The end of vaginal breech delivery

Abstract

Sir, G Burke1 asks: ‘Is it worth doing 60 or 160 more caesareans, which nowadays cost nothing in terms of maternal mortality, morbidity or economically, to avoid one baby’s death?’ Regarding the Netherlands for the 5 years after the Breech Trial (2001–05), the answer is as follows: • Three hundred and twenty extra planned caesarean sections are needed to ‘save’ one extra child (short term)2 and even more in the long term because of uterine rupture, placenta praevia and an increased stillbirth rate before term associated with previous caesarean sections.3 The ‘costs’ were the following:3 • Four maternal deaths as a result of elective caesarean section for breech presentation (1:2200). These women would not have had an elective caesarean section when the child was in cephalic presentation.4 • Potentially life-threatening complications from uterine scars during future pregnancies can be expected. In a nationwide survey of serious maternal morbidity in the Netherlands from August 2004 to August 2006, 78 women with a previous elective caesarean section for breech were registered because of vital obstetric haemorrhage of >3000 ml (n = 39) and uterine scar rupture (n = 39). • In future pregnancies, four children with brain damage after uterine rupture can be expected. • 35 million Euros were spend on the 7500 extra caesarean sections. Out of 2.154 children born after vaginal breech delivery, 2.114 (98.1%) were alive and without ‘severe’ morbidity as compared with 5.515 (99.8%) of 5.524 elective caesarean sections for breech only and 2.088 (99.3%) after emergency caesarean section during a trial of vaginal breech delivery.2 Vaginal breech delivery thus has a slightly worse outcome than elective caesarean section, but this is not a new fact. Adverse outcome of vaginal breech delivery in the Term Breech Trial, however, was much higher (5.1%), but no other study has ever reported such high adverse outcome. The conclusion is that mode of breech delivery does not matter for 98 out of 100 children. The use of short-term combined end-point, mortality and ‘severe’ birth injury, overstates the true risk of planned vaginal delivery. This ‘severe’ birth injury results mainly in short-term morbidity. Twenty-nine ‘severe’ infant morbidities occurred after vaginal breech delivery: 9 clavicle fractures, very likely to heal without permanent injury, and 15 brachial plexus injuries, which are known to result in permanent damage in 10% (n = 2). Furthermore, one should take into account that the pulmonary morbidities were not included in the numbers of ‘severe’ injury, and these are much more frequent in elective caesarean section. In our risk-averse society, the crucial question is: which standard is reasonable to apply? Considering maternal risks, should 997 of 1000 women have a ‘superfluous’ elective caesarean section to ‘save’ the life of 3 out of 1000 babies?