I read with great interest “The term breech: vaginal or cesarean delivery?” [January], by Alex Vidaeff, MD, Edward Yeomans, MD, Ellen Mozurkewich, MD, and Martin Gimovsky, MD, regarding the Term Breech Trial (TBT) conducted by Mary E. Hannah. The study’s remarkable scientific design, along with the work of all those involved, undoubtedly gave significant weight to the conclusion that elective cesarean should be the preferred mode of delivery for term breech fetuses.
Our teaching hospital in Romania had the honor of participating in the TBT. In this country, term breech pregnancies with no other complications are allowed to undertake a well-supervised trial of labor, and approximately 60% of these fetuses are delivered vaginally. But in reviewing the TBT results from our institution, we observed that even in study conditions, only 60% of the patients randomized to planned vaginal birth actually delivered vaginally; the others delivered via cesarean due to complications during labor–findings consistent with the overall results reported by the TBT.
Perinatal mortality and morbidity have more to do with the way a labor is conducted than the mode of delivery.
It should be noted, however, that none of the breech deliveries were counted in the significant perinatal morbidity and mortality cases for that year, unless other obstetric circumstances were present. Could this indicate that it is better to wait and see how a patient’s labor patterns develop before deciding to perform a cesarean? Our impression is that perinatal mortality and morbidity have more to do with the way a labor is conducted than the mode of delivery. We propose that further research is needed to establish a safe and standard way of supervising a breech labor, and to solve such debatable issues as the use of augmentation, epidural analgesia, or premature interference with the fetus during delivery.
—GABRIEL BANCEANU, PHD
Drs. Vidaeff and Yeomans respond:
It appears as though Dr. Banceanu feels—as we do—that further research on term breech deliveries is still needed. Selection of appropriate candidates for vaginal breech delivery is the first step in the process, and undeniably a very important one. However, as Dr. Banceanu points out, the management of labor and delivery is often critical in determining outcomes. Unfortunately, this element could not be controlled or adequately accounted for in the TBT.
A recent challenge to the American College of Obstetricians and Gynecologists (ACOG) endorsement of planned cesarean delivery for breech presentation at term indicates to us that obstetricians can still agree to disagree on this subject.1
Dr. Mozurkewich responds:
I appreciate Dr. Banceanu’s comments. It is interesting to note that at his hospital, a trial of labor did not result in any perinatal deaths or cases of serious perinatal morbidity among TBT participants. He suggests that optimal management of the properly selected breech presentation at term may be to allow a trial of labor and to assign mode of delivery based on intrapartum progress. However, the “planned vaginal birth” group in the TBT essentially received the same management protocol that Dr. Banceanu describes.2 The guidelines that formed the TBT’s protocol for intrapartum management stemmed from a Canadian consensus conference on breech presentation at term and established clear conditions necessary for the continuation of labor trials.3 But even despite these relatively optimal trial conditions, the investigators reported increases in perinatal morbidity and mortality in the planned vaginal birth group.2
In addition, the authors performed a subanalysis in which subjects were excluded if they experienced vaginal breech delivery after prolonged labor, induction or augmentation of labor, footling or uncertain breech presentation at delivery, or if the clinician at delivery was not skilled or experienced. Despite these exclusions, planned cesarean section prevailed. For these reasons, I feel the overall conclusions and recommendations of the TBT are quite robust.
- Hauth JC, Cunningham FG. Vaginal breech delivery is still justified. Obstet Gynecol. 2002;99:1115-1116.
- Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned cesarean section versus planned vaginal birth for breech presentation at term: A randomized multicenter trial. Lancet. 2000;356:1375-1383.
- Hannah WJ, Allardice J, Amankwah K, et al. The Canadian consensus on breech management at term. J SOGC. 1994;16:1839-1858.