A few weeks ago, I shared information on The Society of Obstetricians and Gynaecologists of Canada (SOGC) newly updated guidelines for the Management of Breech Presentation at Term (No. 384) in a post on Connecting the Dots. One of the key takeaways was the underlying principle that shared decision making and informed consent is key in order for families to make decisions that feel right for them.

I recently came across some visuals created by Rixa Freeze, PhD that I thought would be useful as a brief follow up to SOGC’s recent statement. Rixa blogs at Stand and Deliver and is the president and founder of Breech Without Borders, a nonprofit dedicated to breech training, education, and advocacy. She co-teaches vaginal breech workshops with David Hayes, MD.

With the recent release of the 2019 SOCG breech guidelines, Dr. Freeze updated some graphics she had used before with the new information. It illustrates the likelihood of perinatal/neonatal mortality after vaginal breech versus planned cesarean section from both the Royal College of Obstetricians and Gynaecologists (RCOG) and the Society for Obstetricians and Gynaecologists of Canada and compares them to the Term Breech Trial (TBT).

Using the Royal College of Obstetricians and Gynaecologists’ (RCOG) numbers, the *additional* risk of a vaginal breech birth, compared to a vaginal head-down birth, is 1/1000.

To summarize

The baseline risk of mortality after planned cesarean at 39 weeks: 1/2000 (0.5/1000)

+
The additional risk from last weeks of pregnancy & labor: 1/2000 (0.5/1000).

+
The additional risk of a vaginal breech birth: 1/1000.

= 2/1000.

Recent studies do not support the findings of the 2000 Term Breech Trial, a randomized controlled trial that enrolled 2,088 women. 

Two large multi-center studies in France and Belgium found no difference in perinatal/neonatal mortality between planned CS and planned vaginal birth. These studies--one prospective, one retrospective--followed a total of 10,200 women and had 174 & 175 participating hospitals.

Some national registry studies have found no significant differences between planned cesarean section and planned vaginal breech birth. 

A meta-analysis and other registry studies have found some advantage to planned cesarean section, but the advantage is significantly less pronounced than in the Term Breech Trial.  

The images here help to capture this information.  Using these images may help you to share this information effectively with the families you serve.

References

Berhan, Y., & Haileamlak, A. (2016). The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta‐analysis including observational studies. BJOG: An International Journal of Obstetrics & Gynaecology, 123(1), 49-57.

Goffinet, F., Carayol, M., Foidart, J. M., Alexander, S., Uzan, S., Subtil, D., ... & PREMODA Study Group. (2006). Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American journal of obstetrics and gynecology, 194(4), 1002-1011.

Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., Willan, A. R., & Collaborative, T. B. T. (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. The Lancet, 356(9239), 1375-1383.

Kotaska, A., & Menticoglou, S. (2019). No. 384-Management of Breech Presentation at Term. Journal of Obstetrics and Gynaecology Canada, 41(8), 1193-1205.

RCOG. (2017). Guideline 20b: The Management of Breech Presentation.

Vendittelli, F., Pons, J. C., Lemery, D., Mamelle, N., & Obstetricians of the AUDIPOG Sentinel Network. (2006). The term breech presentation: neonatal results and obstetric practices in France. European Journal of Obstetrics & Gynecology and Reproductive Biology, 125(2), 176-184.

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