Many experienced clinicians urged caution in accepting the studys initial outcomes. In his effort to present additional information about the term breech trial, keirse has extracted data from the paper, made incorrect assumptions, misinterpreted information, and. The term breech trial spanned 26 countries and involved 2,088 women with a frank or complete breech presentation at term 37 weeks and later. After the tbt, acog released a committee opinion stating that planned vbd may no longer be appropriate. For most of these women, the approach to delivery is controversial. Term breech trial conclusions challenged mdedge obgyn. Of the 1,041 women allocated to planned cesarean delivery, 941 90. Approved interventions included induction, amniotomy, augmentation, and controlled delivery of the aftercoming head with forceps or the.
This retrospective study, with data taken from the dutch national perinatal registry from 1999 to 2007, including 96% of all births in the netherlands. Publications home of jama and the specialty journals of. The decision regarding the mode of delivery should consider patient wishes and the experience of the health care provider. Rcog statement on new dutch study examining breech. Term breech trial term breech trial hodnett, ellen. In physiological birth, locus of greatest efficacy perceived within motherinfant unit. Successful external cephalic version ecv for breech presenting fetus reduces the need for caesarean section cs. The publication of the term breech trial was followed within 2 months by an increased use of caesarean section for breech presentation in the netherlands 5080% and improved neonatal outcome. We did a randomised trial to compare a policy of planned. The term breech trial, published in 2000, was the largest randomised controlled trial to investigate the effect of mode of delivery for term breech deliveries on neonatal and maternal outcomes. In 2000, the term breech trial collaborative group published the results of a randomized, multicenter trial comparing planned cesarean section to planned vaginal birth for term fetuses with a.
The publication of the term breech trial 12 years ago caused an almost universal change in uk practise towards offering elective caesarean section to women with breech presentation at term. Planned caesarean section versus planned vaginal birth for breech. This is a mini commentary on y berhan and a haileamlak, pp. External cephalic version ecv is recommended by the american college of obstetricians and gynecologists to convert a breech fetus to vertex position and reduce the need for cesarean delivery. The term breech trial compared the safety of planned cesarean and planned vaginal birth for breech presentations at term. Planned caesarean section versus planned vaginal birth for. We wish to correct some of the major factual errors in keirses commentary 1 about the term breech trial 2. Previous article term breech trial next article term breech trial sirin the trial, there were no interactions between treatment group and any of the baseline variables recorded at the time of randomisation, except for country, as defined by the national. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breechpresentation pregnancies.
Inappropriate use of randomised trials to evaluate complex phenomena. The combined outcome of perinatal or neonatal death and serious neonatal morbidity was found to be significantly lower among babies delivered by planned cesarean section. The term breech trial or why people are afraid of breech birth. We conducted a retrospective, nationwide, finnish populationbased casecontrol study. Most cases of neonatal death and morbidity in the term breech trial cannot be. Hannah5 produced neither observational nor experimental data to support the intrapartum management used for breech delivery, but objects to criticism on the grounds that there had. Patients and professionals barriers and facilitators to. Setting and participants a total of 1596 of 1940 women from 110 centers worldwide who had a singleton fetus in breech presentation at term responded to a followup questionnaire at 3 months post partum. For 34% of pregnancies, the fetus will be in the breech presentation at term. The preferred mode of delivery has varied over recent years. A randomized trial of planned cesarean or vaginal delivery. Is planned vaginal delivery for breech presentation at.
Walkinshaw misconstrued the title and purpose of my commentary, explicit as they were 1. The term breech trial was set up to determine for selected breech fetuses whether i planned cs results in less risk of perinatal or neonatal mortality, or serious neonatal morbidity, occurring before 28 days of age, than planned vb. Term breech trial and its consequences on practice. Mary e hannah mdcm, walter j hannah md, sheila a hewson ba, ellen d hodnett phd, saroj saigal md and andrew r willan phd. Furthermore a large contemporary retrospective study in canada, examining the outcomes of 52,000 breech deliveries postpublication of the term breech trial between 2003 2011 found that, while there were now more. As a result, women with a breech presentation at term who desire a trial of labor often have limited choices. Breech presentation mode of delivery neonatal morbidity observational survey vaginal deliveries for breech presentations have long been a topic of debate. Outcomes of children at 2 years after planned cesarean. The costs of planned cesarean versus planned vaginal birth. The commentary asked whether research along the lines of the term breech trial 2 should be extended to give vaginal birth a fair chance to be proven a reasonable method of delivery for all babies. The number of practitioners with the skills and experience to perform vaginal breech delivery has decreased. This is the most common type of vaginal breech delivery. The availability of the pelvimetry findings led to increased vaginal breech birth rate, despite more elective caesarean sections in the study.
Breech infants were identified by examining computerstored maternal discharge records of hospitalization for the years 1990 and 2000 respectively. In this study we conducted a cost analysis of the 2 approaches to breech. These results have entered the public psyche to such an extent that women no longer have confidence undergoing vaginal breech deliveries vbd and experience has been eroded such that clinicians no. Unlimited viewing of the articlechapter pdf and any. The incidence of breech presentation decreases from about 20% at 28 weeks of gestation to 34% at term, as most babies turn spontaneously to the cephalic presentation 1, 2. We aimed to compare the success rate of ecv with either spinal anaesthesia sa or i.
Studies have shown that the prevalence of term breech presentation varies globally. The term breech trial results are generalisable jg thornton university of nottingham, nottingham, uk linked article. Randomized trial of anaesthetic interventions in external. The aim of this study was to identify factors associated with adverse perinatal outcome in term breech pregnancies, and to provide clinicians an aid in selecting women for a trial of vaginal labor with the fetus in breech position. Term breech trial bullet points debunking of the term breech trial, hannah et al 2000 study was a randomized multicenter trial that included 2083 women from 121 centers in 26 countries. Mary e hannah, walter j hannah, sheila a hewson, ellen d hodnett, saroj saigal, andrew r willan, for the term breech trial collaborative. Following the publication of the term breech trial, 1 there was a. In the term breech trial, twice as many turned when a vbb was planned than when a cs was planned, so that 3. Clinical ability to enable rather than control birth process is linked to experience. The goal of this study was to determine the incremental costeffectiveness ratio, from societys perspective, of ecv compared to scheduled cesarean for term breech presentation. Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix.
Planned caesarean section for term breech delivery hofmeyr, gj. January, by alex vidaeff, md, edward yeomans, md, ellen mozurkewich, md, and martin gimovsky, md, regarding the term breech trial tbt conducted by mary e. The infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head. Impact of the international term breech trial on clinical practice and concerns. Term breech trial the midwife, the mother and the breech. Impact of the international term breech trial on clinical practice and. The rise and fall of a randomized controlled trial glezerman, marek 4. Design followup study to the term breech trial, a randomized controlled trial conducted between january 9, 1997, and april 21, 2000. There is professional consensus that ecv should be offered to all women with a fetus in breech presentation, but only up to 70% of women eligible for ecv undergo an ecv attempt. The term breech trial enrolled 2088 women between january 9, 1997, and april 21, 2000, at 121 centers in 26 countries.
Failing to do an intentiontotreat analysis disregards the complexity of breech decisionmaking and the full range of consequences. Breech presentation occurs in 34% of gestations at term. Risk factors associated with adverse perinatal outcome in. The aim of the study was to identify barriers and facilitators. View the article pdf and any associated supplements and figures for a period of 48 hours. National clinical guideline the management of breech. Upright positioning is a tool, and not a rule, of physiological breech birth. Dr kotaska criticizes the selection criteria and the intrapartum management protocol of the term breech trial as being too broad and suggests. A randomized management of term frank breech presentation. The term breech trial by hannah et al 1 has been criticised for the methods used in its organisation2 and for the methods used in its treatment protocol34. We mailed a questionnaire to all term breech trial collaborators. To see the trend in managing singleton breech pregnancy after the term breech trial. Term breech trial term breech trial keirse, marc j. After the tbt, acog released a committee opinion stating.
Planned caesarean section versus planned vaginal birth for breech presentation at term. A randomised controlled trial rct of planned caesarean section cs vs planned vaginal birth vb for breech at term. Breech presentation occurs in approximately 3 to 4% of all women with term pregnancies, and since the publication of the term breech trial, in 2000, in many centers these fetuses are preferably. Many of the term breech trials 121 centres were in. Are the results of the term breech trial generalisable. The article thoroughly itemizes the methodological flaws and clinical problems with the term breech trial and their results state that most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery and that the analysis of outcome after two years has shown no difference between vaginal and. A policy of planned cesarean section for the delivery of twins gained support after the publication of the term breech trial, which showed that planned cesarean delivery was associated with a. The rise and fall of a randomized controlled trial. The studys remarkable scientific design, along with the work of all those. Secondly to compare the safety of different modes of delivery for term, singleton breeches by looking at the immediate neonatal outcome, based on our own experience. The followup study to address outcomes of the children at 2 years involved 85. Hannah and colleagues socalled term breech trial tbt was published over ten years ago now 1, and we still practise in its shadow.
Conclusion planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation. Planned vaginal delivery of a term singleton breech fetus may be reasonable. Vaginal breech delivery is associated with adverse perinatal outcome. Criteria for vaginal breech birth are summarized and the role of.
Outcomes associated with cesarean section versus vaginal. Costeffectiveness of external cephalic version for term. There is a trend in the united states to perform cesarean delivery for term singleton fetuses in a breech presentation. Women who were eligible for the study and consented. Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery.
720 250 671 423 581 1336 229 1210 898 995 155 1303 527 666 1621 1548 38 1136 390 790 193 1386 310 1421 1518 949 359 1218 76 303 645 1336 1487 61 1426