Discussion
Over a 20-year period, 151 out of 272 (56 %) pregnant women with a singleton breech presentation were selected for vaginal delivery at Hammerfest Hospital, in accordance with Norwegian guidelines, but only 57 (21 %) of the total number of pregnant women with a singleton breech presentation ended up with a vaginal delivery. During the same period, 31 % of all breech presentations in Norway were delivered vaginally, according to data from the Medical Birth Registry (12). We also found that 121 of the women with a breach presentation (44 %) underwent a planned caesarean section, which is slightly lower than national figures from Bjellmo et al., where 53 % were selected for a planned caesarean section (8).
Elective caesarean sections were almost evenly split between those performed for obstetric reasons and those based on maternal request. A significant number of women were selected for an elective caesarean section based on obstetric indications that no longer apply in the latest obstetrics guidelines, such as narrow pelvis measurements and a reluctance to induce labour in breech presentations. Breech deliveries accounted for 3.4 % of births at Hammerfest Hospital (data not shown), which is in line with the national average in the Medical Birth Registry.
Over the years, the guidelines for obstetric care have become less restrictive regarding vaginal breech delivery, including no longer recommending pelvimetry.
Since 1998, the recommendation has been for childbirth to take place in a maternity ward or women's clinic. In 2014, the guidelines were updated with a recommendation that maternity facilities should have the capability to perform emergency caesarean sections and ensure a paediatrician is readily available. The availability of adequate anaesthesia/analgesia, such as an epidural, pudendal block and preparedness for general anaesthesia, remains mandatory. In 2022, a new point was introduced concerning systematic training of doctors in vaginal breech delivery. (2, 11, 13–16).
In accordance with the guidelines, Hammerfest Hospital has seen a shift toward a higher proportion of vaginal deliveries since 2019. Over the past two years, the proportion of vaginal breech deliveries has been around 50 % (17). Since 2020, the department has sought to ensure a second specialist is present at breech deliveries in addition to the senior consultant on duty, with the aim of enhancing specialists' practical experience. The department provides practical training in breech delivery, including the implementation of the 'Safe Hands' programme by the Norwegian Society for Gynaecology and Obstetrics', for both specialty registrars and senior consultants. We believe this has yielded positive results. In the period 2004–23, only 21 % of all breech presentations ended in a vaginal delivery, and 62 % of those with a planned vaginal delivery resulted in an emergency caesarean section. We interpret this to mean that the threshold was previously lower for converting a planned vaginal delivery into an emergency caesarean section and/or for planning an elective caesarean section.
Adverse outcomes in our study included an Apgar score < 7 at 5 minutes. This was found in six infants (4 %) planned for vaginal delivery. One infant (0.8 %) had an Apgar score < 7 at 5 minutes after elective caesarean section. These figures are in line with international data (3.0 % and 0.9 %) (3) and with a similar study from Nordland Hospital in Bodø (2.8 % and 0 %) (9). During the same period (2004–23), a total of 1.8 % of all children born in Norway had an Apgar score < 7 at 5 minutes (12). There does not therefore appear to be a significantly higher risk of a low Apgar score with a vaginal delivery or planned caesarean section for breech presentation at Hammerfest Hospital's maternity ward. However, for emergency caesarean sections, the numbers may indicate a potentially higher risk.
No mortality or severe birth-related morbidity was recorded for the newborns, either after caesarean section or vaginal delivery. Nationally, just over 10 % of newborns are admitted to a neonatal unit on average (18). In our data, 4 % of babies born by elective caesarean section, 11 % by emergency caesarean section and 9 % by vaginal delivery were admitted to a neonatal unit. Criteria for transfer to a neonatal unit likely vary between hospitals. Regardless of mode of delivery, breech deliveries at Hammerfest Hospital remain at or below the national average for neonatal unit admissions.
In a recently published study from Södersjukhuset in Stockholm, outcomes were examined for 1067 women with a singleton breech presentation at term (19). They found that infants in the group with a planned vaginal delivery had significantly higher neonatal morbidity based on a composite outcome measure compared to the group with a planned caesarean section (3.1 % vs. 0.7%; odds ratio 4.44, 95 % confidence interval 1.48 to 13.34). There was no difference in the number of infants transferred to a neonatal unit or in the mortality rate. Twenty-one per cent were selected for vaginal delivery, compared to 56 % in our data. Since the Term Breech Trial, the number of vaginal breech deliveries has also seen a substantial decrease in Sweden. The study itself suggests that the historically low number of breech deliveries in Sweden may have impacted on outcomes.
From 2024, the national clinical guidelines for maternity care (20) strongly recommend that vaginal breech deliveries take place at a women's clinic. Hammerfest Hospital has a paediatric department with a neonatal unit and a paediatrician on duty who attends breech deliveries, while the nearest women's clinic is the University Hospital of North Norway in Tromsø. The guidelines permit maternity wards that consider themselves competent to manage conditions normally handled by a women's clinic to confirm this with the obstetrician with clinical responsibility at the women's clinic. Hammerfest Hospital documented and formalised this in a regional selection procedure during the study period.
Although our study population is small, the data span a long period of time. The absence of severe adverse neonatal outcomes in our study does not rule out a potential risk. The weakness of the study is the limited dataset, while the strength is the comprehensive data available for each case.
The national obstetrics guidelines recommend vaginal breech delivery if the selection criteria are met. Our results from the maternity ward at a Norwegian district hospital support this approach but must be interpreted with caution due to the limitations of the data.