Breech babies did better with scheduled cesarean in Canadian study

Women's healthcare providers have long argued about the safest "mode of delivery" (aka vaginal birth versus cesarean section) for babies in the breech position (butt first!) at term. In May 2015, the Green Journal (the big OBGYN scientific publication) published a new trial from the Canadian health information database from 2003 to 2011 looking at the outcomes for breech babies. 

Here's a quick run-down of the history of breech research:

- 2000 Term Breech Trial: Breech babies born by scheduled c-section had a lower risk of death& serious bad outcomes.

- 2001 ACOG & RCOG (the big OBGYN organizations in the US & UK) recommended planned c-sections for all breech babies because it was believed to be the safest option.

- 2004 Term Breech Trial published a 2-year follow up. This included 44% of the original patients. Now, after 2 years, the breech babies born by c-section and vaginal delivery didn't have any difference in death or severe neurodevelopmental delay.

- 2006 PREMODA Study: This study in France & Belgium showed no difference between vaginal delivery and c-section. So, ACOG & RCOG changed their recommendation to say it's "reasonable" to plan for a vaginal delivery of a breech term infant, as long as the clinician is skilled at these types of deliveries.

The Canadian group has now published new data about the matter, collected after the Term Breech Trial changed the landscape for breech deliveries. There were 52,671 breech deliveries. They compared death, need for breathing support, seizures, and birth injuries between three groups of women: planned c-section, vaginal delivery, or c-section after labor. This last group was likely mostly women who planned for a vaginal delivery but ended up needing a c-section anyway, but also included women who planned for a c-section and went into labor before their scheduled date. Some women in this group may even have thought their baby was head first and found out during labor that the baby was breech and then decided to or needed to get a c-section!

The researchers took into account mother's age, weight, and how many babies she already delivered in their statistical models so that these factors would not influence the comparison between the three types of deliveries.

First and foremost, there was no difference in neonatal death between the groups. However, there was a difference between other markers of bad outcomes for these babies. Breech babies delivered by vaginal delivery or c-section after labor had higher risk of needing help with breathing after birth, being asphyxiated, and being injured during birth. Some examples of these birth injuries were injuries to the scalp or the peripheral nervous system (like a nerve palsy).

What we don't yet know is whether these bad outcomes matter in the long run. Perhaps, after getting a little help with breathing or putting some Neosporin on that scalp injury, the babies recover just fine. It's entirely possible that 2 years from now, there will be no difference between the three groups of babies.

A group of British doctors published a commentary on the trial. They conclude, "The totality of the evidence therefore unequivocally shows the relatively greater safety of planned cesarean delivery for breech presentation at term gestation."

Take Home Message: For now, controversy still remains about delivering term breech babies. This new trial adds more weight to the argument that a scheduled c-section is the safest way to go. One of the most important factors is how experienced the clinician is with delivering breech babies, since most OBGYNs trained after 2000 do not have regular experience with vaginal breech deliveries.

Find the abstract here