Risks of vaginal breech delivery at term compared to elective cesarean section – Reply to comment by Page

Abstract

We thank Mr Page 1 for his interest in our work 2. We agree with many of the points of concern that he addresses, and in fact we have already discussed many of them in our paper. Our study was retrospective and we could not apply an intention-to-treat approach. The trend towards performing elective cesarean section at birth might have been present before the publication of the Hannah trial, but we are not aware of any other clinical trial that has fuelled such a massive change of management, as can be seen in our Figure 1. There are few publications associated with such a tremendous change in clinical practice, which makes it an important turning point. We feel it is our task to evaluate the effect of (changes in) clinical practice on neonatal outcome and to learn from it. Perinatal death occurred less frequently among multiparous than nulliparous women and comparison of the perinatal death rates before and after publication of the term breech trial did not show a significant difference within the multiparous group (Table 1). However, comparison of the mode of delivery (planned vaginal breech birth vs. elective cesarean section) did show a significant risk difference regarding perinatal death in both nulliparous and multiparous women (Table 4). This is the most important outcome of our study. Indeed, no matter what subgroup we studied, CS appeared to be the slightly safer option from the perspective of the child. We disagree that our main conclusion is to perform as many cesarean sections as possible. Our main recommendation to share the data we and others have provided with pregnant women, encourages them to choose external cephalic version and, when the fetus is in breech position prior to delivery, to use shared decision making. We challenge those who advocate vaginal breech delivery to provide data in order to facilitate shared decision making.