Best evidence in anesthetic practice prevention: planned Cesarean delivery reduces early perinatal and neonatal complications for term breech presentations

Structured abstractQuestionFor the fetus that presents as breech at term, does a planned Cesarean birth reduce perinatal or neonatal mortality or serious neonatal morbidity compared to vaginal planned birth?DesignMulticenter, randomized trial.SettingOne hundred twenty-one hospitals in 26 countries.PatientsTwo thousand eighty-eight parturients, each with a singleton live fetus in frank or complete breech presentation at ≥37 weeks’ gestation. Exclusion criteria were fetopelvic disproportion, clinically large (estimated weight ≥4000 g) fetus, hyperextension of fetal head, known lethal fetal congenital anomaly, clinically suspected fetal anomaly or condition that might cause mechanical problem at delivery, and contraindication to labour or vaginal delivery.InterventionOne thousand forty-three women were allocated to planned Cesarean section at ≥38 weeks’gestation; 1045 women were allocated to planned vaginal birth by spontaneous labour unless an indication for induction or Cesarean section developed. Management of labour followed a predefined protocol; vaginal deliveries were performed by clinicians experienced in vaginal breech delivery. Randomization was stratified by parity (0 or ≥1).Main outcomesPerinatal / neonatal mortality at < 28 days of age or serious neonatal morbidity were the primary outcomes. Six-week postpartum maternal mortality or serious maternal morbidity were the secondary outcomes.Main resultsAnalysis was intention-to-treat. Maternal (age, parity, frequency of labour or ruptured membranes) and fetal (type of breech presentation, size or weight) characteristics; methods used to assess fetal size, attitude of fetal head, and adequacy of pelvis; attempts at external cephalic version; national perinatal mortality rates; and standard of care in participating centres were similar between both groups. Planned Cesarean section significantly reduced the risks of perinatal / neonatal mortality and serious neonatal morbidity compared to planned vaginal birth (Table). There were no significant differences in maternal mortality or serious maternal morbidity between the two groups.ConclusionPlanned Cesarean delivery of term singleton fetus in breech presentation significantly reduces early (< 28 days) perinatal / neonatal mortality and serious morbidity without increased six-week maternal mortality or serious maternal morbidity.FundingCanadian Institutes of Health Research, Centre for Research in Women’s Health (Sunnybrook and Women’s College Health Sciences Centre), University of Toronto Department of Obstetrics and Gynaecology.