The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta‐analysis including observational studies

Abstract

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.

Breech delivery at a University Hospital in Tanzania

“…In agreement with earlier studies, the present study shows improved fetal outcome for breech fetuses, in terms of intrapartum deaths, early neonatal deaths, and asphyxia, when delivered by CD compared to VD [1, 2, 4, 8]. Results from other, similar settings do not, however, completely agree with our findings.…”

“…Vaginal delivery of breech presentation still remains an option and the systematic review by Berhan et al supports “the practice of individualised decision-making on the route of delivery” [2]. …”

“…A systematic review in 2015 by Berhan et al reports a substantial increase in elective CDs for breech presentation in high-income countries since 2000; at the same time, a two- to fivefold risk increase in perinatal mortality and morbidity has been reported with planned vaginal delivery (VD) [2, 3]. …”

“…Vaginal delivery for breech presentation is still a recommended option where possible [2, 8, 9], especially in low-income settings where CD-associated maternal morbidity and mortality are a serious consideration [3, 6, 10]. The few observational studies of breech delivery in sub-Saharan African Hospitals report a wide range of short-term outcomes, reflecting resource constraints and policy differences [6, 11–13].…”

Finding the breech: Influence of breech presentation on mode of delivery based on timing of diagnosis, attempt at external cephalic version, and provider success with version

“…This study led to a worldwide increase in the proportion of term breech fetuses born by planned cesarean delivery after 2000. The long‐term outcomes from the Term Breech Trial and short‐term outcomes from the Premoda study have suggested that planned vaginal breech birth remains a reasonable option under strict hospital‐based protocols with trained providers; however, most breech fetuses in the United States continue to be born by planned cesarean delivery . Planned cesarean delivery increases risks to the mother in comparison to vaginal delivery and increases the risk for future pregnancies where the mode of delivery is usually a repeat cesarean given the current 10% rate of vaginal birth after cesarean …”