The Term Breech Trial
Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial
Mary E Hannah MDCM, Walter J Hannah MD, Sheila A Hewson BA, Ellen D Hodnett PhD, Saroj Saigal MD and Andrew R Willan PhD
Here is the long and the short of it.
The short first: This was the biggest (international), most organized, randomly controlled trial (RCT-the gold standard in research) for planned vaginal vs. planned cesarean birth. It included only breech babies that were frank or complete breech, and not pre or post mature. The results of the study, published in 2000, were officially so skewed toward cesarean being safer that they cut the trial short. After this came out, almost no one wanted to risk it anymore, and breech mamas were scheduled for cesarean at 38-39 weeks. In the wake of this study, there has been an onslaught of criticism, from doctors around the world and especially from natural birth professionals. In 2006, Dr. Marek Glezerman published an article in the American Journal of Obstetrics and Gynecology that contributed to the recall of many of the official cesarean-only protocols from the TBT. The Term Breech Trial was squashed. Unfortunately, no one remembers how to attend vaginal births anymore, and cesarean remains the status quo most everywhere. Dr. Glezerman, a highly respected researching OB, says that no one argues anymore about the pitfalls of the TBT or the merits and safety of vaginal breech birth; most know it is often a good option. But women are not asking for vaginal birth and most OBs are fine if their colleagues do it but personally choose not to.
The long of it: Proponents of vaginal breech birth point out problems with the way the study was conducted. First, the vaginal birth mothers were often attended by clinicians who were inexperienced and/or poorly trained in breech birth. Second, these babies were delivered in a breech-unfriendly manner. The mothers were not active during labor, were often induced, and/or used augmentation (pitocin) and epidurals. Critics says these common elements of hospital birth spell danger for breech birth. Third, of the babies who died or had problems, most seem unfairly categorized (see below). Knowledgeable caregivers experienced in vaginal breech birth claim that active, natural, drug-free birth with a trained and experienced caregiver is as safe or safer than a cesarean.
According the the TBT, a breech baby born vaginally has an almost 5% combined risk of perinatal mortality (death during labor), neonatal mortality (death in the first 28 days) and serious morbidity (serious problems after birth, because of the birth). Unfortunately, such things as “drowsy” or “hyperalert,” plus other conditions that subsided within hours of birth were counted as morbidity, so this percentage is not that useful.
Additional problems include: 83% of the ‘planned vaginal delivery’ candidates were recruited during labor compared to 50% of the cesarean group. Only 35% of the births were attended in a facility that provided the high standard of care required by the study (quick access to help for problems with birth, mom, or baby).
Out of 2,083 babies, 16 died. The great shocker that caused the change is that 13 of them were from the planned vaginal birth group. (Three were deaths from the cesarean group, and one of those died from c-section complications. Also from the c/s group, a spinal cord injury and a skull fracture. So you see cesarean is not safe, either.) A closer look at these 13 deaths from the vaginal group reveals that all is not so terrifying as it seems. Of the 13:
2 died in their mother’s uterus before they could be born at all
2 went home well with no delivery problems noted, and died later
2 had respiratory problems that appear to have nothing to do with mode of delivery
3 had heart rate abnormalities
1 had a congenital abnormality
and that leaves
3 that died after a difficult vaginal delivery
This is roughly the same percentage as the cesarean group.
Two of those 3 that died after a difficult vaginal delivery used induction, augmentation, or both.
In the end: For the most part, obstetric groups have ‘recalled’, in essence, this extreme swing toward cesarean delivery. Also, follow-up studies in Denmark and the Netherlands have found a huge increase in breech babies born via cesarean, but without as large an improvement in neonatal outcomes as originally seen in the TBT. Both the Canadian (SOGC) and US (ACOG) society of OBGYNs encourage vaginal breech birth under certain circumstances and when a skilled provider can be found. Unfortunately, the training for breech birth is so far gone, and the insurance and malpractice issues are so huge, that it is still very difficult to find a skilled provider to assist at a vaginal breech birth in the US. Your doctor will almost certainly tell you a c-section is your only option. What s/he means is: I will not do it, and I don’t want to encourage you to look elsewhere.
And here is the very long of it: The full text of the published TERM BREECH TRIAL study. http://www.thelancet.com/journals/lancet/article/PIIS0140673600028403/fulltext
A word about studies and statistical figures:
As Dr. Marek Glezerman says, Keep in mind that although something may be statistically significant, this does not make it clinically significant. At the 2012 Coalition for Breech Birth conference he pointed out that if a patient presented with a temperature of 99.4 you would not look around for a drug that had a 98% chance of lowering it to 98.6. So, if you find that, for example, vaginal breech birth increases the risk of bruising to 2.3% from the cesarean-born risk of 1.2%, that is statistically significant. It is twice the rate of bruising. But it is not clinically significant because you would not do a cesarean just to avoid a 1% risk of bruising. See? Keep in mind that figures must be examined from every angle. You can present the same information many ways and get very different reactions and perceived outcomes. Remember what Mark Twain said the three kinds of lies are: lies, damned lies, and statistics.
Marek G. also points out that 91% of medical procedures have no backup in RCTs (randomized, controlled trials). So just because there isn’t a great study out showing that something is safe doesn’t mean it is, or isn’t.
Reactions to the Term Breech Trial
Here are some professional opinions regarding the study.
This article states that the TBT has made too sweeping a change for something that has so many variables. Read part of his commentary at the link below (full text requires subscription). Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery by Andrew Kotaska, MD. http://www.bmj.com/content/329/7473/1039.reprint
After the sweeping change came around from the TBT, doctors and researchers in parts of the world where vaginal breech birth was still common wanted to see if they observed a more favorable outcome for vaginal breeches. They did. Read the summary below to see how vaginal births in France and Belgium were just as safe as planned cesareans.
The Term Breech Trial itself did a 2 Year Follow Up with a number of the toddlers born in the trial. The vaginally delivered group of children were in slightly better health at two years old.
Here is commentary of the TBT from Maggie Banks, a well-known New Zealand midwife. http://www.birthspirit.co.nz/Articles/Articles/Term%20Breech%20Trial%20Commentary.pdf
Here is another review of the TBT: http://www.home4birth.com/pregnancy/special-circumstances/breech/breech-studies/