Caesarean section for preterm birth,
breech presentation and twin pregnancies
Professor A Biswas
National University Health Systems
Singapore

C Section trends
Rising C Section Rates – NUH, Singapore
The group that contributes most
The group that contributes most
 Preterm births, breech presentation and twin pregnancies (Robson
Group 10,6,7,8) together complicate 12–18% of all births.
 The role of caesarean section in these pregnancies is controversial
and lacks good evidence-based guidelines
 Policy on mode of delivery in these three important obstetric
groups is bound to influence overall primary caesarean section
rates
Preterm delivery and caesarean section
(Robson group 10)
 6-11% all births
 34.5% of all Preterm deliveries need CS at NUH
 Does CS delivery provides any benefit to the baby in
cephalic presentation in spontaneous preterm labour is
debatable.
C Section and Preterm birth
 Recent systematic review of all RCTs (Alfirevic et al,
Cochrane database, 2012)
 Only 4 studies involving only 116 infants could be used for
analysis.
 The review failed to show any significant difference in birth
asphyxia or birth injuries between the two groups.
 All RCTs had to be stopped early
Preterm CS and neonatal survival
 Neonatal survival advantage after CS for babies born between 24-34 wks
 Subgroup analysis shows the survival benefit is mainly between 23-26
weeks (very early preterms) (Malloy, Pediatrics, 2009, Lee & Gould,
O&G, 2006)
 The advantage is not seen amongst early pre (27-31wks), intermediate
(32-33 wks) and late preterms (34-36 wks)
 Between 32-36 wks, primary CS may actually increase the risk of
neonatal mortality (Malloy, Birth 2010)
 For low-risk preterm infants at 32–36 weeks’ gestation, primary
caesarean section may pose an increased risk of neonatal mortality
and morbidity
 After adjustment for confounders, the adjusted odds ratios (95%
CI) for neonatal mortality at gestational ages of 32, 33, 34, 35, and
36 weeks were 1.69 (1.31 to 2.20); 1.79 (1.40 to 2.29); 1.08 (0.83
to 1.40); 2.31 (1.78 to 3.00); and 1.98 (1.50 to 2.62), respectively.
Preterm CS and Neurodevelopment
 Incidence of PVL and severe-grade IVH are increased in
vaginally delivered extremely preterm neonates (<1250 Gms)
(Dani, 2010; Duelofeut, 2005)
 No significant difference in long-term neurodevelopmental
outcome at 9 years (Haque 2008)
 Labor does not play a significant role in affecting ND
outcome (Wadhawan, 2003)
Preterm birth (CS vs Vag Del)
 Delivery of extremely preterm infants, (<26 weeks’
gestation) by caesarean section has increased significantly in
many countries during last decade
 The appropriateness of intervening with CS for these very
immature infants needs further evaluation and cannot be
supported at present
 Does not mean we have clear evidence in favor of vaginal
delivery
Technical issues in Extreme Preterm CS
 Uterine relaxation – use of GTN
 J-incision or Low vertical incision
 Amnion Protective C Section
Amnion Protective C Section (APCS)
 Cesarean Section en caul
 A gentler method of delivery of the extremely preterm
Amnion Protective C Section (APCS)
 24 preterm en caul CS
 3 babies had cord Hb beow 15 g/dl and 3 required
transfusion
Abouzeid & Thornton, 1999
Amnion Protective C Section
 A Chinese study over 10 years on 211 cases
 En caul delivery was possible in 66%
 Amount of blood loss similar
 The rate of asphyxia was significantly lower among preterm
infants delivered by the en caul method than in the control
cases
Jin et al, 2013
Breech presentation and caesarean delivery
(Robson group 6 and 7)
 The year 2000 trial that
devastated vaginal breech
delivery
 Perinatal mortality (0.23,
0.07 to 0.81) and serious
neonatal morbidity (0.36, 0.19
to 0.65) were lower for
planned CS than for planned
vaginal delivery
Breech presentation and caesarean delivery
(Robson group 6 and 7)
Has it led to a premature change in clinical practice?
 Inadequate case selection and
intrapartum management
 Maternity units with markedly
different skill levels grouped
together
 Short-term morbidity used as a
surrogate marker for long-term
neurological impairment
The French-Belgian Study (PREMODA
study, 2006)
 Prospective descriptive study of more than 8000 breech births in 174 centres
in France and Belgium
 Trial of labour was undertaken in 31%
 71% of these women (n= 1796) delivered vaginally
•
No difference was reported between trial of labour and planned caesarean
section in
 perinatal mortality (0.08% v 0.15%)
 serious neonatal morbidity (1.6% v 1.45%)
Preterm Breech
 Higher perceived risk with VD
 Head entrapment
 IVH risk
 Cord prolapse
Preterm Breech
 Only one prospective randomized study of only 38 patients
 20 VD
 18 CS
 25% required Em CS
 5 NND in VD group and 1 NND in CS group
Zlatnik, 1993, Iowa Preterm Breech Trial
Preterm Breech
Preterm Breech
Preterm Breech
CONCLUSION from retrospective studies
 Babies weighing between 750 and 1500 g (26–32 weeks) VD is
associated with increased neonatal mortality
 Babies weighing more than 1500 gms, no definite benefit of CS
 The data likely to be flawed by “selection bias”
Twins and Cesarean section
(Robson group 8)
Twins
 Optimum time for delivery 37-38 wks
 Choice between planned CS and planned VD
 Most important deciding factor is presentation of Twin A
Twins and Cesarean section
(Robson group 8)
Twins
Twins
 In an UK study of twins delivered between 1994 to 2003 in which one of
the twins died during or after labour for reasons other than congenital
abnormality (1377 pregnancies).
 Before 37 weeks’ of gestation, the two babies were at equal risk
 At term the risk of death was higher in second twins (OR 2.3, 1.7 to 3.2,
P<0.001).
 Vaginally delivered second twins had a fourfold higher risk than first
twins of death due to intrapartum anoxia.
Twin Birth Study
 In twin pregnancy between 32 weeks 0 days and 38 weeks 6
days of gestation, with the first twin in the cephalic
presentation, planned cesarean delivery did not significantly
decrease or increase the risk of fetal or neonatal death or
serious neonatal morbidity, as compared with planned
vaginal delivery

(Barett et al, 2013)
Twin Birth Study
 No difference in outcome when stratified by gestational age
or presentation of 2nd twin
 Risk of adverse outcome was higher in 2nd twin compared to
1st
 This increased risk was similar in both CS and VD groups

(Barett et al, 2013)
Why the difference between Twin Birth
Study and other cohort studies?
Why the difference between Twin Birth
Study and other cohort studies?
 Presence of experienced obstetrician for all cases in
TBS
Combined Vaginal-CS delivery
 C Section for Twin B is needed in 5-17% of Vaginal twin deliveries
(even for V/V twins)
 Slightly higher incidence of endometritis and neonatal sepsis
 Common causes
 Fetal distress
 Cord prolapse
 Abnormal/unstable lie of twin B
 Abruptio
Conclusion – Preterm CS
 Evidence on the benefits of caesarean delivery for preterm babies
is inconclusive.

A well-powered randomised trial to answer this dilemma is
unlikely to take place anytime soon.
 Caesarean delivery at borderline viability (<26 weeks) should only
be carried out after careful discussion between the patient,
neonatologist and the obstetrician.
Conclusion – Breech CS
 Caesarean section has become the routine delivery option for
breech presentation, both term and preterm
 Careful review of the original and follow-up data from the Term
Breech Trial has cast some doubts about the validity of this change
in practice
 It might not be too late for a resurrection of vaginal breech
delivery in carefully selected cases
Conclusion – Twin CS
 In twin deliveries, twin B is at greater risk than twin A because of
potential malpresentation, cord accidents, or hypoxia, but this does not
translate into better results if elective caesarean delivery is opted for all
twin deliveries
 For uncomplicated V/V twin pair, vaginal delivery should be the first
option
 In V/NV, twin pairs, planned vaginal delivery can be offered only if the
obstetrician is experienced and confident in vaginal breech extraction.
Otherwise, it is safer to carry out planned caesarean delivery
 Although not ideal, in some cases CS may be needed to deliver twin B
after vaginal delivery of twin A