Commentary: Routine Cesarean Section for Breech: The Unmeasured Cost

Abstract

Historically, partial breech extraction under maternal sedation was accompanied by high perinatal mortality rates (1). With the safety of modern cesarean section techniques, many deemed the avoidance of this fetal risk worth the maternal risk of cesarean section, and the proportion of breech fetuses delivered by cesarean section steadily increased. This trend reached its peak after publication of the term breech trial in 2000 (2). This trial implied that cesarean section was safer than vaginal birth for all breech fetuses at term. Professional obstetrical associations in the United Kingdom, United States, and Canada issued guidelines mandating cesarean section for term breech presentation. Across much of the world, vaginal breech birth is no longer ‘‘offered’’ to women. A new generation of specialist obstetricians lacks the skill and confidence to attend even the most straightforward vaginal breech birth, and maternal and perinatal deaths have resulted. The conclusions of the term breech trial were simplistic and erroneous. An overly liberal selection and labor management protocol allowed poorly selected infants to labor without adequate attention to progress. Half of the perinatal deaths in the trial were in growth-restricted fetuses, and infants born after prolonged labor had poorer outcomes compared with those whose labor was shorter (1,3). Inclusion of multiple centers with disparate levels of in-house specialist and surgical capability provided an inconsistent safety net. These factors led to fetal and neonatal harm attributed erroneously to breech presentation rather than to inappropriate management. Use of short-term surrogate outcomes overestimated the long-term risk of the questionable level of care provided. Breech birth technique has evolved. Particularly in Europe, centers with consistent specialist backup and cautious protocols convincingly demonstrated that a significant proportion of breech babies can be delivered safely vaginally (4,5). The professional obstetrical associations of the United Kingdom, United States, and Canada have reversed their restrictive stances and are supportive of selected vaginal breech birth (5‐7). Given the tenuous efforts to reestablish systems to provide safe breech birth, it is important to recognize the dangers of a system that is unwilling to do so.