Trial Of Vaginal Breech Delivery Research Articles

Undiagnosed uterine anomalies revealed by breech on ultrasound prior to external cephalic version – A chance to take a closer look

ObjectiveUterine anomalies (UA) occur in up to 6.7% of women. Breech is eight times more likely to occur with UA which may not be diagnosed prior to pregnancy and may only be found in the third trimester with breech. The objective of the study is to assess the prevalence of both already known and newly sonographically diagnosed UA in breech from 36 weeks of gestation and its impact on external cephalic version (ECV), delivery options and perinatal outcomes. Study DesignWe recruited 469 women with breech at 36 weeks of gestation over a 2-year period at the Charité University Hospital, Berlin. Ultrasound examination was performed to rule out UA. Patients with known and newly ‘de novo’ diagnosed anomalies were identified and delivery options and perinatal outcomes analyzed. ResultsThe ‘de novo’ diagnosis of UA at 36–37 weeks of pregnancy with breech was found to be significantly higher compared to the diagnosis prior to pregnancy with 4.5% vs 1.5% (p < 0.001 and odds ratio 4 with 95% confidence interval 2.12–7.69). Anomalies found included 53.6% bicornis unicollis, 39.3% subseptus, 3.6% unicornis and 3.6% didelphys. A trial of vaginal breech delivery was successful in 55.5% of cases when attempted. There were no successful ECVs. ConclusionBreech is a marker for uterine malformation. Diagnosis of UA with breech can be up to four times improved with focused ultrasound screening in pregnancy even from 36 weeks of gestation prior to ECV to identify missed anomalies. Timely diagnosis aids antenatal care and delivery planning. Importantly, definitive diagnosis and treatment can be planned postpartum to improve outcomes in future pregnancies. ECV plays a limited role in selected cases.

Impact of fetal presentation on neurodevelopmental outcome in a trial of preterm vaginal delivery: a nationwide, population-based record linkage study

PurposeTo assess the risk of adverse neurodevelopmental outcomes at the age of four after an attempted vaginal delivery according to the fetal presentation in birth.MethodsThis retrospective record linkage study evaluated the risks of cerebral palsy, epilepsy, intellectual disability, autism spectrum disorder, attention-deficit/hyperactivity disorder, and speech, visual, and auditory disabilities among preterm children born after an attempted vaginal breech delivery. The control group comprised children born in a cephalic presentation at the same gestational age. This study included 23 803 singleton deliveries at gestational weeks 24 + 0–36 + 6 between 2004 and 2014.ResultsFrom 1629 women that underwent a trial of vaginal breech delivery, 1122 (66.3%) were converted to emergency cesarean sections. At extremely preterm and very preterm gestations (weeks 24 + 0—31 + 6), no association between a trial of vaginal breech delivery and neurodevelopmental delay occurred. At gestational weeks 32 + 0—36 + 6, the risks of visual disability (aOR 1.67, CI 1.07—2.60) and autism spectrum disorders (aOR 2.28, CI 1.14—4.56) were increased after an attempted vaginal breech delivery as compared to vaginal cephalic delivery.ConclusionA trial of vaginal breech delivery at extremely preterm and very preterm gestations appears not to increase the risk of adverse neurodevelopmental outcomes at the age of four. In moderate to late preterm births, a trial of vaginal breech delivery was associated with an increased risk of visual impairment and autism spectrum disorders compared to children born in cephalic presentation. A trial of vaginal preterm breech delivery requires distinctive consideration and careful patient selection.

Trial of vaginal breech delivery in carefully selected women is worth considering—Fruit for thought!

There remains uncertainty about the optimal route of delivering carefully selected breech babies at term. This review argues strongly that vaginal mode of delivery should be considered in selected cases rather than offering an elective caesarean section for every patient.

Outcomes of “one-day trial of vaginal breech delivery of singleton pregnancy” at 37–38 weeks’ gestation at a Japanese perinatal center

Purpose In Japan, the lack of obstetricians has made it impossible for a strict 24-h delivery monitoring system for high risk deliveries such as vaginal breech delivery at many obstetric facilities. The outcomes in the trial of vaginal breech delivery of singleton pregnancy limited one day at 37–38 weeks’ gestation were examined. Materials and methods A planned induction of vaginal breech delivery at 37–38 weeks’ gestation was performed in 72 women who got consent form April 2006 to March 2016 as follows: (1) insertion of a balloon catheter into the uterine cervix filled with a sterile saline fluid of 400–500 mL, (2) intravenous administration of oxytocin after confirming of the natural falling out by itself of the balloon catheter, and (3) selection of cesarean delivery when vaginal delivery cannot be expected by evening. The perinatal outcomes of them were examined from patient charts. Results The completion rate of vaginal delivery in total was 67% (48/72). There were no cases of neonatal asphyxia or respiratory disorders. The severe perineal lacerations occurred in one case (2%). Conclusion Planned vaginal breech delivery limited one day at 37–38 weeks’ gestation seemed to be valid and safe and it can be one of the options for breech delivery in Japan.

VAGINAL BREECH DELIVERY

Objective: To determine the obstetric and perinatal outcome of pregnancieswith singleton breech presentation, and to scrutinize the causes of increasing incidence ofcesarean section in breech presentation. Design: Analytical Observational study. Place andduration: Department of obstetrics and gynecology Fatima hospital Baqai university campusfrom Jan 2010 to Oct 2011. Patients &amp; Methods: This study includes 135 patients with singletonbreech presentation ≥ 34 weeks of gestation, were analyzed in detail with help of designedperforma. Patients were categorized in three groups. Groups a, who had elective C-section,group b. who underwent emergency caesarean section or had C-section after failed trial ofvaginal delivery and group c. who had vaginal breech delivery. Elective caesarean section wasdone in those cases that had some other indications for carrying out this procedure apart frombreech presentation. Trial of vaginal breech delivery was planned for all multiparous womenexcept those falling in group A. All antepartum fetal demise, twin pregnancies and placentaprevia of major degree were excluded. Results: Of 135 women, 7(5%) underwent prelabourcesarean, and 128(95%), had trial of vaginal delivery, of whom 117(91.5%) delivered vaginally.Significantly more infants weighing&gt; 3.5kg were selected for prelabour and intrapartumcesarean than vaginal delivery. Two neonates had Apgar score&lt; 7 at 5 minutes but both werenormal neurologically. There were no nonanomalous perinatal death and no case of significanttrauma or neurological dysfunction. Two infants died due to lethal anomalies. Conclusion:Trial of vaginal breech delivery in well counselled patients, still taken as an appropriate optionwithout compromising prenatal and maternal outcome. It also decreases the rate of cesareansection.

Delivery mode and neonatal outcome after a trial of external cephalic version (ECV): a prospective trial of vaginal breech versus cephalic delivery

To examine the delivery mode and neonatal outcome after a trial of external cephalic version (ECV) procedures. This is an interim analysis of an ongoing larger prospective off-centre randomised trial, which compares a clinical hypnosis intervention against neuro-linguistic programming (NLP) of women with a singleton breech foetus at or after 37(0/7) (259 days) weeks of gestation and normal amniotic fluid index. Main outcome measures were delivery mode and neonatal outcome. On the same day after the ECV procedure two patients (2 %), who had unsuccessful ECVs, had Caesarean sections (one due to vaginal bleeding and one due to pathological CTG). After the ECV procedure 40.4 % of women had cephalic presentation (n = 38) and 58.5 % (n = 55) remained breech presentation. One patient remained transverse presentation (n = 1; 1.1 %). Vaginal delivery was observed by 73.7 % of cephalic presentation (n = 28), whereas 26.3 % (n = 10) had in-labour Caesarean sections. Of those, who selected a trial of vaginal breech delivery, 42.4 % (n = 14) delivered vaginally and 57.6 % (n = 19) delivered via Caesarean section. There is a statistically significant difference between the rate of vaginal birth between cephalic presentation and trial of vaginal breech delivery (p = 0.009), however, no difference in neonatal outcome was observed. ECV is a safe procedure and can reduce not only the rate of elective Caesarean sections due to breech presentation but also the rate of in-labour Caesarean sections even if a trial of vaginal breech delivery is attempted.

Promoting women's health in a complex world

Promoting women's health in a complex world

Maternal and neonatal complications in term breech delivered vaginally.

To evaluate the maternal and neonatal complications in terms of genital tract trauma to mother, perinatal mortality, Apgar score at 5 minutes and neonatal trauma in all singleton term breech cases delivered vaginally. Case series. Department of Obstetrics and Gynaecology, Bolan Medical Complex Hospital, Quetta, from May 2005 to March 2006. A 100 consecutive patients with singleton breech presentation, whether booked or unbooked, were admitted and delivered vaginally in hospital during the study period. They were studied for maternal and neonatal complications. Maternal complication included any genital tract trauma during delivery while neonatal complications were perinatal mortality, low Apgar score (less than eight at 5 minutes) and birth trauma. There were a total 3977 deliveries during this study period, 145 breech presentation (incidence 3.6%). Out of those, 100 were included in the study. All were unbooked cases, 87% were multigravida while 13% were primigravida. An Apgar score of eight was recorded in 87% babies while 10% had an Apgar score of less than eight after 5 minutes. There were 3 still births and one neonatal death. Aggregated perinatal mortality rate was 40/1000 live births. Only one baby had birth trauma (Erb's paralysis) during vaginal breech delivery. Ninety seven (97%) mothers had no complications while only 3 (3%) had complications. Out of these, one had cervical tear and 2 had vaginal tears. Offering a trial of vaginal breech delivery to strictly selected and well-counselled patients remains an appropriate option without compromising perinatal and maternal outcome. It also decreases the rate of operative delivery for this malpresentation.

The case for and against vaginal breech delivery

Critics continue to raise doubts about the conclusions of the Term Breech Trial. Subsequent European population studies have also concluded that the breech neonate benefits from elective caesarean section. Smaller population studies demonstrate the success of vaginal delivery in selected populations. Learning objectives: To be aware of criticisms of the Term Breech Trial and other literature that contradicts its findings. To understand the difficulties of selecting suitable women for trial of vaginal breech delivery. To be able to use current evidence when counselling women about their delivery options. Ethical issues: How can the neonatal advantages of caesarean delivery be balanced with maternal morbidity and the potential for complications in future pregnancies? Should vaginal breech delivery still be considered a safe mode of delivery? Please cite this article as: Deans CL, Penn Z. The case for and against vaginal breech delivery. The Obstetrician &amp; Gynaecologist 2008;10:139–144.

Trial of Vaginal Breech Delivery: Current Role

Breech presentation occurs at term in approximately 3% to 4% of singleton gestations. This presentation is associated with a variety of maternal and fetal conditions including preterm labor, abnormal amniotic fluid volume, hydrocephaly, anencephaly, mullerian anomalies, abnormal placentation, and multifetal gestation. Cesarean delivery has been associated with increased risk of subsequent accreta, placenta previa, hemorrhage, and hysterectomy. The Term Breech Trial initially suggested that planned vaginal breech delivery is associated with increased neonatal morbidity and mortality compared with planned cesarean delivery. Long-term follow-up of these vaginally delivered infants contradict the initial findings. Current debate surrounds the dilemma of whether the untoward complications of cesarean delivery are warranted given uncertain minimal increases in neonatal survival and improvement in neurologic outcome with planned cesarean.

The end of vaginal breech delivery

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?

Outcomes associated with cesarean section versus vaginal breech delivery at a university hospital

To determine whether vaginal breech delivery is associated with increased morbidity in term breech singletons using strict selection criteria. This study encompasses our previous studies (in 1987 and 1995) and extends our experience to 21 years. Retrospective cohort study from 1980 to 2001 including term, non-anomalous singleton breech deliveries selected by strict criteria. Univariable and multivariable analyses were performed for neonatal and maternal outcomes. Five hundred and eleven women underwent cesarean section and 214 a trial of labor. We found greater overall maternal morbidity in the cesarean section group (odds ratio (OR) 1.89, 95% confidence interval (CI)=1.34-2.65). In the vaginal delivery group, neonates were more likely to have had >1 day of mechanical ventilation (OR 10.0, 95% CI=1.56-63.9). No maternal deaths occurred and no neonatal deaths or seizures occurred. Given our findings, offering a trial of vaginal breech delivery to well-counseled strictly selected patients remains an appropriate option.

The end of vaginal breech delivery

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?

TERM BREECH TRIAL AND ITS CONSEQUENCES ON PRACTICE:A RETROSPECTIVE STUDY OF THE UNIVERSITYOF MALAYA MEDICAL CENTRE'S EXPERIENCE

To see the trend in managing singleton breech pregnancy after the termbreech trial. Secondly to compare the safety of different modes of delivery for term, singleton breeches by looking at the immediate neonatal outcome, based on our own experience. Breech infants were identified by examining computer-stored maternal discharge records of hospitalization for the years 1990 and 2000 respectively. Parametersstudied included planned mode of delivery, actual mode of delivery, parity, previous vaginal delivery, Apgar score at five minute, birth weight, referral to special care nursery and neonatal morbidity. Of 6,496 deliveries in 1990 and 5,081 in 2000, there were 220 (3.4%) and 148 (2.9%) term breech infants respectively, of which 115 (for 1990) and 102 (for 2000) case records were available. In 1990, 62.6% of the women had trial of vaginal breech delivery but only 24.5% of the women in 2000 were allowed to do so (p &lt; 0.05). Caesarean section rate for singleton breeches increased from 51.3% in 1990 to 84.3% in 2000 (p &lt; 0.05). Mean Apgar score at five minutes was significantly lower after vaginal breech delivery (9.40 ' 1.36) compared to after Caesarean section (9.72 ' 0.712) but there was no clinical significance. There was a noticeable trend towards Caesarean section and less trial of vaginal delivery. Neonatal outcomes of babies born abdominallywere statistically better than those born vaginally but there was little clinical impact. Perhaps in properly selected cases, a planned vaginal breech delivery still has a role to play.

Singleton vaginal breech delivery at term: still a safe option.

To examine the obstetric and perinatal outcome of pregnancies with singleton breech presentation at term when selection for vaginal delivery was based on clear prelabor and intrapartum criteria. The outcomes of all pregnancies with a breech presentation after 37 weeks of gestation were retrospectively reviewed from January 1997 to June 2000. Criteria for prelabor cesarean or trial of vaginal breech delivery included type of breech, estimated fetal weight (more than 3,800 g), maternal preference, and gestation more than 41 weeks. An intrapartum protocol excluded induction and oxytocin augmentation of labor, combined with a low threshold for cesarean delivery for dystocic labor; an experienced obstetrician was in attendance during labor and delivery. Of 641 women, 343 (54%) underwent prelabor cesarean, and 298 (46%) had a trial of vaginal delivery, of whom 146 (49%) delivered vaginally. Significantly fewer nulliparas (58 of 158, 37%) than multiparas (88 of 140, 63%; P <.001) achieved vaginal delivery after trial of labor. Significantly more infants weighing more than 3,800 g were selected for prelabor (87 of 343, 25%) and intrapartum (31 of 152, 20%) cesarean than delivered vaginally (15 of 146, 10%). Two neonates (0.7%) had Apgar scores of less than 7 at 5 minutes; both were neurologically normal at 6 weeks. There were no nonanomalous perinatal deaths and no cases of significant trauma or neurological dysfunction; 3 infants delivered vaginally died due to lethal anomalies. Safe vaginal breech delivery at term can be achieved with strict selection criteria, adherence to a careful intrapartum protocol, and with an experienced obstetrician in attendance. Our protocol effectively selects larger infants for cesarean delivery. II-2

Patient preference the leading indication for elective Caesarean section in public patients--results of a 2-year prospective audit in a teaching hospital.

In response to a Western Australian Ministerial enquiry into the levels of intervention in childbirth, a 2-year prospective audit was undertaken of the indication and timing of all public Caesarean section deliveries at King Edward Memorial hospital. During the study period, a total of 9,138 deliveries were performed at the hospital, of which 1,624 were by Caesarean section, an overall rate of 17.8%. Of these, 633 (39%) were elective and 911 (61%) were nonelective. The most common primary indication for elective Caesarean section was maternal choice, largely due to a refusal of the patient to consent to a trial of scar following a single previous Caesarean section or a refusal to attempt a trial of vaginal breech delivery. The most common indications for nonelective Caesarean section birth were an intrapartum diagnosis of suspected fetal distress or failure to progress in labour. Strategies to reduce the incidence of Caesarean section birth need to focus on the pathways involved with maternal decision-making in the birth process, and on improving the diagnosis of intrapartum fetal compromise.

Variations in the management of singleton breech presentation throughout Scotland.

Breech presentation occurs in 3-5% of deliveries and can be managed by either a trial of vaginal breech delivery (TOVBD), external cephalic version (ECV) or Caesarean section. A postal questionnaire was completed by 82% of Scottish consultant obstetricians and revealed wide variations in practice. Eighteen percent never offered ECV. Among those who did consensus was lacking on some contraindications. One-quarter sometimes performed ECV before 37 weeks gestations despite the possibility of spontaneous version. Only 70% restricted ECV to one or more designated operators thereby maintaining levels of expertise. Variations were demonstrated in the use of tocolytics, and pre and post procedure investigations. Following failed ECV 28% considered a repeat attempt and 56% a TOVBD. TOVBD was not offered as first line management by one-fifth of respondents. Those who did varied in the pre-procedure investigations performed. Guidelines are required to ensure safe, consistent practice and avoid unnecessary Caesarean sections.

Route of delivery for the breech presentation: A conundrum

OBJECTIVE: Our purpose was to determine the feasibility of resolving the controversy regarding route of delivery for breech presentation in a randomized, prospective fashion.STUDY DESIGN: The National Institute of Child Health and Human Development-sponsored Maternal-Fetal Medicine Units Network, which is composed of 11 perinatal centers, was surveyed to determine the feasibility of a randomized clinical trial of cesarean section versus trial of labor for breech presentation. A review of the literature was performed to determine the experience of other investigators with designing and conducting an adequate prospective, randomized trial.RESULTS: Principal investigators and faculty from seven of 11 centers within the Maternal-Fetal Medicine Units Network agreed to participate and felt that they could adequately recruit patients for a trial in very-low-birth-weight infants. This would provide approximately 200 very-low-birth-weight fetuses in a breech presentation per year. Sample size calculations indicated that 1700 infants would be required. Investigators also had strong reservations about performing a trial of vaginal breech delivery for other gestational ages. A review of the literature indicates that other authors have encountered difficulty in attempting randomized clinical trials of this nature.CONCLUSIONS: The Maternal-Fetal Medicine Units Network with its pool of 60,000 deliveries per year agreed that a randomized, controlled delivery route of labor in the 24- to 28-week breech presentation was not feasible in a reasonable period of time. A randomized clinical trial of larger fetuses in a breech presentation was also considered extremely difficult. These findings are similar to those of other authors who have attempted or proposed randomized clinical trials to determine the safety of planned vaginal delivery of the breech presentation at various gestational ages.

Balancing the risks of planned cesarean section and trial of vaginal delivery for the mature, selected, singleton breech presentation.

The experience of mature, singleton, vaginal breech delivery over the last decade in our hospital is reviewed. This constitutes the largest series of breech delivery reported for over twelve years. Unlike all but two previous reports, we analyze our results by management policy; elective cesarean section, trial of vaginal breech delivery and cesarean section as soon as the diagnosis of breech delivery was made on labor ('expedite' cesarean operations). Six intrapartum or neonatal deaths occurred among 613 patients selected for trial of vaginal delivery--a rate of one per cent. There were none following 217 elective or 69 expedite cesarean sections. A detailed review of the literature over the last decade confirms that trial of vaginal delivery is more dangerous to the fetus and results in about one perinatal death of a normally formed infant in 200 deliveries. Apgar scores were slightly lower following trial of vaginal delivery and there were more irritable or injured babies in this group. The last intrapartum or neonatal death occurred in 1981. However, the elective cesarean section rate has increased from 14 to 33 per cent over this time period. Similarly the rate of failed trial of vaginal breech delivery has increased from 15 to 31 per cent. The proportion of failed trials was highest where the fetus was large but clinicians were poor at estimating fetal weight. Decision theory is used to examine the maternal utility of trial of vaginal breech delivery versus elective cesarean section when the intrapartum cesarean rate rises to these levels. It is shown that, from the point of view of maternal mortality and morbidity in the current pregnancy, trial of vaginal delivery maybe the more dangerous maternal option. Thus a low threshold for cesarean section in labor leads to greater fetal safety at the mother's expense. It is nevertheless concluded that maternal attitude and the long-term effects of a uterine scar should be considered in the final decision.