Bilaga 2 - Litteratur och data

Litteratur och data som stödjer patientinformation

1. Cochrane review 2015: Planned caesarean section for term breech delivery

Results:

  • Perinatal or neonatal death was reduced with planned caesarean section (RR 0.29, 95% CI 0.10 to 0.86).
  • Planned caesarean section was associated with modestly increased short-term maternal morbidity (RR 1.29, 95% CI 1.03 to 1.61).
  • At two years, there were no differences in the combined outcome 'death or neurodevelopmental delay' (RR 1.09, 95% CI 0.52 to 2.30)
  • More infants who had been allocated to planned caesarean delivery had medical problems at two years (RR 1.41, 95% CI 1.05 to 1.89).
  • Maternal outcomes at two years were also similar.
  • All of the trials included in this review had design limitations, and the GRADE level of evidence was mostly low.

Conclusions

  • Planned caesarean section compared with planned vaginal birth reduced perinatal
    or neonatal death as well as the composite outcome death or serious neonatal
    morbidity, at the expense of somewhat increased maternal morbidity.
  • In a subset with 2-year follow up, infant medical problems were increased following planned caesarean section and no difference in long-term neurodevelopmental delay or the outcome "death or neurodevelopmental delay" was found, though the numbers were too small to exclude the possibility of an important difference in either direction.
  • The benefits need to be weighed against factors such as the mother's preference for vaginal birth and risks such as future pregnancy complications in the woman's specific healthcare setting.
  • 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.

2. RCOG Green‐top Guideline No. 20b: Management of Breech Presentation. 2017

  • Planned caesarean section leads to a small reduction in perinatal mortality compared with vaginal delivery. Decision to perform a cesarean section needs to be balanced against the potential adverse consequences.
  • The reduced risk is due to three factors: the avoidance of stillbirth after 39 weeks of gestation, the avoidance of intrapartum risks and the risks of vaginal breech birth. Only the last is unique to a breech baby.
  • When planning delivery for a breech baby, the risk of perinatal mortality is approximately 0,5/1000 with cesarean section after 39+0 weeks of gestation and approximately 2,0/1000 with planned vaginal breech birth. This compares to approximately 1,0/1000 with planned cephalic birth.
  • Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.
  • Planned vaginal breech birth increases the risk of low Apgar scores and serious short-term complications but has not been shown to increase the risk of longterm morbidity.
  • Planned cesarean section carries a small increase in immediate complications for the mother compared with planned vaginal breech birth.
  • Maternal complications are least with successful vaginal breech birth; planned caesarean section carries a higher risk, but the risk is highest with emergency caesarean section which is needed in approximately 40% of women planning a vaginal breech birth.
  • Caesarean section increases the risk for complications in future pregnancy including the risks of opting for vaginal birth after caesarean section, the increased risk of complications at repeat caesarean section and the risks of an abnormally invasive placenta.
  • Caesarean section has been associated with a small increase in the risk of stillbirth for the subsequent babies although this may not be casual.

3. SOCG Guideline No. 384. Management of Breech Presentation at Term. 2019

  • In appropriately selected women with obstetricians skilled in vaginal breech birth, perinatal mortality is between 0,8 and 1,7/1000 for planned vaginal breech birth and between 0 and 0,8/1000 for planned caesarean section.
  • In appropriately selected women, planned vaginal breech birth is associated with greater short- but not long-term neonatal neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1,5/1000 breech births, and any abnormal neurological development occurs in approximately 3/100.
  • The Term Breech Trial found no difference between planned CS and planned VBB. The 2-year follow-up data provide the best prospective evidence of poor correlation between short-term neonatal morbidity and long-term neurological outcome.
  • The mechanics of VBB pose a greater risk of perinatal trauma than CS; however, short-term trauma often resolves, and reliable estimates of permanent damage arelacking. Brachial plexus injury may occur in approximately 1/1000 VBBs. Permanent genital injuries are rare and associated with prolonged labour.

4. CNGOF Guidelines for Clinical Practice: Breech Presentation 2019:

  • In France, 5% of women have breech deliveries. One third of them have a planned vaginal delivery of whom 70% deliver vaginall.
  • In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity.
  • No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years, cognitive and psychomotor outcomes between 5 and 8 years, and adult intellectual performances.
  • Short and long term maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies.
  • A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy.
  • It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term and to check the absence of hyperextension of the fetal head by ultrasonography to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery. Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met.
  • In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery.
  • The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy
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