Acta Obstet Gynecol Scand 2004: 83: 126--130 Printed in Denmark.

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Acta Obstetricia et Gynecologica Scandinavica

ACTA REVIEW

Breechbirthatterm:vaginaldeliveryorelective cesarean section? A systematic review of the literature by a Norwegian review team
HEIM1, SUSANNE ALBRECHTSEN2,3, LILLIAN NORDB BERGE4, PER E. BRDAHL2, THORE EGELAND5,6, LISE LUND HA L IAN7 TORE HENRIKSEN6 AND PA

From 1The Norwegian Center for Health Technology Assessment, Oslo, 2Haukeland University Hospital, Bergen, 3 l University Hospital, Oslo, 5Department Group of Basic The Medical Birth Registry of Norway, Bergen, 4Ulleva 6 Medical Sciences, University of Oslo, Rikshospitalet University Hospital, Oslo, and 7The University Hospital of North Norway, Troms, Norway

Acta Obstet Gynecol Scand 2004; 83: 126130. # Acta Obstet Gynecol Scand 83 2004 Key words: breech presentation; cesarean section; vaginal delivery; perinatal morbidity; external cephalic version Submitted 12 June, 2003 Accepted 18 June, 2003

Whether planned cesarean section is better than planned vaginal delivery for breech presentation at term (3742 weeks) has been the subject of debate for some time. Apart from two small randomized controlled trials (1,2) from the early 1980s, the evidence on breech delivery was based on patient series and register studies, which have been considered to be of low scientic value. However, in October 2000 the randomized multicenter Term Breech Trial (TBT) was published in The Lancet (3), with a 3-month follow-up in 2002 (4). The study included 2083 deliveries from 121 obstetric departments in 26 countries. One Danish and one Finnish, but no Norwegian, obstetric departments took part in the study. The TBT concluded that planned cesarean section led to a signicantly better perinatal outcome than planned vaginal delivery. The occurrence of maternal complications was similar for the two groups. Not surprisingly, the TBT ignited intense discussion among doctors, midwives and the public. Data from the Medical Birth Registry of Norway show a slight increase in the incidence of breech presentation among infants with a birthweight
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greater than 2499 g in the period 198198, and the incidence is 2.9% in 1998 (Fig. 1). In Norway, 40% of approximately 1500 annual term breech infants are currently delivered vaginally (Fig. 2). A change to routine use of cesarean section would have an unprecedented impact on clinical practice in Norway. The use of external cephalic version on the Norwegian population has not been studied previously. A review team was therefore assigned to review (5,25) all current literature on term breech deliveries as well as on external cephalic version, using predetermined standard literature review methodology.
Methods
On the initiative of the National Board of Health and the Norwegian Gynecologic Society a review team was established with the following mandate: To carry out a systematic review of the scientific documentation of the results of elective cesarean section compared to vaginal delivery of the fetus in breech presentation at term and the results of external cephalic version before delivery. To evaluate the perinatal and maternal mortality and morbidity from controlled clinical trials.

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Breech birth at term

3.2 3.1 3 Occurrence (%) 2.9 2.8 2.7 2.6 2.5 2.4 2.3 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 Year

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Fig. 1. The occurrence of breech presentation with birthweight  2500 g in Norway 198198.

To provide an overview of Norwegian practice over time. To discuss the consequences for loss of competence among obstetricians. The work was organized by the Norwegian Center for Health Technology Assessment, and the results are presented in the report: Breech presentation at term: assisted vaginal delivery or cesarean section (printed in Norwegian with English abstract) (5). The study was performed in a systematic manner in accordance with international criteria of health technology assessments. We searched Medline, Embase, Cinahl, MiDirs, Cochrane Controlled Clinical Database, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness, NHS Center for Reviews and Dissemination. Search terms were breech presentation OR breech term NOT premature and version, fetal OR external cephalic version. The literature was graded and given a level of evidence as follows (26): Level 1 meta-analysis, systematic review of randomized controlled trials or randomized controlled trial Level 2 case-control study or cohort study Level 3 nonanalytic studies, e.g. case reports, case series Level 4 expert opinion.

Inclusion criteria were limited to term breech (3742 weeks) or birthweight greater than 2499 g. Twins were excluded. Only literature published after 1980 in English, French, German or the Scandinavian languages was included. A total of 1210 abstracts were evaluated. Two pairs of reviewers independently reviewed the abstracts of the publications, fulfilling the agreed criteria. In addition, one pair evaluated abstracts and literature on external cephalic version. Information on perinatal mortality in Norway was obtained from the Medical Birth Registry of Norway. Unpublished information on morbidity in Norway was assembled from two Norwegian university hospitals (to be published separately) in addition to two published studies (12,13). Information about the Term Breech Trial was given on request from the TBT secretariat.

Results

Literature assessment Randomized trials. Three randomized controlled trials were identified. Two smaller studies from the early 1980s (1,2) concluded that vaginal

70 Proportion ceaserean section (%) 60 50 40 30 20 10 0

Cephalic presentation Breech presentation

81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 Year

Fig. 2. The proportion of cesarean sections in breech and cephalic presentations with birthweight  2500 g, Norway 198198.
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L. L. Ha heim et al. External cephalic version. This is a procedure that may reduce the number of breech births and also the number of breech cesarean sections, but it has not been shown to affect perinatal mortality (1423). Unfortunately, the majority of publications on cephalic version deal with the methods of version rather than the clinical effects of the procedure. The women offered external version should be selected, although there is no general agreement as to which criteria should be used. It is recommended that the mother and fetus should be closely surveyed during and after the actual version. Complications due to an attempt of external version are poorly documented, except for immediate complications (see ref. 5 for references). Studies on Norwegian practice in cephalic version is lacking. Thus, based on current evidence, the effects of introducing external cephalic version routinely could not be assessed (Table II). Appraisal of the results of the literature assessment In order to more completely appraise these results of the literature assessment, organizational costs and Norwegian practice were also examined: With respect to economic evaluations, resources required for vaginal breech delivery were only marginally less than those of cesarean section. Norwegian data on perinatal mortality were obtained from The Medical Birth Registry. From 1970 to 1988 the cesarean section rate for breech birth in Norway increased from 3% to 61%, followed by a slight reduction until 1998. In the past decade about 40% of breech births have been by the vaginal route, while many other countries have a rate of 1020%. In the period 198198 there were 27 433 single breech births with birthweight more than 2499 g in Norway. One hundred and sixty children died in the perinatal period. The crude perinatal mortality was 0.59%. The rate was 0.31% when corrected for lethal malformations and 0.09% after the additional correction for death before admission to the maternity clinic.
Table I. Best level of evidence of selected literature on outcome by mode of delivery of term breech presentation (5,26) Outcome Peri- and neonatal mortality Neonatal morbidity Long-term morbidity for children Mortality, mother Short-term morbidity, mother Long-term morbidity, mother Best level of evidence 1 1 2 1 1 No data

delivery was advisable, while the TBT (3) recommended planned cesarean section. In the TBT a significantly lower risk of perinatal and neonatal mortality (excluding lethal congenital anomalies) was found for planned cesarean section (0.3%) compared with planned vaginal delivery (1.3%); relative risk 0.23 [95% confidence interval (CI) 0.070.81]. The TBT has been criticized mainly because several cases of perinatal death and disease or injury were not related to the method of delivery itself, which was the aim of the study. Observational studies. The designs and endpoints of registry studies (national cohorts, 69), regional cohorts (see ref. 5 for references), casecontrolled studies (1013), and patient series (see ref. 5 for references) are too diverse to allow any conclusions to be drawn as to which mode of delivery is preferable in terms of the short- and the long-term consequences for the child and the mother. Some of these studies indicate that vaginal delivery is associated with increased perinatal mortality and morbidity. However, the outcome may not be related to the method of delivery but to selection bias. Several studies report no mortality, or the reported mortality was found to be related to congenital malformations. The perinatal mortality following vaginal breech delivery has been found to be associated with lethal malformations, antenatal death, intrauterine infection and growth restriction. National cohorts show a marginally increased risk in peri- and neonatal mortality following vaginal delivery compared with elective cesarean section. Most of the studies conclude that vaginal delivery is safe, given a good selection of patients, assistance by qualied staff and careful management during the delivery. Regarding neonatal morbidity, the results of the studies (613) vary. Several studies show an increased risk of 5-min Apgar score <7 following vaginal delivery compared to cesarean section. The increase in risk has been associated with the duration of delivery. A low Apgar score may require use of resources in the neonatal period, but does not necessarily have developmental consequences for the child. Cerebral palsy has been suspected of being a consequence of vaginal breech delivery, but long-term followup studies indicate a relationship with intrauterine growth restriction and not the method of delivery. Acute cesarean section is associated with an increased risk of complications for the mother. No relevant studies were found on long-term morbidity of the mother (Table I).
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Breech birth at term

Table II. Best level of evidence of selected literature on cephalic version (5,26). Best level of evidence On the effect of version Outcome Perinatal mortality Perinatal morbidity Mortality and morbidity, mother Fetomaternal hemorrhage Intervention/procedure Selection to version Procedure before version Procedure at version Procedure after version Proportion versions Factors influencing version On the version procedure

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Discussion

1 1 2 1 1 1 1 1 1 1

1 2 2 1 1 1 1 1 1 2

The Medical Birth Registry of Norway does not record information on morbidity. Such information was obtained from two published studies (12, 13) and two unpublished patient series. The published studies from Haukeland University Hospital, Bergen (12) and Rogaland Central Hospital, Stavanger (13) had total vaginal delivery rates of 52.7% and 65.4%, respectively. Morbidity recorded as 5-min Apgar score <7 was observed in six out of 639 actual vaginal deliveries in Bergen and in 19 out of 448 planned vaginal deliveries in Stavanger. Three fractures were reported in the Bergen study and one in Stavanger. Three newborns suffered intracranial hemorrhage in Bergen and 10 suffered neurological morbidity in Stavanger. In the publication from Bergen (12) it was concluded that no permanent neurological sequelae was observed as a complication to vaginal deliveries. One infant died due to neonatal alloimmune thrombocytopenia after an uncomplicated delivery. The obstetric practice of breech deliveries in Stavanger (13) seems to differ from most other hospitals in Norway, breech extraction was used more frequently and the cesarean section rate for breech presentations was lower compared to the birth population (see Fig. 2). Even though the authors of the Stavanger publication concluded that breech presentation should be delivered by cesarean section, cesarean section for all breech pregnancies is not the current practice of the department, as 39% of term breech pregnancies were delivered vaginally in 2002 (L. Gjessing, personal communication). Norwegian mortality data have been examined further, and the results will be published separately, in addition to Norwegian data on morbidity from the University Hospital of North Norway, Troms and Rikshospitalet University Hospital, Oslo.

In assessing the results of the TBT it was necessary to seek information on Norwegian practice with breech deliveries, because the TBT stratified groups into low vs. high risk of death, the lowrisk group still being considerably higher than current Norwegian rates. Criteria for vaginal delivery in the TBT were different from those recommended in Norway (24). The TBT study also included perinatal deaths not associated with method of delivery. Perinatal mortality in Norway and results on morbidity from four Norwegian hospitals were found to be lower than in both the study groups of the TBT, thus questioning the external validity of the TBT. During the past 20 years the level of practice with vaginal deliveries has been adequate to maintain a high level of obstetric skill in vaginal deliveries of term breech pregnancies. In appraising the literature assessment, more recent Norwegian mortality and morbidity data carried weight in assessing the external validity of the TBT for Norwegian obstetric practice. The possibility of performing a Nordic study similar to the TBT was considered. Two major issues are central to a decision of organizing such a trial. The first is the questionable external validity of the TBT. The second is the sample size required. Sample size calculations based on an anticipated perinatal mortality of 0.25% in the planned vaginal group and 0.1% in the cesarean group would require a total number of 10 000 to be recruited in each group for two-sided testing, a number exceeding practical limits. The review team considered the rate of 0.8% for the planned vaginal deliveries (the TBT rate) to be too high, taking into account the actual perinatal mortality rates in the Nordic countries. On these grounds the review team did not consider it feasible to organize such a study in the Nordic countries, due to the low perinatal mortality and morbidity in these countries. In conclusion, vaginal delivery for term breech presentation was found to be advisable in suitable cases after careful selection, given the facilities for fetal electronic monitoring, experienced obstetric staff, facilities for emergency cesarean section and a good neonatal service. The external validity of the results of the TBT to Norwegian practice is questioned. Several of the centers and countries participating in the study have antenatal care, birth surveillance, experience with term vaginal breech delivery and pediatric service different from those in Norway. The perinatal and neonatal mortality rates are considerably lower in Norway than those reported in the TBT. The
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L. L. Ha heim et al.
11. Krebs L, Langhoff-Roos J. Breech delivery at term in Denmark, 198292: a population-based case-control study. Paediatr Perinat Epidemiol 1999; 13: 43141. 12. Albrechtsen S, Rasmussen S, Reigstad H, Markestad T, Irgens LM, Dalaker K. Evaluation of a protocol for selecting fetuses in breech presentation for vaginal delivery or cesarean section. Am J Obstet Gynecol 1997; 177: 58692. 13. Belfrage P, Gjessing L. The term breech presentation. A retrospective study with regard to the planned mode of delivery. Acta Obstet Gynecol Scand 2002; 81: 54450. 14. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term (Cochrane Review). In: The Cochrane Library, Issue 2. Oxford: Update Software, 2002. 15. Hofmeyr GJ. Effect of external cephalic version in late pregnancy on breech presentation and caesarean section rate: a controlled trial. Br J Obstet Gynaecol 1983; 90: 3929. 16. Mahomed K, Seeras R, Coulson R. External cephalic version at term. A randomized controlled trial using tocolysis. Br J Obstet Gynaecol 1991; 98: 813. 17. Lau TK, Lo KW, Rogers M. Pregnancy outcome after successful external cephalic version for breech presentation at term. Am J Obstet Gynecol 1997; 176: 21823. 18. Impey L, Lissoni D. Outcome of external cephalic version after 36 weeks gestation without tocolysis. J Matern Fetal Med 1999; 8: 2037. 19. Morrison JC, Myatt RE, Martin JN, Meeks GR, Martin RW, Bucovaz ET et al. External cephalic version of the breech presentation under tocolysis. Am J Obstet Gynecol 1986; 154: 9003. 20. Stine LE, Phelan JP, Wallace R, Eglington GS, Van Dorsten JP, Schifrin BA. Update on external cephalic version performed at term. Obstet Gynecol 1985; 65: 6426. 21. Mauldin JG, Mauldin PD, Feng TI, Adams EK, Durkalski VL. Determining the clinical efficacy and cost savings of successful external cephalic version. Am J Obstet Gynecol 1996; 175: 163944. 22. Mashiach R, Hod M, Kaplan B, Friedman S, Ovadia J, Schoenfeld A. External cephalic version at term using broad criteria: effect on mode of delivery. Clin Exp Obstet Gynecol 1995; 22: 27984. 23. Regalia AL, Curiel P, Natale N, Galluzzi A, Spinelli G, Ghezzi GV et al. Routine use of external cephalic version in three hospitals. Birth 2000; 27: 1924. 24. Albrechtsen S, Nesheim B-I, Sande HA, Jenssen TA. Kapittel 39. Seteleie J: Dalaker K og medarbeidere (red). Norsk gynekologisk forening Veileder i fdselshjelp 1998: Setefdsel. Oslo. Den norske lgeforening. (In Norwegian; English version is available). 25. A new System for grading recommendations in evidence based guidelines. http://www.sintef.no/SMM/Publikasjoner/Frameset Publikasjoner.htm. 26. Scottish Intercollegiate Guidelines Network. Br Med J 2001; 323: 3346.

data from four Norwegian hospitals (two published reports and two unpublished) confirm a low risk of complications by vaginal delivery in these hospitals. It was not found feasible to conduct a study similar to the TBT in Norway or the Nordic countries. As the perinatal mortality and morbidity is low in these countries, a very large study population would be required. External cephalic version may reduce the frequency of breech births but has not been shown to affect perinatal mortality. The Norwegian practice regarding external cephalic version is poorly documented. The review team recommends the establishment of a national breech registry for continuous surveillance of delivery practice and results. This is a prerequisite in a field where practical obstetric skill is mandatory for good results.

References
1. Gimovsky ML, Wallace RL, Schifrin BS, Paul RH. Randomized management of the nonfrank breech presentation at term: a preliminary report. Am J Obstet Gynecol 1983; 146: 3440. 2. Collea JV, Chein C, Quilligan EJ. The randomized management of term frank breech presentation: a study of 208 cases. Am J Obstet Gynecol 1980; 137: 23544. 3. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000; 356: 137583. 4. Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung R, Willan A et al. Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomised Term Breech Trial. J Am Med Assoc 2002; 287: 182231. 5. ian P, Albrectsen S, Berge LN, Brdal PE, Egeland T, Henriksen T et al. Fdsel av barn i seteleie til termin: Assistert vaginal fdsel eller keisersnitt. [Planned cesarean section for breech birth at term systematic review.] SMM report no. 3, 2003. 6. Krebs L, Topp M, Langhoff-Roos J. The relation of breech presentation at term to cerebral palsy. Br J Obstet Gynaecol 1999; 106: 9437. 7. Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by mode of delivery among term breech births: Swedish experience 19871993. Obstet Gynecol 1998; 92: 94550. 8. Lindqvist A, Norden-Lindeberg S, Hanson U. Perinatal mortality and route of delivery in term breech presentations. Br J Obstet Gynaecol 1997; 104: 128891. 9. Krebs L, Langhoff-Roos J, Weber T. Breech at term mode of delivery? A register-based study. Acta Obstet Gynecol Scand 1995; 74: 7026. 10. Luterkort M, Marsal K. Umbilical cord acidbase state and Apgar score in term breech neonates. Acta Obstet Gynecol Scand 1987; 66: 5760.

Address for correspondence: Lise Lund Ha heim The Norwegian Center for Health Technology Assessment PO Box 124 Blindern N-0314 Oslo Norway e-mail: lise.l.haheim@sintef.no

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