Cesarean delivery for term breech not associated with long-term benefit [Classics Series]

1. At 2 years of follow-up, planned cesarean delivery was not associated with reduction in neurodevelopmental delay compared to planned vaginal delivery for term breech malpresentation.

Original Date of Publication: September 2004

Study Rundown: Breech malpresentation complicates less than 5% of pregnancies but can be associated with meaningful intrapartum risks, including the rare but morbid complication of head entrapment and resulting fetal asphyxia or even death. Early observational studies demonstrated significant fetal benefit to planned cesarean delivery and subsequently a multicenter randomized controlled trial of over 2000 women, the Term Breech Trial, confirmed these findings. The landmark Term Breech Trial demonstrated a risk reduction in perinatal and neonatal death and serious neonatal morbidity during delivery and through the first 6 weeks of life. It is unclear, however, if the increased risk of adverse neonatal outcomes associated with breech vaginal delivery also portends an elevated risk of adverse neurodevelopmental outcomes later in life. Long-term follow-up studies of the lasting impact of delivery events, including mode of delivery, are of great interest to patients and clinicians but are few. In the mid-1990s, a large observational study of term breech infants delivered vaginally and by cesarean demonstrated similar long-term outcomes at 4-5 years of age between groups. However, no randomized trial had assessed term breech infants beyond the neonatal period. In this study, authors used the Term Breech Trial to assess the long-term impact of randomized planned delivery mode (cesarean delivery versus vaginal delivery) on risk of death and serious, permanent neurodevelopmental morbidity at 2 years of age.

This landmark study demonstrated that cesarean delivery is not associated with reduction in infant mortality or serious neurodevelopmental disability at 2 years of life and suggested that the fetal benefits of planned cesarean delivery for term breech malpresentation may be limited to the early neonatal period. Strengths included randomized, controlled design, long-term follow-up with a modestly high (55.5%) retention rate from the original trial and a high (79.6%) retention rate within the follow-up period. Weaknesses included parent-administered questionnaire, which introduces selection and recall bias. Results may not be applicable to populations with different ethnic compositions than the United Kingdom.

Click to study in AJOG

Dr. Alan Peaceman, MD, talks to 2 Minute Medicine: Northwestern University School of Medicine; Chief, Division of Obstetrics and Gynecology-Maternal Fetal Medicine.

“This study demonstrated that among term infants with breech malpresentation, planned cesarean section is not associated with reduction in neurodevelopmental delay or death at two years of age. Findings are limited by cross-sectional design but imply that fetal benefit to cesarean delivery for breech malpresentation at term might be restricted to the perinatal and neonatal periods.”

In-Depth [cross-sectional follow-up study]: From the original Term Breech Trial, a total of 1159 infants from 85 centers participated in this two-year follow-up study comparing neurodevelopmental outcomes in infants randomized to planned cesarean delivery (n = 580) and vaginal delivery (n = 579) for breech malpresentation at birth. Primary outcomes included death and neurodevelopmental delay. Children were screened for abnormalities with the Ages and Stages Questionnaire and those with abnormal scores underwent neurodevelopmental assessment.

Among infants at 2 years of age, the risk of neurodevelopmental delay and death was similar between those randomized to planned cesarean (3.1%) and planned vaginal delivery (2.8%) for term breech malpresentation (p = 0.85). The absolute risk difference between groups was not significant (95%CI: -1.9%, +2.4%).

Image: PD

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