Elsevier

The Lancet

Volume 356, Issue 9239, 21 October 2000, Pages 1375-1383
The Lancet

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Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial*

https://doi.org/10.1016/S0140-6736(00)02840-3Get rights and content

Summary

Background

For 3–4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.

Methods

At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.

Findings

Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90·4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56·7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1·6%] vs 52 of 1039 [5·0%]; relative risk 0·33 [95% CI 0·19–0·56]; p<0·0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3·9%] vs 33 of 1042 [3·2%]; 1·24 [0·79–1·95]; p=0·35).

Interpretation

Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

Introduction

About 3–4% of all pregnancies reach term with a fetus in the breech presentation.1 Data from previously published cohort studies have shown that, in general, planned caesarean section is better than planned vaginal birth for the fetus that presents as a breech at term.2, 3 These studies are potentially biased, however, because women were not allocated to the different modes of delivery at random. Other concerns are that the studies might have included pregnancies that would not currently be considered for a trial of labour (eg, footling breech presentation [with the feet entering the birth canal ahead of any other part of the body]), and that clinicians undertaking vaginal breech deliveries may not have been experienced in the technique. Two randomised controlled trials and a Cochrane meta-analysis of these trials have not found planned caesarean section to be associated with substantial benefits for the fetus, but both trials had very small sample sizes.4, 5, 6

There is a general consensus that planned caesarean section is better than planned vaginal birth for the delivery of the fetus in the breech presentation at term if the presentation is footling, if the fetus is compromised, if the fetus is large or has a congenital abnormality that could cause a mechanical problem at vaginal delivery, or if a clinician experienced in vaginal breech delivery is not available.7 However, for most breech fetuses at term, the best approach by which to deliver is controversial. Some clinicians believe a policy of planned caesarean section is best because of the results of observational studies, whereas others remain sceptical since there is no evidence from randomised controlled trials that perinatal outcome is improved with a policy of planned caesarean section. We undertook the Term Breech Trial to determine whether planned caesarean section was better than planned vaginal birth for selected fetuses in the breech presentation at term. The study was done in centres that could assure women having a vaginal breech delivery that an experienced clinician would be present at the birth.

Section snippets

Patients

Women were eligible for the trial if they had a singleton live fetus in a frank or complete breech presentation at term (⩾37 weeks' gestation). Frank breech presentation was defined as hips flexed, knees extended; complete breech was defined as hips flexed, knees flexed, but feet not below the fetal buttocks. Women were excluded if there was evidence of fetopelvic disproportion, if the fetus was judged to be clinically large or to have an estimated fetal weight of 4000 g or more, if there was

Results

We cnrolled 2088 women between Jan 9, 1997 and April 21, 2000, at 1212 centres in 26 countries. We received entry and outcome data for 2083 (99·8%) women, of whom 1041 were randomised to the planned caesarean section group and 1042 to the planned vaginal birth group (figure). Baseline characteristics were similar in both groups (table 1). 1027 (49·3%) women were from centres with a low perinatal mortality rate, and 1056 (50·7%) were from centres with a high perinatal mortality rate. The numbers

Discussion

Some clinicians have recommended a policy of caesarean section for breech presentation at term based on results of non-randomised studies, anecdotal experiences, and medicolegal concerns.2, 3, 10, 11 Other clinicians who are experienced with vaginal breech delivery have continued to recommend planned vaginal birth for selected women, with the view that vaginal birth would be associated with lower morbidity for the mother, would require fewer health-care resources, and would be less costly.7, 12

References (15)

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