‘Mother’s wish/fear of birth’ was the second most frequent indication in the ‘planned caesarean section’ group during both periods. These women meet the selection criteria for vaginal delivery, but do not wish or are afraid to give birth vaginally if the fetus presents in a breech position (20).
Pregnant women may be anxious about vaginal breech deliveries due to information received through the media or from healthcare personnel. It is therefore important that all information provided about outcomes is correct, and that details are accurate in respect of the facilities available at the maternity unit concerned (24).
The percentage share of caesarean sections based on ‘mother’s wish/fear of birth’ is relatively similar in the two periods. This may suggest that the pregnant women have received no new evidence-based information. Alternatively, they dare not trust the new results.
What influences a low Apgar score?
Our analyses show that there were higher odds of giving birth to an infant with a low Apgar score in the ‘planned vaginal delivery’ group compared to the ‘planned caesarean section’ group. There were few newborn infants with a low Apgar score, which may explain the wide confidence interval. Our analysis adjusted for gestation period and mother’s age.
Our material did not include enough details or sufficiently good data to examine other factors that may influence the Apgar, such as a high body mass index (25) or mother’s smoking habits (26). The results must therefore be interpreted in this light.
A low Apgar score may suggest that the well-being of the newborn is below optimal immediately after delivery, which is therefore an undesirable outcome (27). A low Apgar score may be associated with underlying factors, maternal or fetal illness, or pregnancy complications, or it may be associated with the delivery, or the fact that the fetus presented in a breech position.
For newborn infants with an Apgar score of <7 at 5 minutes after birth, there may often be a brief period before the infant recovers (19). A poorer prognosis is expected for those with an Apgar score of <4 at 5 minutes, and they will probably need a period of observation and/or treatment after birth (15).
The risk of a low Apgar score in connection with breech delivery has been described in several studies (19, 20, 27), but this risk has been approached in different ways. In Norwegian (20, 26) and Finnish studies (19) the risk is recognised, but selecting certain pregnancies for planned vaginal delivery is still the recommended practice.
An important point in this context is that the researchers found no differences after two years, despite the increased risk of mortality and morbidity among those who had a planned vaginal delivery in the TBT study (29). Although we saw a change in clinical practice with respect to the planned mode of delivery during the study period, there was no difference in the percentage share of infants with a low Apgar score when the period was split into two.
Strengths and weaknesses of the study
The maternity unit at Ullevål Hospital is the largest in Norway, thus providing a sizeable volume of material for our study. It is a strength that the data were obtained from the unit’s registry of births, which has been subjected to multiple quality control procedures in order to ensure that the records are correct. Apgar scores are important and useful assessments of outcomes for newborn infants immediately after birth (30).
However, the weakness of the Apgar score as a method is the fact that it is based on a subjective assessment. A supplementary blood gas analysis of the umbilical cord pH would have given a more objective answer to whether, and to what extent, the fetus has been exposed to stress during birth (31). The data from Ullevål included recorded blood gas analyses for 40 per cent of deliveries in the ‘planned vaginal delivery’ group, so umbilical cord pH could not be used to measure outcomes.
Another weakness associated with the registry data is the absence of follow-up data about the well-being of infants with a low Apgar score. The methods used in our analyses require independent data. We have not allowed for a potentially increased dependency between observations made in 2000 and 2001, for example, compared to observations made in 2000 and 2006.
Our analysis of the clinical practice at Ullevål with respect to modes of delivery for women with breech presentation shows that practice may have been influenced by the results of the Term Breech Trial (TBR), which were published in 2000. In 2007 we saw a beginning return to pre-TBT practice, although the percentage share of planned vaginal deliveries never reached the same heights as before the study.
We found a larger percentage share of infants with a low Apgar score at 5 minutes if the mother was in the group selected for a planned vaginal delivery, and if the infant was born before full term. Despite changes in clinical practice during the study period, there was no difference with respect to the number of infants with a low Apgar score when the study period was split into two.
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