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. Randomized management of the nonfrank breech presentation at term: a preliminary report. A multicentre randomised controlled trial comparing elective and selective caesarean section for the delivery of the preterm breech infant. Effect of external cephalic version in late pregnancy on breech presentation and caesarean section rate: a controlled trial. Randomized management of the second nonvertex twin: vaginal delivery or cesarean section. [The benefit of external version in full-term breech presentation]. Tocolysis for repeat external cephalic version in breech presentation at term: a randomised, double-blinded, placebo-controlled trial.
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. Cesarean section has become the standard management used by many clinicians for breech presentation in labor. Proof of the superiority of routine cesarean section has been largely circumstantial. Concern over rising cesarean section rates has led to renewed interest in possible alternatives. Protocols have been developed to select which patients may be allowed a trial of labor with frank breech presentation at term. We undertook a prospective clinical trial comparing elective cesarean section with a selective management protocol for the nonfrank breech presentation at term. One hundred five patients with nonfrank breech presentations at term in labor were studied. Seventy (67%) were randomized to a trial of labor and 35 (33%) to elective cesarean section. Of the patients allowed a trial of labor, 31 (44%) were delivered vaginally, and 39 (56%) required cesarean section. The largest single cause of a "failed" trial of labor was inadequate pelvic dimensions on x-ray pelvimetry (23 patients, 59%). Neonatal morbidity assessed by Apgar scores, cord gases, birth injury, and hospital stay was not different for those delivered vaginally or by cesarean section. Maternal morbidity in terms of febrile morbidity, blood transfusion, wound infections, and hospital stay was significantly greater among women delivered by cesarean section. Two of three neonatal deaths occurred in infants with major congenital anomalies. The third infant, apparently normal, died after vaginal delivery. Extensive evaluation suggests the death was attributable to inadequate resuscitation. We conclude that the use of a selective management protocol under controlled conditions is a reasonable alternative to elective cesarean section. Approximately one half of patients allowed a trial of labor may be expected to deliver vaginally with neonatal morbidity comparable to that seen with cesarean section. To determine the optimum mode of delivery for women in preterm breech labour at a gestational age of 26 to 32 weeks.
                A multicentre randomised controlled trial.
                Twenty-six hospitals in England, UK.
                Women with a singleton breech fetus in spontaneous preterm labour between 26 and 32 completed weeks of gestation, with no clear indication for a caesarean section or vaginal breech delivery.
                Random allocation to either "intention to delivery vaginally' or "intention to deliver by caesarean section'.
                Perinatal mortality, neonatal morbidity, maternal morbidity and gestation at delivery.
                The trial was closed after 17 months because of low recruitment, by which time substantial numbers of women had been in the eligible gestation period. Thirteen women from six hospitals were recruited. One infant, randomised to and delivered vaginally, was stillborn. Three fetal presentations were cephalic at delivery despite a diagnosis of breech presentation at trial entry. No formal statistical analysis was performed due to the small numbers.
                No conclusions about the optimum mode of delivery for women in preterm labour with a fetus presenting by the breech can be drawn from this trial. The low accrual rate was due to clinicians' reluctance to randomise eligible women, reflecting the circumstances and nature of the trial. A prospective randomized controlled trial of external cephalic version (ECV) in late pregnancy is reported. All pregnancies were assessed with ultrasound and cardiotocography. ECV was successful in 29 out of 30 patients (97%). Breech presentation at delivery occurred in 67% of the control group and in 3% of the ECV group. The caesarean section rates were 43 and 20% respectively. Tocolysis was used in seven patients. A new technique of ECV with the steep lateral position is described. Complications were limited to cardiotocographic changes and one patient with unexplained vaginal spotting. The procedure is recommended provided appropriate patient selection and surveillance is practised. Sixty twin deliveries after the thirty-fifth gestational week with vertex-breech and vertex-transverse presentations were managed according to a randomization protocol. Thirty-three parturient women (21 vertex-breech and 12 vertex-transverse presentations) were allocated for vaginal delivery and 27 for cesarean section (18 vertex-breech and nine vertex-transverse). Six pairs of twins in the vaginal delivery group were delivered in a different mode than requested by the protocol (two women underwent cesarean section; in four cases the second twin spontaneously changed to vertex presentation). There were no significant differences between 1- and 5-minute Apgar scores and incidence of neonatal morbidity between the second-born twins in both study groups. Firstborn twins had higher 1-minute Apgar scores than the second-born infants irrespective of route of delivery (p less than 0.05). No case of birth trauma or neonatal death was recorded. Maternal febrile morbidity was significantly higher in the cesarean section group than in the vaginal delivery group (40.7% versus 11.1%, p less than 0.05). These results suggest that in twins with vertex-breech or vertex-transverse presentations after the thirty-fifth week of gestational age the neonatal outcome of the second twin was not significantly influenced by the route of delivery. We report a randomised controlled trial of external version in 52 women with breech presentation after 36 weeks' gestation; 83% gave informed consent to undergo the management to which they had been randomized. Only 5% of initial attempts without tocolysis succeeded, but 31% of the failures subsequently had a successful version under tocolysis. External version resulted in a small decrease in the frequency of breech presentation at birth (64% vs. 74%), and in an unexpected increase in the caesarean section rate (28% vs. 11%). The increase in caesarean section rate could be attributed to failed versions, which apparently greatly influenced the choice between abdominal and vaginal delivery. Our findings and data from similar research suggest that benefits of external version at term may not apply to populations with a low caesarean rate, unless versions are carried out with maximal efficiency (which, on the basis of available data, would imply tocolysis) or so indifferently that failed attempts do not influence the choice between abdominal and vaginal delivery. External cephalic version (ECV) reduces the incidence of breech presentation at term and caesarean section for non-cephalic births. Tocolytics may improve success rates, but are time consuming, may cause side effects and have not been proven to alter caesarean section rates. The aim of this trial was to determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt.
                To determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt.
                Randomised, double-blinded, placebo-controlled trial.
                UK teaching hospital.
                One hundred and twenty-four women with a breech presentation at term who had undergone an unsuccessful attempt at ECV.
                Relative risks with 95% confidence intervals for categorical variables and a t test for continuous variables. Analysis was by intention to treat.
                Incidence of cephalic presentation at delivery. Secondary outcomes were caesarean section and measures of neonatal and maternal morbidity.
                The use of tocolysis for a repeat attempt at ECV significantly increases the incidence of cephalic presentation at delivery (RR 3.21; 95% CI 1.23-8.39) and reduces the incidence of caesarean section (RR 0.33; 95% CI 0.14-0.80). The effects were most marked in multiparous women (RR for cephalic presentation at delivery 9.38; 95% CI 1.64-53.62). Maternal and neonatal morbidity remain unchanged.
                The use of tocolysis increases the success rate of repeat ECV and reduces the incidence of caesarean section. A policy of only using tocolysis where an initial attempt has failed leads to a relatively high success rate with minimum usage of tocolysis.
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.