Cesarean Without Labor Safest for Breech Delivery

Jenni Laidman

April 17, 2015

In cases of breech presentation, planned cesarean delivery is associated with fewer adverse outcomes than vaginal delivery or cesarean delivery during labor, according to a study of 52,671 breech births. Moreover, a new review of several studies, including the current study, shows the accumulated evidence supports planned cesarean delivery as the best option for breech presentation.

The two articles are the latest evidence in the see-sawing opinion on breech deliveries, beginning with the 2000 Term Breech Trial. That trial led to recommendations by the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynaecologists advising cesarean delivery for breech presentation.

By 2006, however, things had changed: A 2-year follow-up of the Term Breech Trial failed to show a difference in death or neurodevelopmental delay between planned cesarean delivery and vaginal delivery, and results of the observational Presentation et Mode d'Accouchement (PREMODA) trial conducted in France and Belgium showed no difference between planned cesarean delivery and planned vaginal delivery in a composite endpoint of perinatal mortality or morbidity. Those studies led the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynaecologists, and, 3 years later, the Society of Obstetricians and Gynaecologists of Canada to soften their recommendations, saying that although cesarean delivery remained the preferred approach, vaginal delivery could be reasonably offered to women fully informed of the potential risks.

As a consequence of the softened recommendations, the number of vaginal deliveries has increased in recent years.

In the current study, published online April 7 in Obstetrics & Genecology, Janet Lyons, MD, from the Department of Obstetrics & Gynaecology, Women's Hospital of British Columbia, Vancouver, Canada, and colleagues report an increase in vaginal deliveries in Canadian hospitals from 2.7% in 2003 to 3.9% in 2011, as well as an increase in cesarean deliveries during labor from 8.7% in 2003 to 9.8% in 2011.

With a composite endpoint for neonatal mortality and morbidity for singleton infants born at 37 weeks' gestation or greater, vaginal delivery was associated with a 3.6-fold increase in risk compared with cesarean delivery without labor (95% confidence interval [CI], 2.52 - 5.15). The adjusted rate difference was 15.8 (95% CI, 9.2 - 25.2) per 1000 deliveries. The researchers adjusted ratios for maternal age and parity.

The composite death and morbidity rate ratio for cesarean delivery in labor at 37 weeks was 2.79 (95% CI, 2.18 - 3.58) compared with cesarean delivery without labor in breech presentation.

Dr Lyons and colleagues saw even higher rates of adverse events at 40 weeks of gestation. The rate ratio for composite neonatal death and morbidity was 4.63 (95% CI, 2.74 - 7.84) for cesarean delivery with labor compared with for cesarean delivery without labor for breech presentation. At 40 weeks of gestation, the rate ratio for vaginal delivery compared with cesarean delivery without labor was 5.39 (95% CI, 2.68 - 10.8), for an adjusted rate difference of 24.1 (95% CI, 9.2 - 53.8) per 1000 deliveries.

Dr Lyons and colleagues conclude: "more women delivered vaginally for breech presentation at term gestation in recent years, at least partly the result of changes in recent guidelines. Composite neonatal mortality and morbidity rates were significantly higher after a [vaginal] delivery and after cesarean delivery in labor as compared with cesarean delivery before labor onset. The risks associated with vaginal and cesarean delivery should be carefully considered by women contemplating a singleton breech delivery at term gestation and by their physicians."

In the related literature review published online April 3, K. S. Joseph, MD, PhD, also from the Department of Obstetrics & Gynaecology, Women's Hospital of British Columbia, and colleagues say the evidence shows the best results in breech presentation are associated with planned cesarean delivery.

The lack of difference in composite mortality or neurodevelopmental delay at 2 years of age in the Term Breech Trial, Dr Joseph and colleagues write, was based on data from only 44% of randomized patients and was not an analysis of intention to treat. Further, the PREMODA study's lack of exclusion criteria led to higher-risk women being included in the cesarean delivery group. Even with this selection bias, PREMODA, similar to the Term Breech Trial, showed a nearly ninefold excess in the number of 5-minute Apgar scores of less than 4 for vaginal deliveries, Dr Lyons and colleagues write. Similarly, both showed higher rates of 5-minute Apgar scores less than 7, higher rates of intubation, and higher rates of birth trauma in the vaginal delivery group.

"The totality of the evidence therefore unequivocally shows the relatively greater safety of planned cesarean delivery for breech presentation at term gestation," Dr Joseph and colleagues write.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. Published online April 3, 2015. Lyons abstract, Joseph abstract

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