The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants

Abstract

Objective To examine the effects of the Term Breech Trial on the medical behaviour of Dutch obstetricians and on neonatal outcomes. Design Retrospective observational study.Setting The Netherlands.Population Infants born at term in breech presentation in the Netherlands between 1998 and 2002, with birthweights 4000 g (n ¼ 33,024) and >4000 g (n ¼ 2429), respectively. Multiple pregnancies, antenatal death and major congenital malformations were excluded. Methods Data derived from the Dutch Perinatal Database were used to compare modes of delivery and neonatal outcome of infants born in breech position in the 33 months preceding publication of the Term Breech Trial and in the 25 months thereafter. Main outcome measures Incidence of planned and emergency caesarean section, vaginal breech delivery, perinatal death, 5-minute Apgar score and birth trauma. Results Within two months after publication of the Term Breech Trial, the overall caesarean rate increased from 50% to 80% and has remained stable thereafter. In the group of infants 4000 g, this was associated with a significant decrease of perinatal mortality from 0.35% to 0.18%, a decrease of the incidence of a 5-minute Apgar score <7 from 2.4% to 1.1% and a decrease of birth trauma from 0.29% to 0.08%. In the (small) group of infants >4000 g, a similar trend was observed. Conclusions The Term Breech Trial has resulted in an exceptionally rapid change in medical behaviour by Dutch obstetricians. This change was followed by improved neonatal outcome.

Breech delivery: changing scenario

“…A review of the Dutch perinatal database showed that the rate of planned elective caesarean section for term breech changed from 49% in the 33 months prior to the publication of the Term Breech Trial to 80% in the 25 months afterwards. 9 The analysis included more than 33 000 infants. This change led to a halving of the perinatal mortality rates and rates of low Apgar scores, as well as the rates of birth trauma, which fell by three-quarters.…”

Elective cesarean section for term breech delivery

“…Randomized clinical trials 4 (8,9,12,14) Concurrent cohort studies 2 (18,19) Non-concurrent cohort studies 20 (10,11,13,(15)(16)(17)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32) After applying the inclusion and exclusion criteria, the evidence selected in the search and defined as randomized controlled trials (RCT) were subjected to an appropriate checklist for critical assessment (Table 3). Critical assessment of RCTs allows to classify them according to the Jadad score, so that Jadad < 3 trials are considered inconsistent (B), and those with scores ≥ 3, consistent (A).…”

External cephalic version: a terrible opportunity to waste

“…3 Of these, an increasing number of primary cesarean deliveries are performed for breech presentation. 4 The reasons fewer women today opt for attempted external cephalic version (ECV) are less clear. Patient request and physician ambivalence may be involved, driven by the concern that even if successful, ECV may result in a cesarean.…”