Planned caesarean section for term breech delivery
Compared with planned vaginal birth, planned caesarean section reduced perinatal or neonatal death or serious neonatal morbidity for the singleton breech baby at term, at the expense of somewhat increased maternal morbidity. Information on long-term consequences of caesarean section is limited. In both developing and developed countries a planned caesarean section should only be considered only after external cephalic version has failed.
RHL Commentary by Conde-Agudelo A
1. EVIDENCE SUMMARY
The objective of this review (1), was to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech presentation at term on measures of pregnancy outcome. There was a significantly lower risk of the combined outcome of perinatal or neonatal mortality or of serious neonatal morbidity in the planned caesarean section group than in the planned vaginal birth group. The reduction in risk was smaller in countries with a high perinatal mortality rate. There was also a statistically significant but modest higher risk of maternal morbidity in the planned caesarean section group than in the planned vaginal birth group.
Overall, the methods used to search and retrieve the trials, extract and analyse the data, and the way in which the data are presented (both graphically and in text) were adequate. All relevant controlled trials were included and appropriately analysed. Sub-group analysis was performed by countries with low and high perinatal mortality.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Three to four percent of singleton pregnancies at term are complicated by breech presentation. In a previous study from Latin America, we reported the risk of death during intrapartum period was almost tenfold higher for fetuses with breech presentation when compared with fetuses with cephalic presentation independently of gestational age (2). Data from the Perinatal Information System database of the Latin American Centre for Perinatology and Human Development (Montevideo, Uruguay) show that 66% of singleton term breech presentations underwent caesarean section. Moreover, compared with term breech fetuses delivered by caesarean section, term breech fetuses delivered by vaginal route had almost nine times increased risk of perinatal mortality.
2.2. Applicability of the results
Forty-four per cent of studied women came from countries with a high perinatal mortality rate (developing countries). In these countries, the benefits of planned caesarean delivery to the infant were much lower than in countries with a low perinatal mortality rate. A more plausible explanation is that intrapartum care providers in countries with a high perinatal mortality rate may be more experienced and skilled in vaginal breech delivery. Then, the overall trial findings may not be generalisable to developing countries. There is good evidence that external cephalic version for breech at term reduces non-cephalic births and caesarean section by nearly 60% and 50% respectively, without significant detrimental effect on perinatal mortality in either developing or developed countries (3). Because of increased maternal morbidity and mortality associated with planned caesarean section the primary focus should be on increasing the rate of external cephalic version to reduce the need for caesarean delivery.
2.3. Implementation of the intervention
Performing planned caesarean section for all term fetuses in the breech presentation would require large additional investments in most developing countries. Furthermore, in these countries where there are poor facilities for regional anaesthesia, blood transfusion and aseptic conditions etc, a policy of caesarean section for all breech presentations would increase the risk to women as well as put them at greater risk in their future pregnancies due to the presence of the scar in the uterus. Thus, in some settings the risk of caesarean section may outweigh the risk of vaginal birth.
The number of additional caesarean sections necessary to avoid having one dead or compromised infant was around seven in countries with a low perinatal mortality rate and 39 in countries with a high perinatal mortality rate. Thus, the resource implications of performing more caesarean sections in these countries are greatest.
Both in developing and developed countries a planned caesarean section should only be considered after External cephalic version has been attempted and failed. Moreover, breech deliveries should be delayed as much as possible to allow time for spontaneous version and cephalic birth to take place.
It will be impossible to deliver all term breech pregnancies by caesarean section. The systematic review showed that 9% of women with breech presentation still have a vaginal breech delivery because the mother may insist on vaginal delivery, breech labour may be precipitate, or special situations such as the second fetus in twins. It is therefore imperative to continue providing expertise in vaginal breech delivery to all the intrapartum care providers.
- There should be more research in developing countries to evaluate the resource implications and consequences of a change in policy to caesarean section. However, the possibility to conduct a new randomized study only in those countries with high perinatal mortality rates is low due not only to ethical aspects, but also practical problems as how to recruit a sufficient number of patients accepting randomization.
- Long-term morbidity and psychomotor development of term fetuses delivered with breech presentations, either vaginally or by caesarean section should be evaluated.
- Long-term maternal morbidity, after caesarean section and vaginal breech delivery should be investigated.
- Hofmeyr GJ, Hannah ME. Planned Caesarean section for term breech delivery (Cochrane Review). In: Cochrane database of systematic reviews, Issue 3, 2001. CD000166.
- Conde-Agudelo A, Belizan JM, Diaz-Rossello JL. Epidemiology of fetal death in Latin America. Acta obstetricia et gynecologica Scandinavica 2000;79:371-378.
- Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term (Cochrane Review). In: Cochrane database of systematic reviews, Issue 2, 2001. CD000083.
This document should be cited as: Conde-Agudelo A. Planned caesarean section for term breech delivery: RHL commentary (last revised: 8 September 2003). The WHO Reproductive Health Library; Geneva: World Health Organization.