Planned caesarean section for term breech delivery

Abstract

Background: Poor outcomes after breech birth might be the result of underlying conditions causing breech presentation or due to factors associated with the delivery.

Objectives: To assess the effects of planned caesarean section for singleton breech presentation at term on measures of pregnancy outcome.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015).

Selection criteria: Randomised trials comparing planned caesarean section for singleton breech presentation at term with planned vaginal birth.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

Main results: Three trials (2396 participants) were included in the review. Caesarean delivery occurred in 550/1227 (45%) of those women allocated to a vaginal delivery protocol and 1060/1169 (91%) of those women allocated to planned caesarean section (average risk ratio (RR) random-effects, 1.88, 95% confidence interval (CI) 1.60 to 2.20; three studies, 2396 women, evidence graded low quality). Perinatal or neonatal death (excluding fatal anomalies) or severe neonatal morbidity was reduced with a policy of planned caesarean section in settings with a low national perinatal mortality rate (RR 0.07, 95% CI 0.02 to 0.29, one study, 1025 women, evidence graded moderate quality), but not in settings with a high national perinatal mortality rate (RR 0.66, 95% CI 0.35 to 1.24, one study, 1053 women, evidence graded low quality). The difference between subgroups was significant (Test for subgroup differences: Chi² = 8.01, df = 1 (P = 0.005), I² = 87.5%). Due to this significant heterogeneity, a random-effects analysis was performed. The average overall effect was not statistically significant (RR 0.23, 95% CI 0.02 to 2.44, one study, 2078 infants). Perinatal or neonatal death (excluding fatal anomalies) was reduced with planned caesarean section (RR 0.29, 95% CI 0.10 to 0.86, three studies, 2388 women). The proportional reductions were similar for countries with low and high national perinatal mortality rates.The numbers studied were too small to satisfactorily address reductions in birth trauma and brachial plexus injury with planned caesarean section. Neither of these outcomes reached statistical significance (birth trauma: RR 0.42, 95% CI 0.16 to 1.10, one study, 2062 infants (20 events),evidence graded low quality; brachial plexus injury: RR 0.35, 95% CI 0.08 to 1.47, three studies, 2375 infants (nine events)).Planned caesarean section was associated with modestly increased short-term maternal morbidity (RR 1.29, 95% CI 1.03 to 1.61, three studies, 2396 women,low quality evidence). 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, one study, 1595 women); no difference in 'any pain' (RR 1.09, 95% CI 0.93 to 1.29, one study, 1593 women,low quality evidence); more abdominal pain (RR 1.89, 95% CI 1.29 to 2.79, one study, 1593 women); and less perineal pain (RR 0.32, 95% CI 0.18 to 0.58, one study, 1593 women).At two years, there were no differences in the combined outcome 'death or neurodevelopmental delay' (RR 1.09, 95% CI 0.52 to 2.30, one study, 920 children,evidence graded low quality); more infants who had been allocated to planned caesarean delivery had medical problems at two years (RR 1.41, 95% CI 1.05 to 1.89, one study, 843 children). Maternal outcomes at two years were also similar. In countries with low perinatal mortality rates, the protocol of planned caesarean section was associated with lower healthcare costs, expressed in 2002 Canadian dollars (mean difference -$877.00, 95% CI -894.89 to -859.11, one study, 1027 women).All of the trials included in this review had design limitations, and the GRADE level of evidence was mostly low. No studies attempted to blind the intervention, and the process of random allocation was suboptimal in two studies. Two of the three trials had serious design limitations, however these studies contributed to fewer outcomes than the large multi-centre trial with lower risk of bias.

Authors' conclusions: Planned caesarean section compared with planned vaginal birth reduced perinatal or neonatal death as well as the composite outcome death or serious neonatal morbidity, at the expense of somewhat increased maternal morbidity. In a subset with 2-year follow up, infant medical problems were increased following planned caesarean section and no difference in long-term neurodevelopmental delay or the outcome "death or neurodevelopmental delay" was found, though the numbers were too small to exclude the possibility of an important difference in either direction.The benefits need to be weighed against factors such as the mother's preference for vaginal birth and risks such as future pregnancy complications in the woman's specific healthcare setting. 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 and to further investigate the possible association of caesarean section with infant medical problems is needed.

Conflict of interest statement

Mary Hannah is principal investigator and Justus Hofmeyr a collaborator of the Term Breech Trial (Hannah 2000), which is included in this review. Tess Lawrie undertook assessment and data extraction for this trial. Justus Hofmeyr receives royalties from UpToDate for chapters related to breech pregnancy, delivery of a baby in breech presentation and external cephalic version. UpToDate is an electronic publication by Wolters Kluwer to disseminate evidence‐based medicine (such as Cochrane reviews).

Figures

1

'Risk of bias. graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

2

.Risk of bias. summary: review authors' judgements about each risk of bias item for each included study.

1.1. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 1 Perinatal/neonatal death or severe neonatal morbidity.

1.2. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 2 Death or neurodevelopmental delay at age 2 years.

1.3. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 3 Perinatal/neonatal mortality (excluding fatal malformations).

1.4. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 4 5 minute Apgar

1.5. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 5 5 minute Apgar

1.6. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 6 Cord blood pH

1.7. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 7 Cord blood base deficit =/> 15.

1.8. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 8 Birth trauma, as defined by trial authors.

1.9. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 9 Brachial plexus injury.

1.10. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 10 Infant medical problems at 2 years.

1.11. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 11 Neurodevelopmental delay at age 2 years.

1.12. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 12 Caesarean section.

1.13. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 13 Short‐term maternal morbidity.

1.14. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 14 Woman not satisfied.

1.15. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 15 Postnatal depression at 3 months, as defined by trial authors.

1.16. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 16 Not breastfeeding at 3 months.

1.17. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 17 Perineal pain at 3 months.

1.18. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 18 Abdominal pain at 3 months.

1.19. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 19 Backache after at 3 months.

1.20. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 20 Any pain after at 3 months.

1.21. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 21 Dyspareunia at 3 months.

1.22. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 22 Urinary incontinence at 3 months.

1.23. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 23 Flatus incontinence at 3 months.

1.24. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 24 Faecal incontinence at 3 months.

1.25. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 25 Headache at 2 years.

1.26. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 26 Perineal pain at 2 years.

1.27. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 27 Back pain at 2 years.

1.28. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 28 Sexual problems at 2 years.

1.29. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 29 Painful intercourse at 2 years.

1.30. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 30 Urinary incontinence at 2 years.

1.31. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 31 Flatus incontinence at 2 years.

1.32. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 32 Faecal incontinence at 2 years.

1.33. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 33 Constipation at 2 years.

1.34. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 34 Haemorrhoids at 2 years.

1.35. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 35 Subsequent birth or pregnant at 2 years.

1.36. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 36 Subsequent caesarean section at 2 years.

1.37. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 37 Painful menstrual periods at 2 years.

1.38. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 38 Heavy menstrual periods at 2 years.

1.39. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 39 Depression at 2 years.

1.40. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 40 Difficulty caring for child at 2 years.

1.41. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 41 Relationship with partner unhappy at 2 years.

1.42. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 42 Unhappy with sexual relations at 2 years.

1.43. Analysis

Comparison 1 Planned caesarean section for term breech presentation, Outcome 43 Estimated cost of intervention (in Canadian dollars).