Perinatal mortality in breech presentation sibships

OBJECTIVE: To compare perinatal mortality in breech presentation delivered vaginally and by cesarean in individual births and in sibships. METHODS: A national, population registry-based study, 1967-1994, was conducted, with maternal record linkage of sibships, comprising the first to the third birth of a mother. The main outcome was perinatal mortality. Odds ratios of perinatal mortality were calculated and adjusted by logistic regression analysis. RESULTS: The overall relative perinatal mortality was 4.3 (95% confidence interval [CI] 4.1, 4.5) in breech compared with nonbreech presentation and 5.4 (95% CI 4.7, 6.2) in vaginal compared with cesarean delivery. The relative perinatal mortality in breech compared with nonbreech presentation was lowest in birth order one compared with birth orders two and three. In breech vaginal delivery compared with cesarean delivery, the opposite effect of birth order was found. The highest perinatal mortality was found in a current breech presentation of a sibship with no previous breech births. In birth subsequent to breech births, perinatal mortality was more or less independent of current presentation, without respect to delivery method. The increased perinatal mortality in breech presentation is explained partly by its association with other risk factors for perinatal death. CONCLUSION: Women with recurring breech presentation represent a lower risk of adverse perinatal outcome. This might be explained by a biologic mechanism or by increased quality of antenatal care. An increased mortality in subsequent nonbreech siblings after a breech presentation was surprising.     

Perinatal mortality and route of delivery in term breech presentations

OBJECTIVE: To compare intrapartum related infant mortality in term (> 34 weeks) breech presentations in relation to vaginal delivery or delivery by caesarean section. DESIGN: Register based nationwide study. SETTING: Sweden from 1991 to 1992. PARTICIPANTS: 6542 singleton fetuses born in the breech presentation. MAIN OUTCOME MEASURES: Intrapartum and early neonatal deaths, stillbirths and congenital malformations, low Apgar score < 7 at 5 min, mode of delivery. RESULTS: After exclusion of antepartum stillbirths and congenital malformation, the intrapartum and early neonatal mortality rate was 2/2248 (0.09%) in the group delivered vaginally and 2/4029 (0.05%) in the group delivered by caesarean section. The relative risk was 1.81 (95% CI 0.26-12.84). Thus the difference was not statistically significant. This result was further supported after reviewing individual cases. CONCLUSIONS: The intrapartum related mortality in the group delivered vaginally was low and the result could not verify an increased mortality in term breech presentations delivered vaginally compared with those delivered by caesarean section.     

Management of term breech presentation: a protocol of external cephalic version and selective trial of labor

OBJECTIVE: The results of a program of external version and selective trial of labor for term breech presentation are reviewed. This is a follow-up to our 1987 report describing management of singleton, term breech presentations and expands our 16-year experience to 1180 cases. STUDY DESIGN: All term breech presentations cared for in 1985 through 1992 are reviewed and outcome contrasted with those predicted in our earlier report. During these 8 years a trial of external version was offered if a breech presentation was identified after 36 completed weeks' gestation and before active labor. The criteria for allowing a trial of labor are detailed. RESULTS: Four hundred sixty-four breech presentations were identified for review. Three hundred eighty-two (82%) were diagnosed before active labor. Of these, 344 (90%) underwent an attempt at external version, of which 174 (51%) were successful. The 290 breech presentations where version either was not attempted or was unsuccessful were stratified into three groups: cesarean section without labor (147), trial of labor with cesarean section (90), and trial of labor with vaginal delivery (53). The 174 cases where version was successful were stratified into two additional groups on the basis of the eventual route of delivery. Careful review of maternal and fetal variables indicates that a trial of labor in selected patients resulted in vaginal delivery in only 37% but was achieved without an increase in fetal or maternal mortality or morbidity. Surprisingly, 54 of the 174 cases where version was successful were ultimately delivered by cesarean section. This 31% rate of cesarean delivery is significantly higher than the 15% rate observed for all cases of term, singleton vertex presentation. A higher prevalence of cases complicated by failed progress in labor and failed induction contributed to the excess. CONCLUSION: External version is successful in 51% of cases of term breech presentation. With careful selection, cases where version has failed can be allowed to labor and be delivered vaginally. The incidence of cesarean section (31%) for those cases where version had been successful was surprisingly high, largely because of an increase in labor abnormalities and failed labor inductions.     

Perinatal death associated with planned home birth in Australia: population based study

OBJECTIVE: To assess the risk of perinatal death in planned home births in Australia. DESIGN: Comparison of data on planned home births during 1985-90, notified to Homebirth Australia, with national data on perinatal deaths and outcomes of home births internationally. RESULTS: 50 perinatal deaths occurred in 7002 planned home births in Australia during 1985-90: 7.1 per 1000 (95% confidence interval 5.2 to 9.1) according to Australian definitions and 6.4 per 1000 (4.6 to 8.3) according to World Health Organisation definitions. The perinatal death rate in infants weighing more than 2500 g was higher than the national average (5.7 versus 3.6 per 1000: relative risk 1.6; 1.1 to 2.4) as were intrapartum deaths not due to malformations or immaturity (2.7 versus 0.9 per 1000: 3.0; 1. 9 to 4.8). More than half (52%) of the deaths were associated with intrapartum asphyxia. CONCLUSIONS: Australian home births carried a high death rate compared with both all Australian births and home births elsewhere. The two largest contributors to the excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy and breech presentation, and a lack of response to fetal distress.     

Cesarean section: medical benefits and costs

Cesarean section rates have risen dramatically in the U.S. over the past 20 years. Although infant mortality has declined during the same period, there is little evidence that more frequent cesarean surgery is the cause. Cesareans save lives or benefit health in certain circumstances, but the incidence of those indications has not increased. Cesarean section also has risks, the most significant for the infant being iatrogenic prematurity or respiratory disease. Maternal mortality is 2-4 times higher and morbidity is 5-10 times higher after a cesarean compared to vaginal birth. The four indications responsible for most of the rise in cesarean rates--previous cesarean, dystocia, breech presentation, and fetal distress--are those conferring the least clear-cut benefit. Demographically, women who are most likely to experience pregnancy complications, low birth weight births, or infant mortality are least likely to have a cesarean. Social, economic, and other factors seem to have a greater influence on the decision to perform a cesarean than does expected medical benefit. The development of neonatal intensive care, expanded access to prenatal care, and greater availability of abortion and family planning have contributed more to falling infant mortality. It has been estimated that approximately half the cesareans currently performed in the U.S. are medically unnecessary, resulting in considerable avoidable maternal mortality and morbidity, and a cost of over $1 billion each year.     

Neonatal morbidity and mortality associated with triplet pregnancy

OBJECTIVE: To compare neonatal morbidity and mortality in a large cohort of triplet pregnancies with singleton and twin neonates managed at a single tertiary center over a short time. METHODS: Records from all triplet pregnancies managed and delivered from 1992 to 1996 were reviewed for neonatal outcome data. Pregnancies delivered before 20 weeks' gestation and neonates with lethal congenital anomalies were excluded. The comparison group comprised all singleton and twin neonates managed in the same neonatal intensive care unit (NICU) during the same period. RESULTS: During the 5-year period, 55 triplet pregnancies and their resulting 165 neonates were managed and delivered at this center. Their outcomes were compared with those of 959 singleton and 357 twin neonates born at similar gestational ages. The median gestational age at delivery for triplets was 32.1 weeks, and 149 of the 165 infants were admitted. Sixteen triplet neonates were not admitted to our neonatal intensive care unit, 12 because of previable gestational age, three because of stillbirth, and one because of a lethal congenital anomaly. The crude perinatal mortality rate in triplets was 121 per 1000 births, and there was no significant difference in outcome based on triplet birth order. There were no significant differences in survival rates between singleton, twin, and triplet neonates, with an overall neonatal survival of 95%, 95%, and 97%, respectively. The only significant differences in morbidity were an increased incidence of mild intraventricular hemorrhage (relative risk [RR] 6.20; 95% confidence interval [CI] 2.64, 14.61), mild retinopathy of prematurity (RR 20.05; 95% CI 3.59, 111.79), and severe retinopathy of prematurity (RR 46.69; 95% CI 6.25, 348.85) in triplets compared with singletons, and severe retinopathy of prematurity (RR 6.83; 95% CI 1.24, 37.56) in triplets compared with twins. CONCLUSION: When stratified by gestational age, triplet neonates delivered at 24-34 weeks' gestation have similar outcomes as singleton and twin neonates, with the only clinically significant difference being an increased incidence of retinopathy of prematurity in triplets.     

Effects of long-term pravastatin treatment on spermatogenesis and on adrenal and testicular steroidogenesis in male hypercholesterolemic patients

STUDY OBJECTIVE: To determine if there are significant differences in birth outcomes and survival for infants delivered by certified nurse midwives compared with those delivered by physicians, and whether these differences, if they exist, remain after controlling for sociodemographic and medical risk factors. DESIGN: Logistic regression models were used to examine differences between certified nurse midwife and physician delivered births in infant, neonatal, and postneonatal mortality, and risk of low birthweight after controlling for a variety of social and medical risk factors. Ordinary least squares regression models were used to examine differences in mean birthweight after controlling for the same risk factors. STUDY SETTING: United States. PATIENTS: The study included all singleton, vaginal births at 35-43 weeks gestation delivered either by physicians or certified nurse midwives in the United States in 1991. MAIN RESULTS: After controlling for social and medical risk factors, the risk of experiencing an infant death was 19% lower for certified nurse midwife attended than for physician attended births, the risk of neonatal mortality was 33% lower, and the risk of delivering a low birthweight infant 31% lower. Mean birthweight was 37 grams heavier for the certified nurse midwife attended than for physician attended births. CONCLUSIONS: National data support the findings of previous local studies that certified nurse midwives have excellent birth outcomes. These findings are discussed in light of differences between certified nurse midwives and physicians in prenatal care and labour and delivery care practices. Certified nurse midwives provide a safe and viable alternative to maternity care in the United States, particularly for low to moderate risk women.     

Neonatal outcome depending on the mode of delivery and fetal presentation in twin gestation

A retrospective analysis of 301 twin deliveries managed at The Second Department of Obstetrics and Gynecology, Warsaw Medical Academy, from January 1, 1986 to December 31, 1995 was undertaken in order to investigate the impact of the mode of delivery and twin presentation on neonatal outcome. Vertex presentation of both twins was the most common with an incidence of 47.5% followed by vertex-non-vertex (27.6%) and nonvertex presentation of the first twin (24.9%). 186 (61.8%) patients delivered vaginally, while 115 (38.2%) women underwent caesarean section including 6 operations performed after the vaginal delivery of the first twin. In vertex presentation of the first twin and breech second twin there was no significant difference in neonatal outcome measured by 5-minute Apgar score and birth trauma incidence between second twins delivered vaginally and second twins delivered by caesarean section. Vaginal delivery with internal podalic version of the second twin in vertex-transverse presentations was related to increased risk of lower 5-minute Apgar score and increased risk of birth trauma occurrence compared to caesarean section. Time interval between vaginal delivery of twins had no significant impact on neonatal outcome.     

Reproductive pattern, perinatal mortality, and sex preference in rural Tamil Nadu, south India: community based, cross sectional study

OBJECTIVES: To study reproductive pattern and perinatal mortality in rural Tamil Nadu, South India. DESIGN: Community based, cross sectional questionnaire study of 30 randomly selected areas served by health subcentres. SETTING: Rural parts of Salem District, Tamil Nadu, South India. SUBJECTS: 1321 women and their offspring delivered in the 6 months before the interview. MAIN OUTCOME MEASURES: Number of pregnancies, pregnancy outcome, spacing of pregnancies, sex of offspring, perinatal and neonatal mortality rates. RESULTS: 41% of the women (535) were primiparous; 7 women (0.5%) were grand multiparous (> 6 births). The women had a mean age of 22 years and a mean of 2.3 pregnancies and 1.8 live children. The sex ratio at birth of the index children was 107 boys per 100 girls. The stillbirth rate was 13.5/1000 births, the neonatal mortality rate was 35.3/1000, and the perinatal mortality rate was 42.0/1000. Girls had an excess neonatal mortality (rate ratio 3.42%; 95% confidence interval 1.68 to 6.98; this was most pronounced among girls born to multiparous women with no living sons (rate ratio 15.48 (2.04 to 177.73) v 1.87 (0.63 to 5.58) in multiparous women with at least one son alive). CONCLUSIONS: In this rural part of Tamil Nadu, women had a controlled reproductive pattern. The excess neonatal mortality among girls constitutes about one third of the perinatal mortality rate. It seems to be linked to a preference for sons and should therefore be addressed through a holistic societal approach rather than through specific healthcare measures.     

Perinatal risk factors for developmental dysplasia of the hip

AIMS: To identify perinatal risk factors for developmental dysplasia of the hip (DDH) and define the risk for each factor. METHODS: In this case control study, using logistic regression analysis, all 1127 cases of isolated DDH live born in South Australia in 1986-93 and notified to the South Australian Birth Defects Register were included; controls comprised 150130 live births in South Australia during the same period without any notified congenital abnormalities. RESULTS: Breech presentation, oligohydramnios, female sex and primiparity were confirmed as risk factors for DDH. Significant findings were an increased risk for vaginal delivery over caesarean section for breech presentation (as well as an increased risk for emergency section over elective section), high birthweight (> or = 4000 g), postmaturity and older maternal age; multiple births and preterm births had a reduced risk. There was no increased risk for caesarean section in the absence of breech presentation. For breech presentation, the risk of DDH was estimated to be at least 2.7% for girls and 0.8% for boys; a combination of factors increased the risk. CONCLUSIONS: It is suggested that the risk factors identified be used as indications for repeat screening at 6 weeks of age and whenever possible in infancy. Other indications are family history and associated abnormalities.     

Impact of maternal and child health strategy on child survival in a rural community of Pondicherry

OBJECTIVE: To determine the impact of Maternal and Child Health (MCH) services on child survival in a socio-economically backward rural community. SETTING: Twelve villages in Pondicherry with a population of 16,803. DESIGN: Prospective study. SUBJECTS: A birth cohort of 356 live births (LB) born between January 1st and December 31st 1988. METHODS: The live births were followed-up from birth to five years age (1988-1993). The health care received by this cohort and the antenatal services received by the cohort mothers was reviewed. Outcome measures related to child survival were determined and their changing trend since 1967 was examined. RESULTS: Fifty-four per cent of the cohort children were from families below the poverty line. Antenatal registration and tetanus immunization coverage of the mothers of the cohort was 100%. Immunization coverage of the cohort children was more than 98% for BCG, DPT (three doses) and OPV (three doses) and 82% for measles. The infant mortality rate had reduced from 201/1000 LB in 1967 to 64/1000 LB (95% CI 58.9-68.1) in 1989. The child death rate decreased from 29.4/1000 children 1-4 years of age (1970) to 18/1000 (95% CI 13.9-22.1) in 1992. There were no deaths due to neonatal tetanus or measles. Neonatal mortality (35/1000 LB; 95% CI 29.9-40.1) was higher than the post-neonatal mortality (29/1000 LB; 95% CI 24.1-33.9). Fifty eight per cent of the neonatal deaths were due to non-infective causes like prematurity, birth asphyxia, birth injuries and congenital anomalies. Eighty per cent of post neonatal deaths were due to infections. Overall, the child survival index was high (91.27%; 95% CI 88.14-94.26). This was inspite of the low socio-economic background of the children's families. CONCLUSIONS: Good MCH services can substantially improve child survival inspite of prevailing low socio-economic situations. Inputs for neonatal care need to be strengthened to further enhance child survival.     

Vaginal birth after cesarean section in twin gestation

OBJECTIVE: We report a 10-year experience with vaginal birth after cesarean section in women with twins. STUDY DESIGN: Data were gathered from labor and delivery records and maternal and neonatal hospital charts. Women with a vertical uterine scar, a previous uterine rupture, an unrepaired dehiscence, or obstetric contraindications to labor were excluded from a trial of labor. Full-thickness uterine defects requiring intervention were classified as ruptures; all others were classified as dehiscences. RESULTS: Between Jan. 1, 1985, and Dec. 31, 1994, at Los Angeles County/University of Southern California Women's Hospital, 210 women with previous cesarean births were delivered of twins. One hundred eighteen (56%) underwent repeat cesarean delivery without a trial of labor. Ninety-two (44%) undertook a trial of labor with no uterine ruptures and no increase in maternal or perinatal morbidity or mortality. CONCLUSIONS: In women with twins a trial of labor after a previous cesarean section is a safe and effective alternative to routine repeat cesarean delivery.     

The effect of labor on the acid-base status of the newborn

BACKGROUND: There has been some controversy regarding the effect that a long labor can have on fetal well-being. This study was undertaken to evaluate the effect of duration of labor both the first and second stage on the acid-base variables in the umbilical artery of the newborn. METHODS: Bloodsampling was attempted from all infants born at our department between October 1994 and September 1995. Nineteen hundred and forty-one live infants were delivered during the period. Sampling was unsuccessful in 264 cases and after excluding infants with operative delivery, multiple gestations, breech presentation, prematurity, postmaturity and infants small for gestational age 1255 remained singleton, term infants with vertex presentation and non-operative vaginal birth. RESULTS: We found no correlation between duration of the first stage of labor and neither pH nor base excess in umbilical artery blood. There was a significant correlation between duration of the second stage of labor and both the pH and base excess. For vaginal nulliparas we found that pH=7.30-0.016 x second stage duration in hours and base excess=-3.71-0.692 x second stage duration in hours. For women with previous vaginal births pH=7.31-0.029 x second stage duration in hours and base excess=-2.38-1.306 x second stage duration in hours. CONCLUSIONS: We find no correlation between duration of the first stage of labor and umbilical artery pH or base excess. We do find a correlation between duration of the second stage of labor and the umbilical artery pH and base excess. However, a prolongation of the second stage with as much as three hours would give an expected lowering of the umbilical artery pH with only 0.05 and of base excess with 2.1 mmol/l for vaginal nulliparas and correspondingly with 0.09 and 3.9 mmol/l in women with previous vaginal births. This effect on pH and base excess is so small that it is hardly clinically relevant and we do not find any support for the belief that a long labor -- in the absence of other risk factors -- is to the disadvantage of the fetus.     

Cesarean birth: how to reduce the rate

The cesarean section rate, which approached 25%, has stabilized and started a modest decline. A stated United States national goal by the year 2000 is a rate of 15%. Suggested rates are 12% for primary and 3% for repeat cesarean sections. The major indications for cesarean section are prior cesarean delivery (8%), dystocia (7%), breech presentation (4%), fetal distress (2% to 3%), and others. The major areas of reduction must occur in the categories of prior cesarean delivery and dystocia. An expanded use of trial of labor and vaginal birth after a prior cesarean section will produce further reductions. Countries in Europe achieve > 50% vaginal birth after a prior cesarean section compared with 25% in the United States. A heightened awareness must occur regarding the decision to perform the first cesarean section. The residual impact, a scarred uterus, affects 12% to 14% of women seen for delivery. Even if 50% achieve a vaginal birth after a prior cesarean section, the national goals are unachievable. The obstetrician must consciously consider the impact of "once a cesarean, always a scar."     

The effect of fetal maturity and the delivery method on fetal status in breech presentation

In a retrospective study of 363 pregnancies with one foetus in breech presentation is evaluated the effect of foetal maturity and the route of delivery on the state of the newborn, assessed by the 5 min. Apgar score. The cases are allocated in subgroups according the foetal weight and height, gestational week and the route of delivery. The results show 37% small for gestational age in the subgroup with low birth weight (1500-2500 g). From the group with low weight SGA sustain better the labor and delivery than the eutrophic. The term newborn in breech presentation are with higher Apgar score than delivered by cesarean section. In the group of newborn with low weight the route of delivery has not effect on the Apgar score. The estimated weight and gestational week should be taken in account than managing breech labor.     

Stress, endocrine, and immune system; stress induces the onset of autoimmune diseases

Previous studies of birth certificates have not fully evaluated how accurately they identify delivery methods that have a historical component, such as repeat cesarean and vaginal birth after previous cesarean (VBAC). The authors used linked Georgia birth certificates for first and second deliveries to examine the accuracy of four reported delivery methods in the second pregnancy: vaginal (without previous cesarean), VBAC, primary cesarean, and repeat cesarean, as well as an indicator of a previous cesarean. From the immediate birth certificates, the delivery method for each of the two births was classified as vaginal (V) or cesarean section (CS), which produced possible sequences of V-V, CS-V, V-CS, and CS-CS. The delivery method for the second births to 106,049 women from 1989 through 1992 was reviewed, taking into account the historical information from the linked certificates regarding the first births. Only 42.0% of women with a CS-V sequence were correctly designated on the second birth certificate as a VBAC; 79.3% of women with a V- CS sequence were correctly designated as primary cesarean. From 1980 through 1988, birth certificates contained a check box indicating a previous cesarean (but no VBAC box). During this period, only 75.5% of 25,491 women with a previous cesarean were so designated on the birth certificate. These findings suggest that cross-sectional vital records data substantially underestimate VBAC and primary cesarean rates.     

Previous cesarean birth. A risk factor for placenta previa?

OBJECTIVE: To study the risk of placenta previa following a previous cesarean birth. STUDY DESIGN: We conducted a population-based, case-control study using 1990 North Carolina state birth certificate data. The study population included 342 women with a pregnancy complicated by placenta previa and 1,082 randomly selected controls. Analysis was restricted to women who reported one or more previous live births and delivered a singleton, live neonate. Adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated using logistic regression, controlling for maternal age, race, prior spontaneous or induced abortions and cigarette use. RESULTS: When the data were adjusted for maternal age, race, prior spontaneous or induced abortions, and cigarette use, women who had a previous cesarean birth and had a parity of 3 were 1.7 times more likely (OR 1.7, 95% CI 0.7, 4.2) and women of parity > or = 4 were 5.5 times more likely (OR 5.5, 95% CI 1.0, 30.1) to have placenta previa than women of parity 1 who had a previous cesarean birth. CONCLUSION: Women with a history of a previous cesarean birth and parity > or = 3 were at increased risk of having a pregnancy complicated by placenta previa.     

Increasing social variation in birth outcomes in the Czech Republic after 1989

OBJECTIVES: This study investigated social variation in birth outcome in the Czech Republic after the political changes of 1989. METHODS: Routinely collected records on singleton live births in 1989, 1990, and 1991 (n = 380,633) and 1994, 1995, and 1996 (n = 286,907) were individually linked to death records. RESULTS: Mean birthweight fell from 3,323 g to 3,292 g (P < .001) between 1989 and 1991 and then increased to 3,353 g by 1996. The gap in mean birthweight between mothers with a primary education and those with a university education, adjusted for age, parity, and sex of infants, widened from 182 g (95% confidence interval [CI] = 169, 19) in 1989 to 256 g (95% CI = 240, 272) in 1996. Similar trends were found for preterm births. Postneonatal mortality declined most among the better educated and the married. The odds ratio for postneonatal death for infants of mothers with a primary (vs university) education, adjusted for birthweight, increased from 1.99 (95% CI = 1.52, 2.60) in 1989 through 1991 to 2.39 (95% CI = 1.55, 3.70) in 1994 through 1995. CONCLUSIONS: Despite general improvement in the indices of fetal growth and infant survival in the most recent years, social variation in birth outcome in the Czech Republic has increased.     

Breech delivery. Selection by X-ray pelvimetry

An attempt was made to evaluate the possible benefit of selecting women for vaginal breech delivery at term by radiological pelvimetry. Information from medical records on 276 singleton breech deliveries were analysed. A total of 188 breech presentations were diagnosed before the onset of labour, pelvimetry was performed in 74 women, where pelvic dimensions too small for recommendation of vaginal breech delivery were found in 30 cases. The overall rate of caesarean section was 78%, among diagnosed patients it was 84% and 64% among undiagnosed breech presentations. Rates of morbidity (low Apgar score and admission to the neonatal care unit) did not differ significantly between infants delivered vaginally or by elective caesarean section. The material, however, is too small for valid conclusions regarding safety of vaginal delivery of term breech in women selected by criteria including estimate of pelvic size.     

Reattempting failed external cephalic version under epidural anesthesia

OBJECTIVES: We hypothesize that the success rate of external cephalic version may be increased by performing a repeat attempt with the patient under epidural anesthesia. STUDY DESIGN: One hundred eight women with term singleton pregnancies in breech presentation underwent attempted external version. When external version failed, we offered them the option of a later attempt under epidural anesthesia. All fetuses who remained in breech position were delivered by elective cesarean section. RESULTS: Fifty (60%) of the 83 attempted external versions performed without anesthesia were successful. Seventeen of the 33 women whose versions were unsuccessful underwent elective cesarean delivery, and 16 elected to undergo repeat version attempts under epidural. Nine (56%) of these 16 procedures were successful, and 7 of these 9 women were delivered vaginally. The overall success rate was 71%, similar to the success rate of versions attempted on 25 women under epidural anesthesia. CONCLUSIONS: When an attempted external version fails, a repeat attempt under epidural anesthesia will usually be successful, resulting in a lower cesarean delivery rate.