Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium

Abstract

Objective: A large trial published in 2000 concluded that planned vaginal delivery of term breech births is associated with high neonatal risks. Because the obstetric practices in that study differed from those in countries where planned vaginal delivery is still common, we conducted an observational prospective study to describe neonatal outcome according to the planned mode of delivery for term breech births in 2 such countries. Study design: Observational prospective study with an intent-to-treat analysis to compare the groups for which cesarean and vaginal deliveries were planned. Associations between the outcome and planned mode of delivery were controlled for confounding by multivariate analysis. The main outcome measure was a variable that combined fetal and neonatal mortality and severe neonatal morbidity. The study population consisted of 8105 pregnant women delivering singleton fetuses in breech presentation at term in 138 French and 36 Belgian maternity units. Results: Cesarean delivery was planned for 5579 women (68.8%) and vaginal delivery for 2526 (31.2%). Of the women with planned vaginal deliveries, 1796 delivered vaginally (71.0%). The rate of the combined neonatal outcome measure was low in the overall population (1.59%; 95% CI [1.33-1.89]) and in the planned vaginal delivery group (1.60%; 95% CI [1.14-2.17]). It did not differ significantly between the planned vaginal and cesarean delivery groups (unadjusted odds ratio = 1.10, 95% CI [0.75-1.61]), even after controlling for confounding variables (adjusted odds ratio = 1.40, 95% CI [0.89-2.23]). Conclusion:In places where planned vaginal delivery is a common practice and when strict criteria are met before and during labor, planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women. Keywords: Breech presentation Mode of delivery Neonatal morbidity Observational surveyVaginal deliveries for breech presentations have long been a topic of debate.1 The Term Breech Trial by Hannah et al, published in 2000, confirmed for many physicians that neonatal risks associated with term breech births are much higher among planned vaginal deliveries and implied that cesarean deliveries should be systematically planned for all such women. 2,3Vaginal delivery of breech infants remains standard practice in France. In 1998, the proportion of planned vaginal deliveries among term breech infants here was 51.2%, and 65.1% of this group actually delivered vaginally. 4 In 2000, the French College of Gynecologists and Obstetricians (CNGOF) defined the optimal criteria for deciding to attempt vaginal delivery (Table I). 5,6 Although the internal validity of Hannah's trial is irrefutable, some aspects raise questions about the extrapolation of its results to other settings. The absolute risk of mortality and serious perinatal morbidity for the planned vaginal birth group in countries with low perinatal mortality rates was high (5.7%), as was the difference between the 2 groups (14 times higher in ...

Outcome of Breech Deliveries in Cameroonian Nulliparous Women

“…Similar results have been reported by other authors [10][11][12]. The rate observed in this study is higher than the rates observed in the other series [8].…”

Decreased neonatal tibial bone ultrasound velocity in term infants born after breech presentation

“…3 This position, usually maintained for days or weeks after delivery, may affect gait and motor function up to the age of 12 to 18 months. 2 Previous reports have shown that lack of motion leads to a decrease in bone mineral density. 4 Using the mechanostat model, Frost et al 5 established the importance of mechanical loading in the development and maintenance of bone health.…”

“…1,2 These fetuses usually have a limited motion of their lower limbs during the last weeks of gestation. 3 Being crammed in utero, these fetuses often adopt abnormal position such as extreme hips flexion and/or knees hyperextension.…”

Breech delivery: changing scenario

“…10 The PREMODA trial which is often referred to as the "antidote to the Term Breech Trial" was conducted in France and Belgium. They used the same criteria and outcome measures as the Term Breech Trial (TBT), except the decision for a Caesarean Section (CS) or Vaginal Breech Birth (VBB) was the woman"s, not randomized.…”