Scheduled Cesareans: The Best Option for Breech Babies?

Editorial Comment: When I first reviewed this study, it troubled me. It concluded that planned cesarean for breech produced fewer serious newborn complications than planned vaginal birth, which did not agree with other studies of vaginal breech birth. However, the trial seemed well-designed, and a large, well-designed trial in which participants are randomly assigned to one form of care or the other produces the strongest research evidence. I decided that not liking this conclusion didn't relieve me of the responsibility to report it.

Since that time, I have read and heard criticisms, which, if accurate, would invalidate the trials results. Newborn outcomes at vaginal birth necessarily depend on the expertise of the birth attendant. Overly forceful, hasty, or ill-judged manipulations can cause serious birth injuries or birth asphyxia. On paper, at least, the researchers had ensured that obstetricians attending vaginal breech births were experienced with them. But Maggie Banks, a New Zealand midwife, followed the bulletins sent to the hospitals involved in the trial. She believes that the increasingly detailed instructions and warnings as the trial progressed indicate that, in fact, some of the attending obstetricians lacked the requisite skills.

I have also heard third hand that many of the serious newborn complications occurred at only one or two of the participating institutions. This too would indicate that the problems experienced with vaginal breech related to the competency and experience of the birth attendants, not vaginal breech per se. The researchers chose not to report outcomes on a site-by-site basis, so I cannot verify whether the allegation is true. Nonetheless, what should have been (and what has been hailed as) the definitive study in determining the best course of action with a full-term breech may be nothing of the kind, and the question posed in the title of this piece has yet to be answered.

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