Planned caesarean section for term breech delivery

Abstract

Background: Poor outcomes after breech birth might be the result of underlying conditions causing breech presentation or due to factors associated with the delivery. Objectives: To assess the effects of planned caesarean section for singleton breech presentation at term on measures of pregnancy outcome. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2011). Selection criteria: Randomised trials comparing planned caesarean section for singleton breech presentation at term with planned vaginal birth. Data collection and analysis: We assessed trial eligibility and quality. We extracted and analysed data using routine Cochrane Collaboration methodology. Main results: Three trials (2396 participants) were included in the review. Caesarean delivery occurred in 550/1227 (45%) of those women allocated to a vaginal delivery protocol. Perinatal or neonatal death (excluding fatal anomalies) or serious neonatal morbidity was reduced with planned caesarean section (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.19 to 0.56). This reduction was less for countries with high national perinatal mortality rates. Perinatal or neonatal death (excluding fatal anomalies) was also reduced with planned caesarean section (RR 0.29, 95% CI 0.10 to 0.86). The proportional reductions were similar for countries with low and high national perinatal mortality rates. Planned caesarean section was associated with modestly increased short-term maternal morbidity (RR 1.29, 95% CI 1.03 to 1.61). At three months after delivery, women allocated to the planned caesarean section group reported less urinary incontinence (RR 0.62, 95% CI 0.41 to 0.93); more abdominal pain (RR 1.89, 95% CI 1.29 to 2.79); and less perineal pain (RR 0.32, 95% CI 0.18 to 0.58). At two years, there were no differences in the combined outcome 'death or neurodevelopmental delay'. Maternal outcomes at two years were also similar. In countries with low perinatal mortality rates, the protocol of planned caesarean section was associated with lower healthcare costs, expressed in 2002 Canadian dollars (one trial; mean difference -$877.00, 95% CI -894.89 to -859.11). Authors' conclusions: Planned caesarean section compared with planned vaginal birth reduced perinatal or neonatal death or serious neonatal morbidity, at the expense of somewhat increased maternal morbidity. The option of external cephalic version is dealt with in separate reviews. The data from this review cannot be generalised to settings where caesarean section is not readily available, or to methods of breech delivery that differ materially from the clinical delivery protocols used in the trials reviewed. The review will help to inform individualised decision-making regarding breech delivery. Research on strategies to improve the safety of breech delivery is needed.