How does the 2000 Term Breech Trial compare to more recent evidence on term breech?

Recent studies do not support the findings of the 2000 Term Breech Trial, a randomized controlled trial that enrolled 2,088 women.

Two large multi-center studies in France and Belgium found no difference in perinatal/neonatal mortality between planned CS and planned vaginal birth. These studies--one prospective, one retrospective--followed a total of 10,200 women and had 174 & 175 participating hospitals.

Some national registry studies have found no significant differences between planned CS and planned vaginal breech birth.

A meta-analysis and other registry studies have found some advantage to planned CS, but the advantage is significantly less pronounced than in the Term Breech Trial.

What would happen if all Dutch women had a planned c-section for breech?

Each year around 6,490 women in the Netherlands (40%) still plan a vaginal breech birth. This number is significantly lower than it was before the 2000 Term Breech Trial, where roughly 75% planned a vaginal breech birth and around 50% overall gave birth vaginally to their breech babies (see Rietberg et al 2003).

A national registry study by Vlemmix et al (2014) calculated the anticipated neonatal benefits if these remaining 6,490 Dutch women all planned c-sections.

If all women who nowadays still undergo a planned vaginal breech birth were to receive an elective cesarean, 6490 more elective cesareans would be performed. This would lead to an additional annual reduction of 10 neonatal mortalities, 116 neonates with low Apgar scores and 20 neonates with birth traumata.

This calculation only considers short-term neonatal benefits--not long-term neonatal outcomes, not short- or long-term maternal outcomes. Here is another way of understanding these numbers:

In several national registry studies, planned CS for breech leads to small but measurable improvements in short-term neonatal outcomes (mortality and morbidity). However, these improvements are consistently much smaller than the Term Breech Trial's findings.

This pressing question remains: at what point do the short- and long-term risks of routine cesarean begin to outweigh the short-term benefits to the baby? How many elective cesareans are justified to save 1 baby? What if women are forced into having these cesareans?

A policy of routine cesarean for breech does not allow women to decide what the acceptable risk/benefit trade-off is.

Hike to Villefranche and Mont Alban

Last Saturday we hiked the Circuit du Mont Alban. So many stairs!

Risk-benefit calculus for breech presentation

Making a decision about how to birth a breech baby involves a complex risk calculus. Women have to weigh the short- and long-term benefits to themselves, their babies, and their future pregnancies. This graphic (created for me by Lauren McClain of Better Birth Graphics) shows how planned CS for breech has affected women and their babies in the Netherlands. Verhoveen et al (2005) discuss the effects of the increase in planned CS since the Term Breech Trial, and the results show a risk trade-off.

Between 2001-2005, 8,500 women in the Netherlands had a planned CS for breech. This increase in pCS saved an estimated 19 babies, but it also led to 4 direct maternal deaths, 9 additional babies dying in future pregnancies due to the uterine scar, and 140 additional life-threatening maternal complications in future pregnancies.

Alternative version of the graphic with text embedded in the image:

Perinatal mortality in term breech birth

In preparation for my Jan 24th Indie Birth webinar--Is vaginal breech birth safe?--I wanted to share this series of graphics I have created. These will be explained in more detail during the presentation.

This first illustration shows neonatal and/or perinatal mortality rates from the Term Breech Trial, two large multi-center studies in France & Belgium (PREMODA and Vendittelli), a meta-analysis of several single-center studies (Krebs), and then a series of national registry studies.

These are all studies of term breech births of singleton fetuses alive at the beginning of labor with congenital anomalies excluded (exception: the TBT also included antepartum stillbirths).

On the right of the graphic is the type of mortality studied:

• PNM/NNM: intrapartum deaths + neonatal deaths up to 28 days
• PNM: intrapartum deaths + neonatal deaths up to 7 days
• NNM: infant deaths through 28 days; intrapartum stillbirths excluded

For Vlemmix, Vistad, Hartnack-Tharin, and Vistad, I included only the data from the later time periods (usually post-TBT).

The next slide shows the same dataset, adding in planned cephalic births (vaginal & cesarean)  analyzed in two of the registry studies.

The last slide shows the relative samples sizes of the various studies. On the right side, you can see the sample sizes of the pVBB and pCS groups.

Is vaginal breech birth safe? Jan 24 webinar

On January 24, I will be giving a webinar about term breech: Is vaginal breech birth safe? Come join me!

This presentation reviews research on term breech that has emerged since the 2000 Term Breech Trial. From a PubMed search of “breech” and “pelvic presentation” in the title & abstract, I extracted over 1,900 articles published between 2000-2017.

I examine the evidence on term breech broken into several categories: neonatal morbidity, perinatal/neonatal mortality, long-term childhood outcomes (1-18 years old), short-term maternal morbidity, maternal mortality, long-term maternal outcomes, and outcomes for the mother’s future babies. I examine where the evidence falls for term breech in developed versus developing countries and for breech birth at home. I present research updates on other relevant topics, such as upright breech birth and the role of maternal positioning in altering the dimensions of the pelvis. I also discuss how vaginal breech skills help make cesarean sections safer for head-down babies that are deeply wedged in the maternal pelvis.

I finally put all of the evidence together—short- and long-term for both mother and child and the mother’s future babies—and demonstrate the complex risk calculus involved in answering the question, “Is vaginal breech birth safe?”

Time: Jan 24 at 3 pm EST (12 pm PST, 9 pm in Western Europe) or listen later to the recording
Cost: $30
Duration: approx 90-120 minutes, including time for Q&A

If you can't listen live, you will also be able to access the recording. Please register today!