THE COPPERBELT UNIVERSITY

MICHEAL CHILUFYA SATA

SCHOOL OF MEDICINE

PUBLIC HEALTH DEPARTMENT UNIT

TITLE: A RETROSPECTIVE STUDY ON PREVALENCE AND OUTCOME OF

VAGINAL SINGLETON BREECH DELIVERIES AT NDOLA TEACHING HOSPITAL
FROM 2015 TO 2019.

NAME : RICHARD SAKALA

STUDENT ID : 16102128
PROGRAMME : MBChB
COURSE : PUBLIC HEALTH
TASK : RESEARCH REPORT
SUPERVISIOR : DR BANDA C.
DATE : 13TH MAY,2022.

THE DISSERTATION IS BEING SUBMITTED TO THE COPPERBELT UNIVERSITY

IN PARTIAL FUFILLMENT OF THE REQUIREMENTS FOR THE DEGREE IN
BACHELOR OF MEDICINE AND SURGERY (MBChB).

PROJECT REPORT @2022

DECLARATION

RESEARCHER’S DECLARATION

I, Richard Sakala a student of the Copperbelt University Michael Chilufya Sata School of
Medicine of Student Identification Number 16102128, hereby declare that this research report is
my own piece of work and that it has not been partially or wholly presented before for any
degree or examination in any University or College. All the sources of information used or
quoted have been thoroughly cited and acknowledged as complete references.

Signature……………………………………
Date…………………………………………..

Supervisor;

I, Dr Banda C, hereby declare that this research has been conducted under my supervision and
assistance and that it is the original work of the author. I have therefore approved this
dissertation for examination.

Signature… ……………………………………………..

Dr Chikafuna Banda

The Copperbelt University

School of medicine

Date………………………………………………………

I
CERTIFICATE OF APPROVAL

The board of examiners have approved/not approved the dissertation of Richard Sakala as a
partial fulfillment of the requirements for the award of a Bachelor of Science Degree in Medicine
and Surgery (MBChB) by the Copperbelt University, Michael Chilufya Sata school of Medicine.

Head of department

Name:.………………………………………………………………………………

Signature:…………………………………………………………………………..

Date: ………………………………………………………………………………..

Examiners

Name:……………………………………………………………………………....

Signature:………………………………………………………………………….

Date: ………………………………………………………………………………..

Name:………………………………………………………………………………

Signature:…………………………………………………………………………..

Date: ……………………………………………………………………………...…

External examiner

Name:…………………………………………………………………………........

Signature:…………………………………………………………………………..

Date: ………………………………………………………………………………

II
ABSTRACT

Background: The incidence of breech presentation at term among singleton pregnancies is 3–

5%. Delivery of the singleton term breech fetus is still one of the most controversial subjects in
modern obstetrics. Changes in clinical practice were introduced following the publication of the
Term Breech Trial which indicated that perinatal and neonatal mortality as well as serious
neonatal morbidity were increased in the group delivered vaginally.However, an increase in rates
of C-Section for vaginal singleton breech fetuses results into lack of expertise by obstetricians
which consequently might lead to either complications due to poor assistance to vaginal
deliveries or to the rise of cesarean section rates with uncertain effects on maternal and perinatal
outcomes. Therefore, main objective of this study is to evaluate the prevalence and outcomes of
vaginal singleton breech deliveries at Ndola Teaching Hospital in order to determine the safety
of vaginal breech delivery.
Methods : A five year retrospective and cross sectional study was conducted in 255 women
who had singleton vaginal breech deliveries at Ndola Teaching Hospital from 2015 to 2019. Data
was collected from clinical records and labor ward delivery registers using a structured data
collection tool. Data was then entered on the computer and analyzed using a statistical software
SPPS version 22.
Results : The incidence of breech deliveries at Ndola Teaching Hospital was 3.2%. Out of 255
cases of vaginal breech deliveries studied, 32.2% were term and 67.8% were preterm. Most
women were within 21-25 age group. Breech presentation was common in women with parity of
greater than one. There were good fetal outcomes in 72.5% of babies with Apgar score greater
than 7 at 5 minutes. However , 27.5% of babies had low Apgar score at 5 minutes, 2.4% rate of
perinatal mortality and 4.7% babies had low birth weight of less than 2.5kg. The study showed
an association between Apgar score with parity and neonatal birthweight. Maternal
complications observed were episiotomy (7.5%) and postpartum hemorrhage (0.8%).
Conclusion
This study showed a favorable feto-maternal outcomes of vaginal breech delivery of which good
fetal outcomes were reported in 72.5% cases. However, perinatal morbidity rate was high with a
percentage of 28.2% and a mortality rate of 2.4%. Therefore, breech vaginal delivery may still be
a viable option at NTH as demonstrated by this study.

III
ACKNOWLEDGEMENT

The successful development of this research involved the support and contribution of several
individuals. Above all I thank God, the Almighty for guiding me through this research. I also
humbly wish to submit and extend my appreciation and abundant thanks to the Public Health
Unit lecturers for their guidance throughout the programme.

Extremely special thanks also go to my supervisor, the public health unit lecturer, Dr. Banda C
for guidance ,patience and time invested in conducting this research . I would like to convey my
sincere gratitude to my family members. My father Mathews, my mother, my friend Gelita
Banda as well as my brothers and sisters who have given me support both emotionally and
financially.

I wish to acknowledge the assistance of Dr Phiri C who read through this research and made
constructive criticism.

I am also grateful to the Management of Ndola Teaching Hospital for granting me access to
patient records and a conducive environment to carry out this research.

IV
LIST OF ABBREVIATIONS

CS- Caesarean Section

NTH - Ndola Teaching Hospital
PPH - Postpartum Hemorrhage
PVD- Planned Vaginal Delivery
RCOG- Royal Committee of Obstetricians and Gynecologists
TBT- Term Breech Trial
TDRC- Tropical Disease Research Centre
WHO - World Health Organization

V
 Table of Contents
DECLARATION ............................................................................................................................. I
CERTIFICATE OF APPROVAL ...................................................................................................II
ABSTRACT .................................................................................................................................. III
ACKNOWLEDGEMENT ............................................................................................................ IV
LIST OF ABBREVIATIONS ........................................................................................................ V
LIST OF TABLES ..................................................................................................................... VIII
LIST OF FIGURES ....................................................................................................................VIII
CHAPTER ONE: INTRODUCTION ............................................................................................. 1
1.1Background. ....................................................................................................................... 1
1.2 STATEMENT OF THE PROBLEM ................................................................................ 2
1.3 LITERATURE REVIEW ..................................................................................................3
1.3.1. Global perspective .................................................................................................3
1.3.2. Regional perspective ............................................................................................. 4
1.3.3 National perspective ............................................................................................... 5
1.4 OBJECTIVES ................................................................................................................... 5
1.4.1 General objective ....................................................................................................5
1.4.2 Specific objectives ..................................................................................................5
1.5 RESEARCH QUESTIONS ...............................................................................................5
1.6 RATIONALE AND JUSTIFICATION ............................................................................ 6
1.7 MEASUREMENTS .......................................................................................................... 7
1.7.1 Variables of the study .............................................................................................7
1.7.2 Operational definitions ........................................................................................... 7
1.8 CONCEPTUAL FRAMEWORKS .................................................................................. 9
CHAPTER TWO: METHODOLOGY ......................................................................................... 10
2.1 Study site ......................................................................................................................... 10
2.2 Target population ............................................................................................................ 10
2.3 Study design .................................................................................................................... 10
2.4 Sample size ......................................................................................................................10

VI
 2.5 Sampling procedure .........................................................................................................11
2.6 Inclusion and exclusion criteria .......................................................................................11
2.7 Data collection and Data analysis ................................................................................... 11
2.7.1 Data collection tool .............................................................................................. 11
2.7.2 Data analysis .........................................................................................................11
2.8 Ethical consideration ....................................................................................................... 11
2.9 Study limitations ..............................................................................................................12
CHAPTER THREE: RESULTS ................................................................................................... 13
3.1 Demographics and obstetric characteristics .................................................................... 13
3.2 Perinatal outcomes .......................................................................................................... 15
3.3 Associations .....................................................................................................................16
3.4: Maternal outcomes ......................................................................................................... 17
CHAPTER FOUR ......................................................................................................................... 18
4.1 DISCUSSION ................................................................................................................. 18
4.2 CONCLUSION ............................................................................................................... 19
4.3 RECOMMENDATIONS ................................................................................................ 19
REFERENCES ..............................................................................................................................20
APPENDICES ...............................................................................................................................22
Appendix 1:INFORMATION SHEET ..................................................................................22
Appendix 2: Consent form .................................................................................................... 23
Appendix 3: Data extraction tool .......................................................................................... 24
Appendix 4: Ghantt chart ...................................................................................................... 25
Appendix 5: Budget ...............................................................................................................26
Appendix 6: Ethical approval letter .......................................................................................27
Appendix 7: Copperbelt Provincial Health Office letter .......................................................28
Appendix 8: Senior Medical Superintendent letter NTH .....................................................29
Appendix 9: Proof of submission of publication ...................................................................30
Appendix 10; Approval from NHRH. ...................................................................................31

VII
LIST OF TABLES

Table 1:Description of variables and concepts…………………………………………8

Table 2: Sample size determination……………………………………………………10
Table 3: Incidence of breech delivery……………………………………………….…13
Table 4: Demographic and obstetrics characteristics…………………………………..13
Table 5: Perinatal outcomes……………………………………………………………15
Table 6: Crosstabulation of Apgar score against parity……………………………….16
Table 7: Crosstabulation of Apgar score against neonatal weight…………………….17
Table 8: Other Associations……………………………………………………………17

LIST OF FIGURES

Figure 1: conceptual framework ………………………………………………………….9

VIII
CHAPTER ONE: INTRODUCTION

1.1Background.

The incidence of breech presentation a term among singleton pregnancies is 3-5%(Basnet B

et al ,2020). Regardless of the mode of the delivery, breech presentation is associated with
increased rates of maternal and perinatal morbidity. The outcomes however, may vary
depending on the health practices and available facilities, socioeconomic conditions and
other factors pertaining to health care delivery system (Impey W.M et al, 2017). The results
of Term Breech Trial (TBT) showed that planned caesarean delivery for singleton breech
presentation is associated with lower perinatal mortality and serious mortality in comparison
to vaginal delivery.
This led to C-section being recommended for all breech babies (Wasim et al, 2017). However,
the follow up studies of TBT for both feto -maternal outcomes showed different results.
Goffinets prospective study (PREMODA) showed that when cases are adequately selected
with skilled obstetricians, outcomes in vaginal singleton delivery are not significantly
different. In addition, several retrospective and cross-sectional studies have reported no
significant difference in neonatal morbidity between planned vaginal delivery and planned
cesarean section as long as they apply predefined selection criteria for both mode of delivery
(Vistad I et al ,2015). Furthermore, in 2006 Royal and American college of obstetricians and
gynecologists revised the breech guidelines with new versions supportive of selected vaginal
delivery. The guidelines says that a woman who wishes to choose the vaginal breech birth
should be referred to unit where the option is available. This has been due to the Caesarean
section policy was associated with an increase in maternal mortality and morbidity especially
in low resource areas. Wasim T et al (2017) states that an observation was seen that
clinicians are losing skills of vaginal breech safely and the decline of vaginal breech delivery
rate got the attention of authors and studies have been done to give evidence that a careful
case selection and labor management may achieve a level of safety similar to elective
Caesarean section. In addition, another author said that some countries where pregnant
women still don’t receive antenatal care and prefer to deliver under the care of unskilled birth
attendants , assisted vaginal delivery still remain a valid option (Obuna J.A et al , 2014). The

1
study likewise report that it is difficult to detect pregnant women with persistent breech
presenting fetus in such an environment where women prefer to deliver under the care of
unskilled birth attendants and thus some practitioners have supported the vaginal delivery
based on various outcomes. A similar study done by Wasim et al (2017) shows that vaginal
breech delivery is still being done successfully in places where expertise is available
especially in developing countries where women resist caesarean section and often present
late in labor to avoid it. In addition, where women want more children and where follow-up
of caesarean section is poor, vaginal breech delivery remains a valid option In spite of C-
section being advocated in attempt to improve perinatal outcomes , there has been an
increased rate of maternal morbidity and mortality.The feto-maternal outcomes of the vaginal
breech deliveries conducted at Ndola Teaching Hospital(NTH) are not known. Therefore the
aim of this study is to determine the fetal outcomes in mothers who underwent assisted
vaginal breech deliveries at NTH so that safety of vaginal breech delivery is determined.

1.2 STATEMENT OF THE PROBLEM

The number of caesarean sections is increasing worldwide with an increase in complications

like hemorrhage, sepsis and abnormal placentation with consequences of hemorrhage,
obstetrical hysterectomy, ruptured uterus and maternal death in subsequent pregnancy
(Wasim et al 2017). Elective caesarean section for failed vaginal breech delivery has been
criticized for this very reason. However, several authors have presented evidence that if strict
selection criteria are followed before and during labor, vaginal breech delivery is a safe
option without associated increase in perinatal morbidity (Kasela J et al 2018). Though there
is evidence of serious complications on the mother and subsequent pregnancies, the C-
section rates are still increasing. C-section must therefore be indicated as a last resort in
delivery of breech singleton fetus. Furthermore, RCOG,2011 suggest that external cephalic
version can be offered to women with singleton breech babies provided that there are no
contradictions. Moreover, there are additional maneuvers such as Duhssens incision,
exceptional maneuvers, Zavanelis maneuvers which can facilitate safe vaginal singleton
breech deliveries(Fonseca A et al 2017). A surgical procedure known as episiotomy is also
recommended in breech babies where a planned surgical incision is done on the perineum
and posterior vaginal wall in the second stage of labor to facilitate easy and safe delivery of

2
fetus. Therefore, the future problem will be that future obstetrician will be less qualified to
deliver breech fetus vaginally and lack of expertise will lead to either complication due to
poor assistance to vaginal deliveries or rise of C-section with uncertain effects on maternal
outcomes(Kotaska A et al 2009). The aim of this study is to determine feto outcomes in
patients undergoing vaginal breech delivery so that its safety may be determined at Ndola
Teaching Hospital.

1.3 LITERATURE REVIEW

1.3.1. Global perspective

The management of term breech delivery varies in obstetric units and for decades this has
been a controversial subject (Uotila J et al ,2005). Results from the same study shows good
fetal outcomes if vaginal breech delivery is allowed in selected cases provided that strict
criteria is followed during labor. However, results of vaginal breech delivery can also be
unfavorable.
Publication of Term Breech Trial brought changes in clinical practice which showed a
perinatal and neonatal mortality in group delivered vaginally. This study done by Hannah
M.E et al concluded the policy of caesarean delivery had better neonatal outcomes and this
led into an increase of about 80% worldwide (Rietberg C.E et al 2003). This research was
done to determine the best mode of delivery and it revealed that the perinatal and maternal
mortality was significantly lower for the planned Caesarean section than planned vaginal
group. However, studies from Kotaska A et al, (2009) and Schutte J.M et al (2007) showed
different findings that assisted vaginal delivery is still an option. In fact, after the publication
of caesarean section delivery policy in 2000,people thought that elective caesarean delivery
is safe but studies have proven that it does not guarantee the improved outcome of the child
to be born but rather it might be more dangerous for the mother and enhances the risks of
complications in subsequent pregnancies (Schutte J.M et al 2007). Schutte J.M et al(2007)
reported that the number of caesarean section is increasing worldwide with a subsequent
increase in complications like hemorrhage, sepsis and maternal death. Furthermore, many
authors were concerned about the reduction of vaginal delivery rate and the increased

3
maternal mortality and morbidity rate following the policy. Glezerman M (2005) in his study
on five years to term breech trial; the rise and fall of a randomized controlled trial stated that
most reports of neonatal morbidity and mortality in planned vaginal delivery after TBT were
due to no attendance of clinicians with adequate expertise and short term assessment of
neonatal outcomes. Similarly, a study done by Wasim et al 2017, documented increased
mortality and morbidity in mothers undergoing elective C-section with complications such as
hemorrhage, sepsis, hysterectomy, ruptured uterus and maternal death in subsequent
pregnancies. This study reported a good feto outcome in 87% of babies. Only 20 babies had
Apgar score less than 7 and required nursery admission. Two babies had cord prolapse
during labor and one had fracture of the humerus who was sent home in satisfactory
condition. In addition, the world health organization (WHO) study done by Villa J et al (2005)
showed that the odds of maternal mortality and severe morbidity in patients were 3.4- 2.3 by
elective Caesarean section as compared to vaginal. Furthermore, higher maternal mortality
rate by Caesarean section compared to vaginal delivery agrees with findings from Rietberg
C.C et al (2003) and Deneux Tharnux C et al (2006). Apart from that, Minkoff H &
Chervenak F(2003) states that primary elective cesarean section is associated with risks to
fetus and mother such as maternal death, complications (e.g. infection, hemorrhage, visceral
injury),postpartum depression and negative feelings about experience of child health. He
added that not only does it have risks to the mother but also to the fetus which include
iatrogenic maturity and fetal injury.

1.3.2. Regional perspective

Wasim et al, (2003) reveal that there can be successful vaginal breech delivery without any
feto- maternal complications if there can be a proper section of cases and labor management.
The same cross sectional study reported a good perinatal outcome in 87% of patients. In fact,
the study agrees with findings from another retrospective study done by Orji E.O et al (2003).
Orji E.O et al (2003) states that a given appropriate selective criteria and management
protocol can make vaginal planned delivery have better outcomes than elective caesarean
section. On the other hand the research reviewed a low 5 minutes Apgar score in planned
vaginal delivery.

4
1.3.3 National perspective

In Zambia, a retrospective cross sectional study by Kasela J et al (2018) reported a good

feto-maternal outcomes of assisted term breech deliveries at University Teaching Hospital,
Lusaka. This study revealed that vaginal breech delivery can still be an option at UTH. The
same study recommends booking status and antenatal care as important parameters in
determining the successful outcomes when large of delivery is not in rural setup. This study
will therefore aim at determining feto- outcomes in patients undergoing vaginal breech
delivery so that its safety may be determined.

1.4 OBJECTIVES

Based on the stated problems and the justification of the study, the following were the
general and specific objectives.

1.4.1 General objective

The main objective of this study was to evaluate the prevalence and outcome of assisted
singleton breech vaginal deliveries at Ndola Teaching Hospital from 2015 to 2019.

1.4.2 Specific objectives

To determine the prevalence of singleton breech deliveries at NTH.

To determine the perinatal outcomes of associated singleton vaginal breech delivery at
NTH.
To determine the maternal outcomes in assisted vaginal singleton breech delivery at NTH.
To assess the risk factors associated with poor vaginal breech delivery outcomes at NTH.

1.5 RESEARCH QUESTIONS

This will attempt to answer the following questions:

1.What is the prevalence of singleton breech deliveries at NTH?
2.What are the perinatal outcomes of assisted singleton of vaginal breech deliveries?

5
 3. To determine the maternal outcomes in assisted vaginal singleton breech delivery at
NTH?
4. What are the risk factors associated with poor vaginal breech delivery outcomes at
NTH ?

1.6 RATIONALE AND JUSTIFICATION

Studies have shown that singleton vaginal term breech delivery is still done successfully in
places where expertise is available. A study done by Wasim et al 2017, have reported better
neonatal outcomes with patients undergoing vaginal breech birth, in the same study ,87% of
babies delivered vaginally hard good fetal outcome. This study showed that proper selection
of cases with intrapartum monitoring can minimize neonatal complications. Therefore,
assisted vaginal breech delivery should not be thrown to the dustbin and this will help reduce
caesarean section rate and scare women who are already aversed to C-section from antenatal
care and hospital delivery. My study will focus on the reasons why many term breech babies
are delivered via C-section while a number of maneuvers can be performed in breech
presenting fetuses. In addition, the researcher hopes to provide findings that will bridge this
information gap and inform NTH policy. The recommendations made from findings will
result into lower C-section rates and improved maternal outcomes. Most importantly, the
results from the study will be useful to policy makers and facilities managers in other
districts hospital in saving costs of improving obstetric practices.

6
1.7 MEASUREMENTS

1.7.1 Variables of the study

The case variables studied were gestational age, birth weight, maternal age, parity ,gender of
the baby, perinatal complications such as birth trauma , mortality at birth or within 7 days
and maternal complications such as maternal mortality , postpartum hemorrhage, wound
infection.

1.7.2 Operational definitions

Breech delivery- this term refers to a delivery of a child either by caesarean section or
vaginally
in fetus presenting with buttocks or feet.
Risk factors- this term refers to variable that is associated with an increase in poor breech
delivery outcomes.
Prevalence –refers to numerical description of a sample which tells us about how many
times
breech deliveries occurred.
Outcomes – refers to the results of delivery either by C-section or Vaginal delivery.
Perinatal mortality- refers to intrapartum death or death within 7 days after birth due to
cord
prolapse, severe asphyxia and head entrapment excluding antepartum stillbirth.
Neonatal morbidity- is defined as birth trauma (bone fracture, intra cranial hemorrhage) or
any injury to infant including bruises and lacerations.
Maternal morbidity- is defined as any occurrence of illness or symptom of being unhealthy
which includes cervical tear, PPH, perinea tear, puerperal pyrexia, urinary tract infections,
endometritis, blood transfusion and wound infection.
Low Apgar score- refers to a score less than 7.

7
Table 1; a table of description of variables
Variables Type of variable Scale of measurement Indicator
Gestational age Independent Ratio and interval 1. less than 34
weeks
2. 34-37 weeks
3. 37-40 weeks
4. greater than 40
weeks

Neonatal weight Dependent Ratio 1.<2.5kg

2.2.5-3.5kg
3.>3.5kg
Residence Dependent Ordinal 1. high density
2. middle density
3. low density
Apgar score Dependent Ratio 1. >3
2. 3-5
3. 6-7
Mode of delivery Dependent Nominal 1. Vaginal delivery
2. Caesarean section
Parity Independent Ratio 1. 0
2. 1-4
3. greater than or
equal to 5
Admission to NIC Dependent Nominal 1.yes
2. No
Maternal age Independent Ratio 1. less than 16 years
2. 16-20 years
3. 21-25 years
4. 26-30 years
5. 31-35 years
6. 36-45 years
Sex of the baby Independent Nominal 1. male
2. female

8
1.8 CONCEPTUAL FRAMEWORKS

OUTCOMES MODE OF DELIVERY

FETAL
-APGAR
SCORE
-NURSERY
ADMISSION VAGINAL
DELIVERY
-BIRTH
TRAUMA

MATERNAL
MOTHERS
- WOUND WITH BREECH
INFECTION BABIES
-PPH

FETAL
-APGAR SCORE
-NURSERY ADMI
-BIRTH TRAUMA
INDICATIONS FOR
-MORTALITY ELECTIVE C-SECTION

MATERNAL
-ABNORMAL
PLACENTATION
--RUPTURED
UTERUS

9
CHAPTER TWO: METHODOLOGY

2.1 Study site

This study was carried out on the Copperbelt Province at Ndola Teaching Hospital, Zambia ,
which is a tertiary care hospital located in Ndola district. The hospital provides the obstetrics
and gynecologic services to women on the Copperbelt province and some parts of Zambia.
Ndola is a commercial capital city of Zambia with a total population of 503,649(WHO,2015).

2.2 Target population

All women who had a singleton pregnancy with breech presentation who came to Labor ward
at Ndola Teaching Hospital from the age of 15 to 45.

2.3 Study design

The study was carried out through a retrospective analysis and review of a five years of case
records of women who had singleton breech vaginal delivery from 2015 to 2019.

2.4 Sample size

The formula that will be used for sample determination is;

�2��
n=
�2

Where z = 1.96 at = 0.05 and Q = 100 – P.

Using the information in the table, the sample size calculated was 255.

Table 2; sample size

Level of confidence measure(Z) 1.96 (at 95% confidence level).

Prevalence rate (P) 80%

100—P (Q) 20%
Width of confidence level (d) 5%

10
2.5 Sampling procedure

Participants with singleton breech pregnancy from 2015 to 2019 were systematically and
random selected from labor ward delivery registers in accordance with the sample size.

2.6 Inclusion and exclusion criteria

All women with singleton breech pregnancy that delivered vaginally were included and those
who delivered by caesarean section were excluded.

2.7 Data collection and Data analysis

2.7.1 Data collection tool

Secondary data was collected from the clinical records and labor ward delivery registers
using a structured data collection tool. All the information on the social and demographic
characteristics of mothers , total number of deliveries ,gestational age at delivery, weight of
the neonates and feto-maternal outcomes was contained in data collection tool.

2.7.2 Data analysis

All data were entered in an Excel spreadsheet and then imported into statistical software
SPSS version 22 for analysis. Descriptive statistics like frequency and percentages were
calculated and results were presented in tables. Association between the maternal and fetal
characteristics and perinatal outcomes was estimated using Chi-square. P<0.05 was
considered statistically significant. Data was checked consistently to avoid errors and ensure
completeness during entry.

2.8 Ethical consideration

Ethical clearance was obtained from the Tropical Disease and Research Centre (TDRC) in
Ndola, Zambia. Apart from that, permission to conduct the study was given by Michael
Chilufya Sata School of Medicine Public Health Unit, The Copperbelt Provincial office ,
Senior Medical Superintendent as well as Senior Health Information Officer. Participants as

11
well as the managements were vividly assured of confidentiality and data generated was not
to be used for other purposes apart from purely and strictly academic purposes. Due to Covid
-19 pandemic, social distance of one meter apart and wearing of face mask was be observed.

2.9 Study limitations

This study presents several limitations, starting with its retrospective design. Data was
collected from labor ward delivery registers and was, therefore , limited to the observations
documented. Thus, lack of data concerning important outcomes might have compromised my
results. For example, perinatal mortality after nursery admission could not be determined.
Another limitation of this study is that i did not compare the outcomes of vaginal breech
delivery with caesarean breech delivery.

12
CHAPTER THREE: RESULTS

This section provides a detailed description of results obtained from analysis of the study.

3.1 Demographics and obstetric characteristics

The total number of hospital deliveries during the study period was 27,649 while 891 had a
singleton breech delivery at 30 weeks gestation and above giving an incidence of 3.2%. The
term breech deliveries were 82 and preterm constituted 173 cases. The study shows that most
of the women were within the age groups 21–25 years 62(24.3%) and least number of
mothers were below age of 16 with a percentage of 1(0.4%). Most of the women were within
gestational age 34-36 weeks with a percentage of 153(60%) and most of women had a parity
of 1-4 giving a percentage of 157(61.6%).
The demographic and obstetric characteristics are presented in table 4.

Table 3. Incidence of breech delivery

SI Total no. of Breech Percentage
No. (n=255)

1 Term breech 32.2

(n= 82 )
2 Preterm breech 67.8
(n= 173 )

Table 4. Demographic and obstetric characteristics of parturient.

Characteristics Frequency Percentages
Age (years)
<16 1 0.4
16-20 57 22.4
21-25 62 24.3
26-30 59 23.1
31-35 47 18.4
36-40 29 11.4
Total 255 100.0

13
Parity
Nullipara 81 31.8
1-4 157 61.6
>5 17 6.7
Total 255 100.0
Gestational age (weeks)
<34 20 7.8
34-36 153 60
37-40 81 31.8
>40 1 0.4
Total 255 100.0
Birthweight(gm)
<2.5 27 10.6
2.5-3.5 184 72.2
>3.5 44 17.3
Total 255 100.0
Sex of baby(kgs)
Male 128 50.2
Female 127 49.8
Total 255 100.0

Apgar score at 5
<4 19 7.5
4-6 51 20.0
7-10 185 72.5
Total 255 100.0

14
3.2 Perinatal outcomes

Regarding fetal outcome, 185(72.5%) of fetuses had an Apgar score at 5 minutes greater than
7 and out of 185 babies ,165(64.7%) babies were with the mother without any complication.
There were 72 (28.2%) fetuses with Apgar score less than 7 and required nursery admission.
There were 6 perinatal death recorded during this study period which were macerated and
fresh stillbirth giving a mortality rate of 2.4%. There were 27(10.6%) babies with birth
weight less than 2.5kg ,184(72.2%) between 2.5-3.5kg and 44(17.3) with birth weight above
3.5kg.The perinatal outcomes are summarized in Table 5.

Table 5: Perinatal outcomes of vaginal breech delivery

Perinatal outcomes Frequency Percentage (%)
Baby is with the mother 165 64.7
Neonatal admission 72 28.2
Perinatal mortality 6 2.4
Low birth weight 12 4.7

15
3.3 Associations

The association was sought between the independent variables: maternal age, parity ,
gestational age , birth weight and perinatal outcomes against APGAR score at 5. The results
are presented in Tables 6 and 7.

Table 6; Cross-tabulation of parity against Apgar score.

Parity
VARIABLES (n=255) 0 1-4 greater than 5 P-value
Apgar score 0-3 Count 5 13 1

% of Total 2.0% 5.1% 0.4%

4-6 Count 30 19 2 0.000
Expected Count
% of Total 11.8% 7.5% 0.8%
7-10 Count 47 124 14

% of Total 18.4% 48.6% 5.5%

Total Count 82 156 17

% of Total 32.2% 61.2% 6.7%

The study revealed that there is an association between parity and Apgar score which is
evidenced by the P-value of 0.000 in the cross-tabulation above.

16
Table 7; Crosstabulation of neonatal weight against Apgar score.
Neonatal weight
greater than
VARIABLES(n=255) less than 2500 2500-3500 3500 P-value
Apgar score 0-3 Count 5 9 5
0.048
% of Total 2.0% 3.5% 2.0%
4-6 Count 5 41 5

% of Total 2.0% 16.1% 2.0%

7-10 Count 17 134 34

% of Total 6.7% 52.5% 13.3%

Total Count 27 184 44

% of Total 10.6% 72.2% 17.3%

The study showed that there is an association between neonatal weight and Apgar score
which is evidenced by p-value of 0.048.
Table 8; Other Associations
Association Pearson Chi-Square (P-value) Comment
Maternal age 0.065 No association between the two
Gestational age 0.419 No association between the two.

3.4: Maternal outcomes

Regarding maternal outcomes , 19(7.5%) had episiotomy and 2(0.8%) had postpartum
hemorrhage. No maternal deaths were recorded.

17
CHAPTER FOUR

4.1 DISCUSSION

This retrospective study is aimed at determining the fetal outcomes of vaginal breech
deliveries at Ndola Teaching Hospital from 2015 to 2019. There were a total number of
27,649 hospital deliveries of which 891 were breech deliveries giving an incidence of 3.2%.
The breech delivery rate obtained in this study is within the widely reported range of 2.5% to
4.0% (Obuna J et al ,2014). The study consisted of 255 cases of vaginal breech deliveries out
of them, term breech deliveries were 82(32.2%) and preterm were 173(67.8%).
In this study, it was observed that most of the women belonged to 21-25 age group and it was
also revealed that breech presentation was common in multiparous women (parity greater
than 1) as shown in the table 2. A greater proportion of breech presentation occurred in
women with parity of 1-4 with a percentage of 157(61.6%). These findings are similar to a
study done by Sobika et al (2018). The study reports a good fetal outcome in 72.5% of the
babies with no neonatal complications such as birth asphyxia, respiratory distress and low
birth weight. This is lower compared to higher Apgar score > 7 at 5 minutes (90.4%) in the
study conducted at University Teaching Hospital by Kasela J et al (2018). Furthermore, the
perinatal adverse outcomes commonly encountered was low Apgar score < 7 at 5 minutes
70(27.5%), followed by nursery admission 72(28.2%), perinatal mortality 6(2.4%) and low
birth weight of less than 2.5 kg 12(4.7%). The findings were also similar to a study done by
Tulasa B et al (2020). The perinatal deaths were all intrapartum stillbirths and no record of
birth trauma was encountered. The study also revealed that prematurity is associated with
breech presentation as shown in table 1. The indications of caesarean section in breech
delivery seen in study were breech in primigravida, footling breech, post-date breech, breech
in sickle cell disease, breech with macrosomia, breech with multiple uterine fibroids, breech
with oligohydramnios and breech with placenta previa.
In this study, the bivariate analysis showed that there was an association between Apgar with
parity and neonatal weight. The association between Apgar score with parity was evidenced
by the P-value of 0.000 and with neonatal weight by p-value of 0.048. Babies born with less

18
than 2.5kg had severe birth asphyxia with a low Apgar score. The period of gestation and
maternal age were not associated with Apgar score.
Regarding maternal outcomes, 19(7.5%) had episiotomy and 2(0.8%) had postpartum
hemorrhage and no blood was transfused. There were no admissions to main intensive care
unit and no maternal deaths were recorded.

4.2 CONCLUSION

This study showed that the feto- outcomes of vaginal breech delivery , perinatal morbidity
rate was high 72(28.2%) with a favorable mortality rate of 2.4%. However, good fetal
outcomes were reported in 72.5% cases which entails that assisted vaginal breech delivery is
still a viable option at NTH. Furthermore , this study confirms association of breech
presentation with multiparity and prematurity. It also showed an association between Apgar
score with parity and neonatal weight.

4.3 RECOMMENDATIONS

The findings of this study identify the need for proper selection of cases ,strict ante and
intrapartum protocols to be followed for better outcomes of vaginal breech deliveries. An
accurate selection criterion has to be identified in order to adequately counsel each woman on
the mode of delivery.
There is also a need for future studies especially prospective study to investigate the
relationship between mode of delivery and adverse neonatal outcomes in breech deliveries.
Assisted vaginal breech delivery must continue to be practiced at Ndola Teaching Hospital.

19
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Mode of term breech delivery. Am J Obstetric Gynecology .108. pp. 235-237.
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mortality and cesarean delivery. American college of Obstetricians and Gynecologists.108
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Glezerman, M. 2005. Five years to the term breech trial: The rise and fall of randomized
controlled trial. American Journal of Obstetrics and Gynecology.194, pp.20-5.
Goffinet. F, Carayol. M, Fordart. JM, Alexander S, Uzan S, Subtil. D, Breart. G. 2006. Is
planned vaginal delivery for breech presentation at term still an option? Results of an
observational study in France and Belgium .AJOG. 194(4), pp.1002-1011.
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, William AR. 2000. Planned
caesarean section vs. vaginal birth for breech presentation at term: a randomized multicenter
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Khanum. F, Sabir. S, Hassan L. 2007. Impact of ECV on the mode of delivery of term
singleton breech. JPMI. 21(04), pp. 283-286.
Kotaska A, Menticoglons S, Gagnan R. 2009. Vaginal Delivery of breech presentation.
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and severe mortality associated with low-risk planned caesarean delivery versus planned
vaginal delivery at term. Canadian Medical Association Journal. 176(4), pp. 455-475.
L. W. M. Impey, D. J. Murphy, M. Griffiths, and L. K. Penna.2017.“On behalf of the royal
college of obstetricians and gynecologists. management of breech presentation,” An
International Journal of Obstetrics and Gynecology.124.pp.151–77.
Macharey G, Gissler M, Ulander V, Rahkonen L, Vaisanem-Tommiska M, Nuvtila M,
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Minkoff. H, Chervenall. FA. 2003. Elective primary caesarean delivery. New England
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Obuma JA, Ugboma HA, Agwu UM, Ejikeme BN. 2014. The prevalence and outcome of
singleton breech delivery in Abakalaki south-East Nigeria. The Journal of Medical science
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Orji O.E, Ajenifuja K.O. 2003. Planned vaginal delivery vs. Caesarean section for breech
presentation in Ile –Ife, Nigeria. East African Medical Journal. 80(11), pp. 589-591.
Purissenti. TK, Hebisch. G, Sell. W, Staedele. PE, Viereck. V, Fehr MK. 2017. Risk factors
for emergency caesarean section in planned vaginal breech delivery. Arch Gynecolo Obstet.
295, pp.51-58.
Rietberg C.Th, Elferink-Stinkers. PM, Brand. R, Van Loon A.J, Van Hemel O.J.S, Visser
G.H.A. 2003. Term breech presentation in the Netherlands from 1995-1999: Mortality and
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Schutte J.M, Steegers Eric A.P, Santema JOB G, Schuitemaker. NWE, Roosmalen J.V. 2011.
Maternal deaths after elective caesarean section for breech presentation in the Netherlands.
Tulasa B, Baburam D, Dipti D, Ramesh S, Sarita S, Ann T.2020. Maternal and perinatal
outcomes of singleton term breech vaginal delivery at a tertiary care center in Nepal:
Retrospective analysis. Obstetrics and Gynecology International.pp.2-4.
T, Wasim AZ, Majrooh M.A.2017. Singleton vaginal breech delivery at term: Maternal and
perinatal outcome. ANNALS. 23(01)
Uotila J, Tuimala R, Kirkinen. 2005.Good perinatal outcome in selective vaginal breech
delivery at term. Acta Obstet Gynecol Scand.84. pp.578-583
Villar. J, Carroli .G, Zavaleta. N, Donner A et al for World Health Organization Study
(WHO) Global Survey on Maternal and Perinatal Health Research Group. 2005. Maternal
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trial prospective study .pp.2-11.
Vistad I, Klungsoyr K, Albechtsea S, Skjeldestad FE. 2015.Neonatal outcome of singleton
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21
APPENDICES

Appendix 1:INFORMATION SHEET

Introduction
My name is RICHARD SAKALA, a fifth year medical student at the Copperbelt University
School of Medicine, Ndola campus. I am carrying out a study on prevalence and outcome of
vaginal singleton term breech delivery at Ndola Teaching Hospital. Be informed that this
study is purely academic.
Purpose of the study
The purpose of this study is to determine feto outcomes in patients undergoing vaginal
breech delivery so that its safety may be determined and also indications of elective C-
section for singleton breech deliveries.
Study procedure.
Secondary data will be collected from the clinical records and delivery registers
Confidentiality
All the information obtained will remain confidential and only accessed by the researcher.
Study benefits
The study may have no direct benefits now but findings of the study will bring advancement
in information regarding safety of vaginal singleton term breech delivery and
recommendations made from findings will result into lower C-section rates and improved
maternal outcomes. In addition, the results from the study will be useful to policy makers and
facilities managers in other districts hospital in saving costs of improving obstetric practices.
Risks
There are no risks anticipated to encounter in this study.
Voluntariness
Your participation in this study is completely voluntary and if you have any doubts or wish to
seek clarification on the research, below are my details.
Name: RICHARD SAKALA
Organization: Copperbelt University
Email address: sakalarichards624@gmail.com

22
Phone number: +260972713097
If you have any complaint about my study, please contact the Secretary of the TDRC ethics
Review Committee at the following details.
The secretary
TDRC Ethics Reviews Committee
P.O.BOX 71769
Ndola
Email: tdrc-ethics@tdrc.org.zm
Tel:+260612837

Appendix 2: Consent form

I understand the information given to me and that my participation in this research is

completely voluntary and its purpose has been fully explained to me. I also understand that
my rights and privacy will be respected.
Name of participant (initials)…………………….
Signature...............................................................
Date........................................................................

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Appendix 3: Data extraction tool

1. TOTAL HOSPITAL IN- DELIVERIES AT NTH FROM 2015-2019: __________

2. TOTAL NUMBER OF BREECH DELIVERIES FROM 2015-2019:
_______
3. DOES THE PARTICIPANT MEET THE INCLUSION CRITERIA? __________
4. GENERAL INFORMATION:
i. Date form completed__________
ii. File number___________
ii. Name/ID of person extracting data_____________
5. SOCIO-DEMOGRAPHIC CHARACTERISTICS:
i. Gestational age at delivery_______
ii. Parity
iii. Residence_____
6. FETO –MATERNAL OUTCOMES:
i. Apgar score of five minutes_______
ii. Nursery admission________
iii. Birth trauma___________
iv. Perinatal Mortality _________
v. Successful child birth_______
vi. Maternal mortality_________
vii. Postpartum hemorrhage and Wound infection______
viii. Risk factors ________
ix. Type of breech___________
x. Weight and sex of neonate______

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Appendix 4: Ghantt chart

Task to be performed March March April May

2019 2022 2022 2022

Handing in project idea

+Approval handing in of
research proposal

Data collection

Data Entry

Data Analysis

Report writing

Submission of report

25
Appendix 5: Budget

Item Cost Units Total

Assistants K500 2 K1000

allowance

Ethical K500 1 K500

clearance

Transport K350 1 K350

Printing and K10 1 K10

photocopying

Other stationary K100 1 K100

Lunch K30 per day 35days(5 weeks) K875

Contingency K175 1 K175

funds at 10%

Total K3,010

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Appendix 6: Ethical approval letter

27
Appendix 7: Copperbelt Provincial Health Office letter

28
Appendix 8: Senior Medical Superintendent letter NTH

29
Appendix 9: Proof of submission of publication

30
Appendix 10; Approval from NHRH.

31