The proposed benefit of elective cesar-ean section for breech presentation is

improved neonatal outcome. Table 2 shows the corrected perinatal mortality rate
per 1000 live births across the 3 in-stitutions during the 16-year study pe-riod.
Comparison of the corrected peri-natal mortality rates across consecutive 4-year
time epochs showed that rates of perinatal mortality decreased in each subsequent
time period. This decreasing trend reached statistical significance when the 4-year
periods from 2001-2004 and 2005-2008 were compared (6% 0.5% vs 4.9% 0.4%;
P .02; 95% CI, 1.9 to 0.22).

COMMENT

The findings of this study demonstrate that, in this single large metropolitan
population, the attitude of clinicians to-wards vaginal breech delivery has changed
over the 16-year period that we analyzed. The recommendations of the TBT as
well as changing opinions have led to an increased cesarean deliv-ery rate among
breech presentations. We consider our data to be robust in nature because of large
cohort size and the ob-vious significant decrease in the number of vaginal breech
deliveries during the study period. These findings were also found to be consistent
when patients were separated into groups of nullipa-rous and multiparous women.
When we examined the individual 4-year time pe-riods, we found that there was a
statisti-cally significant decrease in vaginal breech delivery rates during
successive 4-year epochs. This suggests that clini-cians were already favoring a
move away from vaginal breech delivery and that the findings of the TBT
continued an estab-lished trend.

We also sought to examine whether a decrease in vaginal breech delivery rates

had an impact on overall perinatal death in the 3 institutions. We found that there
was no significant difference in corrected perinatal mortality rates over the course
of the study period, despite a significant decrease in vaginal breech delivery rates
over the 16-year study. The most appro priate mode of delivery of a breech pre-
sentation remains a controversial topic in obstetric practice, and attitudes still vary
considerably between institutions and individual clinicians, despite the data
presented by various publications. The institutions that were investigated in this
study are located uniquely in terms of proximity to each other and serve a similar
patient population with similar risk factor profiles. All 3 institutions have very
similar attitudes towards vaginal breech delivery, and the practice of offer-ing
elective external cephalic version be-fore offering elective cesarean delivery at 39
weeks gestation is standard. All patients are thoroughly counseled about the risks
and benefits at every step of the process. The main limitation of this study is its
retrospective nature. How-ever, the Dublin maternity hospital an-nual reports are
regarded widely as hav-ing a highly reliable and in-depth system of data reporting
and retention. Because our report is retrospective, it was chal-lenging to report on
cases of morbidity that were associated with breech presen-tation. We have sought
to give an indica-tion of the effect of declining vaginal breech delivery rates on
neonatal out-come by reporting on rates of corrected perinatal mortality among
the 3 institutions. A significant decrease in perinatal mortality rates was found;
although this cannot be directly attributed to decreas-ing rates of vaginal breech
delivery, it certainly may play a role along with nu-merous other factors. Despite
these lim-itations and given the size of the study cohort, we believe our results are
signif-icant and worthy of reporting.

Despite intensive research, a definitive solution to the question of the safest

method of breech delivery remains elusive. A number of studies have highlighted
lim-itations in the study design, patient treat-ment, and recommendations of the
TBT; most notably that the TBT included only nulliparous patients and was
stopped be-fore its designated completion date. Other investigators since 2000
have dem-onstrated that, with appropriate selection criteria, it is possible to have
favorable out-comes with vaginal breech delivery, partic-ularly in multiparous
patients, with peri-natal morbidity and mortality rates in keeping with the general
obstetric population.

Our study demonstrates that clini-cians attitudes towards vaginal breech delivery
have been changing steadily since the mid 1990s and that this shift in approach
was solidified by the publica-tion of the TBT in late 2000. Cesarean delivery is
now undoubtedly the favored method of delivery for clinicians in con-temporary
practice when dealing with a breech presentation. This effect has been seen in
both nulliparous and multipa rous patients, despite the fact that the TBT did not
include multiparous patients.

Although the follow up of patients in the TBT in 2003 showed no evidence that
the long-term health of infants with a breech presentation, who were delivered at
term, was influenced by the mode of delivery, this appears to have had little
impact on the declining vaginal breech delivery rates. Planned cesarean delivery
for breech presentation also carries a small increase in serious immediate
complications for the mother, compared with planned vaginal birth. The declin-
ing rate of vaginal breech delivery is likely to impact on the number of obste-
tricians who are competent at perform-ing this procedure, which is a skill that is
still required for delivery of a breech sec-ond twin or for a patient in advanced
labor with a breech presentation. Our findings would suggest that vaginal breech
delivery in the future may be lim-ited by the decreasing numbers of clini-cians
who are adequately skilled to conduct these deliveries safely.