Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Value and pregnancy outcome of external cephalic version. A randomized trial of external cephalic version with tocolysis in late pregnancy.
For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.
                At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.
                Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35).
                Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups. To determine the efficacy and pregnancy outcome of external cephalic version at > or = 37 weeks gestation, 90 women with a singleton breech fetus in King Hussein Medical Centre who had the procedure were compared with 102 women in a control group in whom the procedure was not attempted. External cephalic version was successfully performed on 59 fetuses (64%). Caesarean section was performed on 39% of patients who underwent the procedure compared to 61% of the control group. Version was more successful in multiparous than nulliparous women. External cephalic version was effective in reducing the number of caesarean deliveries in term breech infant in different obstetric settings, with no major neonatal adverse outcome. The effect of external version under tocolysis with intravenous ritodrine during the 37th week of gestation was studied in a prospective randomized trial comprising 130 consecutive women with a fetus in breech presentation. Version was successful in 41% of the patients, all of whom had a cephalic vaginal delivery. Of the 56 women in the control group in whom version was not attempted; 8 (14%) converted to the vertex presentation spontaneously. Failure of version was significantly correlated with primiparity, location of the placenta on the anterior uterine wall, and maternal weight. The caesarean section rate was significantly lower in the version group (27%) than in the control group (46%) (P less than 0.05). The overall caesarean section rate for a fetus in breech presentation was 50%. There were no serious complications associated with version and the condition of the infants at birth was better in the version group than in the control group. We advise external version under tocolysis in late pregnancy to reduce the frequency of breech presentation in labour.
Planned caesarean section compared with planned vaginal birth reduced perinatal or neonatal death or serious neonatal morbidity, at the expense of somewhat increased maternal morbidity. The option of external cephalic version is dealt with in separate reviews. The data from this review cannot be generalised to settings where caesarean section is not readily available, or to methods of breech delivery that differ materially from the clinical delivery protocols used in the trials reviewed. The review will help to inform individualised decision-making regarding breech delivery. Research on strategies to improve the safety of breech delivery is needed.