DOI: 10.1111/1471-0528.

13524 Systematic review

www.bjog.org

The risks of planned vaginal breech delivery

versus planned caesarean section for term
breech birth: a meta-analysis including
observational studies
Y Berhan,a A Haileamlakb
a
Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia b Jimma University College of Public Health and Medicine,
Jimma, Ethiopia
Correspondence: Y Berhan, Hawassa University College of Medicine and Health Sciences, PO Box 1560, Hawassa, Ethiopia.
Email yifrub@yahoo.com

Accepted 19 May 2015. Published Online 29 July 2015.

Background The mode of delivery in term singleton breech
presentation has been debated for more than half a century and
has been examined in both randomised and observational studies.
Objective To determine the absolute and relative risks of
perinatal mortality and morbidity in planned vaginal breech
delivery.
Search strategy A computer-based literature search was conducted
mainly in the databases of HINARI, PubMed and Google scholar
for studies comparing planned vaginal delivery and planned
caesarean section.
Selection criteria Studies that assessed the perinatal mortality and
morbidity in relation to the term singleton breech mode of
delivery between 1993 and 2014 were included.
Data collection and analysis In this meta-analysis, 27 articles with
a total sample size of 258 953 women were included. Relative and
absolute risks of perinatal mortality and morbidity in relation to
mode of delivery were determined.
Main results The relative risk of perinatal mortality and morbidity
was about two- to five-fold higher in the planned vaginal than in
the planned caesarean delivery group. The absolute risks of perinatal
mortality, fetal neurologic morbidity, birth trauma, 5-minute Apgar
score <7 and neonatal asphyxia in the planned vaginal delivery
group were 0.3, 0.7, 0.7, 2.4 and 3.3%, respectively.
Conclusion Perinatal mortality and morbidity in the planned
vaginal breech delivery were significantly higher than with planned
caesarean delivery. Even taking into account the relatively low
absolute risks of vaginal breech delivery, the current study
substantiates the practice of individualised decision-making on the
route of delivery in a term breech presentation.
Keywords Absolute risk, birth trauma, meta-analysis, neonatal
asphyxia, perinatal mortality, relative risk, term breech caesarean
delivery, term breech vaginal delivery.
Tweetable abstract Although vaginal breech delivery is
controversial, this review has shown low absolute risk.
Linked article This article is commented on by JG Thornton,
p. 58 in this issue. To view this mini commentary visit http://
dx.doi.org/10.1111/1471-0528.13535.

Please cite this paper as: Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a
meta-analysis including observational studies. BJOG 2016;123:4957.

mendation served to question the longstanding practice of

Introduction
The route of delivery in a term singleton breech presenta-
tion continues to be debated.13 The safety of vaginal
breech delivery represents the main point of controversy,
which came into the forefront in 1931 when Soni recom-
mended elective caesarean section (c/s) for term breech.4
Echoed by Wright in 1959 and Kubli in 1975, this recom-
trial of labour.5,6
The publication of the Term Breech Trial (TBT) in 2000,
showing a significant reduction of perinatal mortality and
morbidity in planned caesarean delivery7, added more sup-
port to routine c/s for all breech presentations.5,8 Following
the TBT, the American College of Obstetricians and Gyne-
cologists (ACOG) and the Royal College of Obstetricians

2015 Royal College of Obstetricians and Gynaecologists 49

 Berhan, Haileamlak
and Gynaecologists (RCOG, UK) 2001 guidelines recom-
mended elective c/s for all term breech.9,10 In 2006, how-
ever, both ACOG and RCOG recommended the use of a
trial of labour in certain circumstances.11,12 In 1993, the
International Federation of Gynecology and Obstetrics
(FIGO) also recommended widespread use of c/s for breech
presentation in developed countries.13 As a result, the
majority of term breech presentations in developed nations
in the last decade were delivered by c/s.5,8
However, the shift from a trial of labour to c/s dates
back to the 1970s, and since then the c/s rate for term sin-
gleton breech in some countries has increased by more
than seven-fold.2 For instance, in the USA the proportion
of c/s for term singleton breech presentation has increased
from about 10% in 1956 and 12% in 1970, to 79% in
1985, 84% in 1997 and 95% in 199199 (California).2,1417
Furthermore, rates of c/s for term breech in other Western
countries before TBT were reported as 7290% in Ger-
many, 74% in Sweden, 77% each in England and Ireland,
79% in Greece, and 90% in Australia.5,18,19
Supporting Information Figure S1 shows the proportion
of c/s breech delivery in selected developed countries.2,5,1430
In some countries such as the Netherlands, Sweden, Fin-
land, Norway and France, a marked increase in c/s rate for
term singleton breech was observed after the TBT, probably
because they considered planned c/s best practice for deliv-
ery of the term singleton breech.1 This was echoed by state-
ments such as: vaginal breech delivery is no longer
justified and the end of vaginal breech delivery.32,33
Nevertheless, several authors have continued to express
serious concerns about the TBT recommendation and the
progressively declining practice of vaginal breech deliv-
ery.5,3437 Several authors presented evidence that vaginal
delivery is still a safe option in selected women with breech
presentation.1,3841 Others showed contrary evidence to
support the TBT findings.16,18,19,31 As a result, the contro-
versy continues. The objective of this study was to deter-
mine the relative and absolute risks of planned vaginal
breech delivery to the baby.
Methods
Search strategy
A computer-based systematic literature search was
conducted using the databases of HINARI, PubMed and
Google scholar. The reference lists of selected articles were
exhaustively searched. Our search terms included: breech,
breech caesarean delivery, breech vaginal delivery,
caesarean versus vaginal delivery in breech, breech mode
of delivery, breech perinatal morbidity and mortality,
breech intrapartal and neonatal mortality and morbidity.
During searching, the search terms were combined alterna-
tively using Boolean logic (and/or).
50
Inclusion criteria and study selection
For this study, the predetermined inclusion criteria were: (1)
studies that assessed the perinatal mortality and morbidity in
relation to the term singleton breech mode of delivery and
(2) studies published in English between 1993 and Septem-
ber 2014. Additionally, cases excluded in the primary studies
due to lethal congenital anomalies, c/s done for other obstet-
ric indications while being term such as multiple pregnancy,
and intrauterine fetal deaths were excluded.
Study selection was performed in three stages by both
authors (Y.B., A.H.). First, after reviewing the titles, all rel-
evant literature were retrieved from the respective databas-
es. Secondly, the abstracts of all the retrieved articles were
reviewed and then grouped as eligible for inclusion or
ineligible for inclusion. Thirdly, articles which were
grouped as eligible for inclusion were reviewed in detail
for final decision. The sample sizes of the included studies
ranged from 162 to 100 667.
Data extraction
Data were extracted using a standard EXCEL spreadsheet.
Extracted data include: the name of the first author, year of
publication, study period, included sample size, country
study conducted, study conclusion, planned and actual
mode of delivery, intrapartum and early neonatal deaths,
neonatal morbidity, birth trauma, admission to the neona-
tal intensive care unit (ICU), neonatal asphyxia/hypoxia,
cord blood pH, 5-minute Apgar score, and neurological
morbidity. The conclusions of each study were rephrased
without changing the concept.
Operational definitions
In this meta-analysis, the perinatal mortality indicates in-
trapartum and early neonatal deaths (before 7 days of age
after birth). The overall neonatal morbidity data were taken
as reported in the primary studies. Specific neonatal mor-
bidity data such as hypoxia, asphyxia, and required intuba-
tion and ventilation were meta-analysed together. Similarly,
neurological morbidity was defined as mean neonatal sei-
zures and hypoxic ischaemic encephalopathy. The compos-
ite score of trauma includes: fracture of clavicle, humerus
or femur, intracerebral bleeding, cephalic haematoma, facial
nerve paresis, brachial plexus injury and other trauma.
Statistical analysis
Meta-analysis was carried out to assess the effect of
planned vaginal and planned c/s breech delivery on intra-
partum and early neonatal mortality and morbidity. The
overall relative risk (RR) and absolute risk (AR) of mortal-
ity and morbidity during the intrapartum and early neona-
tal period were determined. The RR and the 95%
confidence intervals (CI) were computed with the DerSi-
monianLaird method for the following variables: (1) in-
2015 Royal College of Obstetricians and Gynaecologists
 Risks of vaginal breech delivery

trapartal and early neonatal deaths, (2) birth trauma, (3)
neonatal admission to ICU, (4), neonatal asphyxia, (5)
5-minute Apgar score and (6) neurological morbidity, (7)
cord blood pH level and (8) the overall neonatal morbidity.
Since the fixed effect model showed a heterogeneity testing
of 3666% variability, the effect size for each study and the
pooled effect were computed using the random effects
model.
Heterogeneity among the studies was assessed by
computing values for I2 and P-values. The I2 value was
interpreted as no heterogeneity (0%), low heterogeneity
(125%), moderate heterogeneity (>26% and <50%) and
high heterogeneity (50%). The stability of the overall RR in
the withdrawal of any of the studies was done by sensitivity
analyses (leaving one study out at a time). When the 95%CI
did not include the number 1, it was considered statistically
significant. All the meta-analyses were produced using
OPENMETAAANALYST software for Windows 8 (64-bit).
Results
Description of the included studies
As presented in Supporting Information Figure S2 (PRIS-
MA flow chart), the literature search for the selected search
terms identified 12 402 citations. Of these, 219 articles were
retrieved for abstract review. After reviewing the abstracts,
110 articles were excluded. Eighty-two articles were
excluded for the following reasons: the majority were unre-
lated to the current review; some made comparisons
between breech and vertex presentation; others assessed the
long-term maternal and childhood complications of c/s
and vaginal breech delivery. Finally, 27 articles were
selected for analysis.7,16,18,2026,28,29,31,4255 Of the included
Authors
studies, 20 were from Europe, two from Australia, two
from Asia, one multicountry and one each from the USA
and Trinidad. The study design for 23 and four studies was
retrospective and prospective, respectively. One study was a
randomised control trial. The authors of 17 studies con-
cluded that vaginal delivery in term singleton breech
remains an acceptable option with strict selection criteria.
However, the authors of 10 studies concluded that routine
elective c/s for term singleton breech presentation is a safer
option (Supporting Information Table S1).
Methodological quality of the included studies
As recommended by the Cochrane collaboration,56 the
Evers checklist was used to assess the methodological qual-
ity of the selected studies. All the included studies
described well the study population, study design, objec-
tives, outcome measures and ethical issues. The strengths
and weaknesses of each study were discussed. Furthermore,
the statistical tests performed in each primary study were
appropriate. Each conclusion was drawn from the results.
However, there was significant variation in the sample sizes
of the included studies. Twenty-two studies compared the
perinatal outcome of planned vaginal and planned caesar-
ean births. The remaining five studies compared the peri-
natal outcome by the actual mode of delivery.
Findings of the meta-analysis
In this meta-analysis, 258 953 term singleton breech pre-
sentations were included. As shown in Figure 1, the overall
perinatal mortality (intrapartum and early neonatal deaths)
in the planned vaginal delivery and planned c/s group for
term singleton breech was 253 (0.3%) and 79 (0.05%),
respectively;7,16,18,20,21,25,26,28,31,43,44,5154 thus, the risks of
RR (95%CI) Planned vag Planned C/S

Hannah ME et al. (2000) 3.1 (1.8, 5.3) 52/1039 17/1039

Daskalakis G et al. (2006) 20.7 (1.1, 399.5) 3/392 0/1160
Tharin JH et al. (2011)part1 10.0 (1.2, 79.8) 8/2938 1/3667
Tharin JH et al. (2011)part2 18.9 (2.3, 153.9) 7/4101 1/11 097
Pradhan P et al. (2005) 4.4 (0.2, 84.8) 3/881 0/552
Vlemmix F et al. (2014)part1 9.1 (0.5, 151.3) 16/9429 0/2594
Vlemmix F et al. (2014)part2 91.4 (5.6, 1494.4) 30/18 388 0/27 549
Rietberg CCT et al. (2003) 35.6 (2.2, 573.5) 98/25 944 0/4691
Belfrage P et al. (2002) 2.6 (0.1, 47.3) 4/448 0/127
Golfier F et al. (2001) 8.5 (0.4, 176.0) 2/414 0/702
Goffinet F et al. (2006) 0.6 (0.1, 2.6) 2/2502 8/5573
Singh A et al. (2012) 11.0 (1.5, 81.6) 13/60 1/51
Ulnder VM et al. (2004) 3.9 (0.2, 95.0) 1/1270 0/1640
Subgroup planned vag vs planned C/S (I 2 = 40%, P = 0.1) 6.3 (3.0, 13.4) 239/67 806 28/60 442

Lindqvist A et al. (1997) 3.6 (0.7, 19.6) 4/2248 2/4029

Bassaw B et al. (2004) 0.4 (0.0, 4.6) 1/187 2/157
Gilbert WM et al. (2003) 3.7 (1.8, 7.5) 9/4952 47/95 715
Subgroup vaginal vs C/S delivery (I 2 = 32%, P = 0.2) 2.7 (1.0, 7.2) 14/7387 51/99 901

Overall (I 2 = 36%, P = 0.1) 4.6 (2.6, 8.1) 253/75 193 79/160 343

0.04 0.08 0.19 0.38 0.77 1.92 3.84 7.68 19.21 38.42 76.85 192.12 384.24 768.48
Relative risk (log scale)

Figure 1. Meta-analysis of perinatal deaths in term singleton breech presentation (planned vaginal delivery versus planned caesarean section),
multicountry (n = 235 536).7,16,18,20,21,25,26,28,31,43,44,5154 In the Hannah et al.7 study, the perinatal/neonatal mortality, and serious neonatal
morbidity data were reported together.

2015 Royal College of Obstetricians and Gynaecologists 51

 Berhan, Haileamlak

perinatal mortality in planned vaginal and planned caesarean
deliveries were about 1 in 300 and 1 in 2000, respectively.
The pooled meta-analysis has also demonstrated a more
than 4.6-fold increased risk of perinatal mortality in the
planned vaginal group. The subgroup analysis including
planned vaginal and planned c/s delivery has also shown a
more than six-fold increased risk of perinatal death in the
planned vaginal delivery group. The overall heterogeneity
testing showed moderate variability among the included
studies (I2 = 36%). The sensitivity analysis, however, showed
the stability of the overall RR (with exclusion of any of the
studies, the RR ranges from 3.9 to 4. 9).
The meta-analysis in Figure 2 included 63 895
and 48 315 babies in term breech presentation initially
planned for vaginal delivery and c/s, respec-
tively.7,18,20,21,24,26,28,29,31,42,4551,53,54 The overall rates of
birth trauma in the planned vaginal delivery and planned
c/s group were about 1 in 150 (0.7%) and 1 in 600 deliver-
ies (0.17%), respectively. The pooled analysis demonstrated
a more than four-fold increased risk of birth trauma in the
planned vaginal delivery group, with no heterogeneity
among the included studies.
From 19 studies (Figure 3), 70 959 and 63 735 term sin-
gleton breech presentations planned for vaginal delivery
and c/s, respectively, were included in the subgroup meta-
analysis of the 5-minute Apgar score.7,18,2026,28,29,31,45,46,4854
The absolute risk of an Apgar score <7 in the planned vagi-
nal delivery group was about five-fold higher than in the
planned c/s group (2.4 versus 0.3%). In the meta-analysis,
the majority of the included studies showed a statistically
significant association of low 5-minute Apgar score in the
planned vaginal delivery group.7,18,20,21,25,26,31,46,50,52,53 As a
result, the overall relative risk of a 5-minute Apgar score
<7 in the planned vaginal delivery group was 4.7-fold
higher than in the planned c/s group. The heterogeneity
testing showed high variability among the included studies
(I2 = 61%). The sensitivity analysis, however, demonstrated
the stability of the overall RR between 4.6 and 4.8.
Another indicator of fetal outcome in term breech in rela-
tion to mode of delivery was neonatal asphyxia
(Figure 4).7,20,23,26,29,42,45,50,55 Association of neonatal
asphyxia with planned mode of delivery was not consistent
in all included studies. However, the overall RR showed that
neonatal asphyxia was 4.7-fold higher in term breech babies
planned to have a vaginal delivery. The AR of neonatal
asphyxia in the planned vaginal delivery was also more than
5.5-fold higher than in planned c/s (3.3 versus 0.6%).
As presented in Figure 5, of 15 037 breech presentations
planned for vaginal delivery, 4.6% required admission to neo-
natal ICU.7,21,22,2426,28,42,46,4851,54 In the planned c/s group,
the risk of admission to neonatal ICU admission was 2.5%.
The pooled analysis demonstrated weak association of ICU
admission with planned vaginal delivery. The heterogeneity
testing showed significant variability among the included stud-
ies (I2 = 61%). With exclusion of any one of the included
studies, the RR remains stable between 1.7 and 1.92.
Figure 6 shows the neurological morbidity that breech
babies developed in the early neonatal period and its asso-
ciation with planned mode of delivery.7,20,21,26,46,50,53,54 The
overall absolute risk of neurologic morbidity in the planned

Authors RR (95%CI) Planned vag Planned C/S

Ulander VM et al. (2004) 10.6 (4.2, 26.7) 41/1270 5/1640

Krupitz H et al. (2005) 12.3 (0.7, 221.6) 5/382 0/427
Daskalakis G et al. (2006) 26.6 (1.4, 492.7) 4/392 0/1160
Hannah ME et al. (2000) 3.2 (1.2, 8.2) 14/691 6/941
Foster AB et al. (2014) 10.7 (0.5, 222.8) 2/243 0/523
Uotila J et al. (2005) 0.7 (0.0, 10.7) 1/590 1/396
Rauf B et al. (2004) 1.6 (0.1, 17.2) 2/148 1/117
Herbst A et al. (2001) 6.1 (0.3, 107.8) 6/699 0/327
Pradhan P et al. (2005) 1.9 (0.1, 46.1) 1/881 0/552
Irion O et al. (1998) 10.8 (0.6, 191.2) 6/385 0/320
Vlemmix F et al. (2014)part1 33.3 (2.1, 538.3) 60/9429 0/2594
Vlemmix F et al. (2014)part2 4.2 (2.7, 6.5) 76/18 388 27/27 549
Rietberg CCT et al. (2003) 3.4 (1.6, 7.2) 131/25 944 7/4691
Belfrage P et al. (2002) 2.6 (0.1, 47.3) 4/448 0/127
Vistad I et al. (2013) 2.9 (0.1, 70.8) 1/289 0/279
Kayem G et al. (2002) 1.7 (0.2, 15.9) 3/322 1/179
Giuliani A et al. (2002) 4.1 (0.2, 75.6) 4/481 0/218
Golfier F et al. (2001) 4.2 (1.7, 10.8) 15/414 6/702
Goffinet F et al. (2006) 3.9 (2.4, 6.2) 45/2502 26/5573
Subgroup planned vag vs planned C/S (I 2 = 0% , P = 0.8) 4.2 (3.3, 5.4) 421/63 898 80/48 315

Roman J et al. (1998) 9.1 (6.0, 13.8) 155/5897 26/9042

Subgroup vaginal vs C/S delivery (I 2 = NA , P = NA) 9.1 (6.0, 13.8) 155/5897 26/9042

Overall (I 2 = 16% , P = 0.2) 5.0 (3.8, 6.6) 576/69 795 106/57 357

0.04 0.08 0.21 0.42 0.84 2.11 4.21 8.42 21.05 42.1 84.21 210.52 421.05
Relative risk (log scale)

Figure 2. Meta-analysis of birth trauma in term singleton breech presentation (planned vaginal delivery versus planned caesarean section),
multicountry (n = 127 152). 7,18,20,21,24,26,28,29,31,42,45-51,53,54

52 2015 Royal College of Obstetricians and Gynaecologists

 Risks of vaginal breech delivery

Authors RR (95%CI) Planned vag Planned C/S

Hannah ME et al. (2000) 5.3 (2.4, 11.4) 31/691 8/941

Daskalakis G et al. (2006) 26.6 (3.4, 209.5) 9/392 1/1160
Tharin JH et al. (2011)part1 3.6 (2.1, 6.1) 52/2938 18/3667
Tharin JH et al. (2011)part2 4.5 (3.0, 6.8) 60/4101 36/11 097
Uotila J et al. (2005) 16.8 (1.0, 282.8) 12/590 0/396
Foster AB et al. (2014) 2.6 (1.1, 5.9) 12/243 10/523
Herbst A et al. (2001) 23.9 (1.5, 391.3) 25/699 0/327
Pradhan P et al. (2005) 6.5 (2.6, 16.2) 52/881 5/552
Irion O et al. (1998) 2.5 (0.5, 12.3) 6/385 2/320
Toivonen E et al. (2012) 2.0 (0.5, 7.8) 4/254 4/497
Alarab M et al. (2004) 5.8 (0.3, 119.3) 2/298 0/343
Vlemmix F et al. (2014)part1 5.7 (3.3, 10.0) 237/9429 13/2954
Vlemmix F et al. (2014)part2 8.6 (6.6, 11.2) 374/18 388 65/27 549
Rietberg CCT et al. (2003) 7.2 (4.5, 11.5) 721/25 944 18/4691
Belfrage P et al. (2002) 5.4 (0.7, 39.8) 19/448 1/127
Vistad I et al. (2013) 14.5 (0.8, 252.4) 7/289 0/279
Giuliani A et al. (2002) 3.2 (0.2, 61.3) 3/481 0/218
Golfier F et al. (2001) 3.1 (1.0, 9.0) 9/414 5/702
Goffinet F et al. (2006) 3.2 (1.9, 5.2) 37/2502 26/5573
Kayem G et al. (2002) 2.5 (0.5, 11.5) 9/322 2/179
Ulander VM et al. (2004 18.1 (4.3, 75.7) 28/1270 2/1640
Subgroup planned vag vs planned C/S (I 2 = 45%, P = 0.0) 5.1 (3.9, 6.6) 1709/70 959 216/63 735

Lindqvist A et al. (1997) 2.5 (1.7, 3.6) 69/2248 49/3955

Roman J et al. (1998) 3.9 (2.9, 5.2) 163/5897 64/9042
Subgroup vaginal vs C/S delivery (I 2 = 73%, P = 0.1) 3.2 (2.0, 4.9) 232/8145 113/12 997

Overall (I 2 = 61%, P = 0.0) 4.7 (3.6, 6.0) 1941/79 104 329/76 732

0.16 0.33 0.82 1.65 3.3 4.66 8.25 16.5 33 82.5 164.99 329.99
Relative risk (log scale)

Figure 3. Meta-analysis of 5-minute Apgar score <7 in term singleton breech presentation (planned vaginal delivery versus planned caesarean
section), multicountry (n = 155 836).7,18,2026,28,29,31,45,46,4854

Authors RR (95%CI) Planned vag Planned C/S

Hannah ME et al. (2000) 5.9 (1.7, 20.6) 13/691 3/941

Krupitz H et al. (2005) 5.6 (0.3, 116.0) 2/382 0/427
Daskalakis G et al. (2006) 4.9 (1.2, 20.5) 5/392 3/1160
Uotila J et al. (2005) 4.0 (0.5, 33.3) 6/590 1/396
Herbst A et al. (2001) 15.4 (2.1, 112.4) 33/699 1/327
Irion O et al. (1998) 2.1 (0.7, 6.6) 10/385 4/320
Alarab M et al. (2004) 1.5 (0.3, 6.8) 4/298 3/343
Ulander VM et al. (2004 5.4 (3.3, 8.8) 84/1270 20/1640
Subgroup planned vag vs planned C/S (I = 0%, P = 0.5)
2 4.7 (3.2, 6.8) 157/4707 35/5554

Babovic'e I et al. (2010) 2.2 (1.0, 4.8) 13/139 11/262

Subgroup vaginal vs C/S delivery (I 2 = NA , P = NA) 2.2 (1.0, 4.8) 13/139 11/262

Overall (I 2 = 9% , P = 0.4) 3.9 (2.7, 5.8) 170/4846 46/5816

0.27 0.54 1.35 2.69 3.93 5.38 13.45 26.91 53.82 116.02
Relative risk (log scale)

Figure 4. Meta-analysis of neonatal asphyxia in term singleton breech presentation (planned vaginal delivery versus planned caesarean section),
multicountry (n = 10 662).7,20,23,26,29,42,45,50,55

vaginal delivery was small but was more than seven-fold
higher than planned c/s (0.7 versus 0.1%). The meta-analy-
sis has also shown the increased risk of neurological mor-
bidity in the planned vaginal delivery group. In the
sensitivity analysis, the RR remains stable between 2.3 and
2.9. There was little difference between the subgroup RR
and the overall RR.
Discussion
Main findings
The current meta-analysis has shown an increased RR of
perinatal mortality and morbidity in a vaginal breech deliv-
ery group in all assessed variables as compared with a c/s
breech delivery group. However, the absolute risks of peri-
natal mortality and morbidity in this group were very
small.
Strengths and limitations
Unlike the previous systematic reviews,2,41 the current
meta-analysis includes all available data. Above all, this
study emphasises the AR and RR of vaginal breech delivery.
As a limitation, as the majority of the included studies were
retrospective and observational by design, they were prone
to bias. Specifically, some of the data might not be accu-
rately recorded and the comparisons made on the temporal

2015 Royal College of Obstetricians and Gynaecologists 53

 Berhan, Haileamlak

Authors RR (95% CI) Planned vag Planned C/S

Hannah ME et al. (2000) 2.6 (1.5, 4.8) 31/691 16/941

Daskalakis G et al. (2006) 6.5 (2.3, 18.6) 11/392 5/1160
Tharin JH et al. (2011)part1 1.1 (0.9, 1.4) 129/2938 143/3667
Tharin JH et al. (2011)part2 1.5 (1.3, 1.8) 175/4101 314/11 097
Foster AB et al. (2014) 0.9 (0.3, 2.2) 6/243 15/523
Herbst A et al. (2001) 2.2 (1.2, 4.0) 62/699 13/327
Pradhan P et al. (2005) 2.5 (1.2, 5.2) 36/881 9/552
Toivonen E et al. (2012) 1.0 (0.2, 5.3) 2/254 4/497
Belfrage P et al. (2002) 2.5 (1.2, 5.1) 71/448 8/127
Vistad I et al. (2013) 3.5 (1.6, 7.5) 29/289 8/279
Giuliani A et al. (2002) 2.7 (0.3, 22.5) 6/481 1/218
Golfier F et al. (2001) 3.2 (1.6, 6.6) 21/414 11/702
Kayem G et al. (2002) 0.9 (0.5, 1.7) 21/322 13/179
Goffinet F et al. (2006) 1.3 (0.9, 1.8) 54/2502 91/5573
Krupitz H et al. (2005) 1.5 (0.9, 2.4) 39/382 29/427

Overall (I 2 = 61%, P < 0.1) 1.8 (1.4, 2.2) 693/15 037 680/26 269

0.18 0.36 0.9 1.77 3.61 9.02 18.04

Relative risk (log scale)

Figure 5. Meta-analysis of intensive care unit (ICU) admission in term singleton breech presentation (planned vaginal delivery versus planned
caesarean section), multicountry (n = 41 306).7,21,22,2426,28,42,46,4851,54

Authors RR (95%CI) Planned vag Planned C/S

Hannah ME et al. (2000) 9.5 (1.2, 77.3) 7/691 1/941

Daskalakis G et al. (2006) 8.9 (0.4, 217.1) 1/392 0/1160
Foster AB et al. (2014) 6.4 (0.3, 157.6) 1/243 0/523
Herbst A et al. (2001) 11.2 (1.5, 82.6) 24/699 1/327
Pradhan P et al. (2005) 1.9 (0.1, 46.1) 1/881 0/552
Lashen H et al. (2002) 5.5 (0.3, 93.2) 10/488 0/127
Goffinet F et al. (2006) 1.2 (0.4, 3.7) 5/2502 9/5573
Ulander VM et al. (2004) 0.6 (0.1, 7.1) 1/1270 2/1640
Subgroup planned vag vs planned C/S (I 2 = 10%, P = 0.4) 2.9 (1.3, 6.6) 50/7166 13/10 843

Roman J et al. (1998) 2.5 (0.9, 7.0) 12/5897 5/6031

Subgroup vaginal vs C/S delivery (I 2 = NA, P = NA) 2.5 (0.9, 7.0) 12/5897 5/6031

Overall (I 2 = 0%, P = 0.5) 2.6 (1.4, 4.7) 62/13 063 18/16 874

0.06 0.12 0.29 0.59 1.17 2.62 5.86 11.72 29.31 58.61 117.23 217.11
Relative risk (log scale)

Figure 6. Meta-analysis of neurological morbidity in term singleton breech presentation (planned vaginal delivery versus planned caesarean section),
multicountry (n = 29 937).7,20,21,26,46,50,53,54,56

relationship between planned vaginal delivery and planned
c/s delivery may be biased or exposed to uncertainty.
Secondly, because of the large difference in the sample
size of the included studies, studies with a small sample
size have little weight on the overall RR.
Thirdly, as the majority of the included studies assessed
the perinatal outcome with respect to planned vaginal ver-
sus planned c/s delivery, we were not able to assess the
perinatal outcome for this group by actual mode of deliv-
ery.
Finally, all the included studies, with the exception of
three, were from high income countries, which may not be
representative of the rest of the world.
Interpretation
Although the RRs of perinatal mortality and morbidity in
the vaginal delivery group were high, the ARs were not
high or comparable with previous reports.2,57 For example,
the 0.3% perinatal deaths from 75 193 vaginal breech deliv-
eries was even lower than the perinatal mortality in a
cephalic vaginal delivery group reported by a WHO team.58
In a multicentre study with a large sample size study, the
proportions of fetal and neonatal deaths in the cephalic
vaginal delivery were 0.39 and 0.38%, respectively.58 On
the other hand, some authors were not convinced of the
increased risk of perinatal mortality in the planned vaginal
delivery group reported in the TBT; they strongly argued
that the reported 13 perinatal deaths in this trial had no
connection with mode of delivery or labour.3,37
This analysis has also shown that the AR of birth trauma
in vaginal breech delivery was <1%, which was comparable
to the AR of birth trauma in vaginal cephalic deliveries of
babies who had shoulder dystocia, a birthweight >3.5 kg
and instrumental delivery.5962 Specifically, in the USA the

54 2015 Royal College of Obstetricians and Gynaecologists


maximum risk of brachial plexus palsy for vaginal delivery
and c/s was estimated as 0.6 and 0.1%,62 which was close
to the overall risk of birth trauma in the current analysis
(0.7 and 0.17%, respectively).
The low 5-minute Apgar score, increased admission to
ICU, increased neonatal asphyxia and neurological morbid-
ity in the vaginal breech delivery group may be due to
intrapartum asphyxia. Intrapartum asphyxia in vaginal
breech delivery again depends on the length of the second
stage of labour, particularly after half of the body of the
baby is delivered, which again depends on the skill of the
attending clinician.63
This emphasises that although the RR of perinatal mor-
tality and morbidity in the vaginal breech delivery group
was more than two- to five-fold higher than in the c/s
breech delivery group, the ARs of perinatal mortality and
morbidity in the vaginal breech delivery were not as such
higher than the AR of vaginal cephalic delivery. In addi-
tion, the relatively increased perinatal mortality and mor-
bidity in vaginal breech delivery may be due to multiple
factors.3,63
However, taking into account the low risk of fetal and
early neonatal mortality and morbidity in babies delivered
by elective c/s, several authors are against vaginal breech
delivery.7,16,18,19,25,26,28,3133,50,51,53,55,64 The reality is that
elective c/s reduces the risk of perinatal mortality and mor-
bidity for breech presentation, as it does for cephalic pre-
sentation.58,65 Vaginal cephalic delivery carries an increased
risk of birth trauma; shoulder dystocia related-brachial
plexus injuries, subgaleal haemorrhage and cephalohaema-
toma.61,62 Several authors pointed out that elective c/s for
all should not be recommended.1,5,2023,3440,4249
The big question remains: because babies delivered by
elective c/s are found to have a relatively good outcome
during the perinatal period, should every term singleton
breech baby be delivered by c/s as some have strongly rec-
ommended?16,32,33,64 For the moment, for multiple reasons,
this does not seem logical or practicable.
First, spontaneous onset and rapidly advancing labour in
breech presentation before the date of the schedule for elec-
tive c/s is not uncommon22,46,54 and requires skilled man-
agement. Even in the TBT, about 9.6% of the women
scheduled for elective c/s gave birth vaginally.7 Secondly, as
repeatedly raised by previous authors,5,35 unless vaginal
breech delivery is practised, skill transfer to young doctors
and midwives who are likely to encounter unavoidable vag-
inal breech delivery will not occur efficiently. Thirdly, it is
not uncommon to encounter labouring women in breech
presentation, for whom a c/s is not an option.
Elective c/s carries a significant mortality and morbidity
risk to the mother.36,58,6668 In a WHO study, the odds of
maternal mortality and severe morbidity in women who
delivered by elective c/s were 3.4- and 2.3-fold higher
2015 Royal College of Obstetricians and Gynaecologists
Risks of vaginal breech delivery
than vaginal delivery.58 Elective c/s was relatively safe for
the babies in the perinatal period, as this meta-analysis
showed. However, in the Netherlands, the effect of elective
c/s for term breech was found to double the risk of neo-
natal mortality in subsequent pregnancies as compared
with planned vaginal breech delivery.68 Elective c/s may
also increase the risk for late childhood asthma. Two
meta-analyses have shown that children delivered by elec-
tive and emergency c/s had a 20% increase in the subse-
quent risk of asthma.69,70
The implication is that neither elective c/s nor vaginal
delivery for breech presentation is risk free. None of the
available evidence, including the findings in this meta-
analysis, is strong enough to abandon completely vaginal
breech delivery.1,5,2023,3440,4249,52,55,63,71 Eligibility criteria
for vaginal breech delivery can be set at the national
level to guide best practice, such as those published in
Canada by the Society of Obstetricians and Gynaecolo-
gists.72 Otherwise, elective c/s for all term singleton
breech presentation may add to the increasing rate of c/s
across the world.35,63,73 This alarming increase in c/s rate
may increase the risk of immediate and long-term
maternal and neonatal complications, including uterine
scar-related rupture, placenta praevia and morbid placen-
tal adherence.18,63,6870,73,74 Vaginal and abdominal deliv-
eries for term breech presentation have inherent risks for
the baby and the mother during the peripartum period
and in later life.58,62,6669,75 In short, the risks and bene-
fits need to be balanced by carefully selecting eligible
cases.
Conclusion
Although the controversy is still unresolved and the major-
ity of investigators recommend vaginal delivery for selected
term singleton breech babies because the RR of perinatal
mortality and morbidity in planned vaginal breech delivery
is significantly higher, the AR of vaginal breech delivery
remains low. Our study substantiates the practice of indi-
vidualised decision-making on the route of delivery in a
term singleton breech presentation. A comparative study
on vaginal breech and vaginal cephalic delivery is recom-
mended.
Contribution to authorship
YB conceived the idea and worked on the literature search,
data extraction, analysis and write up. AH collaborated in
the literature search and write up. Both authors reviewed
and accepted the final version of the article.
Disclosure of interests
None declared. Completed disclosure of interests form
available to view online as supporting information.
55
 Berhan, Haileamlak
Funding
We received no financial support for this meta-analysis.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Figure S1. The proportion of caesarean delivery in term
singleton breech before and after the 2000 Term Breech
Trial (TBT) in selected developed countries.2,5,1430
Figure S2. Flow diagram showing article selection (PRIS-
MA).
Table S1. General characteristics of the included studies. &
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