BEST EVIDENCE IN ANESTHETIC PRACTICE
1115
differences in maternal mortality or serious maternal
morbidity between the two groups.
simple task. While outcomes are improved, vaginal
birth cannot be dismissed as unsafe when the vast
majority of the babies (94%) were well nor can
Cesarean section be guaranteed to prevent all perina-
tal complications.
Midwives in Ontario are required to seek a medical
consultation for breech presentations persisting after
36 weeks of pregnancy. They must discuss with
women the reasons for the referral and information
about breech presentations. The impact of this trial is
just beginning to be felt. Many questions arise. Will
women have any opportunity to choose a trial of
labour? Will obstetricians decline all except precipitous
vaginal breech births? How will competency in vaginal
breech birth be maintained?
Increasingly important is recognition of the breech
presentation prior to labour and consideration of
external cephalic version (ECV) to reduce the proba-
bility of Cesarean section. Research has shown that
ECV at term reduces the risk of breech presentation at
birth.2 However, for nulliparous women and those
with a frank breech regardless of parity, ECV at term
has a higher failure rate.2 A multicentre randomized
clinical trial is underway to test the effectiveness of
ECV at 34 to 36 weeks gestation compared to 37 to
38 weeks.2 The findings of this trial will contribute to
the information that can be provided to women with
fetuses in breech presentation.
Obstetrical care providers who promote policies to
reduce interventions in childbirth may be disappoint-
ed with the findings, but it is important that they
communicate the findings to women in their care.
Research evidence should inform policy but should
not be used as a dictum. Women are entitled to receive
objective, detailed explanations and, in the words of
Michael Helawa, “non-coercive counselling”,3 which
will enable women to exercise their own decision-
making capacity rather than be subjected to institu-
tional rules.
Conclusion: Planned Cesarean delivery of term sin-
gleton fetus in breech presentation significantly
reduces early (<28 days) perinatal / neonatal mortali-
ty and serious morbidity without increased six-week
maternal mortality or serious maternal morbidity.
Funding: Canadian Institutes of Health Research,
Centre for Research in Women’s Health (Sunnybrook
and Women’s College Health Sciences Centre),
University of Toronto Department of Obstetrics and
Gynaecology.
Correspondence: Dr. Mary E. Hannah, University of
Toronto, Maternal Infant and Reproductive Health
Research Unit, Centre for Research in Women’s
Health, Toronto, Ontario, M5G 1N8, Canada. Email:
Commentary by P. McNiven, K. Kaufman and H.
McDonald
The Term Breech Trial,1 published in October 2000
randomly assigned, in 26 countries, 2,088 women with
a singleton fetus in frank or complete breech presenta-
tion to a policy of planned Cesarean section or a policy
of planned vaginal delivery. With a sample size sufficient
to detect a significant difference in perinatal morbidity
and mortality, the study found improved perinatal out-
comes in the group assigned to planned Cesarean sec-
tion without increase in maternal morbidity.
When Hannah et al. stratified the data by the coun-
try’s perinatal mortality rate (PMR), the improvement
associated with Cesarean delivery was greater in coun-
tries (like Canada) with a low PMR.2 In countries with
a high PMR the benefits of Cesarean delivery were less
with almost no difference in the rate of serious neona-
tal morbidity. In countries with a low PMR, seven
additional planned Cesarean sections are needed to
prevent one serious perinatal complication. The num-
ber needed-to-treat in countries with a high PMR is
39. The authors state that the reduced benefit from
planned Cesarean section in countries with a high
PMR may be due to higher levels of experience with
vaginal breech delivery in those countries. The impli-
cations of increasing the number of Cesarean births in
developing countries are immense: greater numbers of
women will have uterine scarring, its associated com-
plications, as well as an increase in repeat Cesarean
deliveries. Since these are the countries with the least
resources, a policy of planned Cesarean section may be
unjustified.
Patricia McNiven R M PhD
Karyn Kaufman R M DrPH
Helen McDonald R M MHSc
Hamilton, Ontario
References
1
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED,
Saigal S, Willan AR, for the Term Breech Trial
Collaborative Group. Planned caesarean section versus
planned vaginal birth for breech presentation at term: a
randomised multicentre trial. Lancet 2000; 356: 1375–83.
2 Hutton EK, Hannah ME, Amankwah K, Kaufman K,
Hodnett ED. External cephalic version (ECV) and the
In countries with a low PMR, women must be ade-
quately informed about the comparison of vaginal
breech delivery and Cesarean section. This is not a