2000: Year of the Breech

Abstract

Objective: Management of the term breech occupied centre stage in the year 2000 following publication of the Canadian-led multicentre international randomized term breech trial (TBT). The objective of this manuscript is to highlight important recent publications related to the term breech leading to the publication of the TBT, to assess the direction in which our specialty is heading, and to describe the new challenges in dealing with this malpresentation.Method: Medline search of English language publications for the years 1999 to 2000 related to interventions in management, education, training, and women’s views related to the term breech. Articles are analyzed and personal opinion and critique are presented.Results: By early 2000, it was evident that a significant percentage of frank/complete term breech presenting fetuses were being delivered by Caesarean section in many centres, especially in North America. The multicentre randomized clinical trial on the management of the breech, the TBT, offered the highest level of evidence to date, and documented that a policy of planned Caesarean delivery of the term breech results in lower perinatal mortality and morbidity, but not higher maternal morbidity when compared to outcomes with a planned vaginal delivery. The term breech fetus, however, remains intrinsically at a higher risk of neurologic dysfunctional anomalies irrespective of method of delivery. Equally, a policy of planned Caesarean section does not always abolish significant perinatal morbidity, nor abolish vaginal birth of the breech. External cephalic version (ECV) at term, but not preterm, significantly reduces the risk of this malpresentation at term, and training in ECV should be offered in all centres. With a reduction in opportunities for teaching in vaginal birth of the breech, innovative ways in teaching have to be implemented to provide our future obstetricians with the ability to deal with the occasional vaginal breech birth. Women’s surveys showed that women remain more anxious regarding planned vaginal delivery of a breech than with a planned Caesarean section, but many are unaware that ECV could also be offered.Conclusion: With the advent of the evidence supporting a policy of planned Caesarean section for the term frank/complete breech, new challenges are taking shape. We should remain objective in assessing actual risks and acknowledge the outcome limitations inherent with adopting a national policy of planned Caesarean section. We face new resource challenges with emerging new trends in delivery of the breech. We should continue to offer non-coercive counselling to our patients, and strive to teach and educate our staff and residents in the skills of vaginal breech delivery.