The gentle caesarean section (GCS) is a woman-centred technique described by Smith et al (2008) as an improvement for the conventional caesarean section (c-section). The GCS aims to optimise several aspects of a conventional c-section, to mimic a vaginal delivery. This is with a view to improving the mother's experience and decreasing morbidity for both mother and child. If there is a necessity for a c-section then, when possible, a GCS is increasingly frequently performed. Parental request for a GCS is also growing.
Reasons for a c-section in general should be an impossibility of a vaginal birth or an unacceptable increased health risk for the mother or the child in the case of vaginal birth (Hannah et al, 2000). The c-section involves several disadvantages and risks compared to a vaginal birth; neonatal morbidity is increased, for example, neonatal respiratory complications such as transient tachypnoea, admission to the paediatric ward, and less successful breastfeeding. Also, several maternal morbidities, such as postpartum infections and a longer admission to the hospital are more common in cases of a c-section (Villar et al, 2007; Moore et al, 2016; World Health Organization [WHO], 2018). Women undergoing a c-section may have a less satisfactory childbirth experience.
The purpose of a GCS is to simulate several aspects of a vaginal birth, in order to optimise the wellbeing of both the mother and child. One of the important aspects of a GCS is the hands-off method (Smith et al, 2008). When the head of the child enters the abdominal incision, the parents are able to observe the birth of their child. The principle for the surgeon is hands-off, giving time for autoresuscitation while the uterus contracts, which helps expelling amniotic fluid out of the lungs, mimicking vaginal birth. Other aims of the GCS are increasing parental engagement, and direct skin-to-skin contact between mother and child (Klaus et al, 1972; Okan et al, 2010; Bigelow et al, 2012; Cooijmans et al, 2017). Another aim of the GSC is initiating breastfeeding within the first hour after birth (Smith et al, 2017; Chen et al, 2018). This is initiated during skin-to-skin contact, directly after the neonate is born. These aims increase the wellbeing and decrease the morbidity of mother and child.
No increase in adverse maternal and neonatal outcome measures compared to conventional c-section has been shown. Moreover, a shorter postoperative maternal recovery time and hospital admission and a decrease in neonatal admissions to the paediatric ward were associated with the GCS (Posthuma et al, 2016).
In the case of breech presentation, a GCS is performed at the University Medical Centre Groningen (UMCG) when the inclusion criteria are met. To the authors' knowledge, there are no published data on the maternal and neonatal outcome of a GCS for breech presentation.
The aim of this study was to analyse several maternal and neonatal outcome measures, in case of a cephalic presentation versus a breech presentation, delivered by a GCS. The hypothesis was that there would be no significant differences in maternal and neonatal outcome measures performing a GCS for cephalic versus a breech presentation.
Methods
Study design
This single centre retrospective study was conducted at the department of obstetrics and gynaecology of the UMCG. As Dutch obstetrical organisation is quite peculiar, our centre, as a third-line referral hospital, only takes care of pregnancies with a presumed (prenatally or antenatally) or definitive high risk. The centre supervises around 1600–1800 deliveries annually, of which roughly 50% is low/high risk and 50% is tertiary level. In December 2013, the centre began performing the GCS when possible for the low-risk population. Data from women and their newborns were derived from the electronic hospital patient files. Data were stored anonymously in a separate file for analysis. Approval and informed consent of the Medical Ethics Review Board of the UMCG was exempted, as the extraction of clinical data was done retrospectively and stored anonymously.
Sample
Patient files from women who met the inclusion criteria and underwent a GCS in the UMCG and their neonates between December 2013 and November 2018 were analysed.
Inclusion criteria for a planned or primary GCS were healthy mothers with healthy fetuses, singleton pregnancies and a gestational age above 39 weeks.
Inclusion criteria for a secondary GCS were the same, except for the gestational age being above 37 weeks, as long as labour started spontaneously. The gestational age of women with a secondary c-section after induction of labour had to be above 39 weeks.
Exclusion criteria for both primary and secondary GCS, besides the criteria for gestational age, were an estimated weight below the 10th growth percentile (p10) or above 90th growth percentile (p90), maternal insulin use, suspicion of fetal distress and congenital anomalies. A total of 180 women received a GCS in this period, from which there were 120 neonates in cephalic presentation and 60 neonates in breech presentation.
Outcome measures
The differences between outcome measures were analysed, comparing cephalic presentation to breech presentation. Several outcome measures were analysed, both maternal and neonatal. Neonatal outcome measures were 1-minute, 5-minute and 10-minute Apgar scores, temperature, birthweight, lowest glucose values, cord blood pH. Measurements for neonatal morbidity, were glucose values <2,7 mmol/l, mild and severe hypothermia, hyperbilirubinemia, infection, fever (>38°C), deviating weights (<p10 or >p90), pH<7,0 and mortality. The need to consult the paediatrician during the GCS or afterwards, admission to the maternity ward or neonatal intensive care unit and any postnatal complications as a result of transitional problems were also ascertained. The maternal outcome measures were blood loss during the c-section, type of feeding, fever during and after admission and a prolonged hospital admission.
Statistical analysis
For continuous normal deviated variables, the difference between groups was presented as mean with standard deviation. Continuous non-normal distributed variables were presented as median and a minimum and maximum. Dichotomous or categorical variables were presented as a number with its percentage. Continuous, normal distributed data were tested with a t-test for independent samples, and continuous, non-normal deviated data were tested with a non-parametric Mann-Whitney U test. The categorical data were analysed with a Chi-square test. A P value of <0.05 was considered statistically significant. Analysis was performed using the Statistical Package for Social Sciences (SPSS) 23.
Results
A total of 180 women with a GCS were included in this study, where 60 (33%) were breech presentation and 120 (67%) were cephalic presentation. Most of the aims of a GCS were achieved in the cases with a breech presentation, except for the hands-off method. This means waiting for a contraction of the uterus after the head is born and allowing the neonate some time during birth, thereby mimicking a vaginal birth and allowing compression of the thorax for autoresuscitation. This is not feasible with a breech position. Breastfeeding within the first hour is offered and tried in all cases, but not always achieved or wanted by the mother.
Neonatal outcome
Neonatal outcome, morbidity, and admission are presented in Table 1. Only the 1-minute Apgar score was significantly lower for breech presentation, with a median of nine, compared to a cephalic presentation (P=0.019). These Apgar 1 scores were significantly different, despite equal medians in both groups. The result of the Mann-Whitney test reflected the difference in minimum values in both groups; in the breech group, the minimum Apgar was 2, while in the cephalic group, the minimum was 5. As the Apgar score was not an equally deviated value, a significant difference was seen, despite equal medians.
Table 1. Neonatal outcome
| Characteristics | Breech position (n=60) | Cephalic position (n=120) | P value |
|---|---|---|---|
| Neonatal outcome | |||
| 1-minute Apgar (med, min, max) | 9 (5,10) | 9 (2, 10) | 0.019 |
| 5-minute Apgar (med, min, max) | 10 (8, 10) | 10 (6, 10) | 0.234 |
| Apgar score <7 at 5 minutes (n, %) | 0 (0) | 1 (0.85) | 1.000 |
| 10-minute Apgar (med, min, max) | 10 (8, 10) | 10 (8, 10) | 0.228 |
| Temperature (°C ± SD) | 36.8 (±0.36) | 36.9 (±0.39) | 0.046 |
| Birthweight (gram ± SD) | 3413 (±396) | 3576 (±387) | 0.009 |
| Lowest glucose (mmol/L ± SD) | 2.92 (±0.47) | 3.01 (±0.47) | 0.623 |
| Arterial pH (mean ± SD) | 7.23 (±0.08) | 7.24 (±0.07) | 0.369 |
| Arterial BE (mean ± SD) | -3.76 (±2.61) | -3.40 (±2.29) | 0.457 |
| Venous pH (mean ± SD) | 7.30 (±0.05) | 7.31 (±0.06) | 0.397 |
| Venous BE (mean ± SD) | -3.22 (±1.75) | -3.11 (±2.11) | 0.795 |
| Neonatal morbidity | |||
| Postnatal complications (n, %) | 2 (3.3) | 4 (3.3) | 1.000 |
| Glucose <2,7 (n, %) | 2 (3.3) | 5 (4.2) | 1.000 |
| Hypothermia (36.0<36.4) (n, %) | 12 (20) | 14 (12) | 0.072 |
| Severe hypothermia (<36.0) (n, %) | 1 (1.7) | 0 (0) | N/A |
| Hyperbilirubinemia (n, %) | 0 (0) | 0 (0) | N/A |
| Infection (n, %) | 1 (1.7) | 0 (0) | N/A |
| Fever (>38 °C) (n, %) | 0 (0) | 0 (0) | N/A |
| Small for gestational age (<p10) (n, %) | 6 (10) | 2 (1.7) | 0.017 |
| Birthweights p10<p90 (n, %) | 51 (85) | 97 (81) | 0.577 |
| Macrosomia (>p90) (n, %) | 3 (5.0) | 20 (17) | 0.027 |
| pH<7,0 (n, %) | 0 (0) | 0 (0) | N/A |
| Death (n, %) | 0 (0) | 0 (0) | N/A |
| Neonatal admission | |||
| Admission NICU (n, %) | 0 (0) | 4 (3.3) | 0.303 |
| Consulting paediatrician (n, %) | 4 (6.7%) | 10 (8.3) | 0.777 |
Characteristics with more than 5% missing data: lowest glucose, arterial pH, arterial BE, venous pH and venous BE.
Note: med=median, min=minimum, max=maximum, N/A=not applicable, SD=standard deviation, NICU=neonatal intensive care unit
Neonatal temperature was also significantly lower for breech presentation (36.8 ± 0.36) compared to cephalic presentation (36.9 ± 0.39), where P=0.046. There was one case of severe neonatal hypothermia (<36.0°C). This was a neonate in breech position with an unexpected low birthweight (<p10) and was also postnatally admitted for a suspected infection. Birthweight was significantly different between the two groups, in disadvantage of breech presentation (P=0.009). Six (10%) neonates at breech presentation were <p10 compared to two (1.7%) in cephalic presentation (P=0.017). Furthermore, there were three (5.0%) neonates in breech presentation, with a birthweight >p90 vs 20 (17%) in cephalic presentation, P=0.027. Besides the outcome measures mentioned above, there were no significant differences in neonatal outcome measures between breech and cephalic presentation.
Maternal outcome
The maternal outcome data are presented in Table 2. There was significantly more blood loss in cephalic presentation (441 ± 230) compared to breech presentation (353 ± 151), P=0.002. Besides blood loss, there were no significant differences in maternal outcome measures between breech and cephalic presentation.
Table 2. Maternal outcome
| Characteristics | Breech position (n=60) | Cephalic position (n=120) | P value |
|---|---|---|---|
| Blood loss (mL ± SD) | 353 (± 151) | 441 (± 230) | 0.002 |
| Breastfeeding (n, %) | 37 (62) | 58 (48) | 0.091 |
| Bottle feeding (n, %) | 13 (22) | 43 (36) | 0.053 |
| Breastfeeding with supplementary (n, %) | 10 (17) | 19 (16) | 0.886 |
| Fever during admission (n, %) | 1 (1.6) | 3 (2.5) | 1.000 |
| Fever after admission (n, %) | 0 (0) | 0 (0) | N/A |
| Admission days (mean ± SD) | 3.65 (± 1.57) | 3.66 (± 0.86) | 0.939 |
N/A=not applicable; SD=standard deviation
Discussion
This study shows that there are no clinically significant differences for a GCS between a cephalic and breech presentation of the fetus. To the authors' knowledge, this is the first study presenting results on maternal and neonatal outcome concerning a GCS for breech presentation vs a cephalic presentation.
Strengths and limitations
This study has a number of limitations. First, the patient group is relatively small. Second, the retrospective design of this study has its limitations, such as missing information. Third, the use of patient files without pre-specified definitions, could possibly under- or overestimate certain outcome values. However, this study concentrated on clinically important outcome data, which are routinely collected. Also, it is likely that missing data and the under- or overestimated outcome are equally distributed between the cephalic and breech presentation, and therefore are not likely to have influenced the comparisons.
Interpretation
There was a significant difference in the 1-minute Apgar score. A neonate in breech presentation has a significantly lower 1-minute Apgar score than a neonate in cephalic presentation. However, there was no difference in the 5-minute and 10-minute Apgar scores, and there was no difference in the 5-minute Apgar scores below seven.
The hands-off method, which is distinctive for the GCS and involves waiting for a contraction of the uterus after the head is born and allowing the neonate time for autoresuscitation, is less applicable for a breech position. Still, there is a quick recovery within five minutes for breech position, as none of the neonates in breech position had a 5-minute Apgar score below seven. There was also no difference in admission to the paediatric ward or consulting the paediatrician between the two groups. Therefore, it seems safe to start skin-to-skin contact as early as possible for the neonate in breech position.
Birthweight was significantly lower at breech presentation. Although fetal growth is a complex feature, one of the reasons for the difference in birthweight could be that macrosomia may be a primary reason to perform a planned GCS for a fetus in cephalic presentation. For a breech presentation, the presentation itself may be the primary reason for a GCS. So, it is not striking that there were more neonates in cephalic presentation with a larger gestational age/macrosomia. Also, from previous research, a breech presentation is known to have an association with low birthweight and growth restriction (Cammu et al, 2014; Hofmeyr et al, 2015; Zsirai et al, 2016).
The first measured neonatal temperature was significantly lower in breech presentation than cephalic presentation. This could be explained by the differences in birthweight. Being small for gestational age is a risk factor for less optimal temperature regulation (Finken et al, 2018). Another reason for a significant difference in neonatal temperature might be that GCS for breech position were mostly planned and the mothers were not in labour. In the cephalic group, a significant number of the cases were already in labour. A mother in labour is giving effort, which increases her body temperature and possibly also the body temperature of the neonate (Schouten et al, 2008).
Maternal blood loss was significantly higher for cephalic presentation. This is could be explained by the differences in birthweight. As mentioned above, birthweight was significantly higher for cephalic presentation. Macrosomia is a risk factor for more maternal blood loss in labour (Bonnet et al, 2013, Kamana et al, 2015).
Conclusions
In conclusion, when performing a GCS, there is no clinically relevant significant difference in outcome measures between cephalic and breech presentation, because of the GCS, and so it seems safe to perform the GCS for a breech presentation. The hands-off, woman-centred technique of the GCS has proven benefits. It contributes to a more physiological recovery for the mother and neonate. Also, early skin-to-skin contact is achieved, with all its positive effects. Therefore, breech position should not rule out performing a GCS.
A prospective study with a bigger sample size for the breech will be a valuable addition to the data, because more settings are performing the GCS and there are no publications on this topic. Moreover, the c-section is, for breech position, one of the most common surgical procedures performed in the world.
Key points
- The gentle caesarean section has proven positive effects in comparison to the conventional caesarean section
- The principles of a gentle caesarean section can be partially achieved in cases of breech position
- There are no adverse outcomes for breech position resulting from gentle caesarean section, so it seems safe to perform a gentle caesarean section in case of a breech presentation
- Inclusion and exclusion criteria should be clearly protocolised.