FETO MATERNAL OUTCOMES OF SINGLETON BREECH DELIVERIES AT MOI TEACHING AND REFERRAL HOSPITAL, ELDORET, KENYA.

This cross-sectional study at Moi Teaching and Referral Hospital in Kenya found that while the majority of singleton breech deliveries were managed via emergency caesarean section, a significant portion still underwent vaginal delivery, resulting in notable rates of birth complications (approximately 15%) and severe perineal tears (40%) among the mothers.

The Gist

Imagine a pregnancy as a long journey where the baby is usually a passenger sitting head-first in the front seat, ready to slide out the door (the birth canal) feet-first. But sometimes, the baby decides to sit backwards, with their bottom or feet pointing toward the exit. This is called a breech presentation.

This study is like a report card from a busy hospital in Kenya (Moi Teaching and Referral Hospital) that looked at what happened when 75 babies were born in this "backwards" position. The researchers wanted to know: Is it safer to pull the baby out with a knife (C-section) or let them slide out naturally (vaginal delivery), and what are the risks for the mom and baby?

Here is the story of their findings, broken down simply:

1. The Setup: A Rare Event

Breech babies are like finding a four-leaf clover; they are rare, happening in only about 1 out of every 100 births. Because they are so rare, the hospital didn't just pick a few random cases; they looked at every single one that happened over a year. It's like a detective solving a mystery by interviewing every witness in a small town rather than just a few.

2. The Decision: The "Emergency" vs. The "Plan"

The hospital has a rule: "If the baby is sitting backwards, we usually plan a C-section." However, life doesn't always follow the plan.

• The C-Section Group (The Majority): About 87% of the moms had an emergency C-section. Think of this as calling a tow truck when a car breaks down unexpectedly. It's a surgical rescue.
• The Vaginal Group (The Minority): About 13% of the moms had a vaginal delivery. This is like trying to navigate a tricky, narrow path without a tow truck.

3. The Baby's Scorecard (Fetal Outcomes)

How did the babies do?

• The Good News: Most babies (96%) were born alive and healthy. If you imagine a baby's health as a report card, 93% of them got an "A" (an APGAR score of 7 or higher) five minutes after birth.
• The Bad News: About 15% of the babies had a rough start. Some needed to stay in the "Newborn ICU" (the hospital's intensive care unit for babies), and a few had trouble breathing (asphyxia).
• The Big Surprise: The study found that how the baby was born mattered. Babies born vaginally were slightly more likely to have complications (like a "delayed aftercoming head," where the baby's head gets stuck) compared to those born via C-section. It's like driving a car: sometimes taking the scenic, difficult route (vaginal) is riskier than taking the highway (C-section) when the road conditions are tricky.

4. The Mom's Scorecard (Maternal Outcomes)

How did the mothers fare?

• The C-Section Moms: Their main risks were related to the surgery itself, like bleeding or reactions to the anesthesia (the "sleeping medicine").
• The Vaginal Delivery Moms: Their main risk was tearing. Because the baby's bottom and legs are harder shapes to push through than a smooth head, the "fabric" of the birth canal can get stretched and ripped.
  • The Stat: A shocking 40% of the women who had vaginal breech deliveries suffered significant tears (second or third-degree). Imagine trying to pull a large, awkward object through a small opening; the material around the opening is likely to get damaged.

5. The Big Takeaway

The researchers concluded that while vaginal breech delivery can happen, it carries a higher risk of injury for the mother (tears) and the baby (stuck head or breathing issues) compared to a C-section.

The Analogy:
Think of the birth canal as a tunnel and the baby as a package.

• Head-first: The package is shaped like a smooth sphere. It rolls through the tunnel easily.
• Breech: The package is shaped like a jagged rock.
• C-Section: You open a side door and lift the jagged rock out. It's safer for the tunnel (mom) and the rock (baby), but it's a bigger operation.
• Vaginal Breech: You try to push the jagged rock through the tunnel. It might fit, but it's very likely to scratch the tunnel walls (tears) or get stuck.

The Final Recommendation

Because the "jagged rock" (breech baby) causes more trouble when pushed through the tunnel, the study suggests that doctors should try to spot these babies early during check-ups. If they are found, the safest plan is to schedule a C-section (open the side door) before labor starts, rather than waiting and hoping the jagged rock fits through the tunnel.

In short: For breech babies, the "emergency rescue" (C-section) is generally the safer bet for both mom and baby, even though it's a bigger surgery. Trying to force the delivery naturally carries a high risk of tears for the mom and trouble for the baby.

Technical Summary

1. Problem Statement

Breech presentation occurs in approximately 3–4% of term pregnancies and is a significant cause of increased maternal and perinatal morbidity and mortality. While planned caesarean sections (CS) are generally considered safer than spontaneous vaginal delivery for breech presentations, the optimal mode of delivery remains a subject of debate, particularly in developing nations where many women present in labor without prior antenatal diagnosis.

In Kenya, specifically at Moi Teaching and Referral Hospital (MTRH), guidelines recommend planned CS for breech presentations. However, the facility also accommodates emergency CS and vaginal breech deliveries. There is a lack of localized data regarding the specific fetal and maternal outcomes of these mixed-mode deliveries in Western Kenya, necessitating a study to inform local management guidelines and mitigation strategies.

2. Methodology

• Study Design: Cross-sectional descriptive study.
• Setting: Riley Mother and Baby Unit, Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya.
• Study Period: August 30, 2019, to August 27, 2020.
• Population: Women aged ≥18 years with singleton breech deliveries at ≥28 weeks gestation.
• Sampling: A census of all eligible women was conducted due to the low incidence of breech deliveries at the facility.
• Data Collection:
  • Semi-structured interviewer-administered questionnaires for demographic and obstetric history.
  • Review of hospital medical records for clinical outcomes.
• Variables:
  • Fetal Outcomes: 5-minute APGAR score, admission to Newborn Unit (NBU), birth asphyxia, perinatal mortality, and birth complications (e.g., delayed aftercoming head).
  • Maternal Outcomes: Mode of delivery, postpartum hemorrhage (PPH), perineal tears (2nd/3rd degree), and anaesthetic complications.
• Statistical Analysis: Descriptive statistics (frequencies/proportions) and Fisher's exact test to assess associations between mode of delivery and outcomes (significance set at $p \leq 0.05$).
• Ethics: Approved by the Institutional Research Ethics Committee (IREC) of MTRH/Moi University.

3. Key Results

Demographics and Delivery Statistics:

• Total Deliveries: 11,748 singleton deliveries occurred during the study period.
• Breech Incidence: 125 cases (1.06%) were singleton breech deliveries.
• Study Cohort: 75 women met the eligibility criteria for the final analysis.
• Mode of Delivery:
  • Emergency Caesarean Section (CS): 65 (86.7%).
  • Vaginal Breech Delivery: 10 (13.3%).
• Gestational Age: 50.7% delivered between 38–40 weeks; 70.7% delivered at ≥38 weeks.

Fetal Outcomes:

• Survival: 96% live births (72/75). Three fresh stillbirths (4.6%) occurred exclusively in the emergency CS group.
• APGAR Scores: 93.3% of newborns had a 5-minute APGAR score $\geq 7$.
• Birth Weight: 66.7% were normal weight (2500–3499g).
• Complications:
  • Overall birth complications occurred in 14.7% of newborns.
  • Vaginal Delivery Group: Higher incidence of complications, including 1 case of delayed aftercoming head and 2 NBU admissions.
  • Emergency CS Group: 7.7% birth asphyxia and 4.6% NBU admission.
  • Statistical Significance: Mode of delivery was significantly associated with birth complications ($p = 0.006$), with a higher proportion of complications observed in vaginal deliveries.

Maternal Outcomes:

• Overall Complication Rate: 10.6% of women experienced complications.
• Vaginal Delivery Complications: 40% of vaginal deliveries resulted in perineal tears (3 second-degree, 1 third-degree).
• CS Complications: 4.6% Postpartum Hemorrhage (PPH) and 1.5% anaesthetic complications.
• Statistical Significance: Mode of delivery was significantly associated with maternal complications ($p < 0.001$).

4. Key Contributions

• Local Evidence Generation: Provides the first specific data on singleton breech outcomes at a major tertiary hospital in Western Kenya, addressing a gap in regional literature.
• Outcome Stratification: Unlike previous studies focusing solely on fetal outcomes, this study comprehensively assesses both maternal and perinatal outcomes stratified by the mode of delivery (Emergency CS vs. Vaginal).
• Validation of Guidelines: Confirms that while emergency CS is the dominant mode (86.7%), vaginal breech delivery still occurs (13.3%) and carries a statistically higher risk of specific birth complications (e.g., delayed aftercoming head) and maternal trauma (perineal tears).
• Comparative Analysis: The study compares local incidence rates (1.06%) and outcomes with global averages (3–4%) and other African/Asian studies, highlighting variations likely due to study design (retrospective vs. cross-sectional) and eligibility criteria.

5. Significance and Recommendations

• Clinical Implications: The study highlights that despite hospital protocols recommending CS, vaginal breech deliveries still occur and are associated with higher rates of perineal trauma and specific neonatal complications.
• Policy Recommendations:
  • Antenatal Care: Strengthen efforts to identify breech presentations during antenatal visits to facilitate planned elective CS.
  • Labor Management: Women presenting in labor with breech presentation should be prepared for emergency CS to minimize perinatal morbidity and maternal trauma.
  • Guideline Refinement: The findings support the current MTRH protocol favoring CS but suggest a need for rigorous counseling regarding the risks of vaginal breech delivery, particularly regarding perineal tears and birth asphyxia.
• Limitations: As a preprint, the study has not yet undergone peer review. The sample size for vaginal deliveries ($n=10$) is small, which limits the statistical power for some subgroup analyses, though the census approach minimizes selection bias.

Conclusion: The study concludes that while emergency CS is the primary management for breech at MTRH, the occurrence of vaginal breech deliveries results in significant maternal and fetal risks. Early identification and planned intervention are crucial for optimizing outcomes.