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Term breech trial

2001; Elsevier BV; Volume: 357; Issue: 9251 Linguagem: Inglês

10.1016/s0140-6736(05)71320-9

1474-547X

Kiyoshi Uchide, Koichi Murakami,

Hernia repair and management

There are three issues in Mary Hannah and colleagues' report1Hannah ME Hannah WJ Hewson SA Hodnett ED Saigal S Willan AR for the Term Breech Trial Collaborative GroupPlanned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial.Lancet. 2000; 356: 1375-1383Summary Full Text Full Text PDF PubMed Scopus (1525) Google Scholar on term breech delivery that should be addressed. The first is the accuracy of the diagnosis of fetopelvic disproportion. Hannah and colleagues state that women were excluded if there was evidence of fetopelvic disproportion. However six of the 16 deaths were associated with difficult vaginal delivery due to clinical fetopelvic disproportion, and these fetuses should have been excluded before randomisation as cases of existing fetopelvic disproportion.Second, we are unsure about the method of estimating fetal body weight. The investigators state that fetuses judged to be clinically large or to have an estimated fetal weight of 4000 g or more were excluded before enrolment. Yet, 32 (3·1%) of the neonates in the planned caesarean section group and 59 (5·8%) in the planned vaginal birth group weighed more than 4000 g. This high number of fetuses weighing more than 400 g could have affected the poor outcome in the planned vaginal delivery group.Third, the condition of the umbilical cord was not assessed. Many workers have noted that umbilical-cord disorders can cause serious complications; tight nuchal cord and shoulder dystocia are a potentially catastrophic combination,2Flamm BL Tight nuchal cord and shoulder dystocia: a potentially catastrophic combination.Obstet Gynecol. 1999; 94: 853Crossref PubMed Scopus (20) Google Scholar, 3Collins JH Tight nuchal cord morbidity and mortality. Am.J Obstet Gynecol. 1999; 180: 251Summary Full Text PDF Scopus (5) Google Scholar and symptomatic nuchal cords that are identified before labour as being extremely tight or having multiple loops, might be associated with a subclinical deficit in neurodevelopmental performance.4Clapp JF III Lopez B Simonean S Nuchal cord and neurodevelopmental performance at 1 year.J Soc Gynecol Investig. 1999; 6: 268-272Crossref PubMed Scopus (49) Google Scholar Therefore, careful assessment of the cord by colour doppler ultrasonography5Uchide K Ueno H Inuyama R Murakami K Terada S Cord presentation with posterior placenta praevia.Lancet. 1997; 350: 1448Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar would lower the incidence of cord disorders such as cord prolapse, and fetal heartrate abnormalities in planned vaginal births.The risk in planned vaginal birth might decline in the future when obstetricians can appropriately assess fetopelvic disproportion and umbilicalcord disorders for breech presentation at term. There are three issues in Mary Hannah and colleagues' report1Hannah ME Hannah WJ Hewson SA Hodnett ED Saigal S Willan AR for the Term Breech Trial Collaborative GroupPlanned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial.Lancet. 2000; 356: 1375-1383Summary Full Text Full Text PDF PubMed Scopus (1525) Google Scholar on term breech delivery that should be addressed. The first is the accuracy of the diagnosis of fetopelvic disproportion. Hannah and colleagues state that women were excluded if there was evidence of fetopelvic disproportion. However six of the 16 deaths were associated with difficult vaginal delivery due to clinical fetopelvic disproportion, and these fetuses should have been excluded before randomisation as cases of existing fetopelvic disproportion. Second, we are unsure about the method of estimating fetal body weight. The investigators state that fetuses judged to be clinically large or to have an estimated fetal weight of 4000 g or more were excluded before enrolment. Yet, 32 (3·1%) of the neonates in the planned caesarean section group and 59 (5·8%) in the planned vaginal birth group weighed more than 4000 g. This high number of fetuses weighing more than 400 g could have affected the poor outcome in the planned vaginal delivery group. Third, the condition of the umbilical cord was not assessed. Many workers have noted that umbilical-cord disorders can cause serious complications; tight nuchal cord and shoulder dystocia are a potentially catastrophic combination,2Flamm BL Tight nuchal cord and shoulder dystocia: a potentially catastrophic combination.Obstet Gynecol. 1999; 94: 853Crossref PubMed Scopus (20) Google Scholar, 3Collins JH Tight nuchal cord morbidity and mortality. Am.J Obstet Gynecol. 1999; 180: 251Summary Full Text PDF Scopus (5) Google Scholar and symptomatic nuchal cords that are identified before labour as being extremely tight or having multiple loops, might be associated with a subclinical deficit in neurodevelopmental performance.4Clapp JF III Lopez B Simonean S Nuchal cord and neurodevelopmental performance at 1 year.J Soc Gynecol Investig. 1999; 6: 268-272Crossref PubMed Scopus (49) Google Scholar Therefore, careful assessment of the cord by colour doppler ultrasonography5Uchide K Ueno H Inuyama R Murakami K Terada S Cord presentation with posterior placenta praevia.Lancet. 1997; 350: 1448Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar would lower the incidence of cord disorders such as cord prolapse, and fetal heartrate abnormalities in planned vaginal births. The risk in planned vaginal birth might decline in the future when obstetricians can appropriately assess fetopelvic disproportion and umbilicalcord disorders for breech presentation at term. Term breech trialAuthors' reply Full-Text PDF