Professional Documents
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1167
Purpose
o Primary research question:
• For a fetus carried to term who presents as a ‘breech’
delivery (buttocks or feet appearing first), is a caesarean
section (C-section) or a planned vaginal birth better for
the baby and the mother?
o Primary outcomes:
• Perinatal mortality or neonatal mortality at less than 28
days (excluding lethal anomalies)
• Serious perinatal morbidity (e.g., birth trauma, injury,
decreased Apgar score, etc.)
o Secondary outcomes:
• Maternal mortality or serious maternal morbidity during
the first 6 weeks post-partum (e.g. death, hemorrhage,
hysterectomy, etc.).
Principal Investigators
o The Term Breech Trial Collaborative Group
o Lead authors: ME Hannah, WJ Hannah
Design
o Number of participants:
• 2088 pregnant women were randomised
o 1043 assigned to planned caesarean delivery
o 1045 assigned to planned vaginal delivery
o Participant characteristics:
• Women were eligible if they had a singleton live fetus in a
frank or complete breech presentation at term (≥ 37
weeks gestation).
• Exclusion criteria were contraindications for either
delivery method: feto-pelvic disproportion, fetal weight ≥
4000g, hyperextension of fetal head.
• Women randomized to both groups were similar upon
study entry with no substantial differences by: age,
parity, type of breech presentation, gestational age, fetal
size/weight, labor assessment methods, country-level
perinatal mortality rate, or center-level indicator of
standard of care.
o During the course of the trial, one participating center could not
provide the appropriate level of care for patients in the study
and the center’s participation was discontinued: following this
experience a screening tool assessed level of care at
participating centers.
Findings
o Of the 1041 women assigned plan C-section, 90.4% delivered
by C-section. Of the 1042 women assigned to vaginal birth,
56.7% delivered vaginally.
Impact
The Term Breech trial, a multi-center trial across 121 centers in 26 countries
randomizing 2088 women to ‘planned C-section’ or ‘planned vaginal’
deliveries found during interim analyses that C-section was associated with a
reduced risk of perinatal morbidity and mortality. This controversial trial
made a dramatic impact on practice and raised further questions beyond its
scope. Rapid change in clinical practice occurred in many locations, although
not universally, as some desired more evidence and others were reticent to
accept the trials results as conclusive. Despite the deliberate trial process of
consensus building and expert consultation and review, the trial results were
met with both acclaim, criticism and dispute. There was concern that policy
formed out of the trial’s results would lead to a reduction of the role of the
midwife during intra-partum care, the potential restraint of a in women’s
choice in delivery, and the loss of continuity-of-care in the birthing process
that midwives would deliver. The rapid change in practice following the trial
led to concern of that clinical skill in vaginal delivery of breech births would
decrease, as well as unintended increases in adverse outcomes associated
with additional C-sections.
References
10. Walkinshaw SA. Term breech trial (letter). Birth 30[1], 70-73. 2003.
17. Hogle KL, Kilbern L, Hewson S, Gafni A, Wall R, and Hannah ME.
Impact of the international term breech trial on clinical practice and
concerns: a survey of centre collaborators. J Obstet Gynaecol Can
25[1], 14-16. 2003.
19. Mammelle N. Quelle position pour la France face au debat sure les
pratiques d'accouchement en cas de presentation du siege a terme? J
Gynocol Obstet Biol Reprod 30[6], 604-606. 2001.
22. Hannah ME, Hannah WJ, and Hewson S. The Term Breech Trial:
findings of this major international study leave a question mark over
midwives' role in breech delivery. Midwifery 17, 74-77. 2001.
23. Shenan A and Bewley S. How to manage term breedh deliveries. BMJ
232[244], 245. 2001.
26. Vandenbussche F and Oepkes D. The effect of the Term Breech Trial
on medical intervention behavior and neonatal outcome in The
Netherlands: an analysis of 35,453 term breech infants. BJOG 112,
1163. 2005.