4.What information should be given to women with breech presentation regarding mode of delivery?
Women should be informed of the benefits and risks, both for the current and for future pregnancies, of planned caesarean section versus planned vaginal delivery for breech presentation at term.
about the baby
should be given to women with breech presentation regarding mode of delivery?
Women should be informed that planned caesarean section carries a reduced perinatal mortality andearly neonatal morbidity for babies with a breech presentation at term compared with planned vaginalbirth.Women should be informed that there is no evidence that the long term health of babies with a breechpresentation delivered at term is influenced by how the baby is born.
A systematic review of randomised trials comparing a policy of intended caesarean section with apolicy of intended vaginal birth, included three trials with 2396 participants.
Caesarean delivery occurred in 1060/1169 (91%) of those women allocated to planned caesarean section and550/1227 (45%) of those allocated to a vaginal delivery protocol. Perinatal or neonatal death (excluding fatal anomalies) or short-term neonatal morbidity was reduced with a policy of plannedcaesarean section (RR 0.33, 95% CI 0.19–0.56) and perinatal or neonatal death alone (excludingfatal anomalies) was reduced with a policy of planned caesarean section (RR 0.29, 95% CI0.10–0.86). Most of the data for the review were contributed by the Term Breech Trial.
After excluding the following cases: deliveries that occurred after a prolonged labour, labours that wereinduced or augmented with oxytocin or prostaglandins, cases where there was a footling or uncertain typeof breech presentation at delivery and those cases for whom there was no skilled or experienced clinicianpresent at the birth, the risk of the combined outcome of perinatal mortality, neonatal mortality or seriousneonatal morbidity with planned caesarean section compared with planned vaginal birth was 16/1006 (1.6%)compared with 23/704 (3.3%) (RR 0.49; CI 0.26–0.91);
= 0.02). In a further subanalysis, the findingssuggested that the benefits of delivery by caesarean section were more significant in countries with a low perinatal mortality rate.
In another subgroup analysis, planned caesarean was associated with a lower risk of adverseoutcome due to complications of both labour (RR 0.14, 95% CI 0.04–0.45,
< 0.001) and delivery (RR 0.37, 95% CI 0.16–0.87,
= 0.03), compared with planned vaginal birth.
In a secondary analysis of the data from the Term Breech Trial (not according to group allocation),adverse perinatal outcome was lowest with prelabour caesarean section and increased with caesarean section in early labour (latent phase), in active labour and vaginal birth. For womenexperiencing labour, adverse perinatal outcome was also associated with labour augmentation,birth weight less than 2.8 kg, longer time between pushing and delivery and no experiencedclinician at delivery.
The publication of the Term Breech Trial was followed within 2 months by an increased use of caesarean section for breech presentation in the Netherlands (50–80%) and improved neonataloutcome.
A number of questions were raised following publication of the Term Breech Trial,
largely aboutselection criteria and the conduct of labour. At that time there was evidence available to indicatethat different strategies would eliminate the benefits of planned caesarean section for the baby.
RCOG Guideline No.
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Evidencelevel IaEvidencelevel IbEvidencelevel III