Perinatal Outcome of Vaginal Breech Delivery in Nulliparous Mothers in a Tertiary Hospital of a Low-Resource Setting: A Case-Control Study

Perinatal Outcome of Vaginal Breech Delivery in Nulliparous Mothers in a Tertiary Hospital of a Low-Resource Setting: A Case-Control Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perinatal Outcome of Vaginal Breech Delivery in Nulliparous Mothers in a Tertiary Hospital of a Low-Resource Setting: A Case-Control Study Okbu Frezgi, Berhe Tesfai, Khalid Hussein, Hailemichael Gebremariam, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9252418/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Introduction: Nulliparity is a crucial issue to consider in vaginal breech delivery, and this study aims to identify the perinatal outcome in vaginal breech deliveries in nulliparous women. Methodology: A retrospective case-control study conducted at Orotta National Referral Teaching Hospital from 2019 to 2023. Vaginal breech deliveries were enrolled as cases, and four cephalic deliveries as controls. Results A total of 365 medical records of nulliparous mothers were analyzed, and the prevalence of stillbirth was 7.7%. Vaginal breech deliveries were significantly associated with low birth weight of < 2.5 kilogram (aOR: 4.14, 95% CI: 1.74–9.82), first minute Apgar score of < 7 (aOR: 9.21, 95% CI: 3.37–24.65), fifth minute Apgar score of < 7 (aOR: 6.36, 95% CI: 1.36–29.73), and referral to neonatal intensive care unit (aOR: 0.16, 95% CI: 0.035–0.74). Conclusion Vaginal breech deliveries in nulliparous women were associated with low first and fifth minute Apgar scores in a low-resource setting. Breech presentation Cephalic presentation Eritrea Nulliparity Pelvimetry Perinatal Outcome Introduction Breech is the commonest malpresentation, and nulliparous mothers with breech presentation in labor are prone to deliver by cesarean section [ 1 – 3 ]. Since up to 4% of fetuses are in breech presentation at term, a substantial number of mothers seek counseling regarding the most successful and safest mode of delivery [ 2 , 4 ]. Studies in the United States have shown high rates of caesarean section among primigravidas with breech presentation at term (89.6–95.7%, Robson Criteria 6) [ 5 ]. Nulliparity seems not to be an exclusion criterion for intended vaginal breech birth at term. However, it is still important to inform the women of an increased risk of going to a cesarean section during labor [ 4 , 6 ]. An attempt for a vaginal delivery would only be reasonable in a specialized center if the fetal weight is estimated in the normal range and if the woman has experienced a vaginal delivery before [ 4 , 7 ]. Proper planning of delivery methods is important to avoid adverse pregnancy outcomes, in which birth weight and pelvic measurements should be topics of great importance in patient counselling [ 7 ]. Opposite to vertex delivery, in vaginal breech delivery, different parts are delivered in the reverse direction of size, and the last, suddenly increased head size predisposes to dystocia or neck entrapment [ 8 ]. Pelvimetry is often recommended in nulliparous mothers before offering vaginal breech delivery; however, it has not been shown to predict neonatal outcome, and there is still no consensus on the interpretation of magnetic resonance imaging (MRI) measurements [ 9 ]. Neonatal complications, especially birth traumas, are more common among the babies of primiparous mothers, and overall vaginal breech delivery was less safe than cephalic presentation fetuses [ 1 , 2 , 10 , 11 ]. Vaginal breech deliveries (VBDs) are associated with a 10-fold increase in perinatal mortality when compared with vaginal cephalic deliveries (VCDs) [ 12 ]. In low-resource settings like Eritrea, where proper selection of planned vaginal breech delivery was not performed, should a direct caesarean section be preferred for breech presentation at term in nulliparous mothers, as it is being practiced? This study aims to determine the perinatal outcome of vaginal breech delivery in nulliparous mothers. Methodology Study Design and Period This was a unicentre, retrospective case-control study with medical records review of nulliparous mothers delivered vaginally at Orotta National Referral and Teaching Hospital from 2019 to 2023. Study Population The study population was all nulliparous mothers delivered vaginally at Orotta National Referral and Teaching Hospital, with vaginal breech deliveries considered as cases and vaginal cephalic deliveries considered as controls. Eligibility Criteria Delivery registers with complete information of all nulliparous vaginal deliveries were eligible in the study. Twin pregnancy, gross congenital anomalies (anencephaly and hydrocephalus), and instrumental vaginal deliveries were excluded from the study. Sample Size and Sampling Method Since this study utilized secondary data, the sample size was predetermined. The study included all nulliparous mothers who experienced vaginal breech delivery, with four cephalic vaginal deliveries recruited for each case. Controls were randomly selected from a list of nulliparous mothers who had cephalic vaginal deliveries. Although the sample size was fixed, the statistical power of the study was assessed to determine whether it was adequate. To evaluate the study’s power, the first-minute Apgar score was used as a key parameter. The proportion of controls with a low Apgar score (< 7) was estimated at 4%, while among cases, it was 18% [ 13 ]. Based on these estimates, with 73 cases and 292 controls (four controls per case) and a confidence level of 95%, the calculated power of the study exceeded 90%. Therefore, the study had sufficient power to detect a meaningful difference if one truly existed. Data Collection and Analysis A specific data extraction tool was designed to retrieve data from the delivery register based on the available information in the register. The data were entered into MS Excel, cleaned, and missing data were refilled by double-checking the register. Finally, the dataset was exported to SPSS version 26 for analysis. The frequency and percent were determined, and the mean was calculated for continuous variables. Univariate and multivariate analysis was done using logistic regression to determine the association, and a p-value < 0.05 was considered significant. Ethical Considerations Ethical approval was obtained from the Ministry of Health Research Approval and Ethical Committee (reference number 30/03/2023), and respected authorities were informed. Informed consent was not sought as this was secondary data. The personal identifiers of patients were coded and analyzed as aggregates. This study conforms to the principles outlined in the Declaration of Helsinki. Results A total of 365 medical records of nulliparous mothers were analyzed with a case-to-control ratio of 1:4. Most of the mothers were from Zoba Maekel (91.5%), and the mean age was 24.22 ± 4.08. Teenage pregnancy was documented in 11.8% and it was slightly higher in VBDs (Case: 16.4% VS Controls: 10.6%). Only 1.1% had their first baby at an advanced age (> 35 years). The history of abortion was documented in 2.2% of the study participants, and all the abortions had occurred in mothers who gave vaginal breech deliveries. (Table 1 ) Gender of the newborn was almost similar, with equal distribution among vaginal breech deliveries and vaginal cephalic deliveries. Low birth weight was documented in 13.2% of the newborns, with a high proportion among VBDs (Cases: 38.4% VS Controls: 6.8%). The overall < 7 first-minute Apgar score was 23.8% and a markedly higher proportion was found in VBDs (Cases: 67.1% VS Controls: 13%). Fifth-minute Apgar score of < 7 also showed a big difference among the study groups (Cases: 49.3% VS Controls: 5.5%). Total NICU admission was documented in 9% with 16.4% in VBDs and 7.2% in vaginal cephalic deliveries. The prevalence of stillbirth was 7.7% with a significant proportion seen in VBDs (Cases: 28.8% VS Controls: 2.4%). (Table 1 ) Table 1 Sociodemographic characteristics of primiparous vaginal deliveries at Orotta National Referral and Teaching Hospital, 2019–2023. Variables Total N (%) Mode of delivery P- Value VCD N (%) VBD N (%) Maternal age (years) 16–19 43 (11.8) 31 (10.6) 12(16.4) 0.114 20–34 318 (87.1) 259 (88.7) 59 (80.8) >34 4 (1.1) 2 (0.7) 2 (2.7) Address (Zoba) Maekel 334 (91.5) 281 (96.2) 53 (72.6) 0.001 Other zoba 31 (8.5) 11 (3.8) 20 (27.4) Gravida 1 357 (97.8) 292 (100.0) 65 (89.0) 0.001 >1 8 (2.2) 0 (0) 8 (11) History of abortion 0 357 (97.8) 292 (100.0) 65 (89.0) 0.001 >=1 8 (2.2) 0 (0) 8 (11) Birth weight, in KG 3.5 33 (9) 28 (9.6) 5 (6.8) Apgar 1st minute =7 278 (76.2) 254 (87.0) 24 (32.2) Apgar 5th minute =7 313 (85.8) 276 (94.5) 37 (50.7) Sex Female 179 (49) 145 (49.7) 34 (46.6) 0.638 Male 186 (51) 147 (50.3) 39 (53.4) Alive or stillbirth Alive 337 (91.5) 285 (97.6) 52(71.2) 0.001 Stillbirth 28 (7.7) 7 (2.4) 21 (28.8) Referred to the NICU No 332 (91) 271 (92.8 ) 61 (83.6) 0.014 Yes 33 (9) 21 (7.2) 12 (16.4) VBD: Vaginal breech delivery, VCD: Vaginal cephalic delivery In univariable analysis, vaginal breech deliveries were found to be significantly associated with patients referred from other Zobas (OR: 2.08, 95% CI: 1.64–2.63, P < 0.001), birth weight of < 2.5 kilogram (OR: 8.54, 95% CI: 4.39–16.69, P < 0.001), first minute Apgar score of < 7 (OR: 13.6, 95% CI: 7.52–24.75, P < 0.001), fifth minute Apgar score of < 7 (OR: 16.78, 95% CI: 18.49–33.18, P < 0.001), referral to NICU (OR: 2.54, 95% CI: 1.19–5.44, P < 0.017), and stillbirth (OR: 16.44, 95% CI: 6.65–40.64, P < 0.001). In multivariable analysis, vaginal breech deliveries were significantly associated with patients referred from other Zoba’s (aOR: 10.41, 95% CI: 3.97–27.24, P < 0.001), birth weight of < 2.5 kilogram (aOR: 4.14, 95% CI: 1.74–9.82, P < 0.001), first minute Apgar score of < 7 (aOR: 9.21, 95% CI: 3.37–24.65, P < 0.001), fifth minute Apgar score of < 7 (aOR: 6.36, 95% CI: 1.36–29.73, P < 0.019) and referral to NICU (aOR: 0.16, 95% CI: 0.035–0.74, p < 0.019). (Table 2 ) Table 2 Univariable and multivariable analysis of vaginal breech deliveries in nulliparous mothers delivered in Orotta National Referral and Teaching 2019–2023. Variables OR 95% CI P- Value aOR 95% CI P- Value Address (Zoba) Maekel (Ref) 1 - - - Other zoba 2.08 1.64–2.63 0.001 10.41 3.97–27.24 0.001 Birth weight, in KG 3.5 1.09 0.39–2.98 0.86 0.99 0.39–3.52 0.998 Apgar 1st minute =7 (Ref) 1 - - - Apgar 5th minute =7 (Ref) 1 - - - Birth Outcome Alive (Ref) 1 - - - Stillbirth 16.44 6.65–40.64 0.001 0.245 0.03–1.62 0.144 Referred to the NICU No (Ref) 1 - - - Yes 2.54 1.19–5.44 0.017 0.16 0.035–0.74 0.019 OR: Odds Ratio, aOR: Adjusted Odds Ratio Discussion The mode of delivery in breech presentations at term is a controversially discussed topic in obstetrics, and nulliparity is a crucial issue to consider. Pelvimetry is often recommended before offering vaginal breech delivery, and previous successful vaginal delivery is the best pelvimetry method [ 1 , 9 , 14 ]. Several imaging studies, including MRI, are used for pelvimetry mainly due to nulliparity, where their availability in low settings was limited [ 9 , 14 , 15 ]. In our setting, breech presentation at term in nulliparous women was a direct indication for caesarean section, and those included in this study were women who came in later stages of labor and delivered vaginally. We tried to assess their perinatal outcome in comparison with cephalic vaginal deliveries in nulliparous mothers. In this study, the rate of teenage pregnancy was 11.8%, which was similar to a study conducted in a similar low-setting (10.7%) [ 16 ]. This finding identified that teenage pregnancy had no association with mode of delivery but might predispose to adverse perinatal outcomes because teenagers have less developed pelvis and lower antenatal care utilization. In this study, the prevalence of stillbirth was 7.7% with great variation among the cases, which was almost similar to a study conducted in a similar setting in Zimbabwe (5.8%) [ 17 ]. In resource-limited areas where breech presentations are identified during labor, adverse perinatal outcomes could be amplified more in nulliparous mothers due to the passage of the fetus through an untested pelvis. In this study, stillbirths were not significantly associated with the mode of delivery in nulliparous mothers, which aligns with other studies [ 4 , 8 , 18 ]. Our study identified a significant association of adverse perinatal outcomes in nulliparous women (low first and fifth minute Apgar score with vaginal breech delivery compared with vaginal cephalic deliveries. A study conducted in India stated that breech presentation in primigravida results in worse perinatal outcomes compared to multipara [ 19 ]. Furthermore, a study in Finland also reported that nulliparity was associated with adverse perinatal outcomes [ 20 ]. Contrarily, a study conducted on late preterm deliveries stated that primiparity in breech deliveries was not found to be a risk for perinatal morbidity [ 21 ]. The higher adverse perinatal outcome of VBDs in nulliparous women in our study could be due to going into labor without pelvimetry and the shortage of manpower know-how to perform vaginal breech delivery. Referral to NICU was found to be a protective association with vaginal breech delivery in nulliparous mothers, possibly due to its correlation with stillbirth and Apgar score. A study in a Portuguese hospital suggests that breech vaginal delivery remains a safe option under strict selection criteria and in the presence of an experienced obstetrician [ 22 ]. Since some international guidelines still recommend "nulliparity" as an exclusion criterion for a vaginal breech birth [ 4 ] in resource-limited areas like Eritrea, where both pelvimetry and manpower experienced in VBDs were not easily available, direct caesarean section could favor better perinatal outcomes. But, future potential pregnancy consequences after cesarean section, especially trial of labor at home, could lead to fetal loss due to uterine rupture and maternal death [ 9 ]. So, a thorough explanation of the possible future pregnancy complication and the necessity of regular antenatal care at a high-risk clinic and hospital delivery to the mother is necessary, not to jeopardize maternal life, to improve perinatal outcome. This study wasn’t without limitations. Being retrospective in nature, and difficulty in determining fetal status during admission to the labor ward were the main drawbacks. Furthermore, the small sample size of the study also leads to low precision of results. A prospective case-control study of vaginal breech delivery in nulliparous mothers in multiple centers can give a broader and clearer view of perinatal outcome. Perinatal outcomes could be improved by upgrading the quality of antenatal care, including identifying breech presentations before the onset of labor. Furthermore, giving training courses on how to make vaginal breech delivery to health workers and making a prompt joint decision on the mode of delivery might improve birth outcomes. Conclusion Our study identified a low first and fifth minute Apgar score in vaginal breech deliveries compared to cephalic deliveries in nulliparous mothers. In resource-limited settings where proper planning methods of delivery using pelvimetry in breech presentation were not carried out, adverse neonatal outcomes should be explained to mothers to assist in a prompt joint decision on mode of delivery. Abbreviations aOR: Adjusted Odds Ratio ANC: Antenatal Care CI: confidence interval OR: Odds Ratio VCD: Vaginal cephalic delivery NICU: Neonatal intensive care unit ONRTH: Orotta National Referral Teaching Hospital SD: Standard deviations SPSS: Statistical Package for Social Sciences VBD: Vaginal breech delivery Declarations Consent for publication: Not applicable Data availability : All the study materials are included in the manuscript. Funding : No funding. Competing interest s: The Authors have no conflicts of interest to disclose. Acknowledgment: We acknowledge the hospital staff for giving their time Authors Contribution All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. Authors Information Okbu Frezgi, MD, Obstetrician and Gynecologist, Department of Obstetrics and Gynecology, Orotta College of Medicine and Health Science, Orotta National Referral Maternity Hospital, Ministry of Health, Asmara, Eritrea. [email protected] https://orcid.org/0009-0003-0734-2468 Berhe Tesfai , MD, Obstetrician and Gynecologist, Department of Obstetrics and Gynecology, Orotta College of Medicine and Health Science, Orotta National Referral Maternity Hospital, Ministry of Health, Asmara, Eritrea. Email: [email protected] , https://orcid.org/0000-0003-1820-7395 Khalid Hussein: MD, Obstetrician and Gynaecologist, Associate Professor, Department of Obstetrics and Gynecology, Orotta College of Medicine and Health Science, Orotta National Referral Maternity Hospital, Ministry of Health, Asmara, Eritrea. Email: [email protected] https://orcid.org/0009-0008-9889-2591 Hailemichael Gebremariam: MD, Dekemhare Hospital, Zoba Debub, Ministry of Health, Dekemhare, Eritrea. Email: [email protected] https://orcid.org/0000-0003-4370-7666 Fitsum Kibreab, PhD, Statistician, Epidemiologist, and International Public Health Expert, Ministry of Health, Health Research and Resources Center Division, Asmara, Eritrea. Email: [email protected] http://orcid.org/0000-0001-7417-4378 References Basak M, R SA, Roy N, Modak P, Basak R, Sarker A. Comparative Study on Breech Deliveries among the Primiparous and Multiparous Women in a Tertiary Care Hospital. Sch Int J Obstet Gynec. 2022;5(3):95–100. Zeb L, Malik A. Relationship of mode of delivery of breech presentation with fetal and maternal outcome in a tertiary care hospital. J Rehman Med Inst. 2023;9:2. Atakan, Tanacan. Murat Cagan, and Mehmet Sinan Beksac., Changing Trends in the Delivery of Breech Presentation throughout the Last Four Decades. J South Asian Federation Obstet Gynecol, 2019. 11(3). Ulrikke Kielland-Kaisen BP, Jennewein L, Klemt A, Charlotte NB, Möllmann J, Wiebke Schaarschmidt, Dörthe Brüggmann, and, Louwen F. Maternal and neonatal outcome after vaginal breech delivery of nulliparous versus multiparous women of singletons at term—A prospective evaluation of the Frankfurt breech at term cohort (FRABAT). 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Int J Reprod Contracept Obstet Gynecol. 2023;12:2809–13. Macharey et al. Risk factors associated with adverse perinatal outcome in planned vaginal breech labors at term: a retrospective population-based case-control study. BMC Pregnancy Childbirth 2017. 17(93). Toijonen A, et al. Risk factors for adverse outcomes in vaginal preterm breech labor. Arch Gynecol Obstet. 2021;303:93–101. Valente MP. Maria Carvalho Afonso, and NunoClode., Is Vaginal Breech Delivery Still a Safe Option? Rev Bras Ginecol Obstet. 2020;42(11):712–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 May, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers invited by journal 28 Apr, 2026 Editor invited by journal 06 Apr, 2026 Editor assigned by journal 31 Mar, 2026 Submission checks completed at journal 31 Mar, 2026 First submitted to journal 28 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9252418","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635070975,"identity":"fc9193b4-c225-456d-9323-87025b7b9f78","order_by":0,"name":"Okbu Frezgi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYBACPhiDH0QkFBChhQ3GkGwAaTEgRYvBATBJjBaJ3McvPrbdkzc+vzrxwwMDBnl+sQOEtKSbWc5sKzbcduPtZgmgwwxnzk4gpCWNzZh3WwLjthtnN4C0JBjcJkbL320J9ptnnN38g1gtzI8ZtyUkbuDv3UakLTzP2Bh7/yUkz7jBu80iwUCCsF/42dOYP/w4k2Db3392880fFTby/NIEtIDdBqYkwColCCoHAeYPEPsOEKV6FIyCUTAKRiAAALawQYU7Y2mJAAAAAElFTkSuQmCC","orcid":"","institution":"Obstetrics and Gynaecology, Orotta College of Medicine and Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Okbu","middleName":"","lastName":"Frezgi","suffix":""},{"id":635070978,"identity":"36eb18f6-b1a2-4373-9d61-579a147171bb","order_by":1,"name":"Berhe Tesfai","email":"","orcid":"","institution":"Obstetrics and Gynaecology, Orotta College of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Berhe","middleName":"","lastName":"Tesfai","suffix":""},{"id":635070979,"identity":"7979f6a8-4bbc-4d77-a8ec-bf59362f85a6","order_by":2,"name":"Khalid Hussein","email":"","orcid":"","institution":"Obstetrics and Gynaecology, Orotta College of Medicine and Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Khalid","middleName":"","lastName":"Hussein","suffix":""},{"id":635070980,"identity":"e03f28cb-720d-4a31-83b9-3579f25a6cba","order_by":3,"name":"Hailemichael Gebremariam","email":"","orcid":"","institution":"Dekemahre hospital, Zoba Debub, Ministry of health","correspondingAuthor":false,"prefix":"","firstName":"Hailemichael","middleName":"","lastName":"Gebremariam","suffix":""},{"id":635070981,"identity":"5421ba56-9fc2-44f1-bcd7-8695f6596b86","order_by":4,"name":"Fitsum Kibreab","email":"","orcid":"","institution":"Ministry of Health, Health Research and Resources Center Division","correspondingAuthor":false,"prefix":"","firstName":"Fitsum","middleName":"","lastName":"Kibreab","suffix":""}],"badges":[],"createdAt":"2026-03-28 11:53:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9252418/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9252418/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108806351,"identity":"7f08023a-dfac-4663-b430-954a663a570b","added_by":"auto","created_at":"2026-05-08 15:28:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":321997,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9252418/v1/18f68fb2-11a0-49ab-8888-60aa2e5f613c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perinatal Outcome of Vaginal Breech Delivery in Nulliparous Mothers in a Tertiary Hospital of a Low-Resource Setting: A Case-Control Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreech is the commonest malpresentation, and nulliparous mothers with breech presentation in labor are prone to deliver by cesarean section [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Since up to 4% of fetuses are in breech presentation at term, a substantial number of mothers seek counseling regarding the most successful and safest mode of delivery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Studies in the United States have shown high rates of caesarean section among primigravidas with breech presentation at term (89.6\u0026ndash;95.7%, Robson Criteria 6) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Nulliparity seems not to be an exclusion criterion for intended vaginal breech birth at term. However, it is still important to inform the women of an increased risk of going to a cesarean section during labor [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. An attempt for a vaginal delivery would only be reasonable in a specialized center if the fetal weight is estimated in the normal range and if the woman has experienced a vaginal delivery before [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProper planning of delivery methods is important to avoid adverse pregnancy outcomes, in which birth weight and pelvic measurements should be topics of great importance in patient counselling [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Opposite to vertex delivery, in vaginal breech delivery, different parts are delivered in the reverse direction of size, and the last, suddenly increased head size predisposes to dystocia or neck entrapment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Pelvimetry is often recommended in nulliparous mothers before offering vaginal breech delivery; however, it has not been shown to predict neonatal outcome, and there is still no consensus on the interpretation of magnetic resonance imaging (MRI) measurements [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNeonatal complications, especially birth traumas, are more common among the babies of primiparous mothers, and overall vaginal breech delivery was less safe than cephalic presentation fetuses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Vaginal breech deliveries (VBDs) are associated with a 10-fold increase in perinatal mortality when compared with vaginal cephalic deliveries (VCDs) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In low-resource settings like Eritrea, where proper selection of planned vaginal breech delivery was not performed, should a direct caesarean section be preferred for breech presentation at term in nulliparous mothers, as it is being practiced? This study aims to determine the perinatal outcome of vaginal breech delivery in nulliparous mothers.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Period\u003c/h2\u003e \u003cp\u003eThis was a unicentre, retrospective case-control study with medical records review of nulliparous mothers delivered vaginally at Orotta National Referral and Teaching Hospital from 2019 to 2023.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eThe study population was all nulliparous mothers delivered vaginally at Orotta National Referral and Teaching Hospital, with vaginal breech deliveries considered as cases and vaginal cephalic deliveries considered as controls.\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eDelivery registers with complete information of all nulliparous vaginal deliveries were eligible in the study. Twin pregnancy, gross congenital anomalies (anencephaly and hydrocephalus), and instrumental vaginal deliveries were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eSample Size and Sampling Method\u003c/h3\u003e\n\u003cp\u003eSince this study utilized secondary data, the sample size was predetermined. The study included all nulliparous mothers who experienced vaginal breech delivery, with four cephalic vaginal deliveries recruited for each case. Controls were randomly selected from a list of nulliparous mothers who had cephalic vaginal deliveries. Although the sample size was fixed, the statistical power of the study was assessed to determine whether it was adequate. To evaluate the study\u0026rsquo;s power, the first-minute Apgar score was used as a key parameter. The proportion of controls with a low Apgar score (\u0026lt;\u0026thinsp;7) was estimated at 4%, while among cases, it was 18% [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Based on these estimates, with 73 cases and 292 controls (four controls per case) and a confidence level of 95%, the calculated power of the study exceeded 90%. Therefore, the study had sufficient power to detect a meaningful difference if one truly existed.\u003c/p\u003e\n\u003ch3\u003eData Collection and Analysis\u003c/h3\u003e\n\u003cp\u003eA specific data extraction tool was designed to retrieve data from the delivery register based on the available information in the register. The data were entered into MS Excel, cleaned, and missing data were refilled by double-checking the register. Finally, the dataset was exported to SPSS version 26 for analysis. The frequency and percent were determined, and the mean was calculated for continuous variables. Univariate and multivariate analysis was done using logistic regression to determine the association, and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003ewas obtained from the Ministry of Health Research Approval and Ethical Committee (reference number 30/03/2023), and respected authorities were informed. Informed consent was not sought as this was secondary data. The personal identifiers of patients were coded and analyzed as aggregates. This study conforms to the principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 365 medical records of nulliparous mothers were analyzed with a case-to-control ratio of 1:4. Most of the mothers were from Zoba Maekel (91.5%), and the mean age was 24.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.08. Teenage pregnancy was documented in 11.8% and it was slightly higher in VBDs (Case: 16.4% VS Controls: 10.6%). Only 1.1% had their first baby at an advanced age (\u0026gt;\u0026thinsp;35 years). The history of abortion was documented in 2.2% of the study participants, and all the abortions had occurred in mothers who gave vaginal breech deliveries. (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eGender of the newborn was almost similar, with equal distribution among vaginal breech deliveries and vaginal cephalic deliveries. Low birth weight was documented in 13.2% of the newborns, with a high proportion among VBDs (Cases: 38.4% VS Controls: 6.8%). The overall\u0026thinsp;\u0026lt;\u0026thinsp;7 first-minute Apgar score was 23.8% and a markedly higher proportion was found in VBDs (Cases: 67.1% VS Controls: 13%). Fifth-minute Apgar score of \u0026lt;\u0026thinsp;7 also showed a big difference among the study groups (Cases: 49.3% VS Controls: 5.5%). Total NICU admission was documented in 9% with 16.4% in VBDs and 7.2% in vaginal cephalic deliveries. The prevalence of stillbirth was 7.7% with a significant proportion seen in VBDs (Cases: 28.8% VS Controls: 2.4%). (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\" style=\"margin-right: calc(21%); width: 79%;\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic characteristics of primiparous vaginal deliveries at Orotta National Referral and Teaching Hospital, 2019\u0026ndash;2023.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" morerows=\"1\" nameend=\"c4\" namest=\"c3\" rowspan=\"2\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003eTotal N (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c5\" style=\"width: 28.7602%;\"\u003e\n \u003cp\u003eMode of delivery\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" morerows=\"1\" nameend=\"c9\" namest=\"c8\" rowspan=\"2\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e\u003cem\u003eP-\u003c/em\u003eValue\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003eVCD N (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003eVBD N (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c9\" namest=\"c1\" style=\"width: 74.6869%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal age (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e16\u0026ndash;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e43 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c5\" namest=\"c4\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e31 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e12(16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e20\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e318 (87.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c5\" namest=\"c4\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e259 (88.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e59 (80.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u0026gt;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e4 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c5\" namest=\"c4\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e2 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAddress (Zoba)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003eMaekel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e334 (91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e281 (96.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e53 (72.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003eOther zoba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e31 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e11 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e20 (27.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGravida\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e357 (97.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e292 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e65 (89.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u0026gt;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e8 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e8 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of abortion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e357 (97.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e292 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e65 (89.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u0026gt;=1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e8 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e8 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight, in KG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u0026lt;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e48 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e20 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e28 (38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e2.5\u0026ndash;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e284 (77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e224 (83.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e40 (54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e33 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e28 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e5 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApgar 1st minute\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u0026lt;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e87 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e38 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e49 (67.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u0026gt;=7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e278 (76.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e254 (87.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e24 (32.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApgar 5th minute\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u0026lt;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e52 (14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e16 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e36 (49.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u0026gt;=7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e313 (85.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e276 (94.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e37 (50.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e179 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e145 (49.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e34 (46.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.638\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e186 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e147 (50.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e39 (53.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlive or stillbirth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003eAlive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e337 (91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e285 (97.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e52(71.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003eStillbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e28 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e7 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e21 (28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c9\" namest=\"c1\" style=\"width: 74.6869%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReferred to the NICU\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e332 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e271 (92.8 )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e61 (83.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" nameend=\"c2\" namest=\"c1\" style=\"width: 21.6098%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c4\" namest=\"c3\" style=\"width: 13.3473%;\"\u003e\n \u003cp\u003e33 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" style=\"width: 14.4595%;\"\u003e\n \u003cp\u003e21 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c7\" namest=\"c6\" style=\"width: 14.3006%;\"\u003e\n \u003cp\u003e12 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" nameend=\"c9\" namest=\"c8\" style=\"width: 9.8515%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 75.9528%;\"\u003eVBD: Vaginal breech delivery, VCD: Vaginal cephalic delivery\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn univariable analysis, vaginal breech deliveries were found to be significantly associated with patients referred from other Zobas (OR: 2.08, 95% CI: 1.64\u0026ndash;2.63, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), birth weight of \u0026lt;\u0026thinsp;2.5 kilogram (OR: 8.54, 95% CI: 4.39\u0026ndash;16.69, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), first minute Apgar score of \u0026lt;\u0026thinsp;7 (OR: 13.6, 95% CI: 7.52\u0026ndash;24.75, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), fifth minute Apgar score of \u0026lt;\u0026thinsp;7 (OR: 16.78, 95% CI: 18.49\u0026ndash;33.18, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), referral to NICU (OR: 2.54, 95% CI: 1.19\u0026ndash;5.44, P\u0026thinsp;\u0026lt;\u0026thinsp;0.017), and stillbirth (OR: 16.44, 95% CI: 6.65\u0026ndash;40.64, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In multivariable analysis, vaginal breech deliveries were significantly associated with patients referred from other Zoba\u0026rsquo;s (aOR: 10.41, 95% CI: 3.97\u0026ndash;27.24, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), birth weight of \u0026lt;\u0026thinsp;2.5 kilogram (aOR: 4.14, 95% CI: 1.74\u0026ndash;9.82, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), first minute Apgar score of \u0026lt;\u0026thinsp;7 (aOR: 9.21, 95% CI: 3.37\u0026ndash;24.65, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), fifth minute Apgar score of \u0026lt;\u0026thinsp;7 (aOR: 6.36, 95% CI: 1.36\u0026ndash;29.73, P\u0026thinsp;\u0026lt;\u0026thinsp;0.019) and referral to NICU (aOR: 0.16, 95% CI: 0.035\u0026ndash;0.74, p\u0026thinsp;\u0026lt;\u0026thinsp;0.019). (Table \u003cspan refid=\"Tab2\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUnivariable and multivariable analysis of vaginal breech deliveries in nulliparous mothers delivered in Orotta National Referral and Teaching 2019\u0026ndash;2023.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003eP-\u003c/em\u003eValue\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eaOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cem\u003eP-\u003c/em\u003eValue\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\n \u003cp\u003eAddress (Zoba)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMaekel (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOther zoba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e1.64\u0026ndash;2.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e10.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e3.97\u0026ndash;27.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight, in KG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e8.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e4.39\u0026ndash;16.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e4.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e1.74\u0026ndash;9.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2.5\u0026ndash;3.5 (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e0.39\u0026ndash;2.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e0.39\u0026ndash;3.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eApgar 1st minute\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e7.52\u0026ndash;24.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e9.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e3.37\u0026ndash;24.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;=7 (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eApgar 5th minute\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e16.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18.49\u0026ndash;33.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e6.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e1.36\u0026ndash;29.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;=7 (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth Outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAlive (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eStillbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e16.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e6.65\u0026ndash;40.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e0.03\u0026ndash;1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eReferred to the NICU\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNo (Ref)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e1.19\u0026ndash;5.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e0.035\u0026ndash;0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eOR: Odds Ratio, aOR: Adjusted Odds Ratio\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe mode of delivery in breech presentations at term is a controversially discussed topic in obstetrics, and nulliparity is a crucial issue to consider. Pelvimetry is often recommended before offering vaginal breech delivery, and previous successful vaginal delivery is the best pelvimetry method [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Several imaging studies, including MRI, are used for pelvimetry mainly due to nulliparity, where their availability in low settings was limited [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our setting, breech presentation at term in nulliparous women was a direct indication for caesarean section, and those included in this study were women who came in later stages of labor and delivered vaginally. We tried to assess their perinatal outcome in comparison with cephalic vaginal deliveries in nulliparous mothers.\u003c/p\u003e \u003cp\u003eIn this study, the rate of teenage pregnancy was 11.8%, which was similar to a study conducted in a similar low-setting (10.7%) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This finding identified that teenage pregnancy had no association with mode of delivery but might predispose to adverse perinatal outcomes because teenagers have less developed pelvis and lower antenatal care utilization. In this study, the prevalence of stillbirth was 7.7% with great variation among the cases, which was almost similar to a study conducted in a similar setting in Zimbabwe (5.8%) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In resource-limited areas where breech presentations are identified during labor, adverse perinatal outcomes could be amplified more in nulliparous mothers due to the passage of the fetus through an untested pelvis. In this study, stillbirths were not significantly associated with the mode of delivery in nulliparous mothers, which aligns with other studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study identified a significant association of adverse perinatal outcomes in nulliparous women (low first and fifth minute Apgar score with vaginal breech delivery compared with vaginal cephalic deliveries. A study conducted in India stated that breech presentation in primigravida results in worse perinatal outcomes compared to multipara [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Furthermore, a study in Finland also reported that nulliparity was associated with adverse perinatal outcomes [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Contrarily, a study conducted on late preterm deliveries stated that primiparity in breech deliveries was not found to be a risk for perinatal morbidity [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The higher adverse perinatal outcome of VBDs in nulliparous women in our study could be due to going into labor without pelvimetry and the shortage of manpower know-how to perform vaginal breech delivery. Referral to NICU was found to be a protective association with vaginal breech delivery in nulliparous mothers, possibly due to its correlation with stillbirth and Apgar score.\u003c/p\u003e \u003cp\u003eA study in a Portuguese hospital suggests that breech vaginal delivery remains a safe option under strict selection criteria and in the presence of an experienced obstetrician [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Since some international guidelines still recommend \"nulliparity\" as an exclusion criterion for a vaginal breech birth [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] in resource-limited areas like Eritrea, where both pelvimetry and manpower experienced in VBDs were not easily available, direct caesarean section could favor better perinatal outcomes. But, future potential pregnancy consequences after cesarean section, especially trial of labor at home, could lead to fetal loss due to uterine rupture and maternal death [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. So, a thorough explanation of the possible future pregnancy complication and the necessity of regular antenatal care at a high-risk clinic and hospital delivery to the mother is necessary, not to jeopardize maternal life, to improve perinatal outcome.\u003c/p\u003e \u003cp\u003eThis study wasn\u0026rsquo;t without limitations. Being retrospective in nature, and difficulty in determining fetal status during admission to the labor ward were the main drawbacks. Furthermore, the small sample size of the study also leads to low precision of results. A prospective case-control study of vaginal breech delivery in nulliparous mothers in multiple centers can give a broader and clearer view of perinatal outcome. Perinatal outcomes could be improved by upgrading the quality of antenatal care, including identifying breech presentations before the onset of labor. Furthermore, giving training courses on how to make vaginal breech delivery to health workers and making a prompt joint decision on the mode of delivery might improve birth outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study identified a low first and fifth minute Apgar score in vaginal breech deliveries compared to cephalic deliveries in nulliparous mothers. In resource-limited settings where proper planning methods of delivery using pelvimetry in breech presentation were not carried out, adverse neonatal outcomes should be explained to mothers to assist in a prompt joint decision on mode of delivery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eaOR: Adjusted Odds Ratio\u003c/p\u003e\n\u003cp\u003eANC: Antenatal Care\u003c/p\u003e\n\u003cp\u003eCI: confidence interval\u003c/p\u003e\n\u003cp\u003eOR: Odds Ratio\u003c/p\u003e\n\u003cp\u003eVCD: Vaginal cephalic delivery\u003c/p\u003e\n\u003cp\u003eNICU: Neonatal intensive care unit\u003c/p\u003e\n\u003cp\u003eONRTH: Orotta National Referral Teaching Hospital \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSD: Standard deviations\u003c/p\u003e\n\u003cp\u003eSPSS: Statistical Package for Social Sciences\u003c/p\u003e\n\u003cp\u003eVBD: Vaginal breech delivery\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e: All the study materials are included in the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003es: The Authors have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment:\u003c/strong\u003e\u0026nbsp; We acknowledge the hospital staff for giving their time\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOkbu Frezgi,\u003c/strong\u003e MD, Obstetrician and Gynecologist, Department of Obstetrics and Gynecology, Orotta College of Medicine and Health Science, Orotta National Referral Maternity Hospital, Ministry of Health, Asmara, Eritrea. [email protected] https://orcid.org/0009-0003-0734-2468\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBerhe Tesfai\u003c/strong\u003e, MD, Obstetrician and Gynecologist, Department of Obstetrics and Gynecology, Orotta College of Medicine and Health Science, Orotta National Referral Maternity Hospital, Ministry of Health, Asmara, Eritrea. Email: [email protected], https://orcid.org/0000-0003-1820-7395\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKhalid Hussein:\u003c/strong\u003e MD, Obstetrician and Gynaecologist, Associate Professor, Department of Obstetrics and Gynecology, Orotta College of Medicine and Health Science, Orotta National Referral Maternity Hospital, Ministry of Health, Asmara, Eritrea. Email: [email protected] https://orcid.org/0009-0008-9889-2591\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHailemichael Gebremariam:\u0026nbsp;\u003c/strong\u003eMD,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDekemhare Hospital, Zoba Debub, Ministry of Health, Dekemhare, Eritrea. Email: [email protected] https://orcid.org/0000-0003-4370-7666\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFitsum Kibreab,\u003c/strong\u003e PhD, Statistician, Epidemiologist, and International Public Health Expert, Ministry of Health, Health Research and Resources Center Division, Asmara, Eritrea. Email: [email protected] http://orcid.org/0000-0001-7417-4378\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBasak M, R SA, Roy N, Modak P, Basak R, Sarker A. Comparative Study on Breech Deliveries among the Primiparous and Multiparous Women in a Tertiary Care Hospital. Sch Int J Obstet Gynec. 2022;5(3):95\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeb L, Malik A. Relationship of mode of delivery of breech presentation with fetal and maternal outcome in a tertiary care hospital. J Rehman Med Inst. 2023;9:2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtakan, Tanacan. Murat Cagan, and Mehmet Sinan Beksac., Changing Trends in the Delivery of Breech Presentation throughout the Last Four Decades. J South Asian Federation Obstet Gynecol, 2019. 11(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUlrikke Kielland-Kaisen BP, Jennewein L, Klemt A, Charlotte NB, M\u0026ouml;llmann J, Wiebke Schaarschmidt, D\u0026ouml;rthe Br\u0026uuml;ggmann, and, Louwen F. Maternal and neonatal outcome after vaginal breech delivery of nulliparous versus multiparous women of singletons at term\u0026mdash;A prospective evaluation of the Frankfurt breech at term cohort (FRABAT). European Journal of Obstetrics \u0026amp; Gynecology and Reproductive Biology 2020. 252 pp. 583\u0026ndash;587.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEG V. Examining cesarean delivery rates by race: a population-based analysis using the Robson ten-group classification system. J Racial Ethnic Health Disparities. 2021;8:844\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJennewein L, Paul K-KU B, and, Mo\u0026uml;llmann KA-S, Schulze CJ et al. S, Maternal and neonatal outcome after vaginal breech delivery at term of children weighing more or less than 3.8 kg: A FRABAT prospective cohort study. PLoS ONE.,, 2018. 13(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZander N et al. Combined Assessment of the Obstetrical Conjugate and Fetal Birth Weight Predicts Birth Mode Outcome in Vaginally Intended Breech Deliveries of Primiparous Women A Frabat Study. J. Clin. Med., 2022. 11(3201).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTh\u0026eacute;ra T, et al. Breech vaginal delivery among primipara women: A 5 year analytical study at the Bamako\u0026rsquo;s health district in Mali International. J Clin Obstet Gynecol. 2017;1(2):80\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCinari G, et al. Comparison of vaginal breech deliveries with and without magnetic resonance imaging in primigravidas: a retrospective cohort analysis and literature review. Arch Gynecol Obstet. 2025;311:1315\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLong F, Guo YK, Zhaxi D, Xu D, Sun X Z and and, Xiao Z. Term breech presentation vaginal births in Tibet: A retrospective analysis of 451 cases. Front Med, 2023. 10(1048628).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDohbit JS, Foumane P, and e.a., Tochie JN. Maternal and neonatal outcomes of vaginal breech delivery for singleton term pregnancies in a carefully selected Cameroonian population: a cohort study. BMJ Open 2017. 7(e017198.).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConde-Agudelo A, Beliz\u0026aacute;n JM, D\u0026iacute;az-Rossello JL. Epidemiology of fetal death in Latin America. Acta Obstet Gynecol Scand. 2000;79:371\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrezgi O et al. Perinatal outcome of vaginal breech delivery in Orotta National Referral Teaching Hospital, Eritrea, 2024; a case control study. PLoS ONE, 2025. 20(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBevilacqua E, Jani MF et al. JC,.,, Pregnancy outcomes in breech presentation at term: a comparison between 2 third level birth center protocols. Am J Obstet Gynecol Glob Rep, 2022. 2(100086).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLia M, Dathan- Stumpf A, and e.a., Franke J. Prediction of obstetric outcome in vaginal breech birth using ultrasound pelvimetry in nulliparous women\u0026mdash;A feasibility study. Acta Obstet Gynecol Scand, 2025. 00: pp. 1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgwenya S. The incidence and perinatal outcomes of singleton vaginal breech deliveries in a low-resource setting, mpilo central hospital, Bulawayo, Zimbabwe. MOJ Womens Health. 2019;8(1):54\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026ouml;gberg, et al. Breech delivery at a University Hospital in Tanzania. BMC Pregnancy Childbirth. 2016;16(342). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ep. 10.1186/s12884-016-1136-0\u003c/span\u003e\u003cspan address=\"p. 10.1186/s12884-016-1136-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUlf, H\u0026ouml;gberg et al. Breech delivery at a University Hospital in Tanzania. BMC Pregnancy Childbirth 2016. 16(342).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJadhav R, Yadav B, Kumar K. A study of perinatal outcome in patients with breech presentation at tertiary care centre. Int J Reprod Contracept Obstet Gynecol. 2023;12:2809\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacharey et al. Risk factors associated with adverse perinatal outcome in planned vaginal breech labors at term: a retrospective population-based case-control study. BMC Pregnancy Childbirth 2017. 17(93).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToijonen A, et al. Risk factors for adverse outcomes in vaginal preterm breech labor. Arch Gynecol Obstet. 2021;303:93\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValente MP. Maria Carvalho Afonso, and NunoClode., Is Vaginal Breech Delivery Still a Safe Option? Rev Bras Ginecol Obstet. 2020;42(11):712\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breech presentation, Cephalic presentation, Eritrea, Nulliparity, Pelvimetry, Perinatal Outcome","lastPublishedDoi":"10.21203/rs.3.rs-9252418/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9252418/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eNulliparity is a crucial issue to consider in vaginal breech delivery, and this study aims to identify the perinatal outcome in vaginal breech deliveries in nulliparous women.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e \u003cp\u003eA retrospective case-control study conducted at Orotta National Referral Teaching Hospital from 2019 to 2023. Vaginal breech deliveries were enrolled as cases, and four cephalic deliveries as controls.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 365 medical records of nulliparous mothers were analyzed, and the prevalence of stillbirth was 7.7%. Vaginal breech deliveries were significantly associated with low birth weight of \u0026lt;\u0026thinsp;2.5 kilogram (aOR: 4.14, 95% CI: 1.74\u0026ndash;9.82), first minute Apgar score of \u0026lt;\u0026thinsp;7 (aOR: 9.21, 95% CI: 3.37\u0026ndash;24.65), fifth minute Apgar score of \u0026lt;\u0026thinsp;7 (aOR: 6.36, 95% CI: 1.36\u0026ndash;29.73), and referral to neonatal intensive care unit (aOR: 0.16, 95% CI: 0.035\u0026ndash;0.74).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eVaginal breech deliveries in nulliparous women were associated with low first and fifth minute Apgar scores in a low-resource setting.\u003c/p\u003e","manuscriptTitle":"Perinatal Outcome of Vaginal Breech Delivery in Nulliparous Mothers in a Tertiary Hospital of a Low-Resource Setting: A Case-Control Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 14:16:25","doi":"10.21203/rs.3.rs-9252418/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-07T17:05:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248816094501685403144491553338778794348","date":"2026-04-28T12:32:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328007063169086437381123263692154712514","date":"2026-04-28T12:27:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-28T11:42:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-06T04:23:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-31T10:29:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-31T10:28:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-03-28T11:40:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"79511f24-3610-4243-a3df-26295d9d91e1","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-07T17:05:33+00:00","index":65,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T14:16:26+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 14:16:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9252418","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9252418","identity":"rs-9252418","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}