Three studies involving 2 396 women were included in a Cochrane review [Abstract] 1. Caesarean delivery (CS) occurred in 550/1227 (45%) of those women allocated to a vaginal delivery protocol. Perinatal or neonatal death (excluding fatal anomalies) or serious neonatal morbidity was reduced with planned caesarean section (relative risk (RR) 0.33, 95% confidence interval (CI) 0.19 to 0.56). In absolute numbers the reduction was 3/1166 (0.26%) in the planned caesarean section group versus 14/1222 (1.15%) in the planned vaginal birth group. Thus, one death would be prevented for every 112 caesarean sections planned and one death would be prevented for every 53 additional caesarean sections performed.
Planned caesarean section was associated with modestly increased short-term maternal morbidity (RR 1.29, 95% CI 1.03 to 1.61). At three months after delivery, women allocated to the planned caesarean section group reported less urinary incontinence (RR 0.62, 95% CI 0.41 to 0.93); more abdominal pain (RR 1.89, 95% CI 1.29 to 2. 79); and less perineal pain (RR 0.32, 95% CI 0.18 to 0.58). At two years, there were no differences in the combined outcome 'death or neurodevelopmental delay'. Maternal outcomes at 2 years were also similar.
A population-based cohort study 2 used data from the Swedish Medical Birth Register. The rates of neonatal complications and mortality were higher among infants born in vaginal breech compared to the vaginal cephalic group. On the other hand, after CS, the rates of all neonatal complications under study and neonatal mortality were lower among infants in breech presentation than in those in cephalic presentation. After adjustment for confounders, infants delivered in vaginal breech had 23.8 times higher odds AOR (ratio) for brachial plexus injury, 13.3 times higher odds ratio for Apgar score<7 at 5 min, 6.7 times higher odds of intracranial hemorrhage (ICH), or convulsions and 7.6 higher odds ratio for perinatal mortality than those delivered by elective CS.
A meta-analysis 3 included 258 953 women. The relative risk of perinatal mortality and morbidity was about 2- to 5-fold higher in the planned vaginal than in the planned caesarean delivery group. The absolute risks of perinatal mortality, fetal neurologic morbidity, birth trauma, 5-minute Apgar score <7 and neonatal asphyxia in the planned vaginal delivery group were 0.3, 0.7, 0.7, 2.4 and 3.3%, respectively.
Comment: The quality of evidence is downgraded by imprecise results (few outcome events).
Comment: The absolute risk appears to be low. ACOG Committee Opinion No. 745 suggests that obstetrician-gynecologists and other obstetric care providers should offer external cephalic version as an alternative to planned cesarean for a woman who has a term singleton breech fetus, desires a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications. External cephalic version should be attempted only in settings in which cesarean delivery services are readily available. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for eligibility and labor management.
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