trial of labor or cesarean section? Obstet Gynecol 1979;53:88-92.
11. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap III LC, Wenstrom KD (Eds). Abnormalities of the reproductive tract. In: Williams Obstetrics. 22nd ed. New York: McGraw-Hill; 2005. p. 949-70.
12. Dölen İ, Yıldırım A, Akyıl S, Karacadağ O, Hassa H, Özalp S. Kliniğimizde doğum yapan makat prezentasyonlu gebelik olgularının değerlendirilmesi. Zeynep Kamil Tıp Bülteni 1987;19:819-27.
13. Seyisoğlu H, Yalçınkaya T, Erel C, Arvas M. Makat gelişlerinde doğum şeklinin neonatal mortalite üzerine etkisi. Perinatoloji Dergisi 1993;1:219-23.
Table 1.
General characteristics of the patients.
Table 2.
Indications for cesarean section.
Table 3.
Uterine abnormalities.
Table 4.
Apgar scores at 1 and 5 minutes of cesarean and vaginal breech delivery by gestational age.
Table 5.
Apgar scores at 1 and 5 minutes according to the method of delivery and birth weight.