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Review concludes caesarean birth ‘safest’ for breech delivery

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The relative risks of a baby dying or suffering complications after a vaginal breech delivery are higher than in planned caesarean section, however, the absolute risks are low, suggests a new study.

The researchers said many studies, including the Term Breech Trial in 2000, had concluded that planned caesarean was the safest delivery method for term breech presentations.

“Our study substantiates the practice of individualised decision making around delivering a breech baby”

Yifru Berhan

However, they highlighted that there was also contrary evidence, suggesting that vaginal delivery was still a safe option in selected women with breech presentation and the risks of C-section must be considered too.

Their large review looked at 27 articles, involving a total of 258,953 women, to determine the absolute and relative risks of mortality and morbidity associated with planned vaginal breech delivery from delivery up to seven days after the birth.

Overall perinatal mortality baby was 253 (0.3%) in the planned vaginal delivery group for a term breech and 79 (0.05%) for the planned caesarean section group.

In other words, the absolute risks of perinatal mortality in planned vaginal and planned caesarean deliveries were about one in 300 and one in 2,000, respectively, said the study authors.

The results were lower than the perinatal mortality rates associated with a vaginal delivery when the baby was positioned head first in a World Health Organization study, which found the risk of foetal and neonatal deaths to be 0.39 and 0.38%, respectively.

“This is an interesting topic where some studies have had a significant impact in changing practice”

Mervi Jokinen

Additionally, the absolute risks of neurological problems, birth trauma, a 5th minute Apgar score of less than seven and neonatal asphyxia were 0.7%, 0.7%, 2.4% and 3.3%, respectively.

The review’s findings have been published in BJOG: An International Journal of Obstetrics and Gynaecology.

Study co-author Professor Yifru Berhan, from Hawassa University College of Medicine and Health Sciences in Ethiopia, said: “Our results show that the relative risk of perinatal mortality and morbidity was between two and five times higher in planned vaginal breech delivery, compared to planned caesarean section birth. However, the absolute risks were very small.

“Although the controversy is still unresolved, our study substantiates the practice of individualised decision making around delivering a breech baby,” he said. “Future research should focus on a comparative study on vaginal breech and non-breech delivery.”

“The RCOG currently recommends that caesarean delivery is the safest mode of delivery for the baby when in a breech position”

Alan Cameron

Mervi Jokinen is the practice and standards professional advisor at the Royal College of Midwives.

She said: “This is an interesting topic where some studies have had a significant impact in changing practice, reducing women’s choice, and to some extent contributing to the rising numbers of caesarean sections globally.

“The authors conclude even combining all the studies does not necessarily give the right answers on an individual level,” she said. “All births carry an element of risk, however small.

“The important issue here is that women are aware of the evidence around breech birth, including the risks and the benefits of either a vaginal delivery or caesarean, so that they can make a decision about how they want to give birth,” she added.

Professor Alan Cameron, vice president of clinical quality at the Royal College of Obstetricians and Gynaecologists, said its current recommendation was that caesarean delivery was the safest mode of delivery for the baby when in a breech position.

“However, there are benefits and risks associated with both caesarean delivery and vaginal breech birth and women are encouraged to discuss and weigh up the options so they can choose the best plan for themselves and their baby,” he said.

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