436 SPO Abstracts

507 FETAL ACOUSTIC STIMULATION TO REPOSITION 7:HE FETUS IN DIFFICULT EXTERNAL CEPHALIC VERSIONS. R. Johnson, T. strong, T. Radin', J. Elliott. Phoenix Perinatal Associates and Good Samaritan Regional Medical Center, Phoenix, AZ. OBJECTIVE I To determine whether fetal acoustic stimulation (FAS) is useful i n external cephalic version in patients whose fetus is in a midline poSition with fetal spine anterior. STUDY DESIGN: Patients with an initial failed attempt at external cephalic version with a midline breech presentation with the fetal spine anterior were enrolled in the study . A second version was attempted after consent was obtained . If that attempt failed, an electrolarynx device was used to present a one to three second stimulus to the maternal abdomen over the fetal vertex . The position of the fetus after the stimulue was determined and a third version attempt was made. RESULTS: Sixteen patients qualified for the study. Sixteen of 16 responded to FAS with position change (to spine lateral). There were 0/16 position changes without FAS. Following FAS 15/16 (94%) of fetuses were successfully converted to vertex presentation . Twelve patients have delivered (10 vaginally). CONCLUSION I FAS has altered fetal position in 100% of patients from spine anterior to lateral. Version was successful in 15/16 patients who had previously failed two version attempts.

508 IMhEDIATE NEONATAL OUTCOME OF VAG I NAL BREECH DELIVERY AT TEru~ IN OXYTOCIN STlllULATED LABOR. h. Giiaovsky , J.F.O'Graciy, E. Ke r oac k, Dept. of Ob/Gyn, Baystate i·iedical Cent er, Sprinbfield hA OBJECTIVE: The null hypothes i s i s tha t oxytocin s ti[,lula tion in term breech l abo r is not related t o increased neonatal r isk . STUDY DES I GN: 36 infant s bo rn by ass i s ted vaE;inal breech delivery a t ten" were t he sub­j ec t s of this study . Labor and del ivery was direc t ed by a preVious l y desc r ibed sel ec tive cana5ement pr o t ocol. 18 neonates wer e del i ver ed after oxy t oc in s t i mula t ed labor. 12/1 8 und er­went a U5ment a tion . 18 neona t es wer e born aft er spont an eous l a bor. Out come was assessed by co r d bas, APGAR sco r es, r esuscita t ion measures and t he ne ed / duration of N ICU admi ssion . St atis­tical a nalysis was by x2 wi t h Ya t e s modifica­tion and Fisher's exact test as appropriate. RESULTS: There was no statis tica lly s i5nificant difference in the outcome measures bet ween the br ouPS . There was a tr end t o mo r e frequent and lone;er iHCU adm i s sion amon;; neona t es deliver ed af t e r oxyt oc in aU5men tation . CONCLUS IONS: Va b inal breech deliv e r y af t er oxy t ocin induc tion r esul ted i n n eona t a l out come in~ istin5uishable fr om t ha t seen af t er sponta ­neous ci e liver y . Oxy t ocin a ugmen t a t ion [,lay be associated with wo r e f requen t adverse ou t comes .

J anuar y 1993 Am J Obste t G ynecol

509 BREECH DELIVERY AT TERM - A CRITICAL REVIEW AND META­ANALYSIS OF PUBLISHED STUDIES. ~', M. Hannah. Dept.Ob I Gyn, Women's College Hospital, Univ. ofToronto, Ontario, Canada. OBJECTIVE: Despite an attempt to lower cesarean section rates, an increasing proportion of women with breech presentation at term is deliv­ered by elective cesarean section. This critical review and meta·analysis aims to find out whether planned vaginal delivery or elective cesarean sec­tion is better for singleton term breech infants.

510

STUDY DESIGN: All papers published in English between 1966 and March 1992 were reviewed. Studies which included singleton term preg· nancies with breech presentation and pr~sented results according to the intended mode of delivery were analyzed. A typical odds ratio was caleu­lat~ for ~ach of the following adverse outcomes: perinatal mortality, low Apgar score at 5 minutes, neonatal birth trauma, overall short-term neona­tal morbidity, long-term infant morbidity and maternal morbid ity. RESULTS: Among 79 papers reviewed, twenty-one fulfilled the criteria of this study. These 21 studies included two prospective randomized trials, 6 prospective and 13 retrospective cohort studies. Sample sizes ranged from 51 to 1779. Corrected perinatal mortality was higher for babies in the planned vaginal delivery groups than for those in the planned cesarean section groups I typical odds ratio (95% Confidence Interval [CII) = 3.87 ( 2 .07 to 7.23 )}. Neonatal birth trauma and overall short-term neonatal morbidity were also higher for those in the planned vaginal delivery groups I typical odds ratio (95% CI) = 3.72 (2.58 to 5.37) and 2.57 ( 1.77-3.73) respectively}. CONCLUSIONS: The results suggest that planned vaginal delivery is asso­ciated with a perinatal morbidity and mortality rate which is 3 to 4 times that associated with elective cesarean section. However, due to the non­experimental nature of the majority of the studies, a large randomized trial would be necessary to eliminate selection bias and to substantiate the effectiveness of elective cesarean section versus planned vaginal delivery for the term breech.

EffECT Of PARITY mI IUl.TERIIAl. AlII IlEmlATAI. CllTIDIE II SELECTIVE VACllIAl. IREECil DELIVERY_ Daniel Gauthier Ill, Anne Lipinski IIlx Depart....,t of Ob/Gyn, St. Mary's Hospital, Milwaukee, WI. OBJECTIVE: Breech presentation in the null iparous (NP) patient is cons idered an incHcation for cesarean section (CS) by many obstetricians. The purpose of this study was to determine if null ipar ity had an adverse effect on maternal and neonatal outcome in selective vaginal breech del ivery (SVBD). STillY DESIGII: A retrospective analysis of all singleton breech de l iveries ~ 34 week.s gestation during a 12 year period was perforllled. All patients managed by SVBD (in wh i ch route of de-l ivery was determined after evaluation of fetal weight, head pos i tion and maternal pelvis) and NP pat i ents who underwent elective CS for breech presentat i on were included inzthe study. Maternal and neonatal outcomes were c~red using)( analysis and Fi sher'S ~xact test (p < 0 _05 considered significant). RESlILTS: During the study period , 821 singleton breech del i v­eries ~ 34 weeks occurred, of wh i ch 456 were in NP patients . Elect ive CS was perfornoed on 143 NP patients (41%). 271 NP pat ients (59%) and 202 .... ltiparous (HP) pat ients (55%) were managed by SVBD_ Vaginal del i very rate i n NP patients and HP pat ients managed by SVBD were 52% (141/271) and 60% (121/202) respectively. Given a trial of labor, 87X (141/163) of NP patients and 88% (121/137) of MP patients del ivered vaginally. Maternal and neonatal outcome of NP managed by SVBD, MP man­aged by SVBD, and NP managed by elective CS are outl ined below.

Maternal Morbi di ty 5 minute Birth Neonatal N Infect Non-Inf Apgar <7 TralJllll Mortal Ity

NP -SVBD 271 32(12%) 6(2.2%) 6 (3)* 4(2VD,2CS) 3 (0)* HP-SVBD 202 21(10%) 5(2.5%) 9 (4)* 2(1VO,1CS) 7 (1)* NP-ECS 143 37(26%) 7(4.9%) 7 (2)* 1 3 (0)* *C ) -Corrected for congenital anomal i es , single case of !Steor­rected neonatal "",rtality due to Gr"'4' 8 Str~ptococcus sepsis . alIIClUSlmlS: Mat~rnal and neonatal "",rbid i ty was not increased in NP pat i ents ... naged by SVBD when c~r~ to HP pat i ents managed by SVBD . No di fference in advers~ neonatal outc"",,, was seen in NP patients who delivered vaginally when cOfI1)8red to those managed by elective CS but there was a significant in­creaSe in maternal morbidi ty in the latter group (p < 0.001).