Outcomes with cesarean delivery vs vaginal birth in extremely preterm breech singletons.
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BACKGROUND: Decision-making regarding breech extremely preterm mode of birth is difficult. Seeming benefits with cesarean delivery in previous studies may have been due to other factors that had not been adequately accounted for. OBJECTIVE: To determine the association of cesarean delivery vs vaginal birth with neonatal outcomes among live-born, extremely preterm, breech singletons who received active care at birth. STUDY DESIGN: This population-based cohort study included all live-born breech singletons between 23 and 27 weeks of gestation from 2010 to 2022, who received active resuscitation including those who died in the resuscitation room. We excluded outborn infants and those with major congenital anomalies. Our primary outcome was a composite of death, severe neurological complications, or birth trauma (mainly intracranial or other hemorrhage). The primary analysis comparing infants born by cesarean delivery vs vaginally used a generalized estimating equation Poisson regression model; sensitivity analyses included propensity score matching. RESULTS: From the 3332 extremely preterm breech singletons, 83.4% (2778/3332) were born by cesarean delivery. The adjusted incidence of mortality or severe morbidity was lower in the cesarean delivery group than in the vaginal birth group (26.1% vs 33.7%, respectively, adjusted relative risk of 0.77, 95% confidence interval, 0.63, 0.95, with adjustment for 14 factors including gestational age at birth). The reduction in mortality or severe morbidity following cesarean delivery persisted: after propensity score matching (adjusted relative risk, 0.69; 95% confidence interval, 0.53, 0.89), and in those receiving optimized perinatal care (all of: antenatal corticosteroids, antenatal magnesium sulfate, and deferred cord clamping) or likely in those without optimized perinatal care, and in the subgroups of singletons born early (23-24 weeks) or likely later (25-27 weeks). CONCLUSION: Extremely preterm breech singleton birth by cesarean delivery was associated a reduction in mortality or severe morbidity. This association was robust and consistently observed in analyses addressing potential confounding through different methods and in clinical-relevant scenarios. Given that all 3 previous randomized controlled trials were stopped early due to recruitment challenges, this type of cohort data are the best available evidence for decision-making.
