Authors' Reply
2
588 Correspondence 17) of those born by caesarean section. The clinical details given of the pregnancies in 1979-1 980, where babies survived with abnor- malities, show that in most of the pregnancies delivered by caesarean section multiple antenatal factors were often present (6 of 9 patients), which would, beforehand, have placed the baby at a high risk of subsequent poorer perinatal per- formance and survival quality. Such factors (ante- partum haemorrhage) were present in only 2 of the 5 babies that were born vaginally. Two breech extractions amongst these five babies are note- worthy. The difference between the groups is further reflected in the overall smaller birth- weights of the babies born by caesarean section. From the obstetric point of view these data do not allow a conclusion on the best mode of delivery. Most babies presenting by the breech at all birthweights are normal with a normal life- potential. The concluding remark of your Com- mentary (Hytten 1982) that ‘it may often be that the baby is presenting by the breech because it is already brain damaged’ thus pertains only to a minority of babies most of which cannot be identified with certainty before birth by the present methods of antenatal risk assessment. In a large case-control study Fianu & Joelsson (1979) showed that in infants with a birthweight of > 2500 g and presenting by the breech, minimal brain dysfunction (hyperkinesia and learning disabilities) was 20 times more common in those born vaginally compared with those born by caesarean section. A baby already compro- mised in zitero needs whatever potential it has protected from further compromise. Without wishing to detract from the dangers of caesarean section to the mother and occasionally to the baby, it seems to us that a policy of abdominal delivery for low birthweight breech infants, com- bined with effective antenatal screening and good anaesthetic and neonatal facilities, may be safer, both as regards survival and survival quality. A finding of no statistical significance in regard to handicap and mode of delivery in the somewhat special case of very low birthweight breech babies reported in the same issue (Kitchen et al. 1982) emphasizes that the case is not proven either way and that further study is needed. R. T. Geirsson, J. Crawford & N. Patel Department of Obstetrics and Gynaecology, University of Dundee Medical School, Ninewells Hospital, Dundee DDl 9SY, UK References Cox, C., Kendall, A. C. & Hommers, M. (1982) Changed prognosis of breech-presenting low birth- weight infants. Br J Obstet Gynaecol89’88 1-886. Fianu, S. & Joelsson, I. (1979) Minimal brain dys- function in children born in breech presentation. Acta Obstet Gynecol Scand 58,295-299. Geirsson, R. T., Namunkangula, R., Calder, A. A. & Lunan, C. B. (1982) Preterm singleton breech pre- sentation: the impact of traumatic intracranial haemorrhage on neonatal mortality. J Obstet Gynaecol2’2 19-223. Hytten, F. E. (1982) Commentary, breech presenta- tion: is it a bad omen? Br J Obsiet Gynaecol 89, Ingemarsson, I., Westgren, M. & Svenningsen, N. W. (1978) Long-term follow-up of preterm infants in breech presentation delivered by caesarean section. Lancet ii, 172-175. Kitchen, W. H., Yu, V. Y. H., Orgill, A. A., Ford, G., Rickards, A., Astbury, J., Ryan, M. M., Russo, W., Lissenden, J. V. & Bajuk, B. (1982) Infants born before 29 weeks gestation: survival and morbidity at 2 years of age. Br J Obstet Gynaecol 89, 887- 891. 879-880. Authors’ Reply Dear Sir, We were interested to read the letter from Dr Geirsson and his colleagues. It seemed to us to give a balanced view of a difficult subject. We would broadly agree with the points made, but feel that some consideration should be given to the overall family background especially in those cases where antenatal data suggest a higher than normal risk of abnormality or pre-existing fetal compromise, and that parents should be involved in the decision making if they so wish. Adoption of a policy of widespread caesarean section for these at-risk babies will undoubtedly reduce obstetricians’ distress while at the same time demonstrating to the patient, and sometimes the neonatal paediatrician, that every effort is being made obstetrically. It may well be that with the impressive advances in neonatal care, caesarean section may confer further benefits on the small baby in breech presentation but this is not yet proven, and we would wholeheartedly endorse Dr Geirsson’s plea for further results particularly from other sub-regional centres. At present, we are lacking the information necessary to give a realistic prog-
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Transcript of Authors' Reply
588 Correspondence
17) of those born by caesarean section. The clinical details given of the pregnancies in
1979-1 980, where babies survived with abnor- malities, show that in most of the pregnancies delivered by caesarean section multiple antenatal factors were often present (6 of 9 patients), which would, beforehand, have placed the baby at a high risk of subsequent poorer perinatal per- formance and survival quality. Such factors (ante- partum haemorrhage) were present in only 2 of the 5 babies that were born vaginally. Two breech extractions amongst these five babies are note- worthy. The difference between the groups is further reflected in the overall smaller birth- weights of the babies born by caesarean section. From the obstetric point of view these data do not allow a conclusion on the best mode of delivery.
Most babies presenting by the breech at all birthweights are normal with a normal life- potential. The concluding remark of your Com- mentary (Hytten 1982) that ‘it may often be that the baby is presenting by the breech because it is already brain damaged’ thus pertains only to a minority of babies most of which cannot be identified with certainty before birth by the present methods of antenatal risk assessment. In a large case-control study Fianu & Joelsson (1979) showed that in infants with a birthweight of > 2500 g and presenting by the breech, minimal brain dysfunction (hyperkinesia and learning disabilities) was 20 times more common in those born vaginally compared with those born by caesarean section. A baby already compro- mised in zitero needs whatever potential it has protected from further compromise. Without wishing to detract from the dangers of caesarean section to the mother and occasionally to the baby, it seems to us that a policy of abdominal delivery for low birthweight breech infants, com- bined with effective antenatal screening and good anaesthetic and neonatal facilities, may be safer, both as regards survival and survival quality. A finding of no statistical significance in regard to handicap and mode of delivery in the somewhat special case of very low birthweight breech babies reported in the same issue (Kitchen et al. 1982) emphasizes that the case is not proven either way and that further study is needed.
R. T. Geirsson, J. Crawford & N. Patel
Department of Obstetrics and Gynaecology, University of Dundee Medical School,
Ninewells Hospital, Dundee DDl 9SY, UK
References
Cox, C., Kendall, A. C. & Hommers, M. (1982) Changed prognosis of breech-presenting low birth- weight infants. Br J Obstet Gynaecol89’88 1-886.
Fianu, S. & Joelsson, I. (1979) Minimal brain dys- function in children born in breech presentation. Acta Obstet Gynecol Scand 58,295-299.
Geirsson, R. T., Namunkangula, R., Calder, A. A. & Lunan, C. B. (1982) Preterm singleton breech pre- sentation: the impact of traumatic intracranial haemorrhage on neonatal mortality. J Obstet Gynaecol2’2 19-223.
Hytten, F. E. (1982) Commentary, breech presenta- tion: is it a bad omen? B r J Obsiet Gynaecol 89,
Ingemarsson, I., Westgren, M. & Svenningsen, N. W. (1978) Long-term follow-up of preterm infants in breech presentation delivered by caesarean section. Lancet ii, 172-175.
Kitchen, W. H., Yu, V. Y. H., Orgill, A. A., Ford, G., Rickards, A., Astbury, J., Ryan, M. M., Russo, W., Lissenden, J. V. & Bajuk, B. (1982) Infants born before 29 weeks gestation: survival and morbidity at 2 years of age. Br J Obstet Gynaecol 89, 887- 891.
879-880.
Authors’ Reply Dear Sir, We were interested to read the letter from Dr Geirsson and his colleagues. It seemed to us to give a balanced view of a difficult subject.
We would broadly agree with the points made, but feel that some consideration should be given to the overall family background especially in those cases where antenatal data suggest a higher than normal risk of abnormality or pre-existing fetal compromise, and that parents should be involved in the decision making if they so wish.
Adoption of a policy of widespread caesarean section for these at-risk babies will undoubtedly reduce obstetricians’ distress while at the same time demonstrating to the patient, and sometimes the neonatal paediatrician, that every effort is being made obstetrically.
It may well be that with the impressive advances in neonatal care, caesarean section may confer further benefits on the small baby in breech presentation but this is not yet proven, and we would wholeheartedly endorse Dr Geirsson’s plea for further results particularly from other sub-regional centres. At present, we are lacking the information necessary to give a realistic prog-
Correspondence 5 89
nosis for the outcome in low birthweight babies and for the benefits or otherwise of routine caesarean section.
Charles Cox Senior Registrar,
Obstetrics and Gynaecology, Coventry Maternity Hospital,
Walsgrave, Coventry CV2 2DX
A. C. Kendall, Consultant Paediatrician,
Coventry Hospitals Marion Hommers
Specialist in Community Medicine (Child Health),
Coventry Area Health Authority, Spire House,
New Union Street, Coventry CVI 2PT, UK
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