Planned caesarean section for term breech delivery

G Justus Hofmeyr; Mary Hannah; Theresa A Lawrie

doi:10.1002/14651858.CD000166.pub2

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Figure 1

'Risk of bias. graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

.Risk of bias. summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Planned caesarean section for term breech presentation, Outcome 1 Perinatal/neonatal death or severe neonatal morbidity.

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Analysis 1.2

Comparison 1 Planned caesarean section for term breech presentation, Outcome 2 Death or neurodevelopmental delay at age 2 years.

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Analysis 1.3

Comparison 1 Planned caesarean section for term breech presentation, Outcome 3 Perinatal/neonatal mortality (excluding fatal malformations).

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Analysis 1.4

Comparison 1 Planned caesarean section for term breech presentation, Outcome 4 5 minute Apgar < 7.

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Analysis 1.5

Comparison 1 Planned caesarean section for term breech presentation, Outcome 5 5 minute Apgar < 4.

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Analysis 1.6

Comparison 1 Planned caesarean section for term breech presentation, Outcome 6 Cord blood pH < 7.0.

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Analysis 1.7

Comparison 1 Planned caesarean section for term breech presentation, Outcome 7 Cord blood base deficit =/> 15.

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Analysis 1.8

Comparison 1 Planned caesarean section for term breech presentation, Outcome 8 Birth trauma, as defined by trial authors.

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Analysis 1.9

Comparison 1 Planned caesarean section for term breech presentation, Outcome 9 Brachial plexus injury.

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Analysis 1.10

Comparison 1 Planned caesarean section for term breech presentation, Outcome 10 Infant medical problems at 2 years.

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Analysis 1.11

Comparison 1 Planned caesarean section for term breech presentation, Outcome 11 Neurodevelopmental delay at age 2 years.

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Analysis 1.12

Comparison 1 Planned caesarean section for term breech presentation, Outcome 12 Caesarean section.

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Analysis 1.13

Comparison 1 Planned caesarean section for term breech presentation, Outcome 13 Short‐term maternal morbidity.

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Analysis 1.14

Comparison 1 Planned caesarean section for term breech presentation, Outcome 14 Woman not satisfied.

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Analysis 1.15

Comparison 1 Planned caesarean section for term breech presentation, Outcome 15 Postnatal depression at 3 months, as defined by trial authors.

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Analysis 1.16

Comparison 1 Planned caesarean section for term breech presentation, Outcome 16 Not breastfeeding at 3 months.

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Analysis 1.17

Comparison 1 Planned caesarean section for term breech presentation, Outcome 17 Perineal pain at 3 months.

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Analysis 1.18

Comparison 1 Planned caesarean section for term breech presentation, Outcome 18 Abdominal pain at 3 months.

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Analysis 1.19

Comparison 1 Planned caesarean section for term breech presentation, Outcome 19 Backache after at 3 months.

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Analysis 1.20

Comparison 1 Planned caesarean section for term breech presentation, Outcome 20 Any pain after at 3 months.

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Analysis 1.21

Comparison 1 Planned caesarean section for term breech presentation, Outcome 21 Dyspareunia at 3 months.

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Analysis 1.22

Comparison 1 Planned caesarean section for term breech presentation, Outcome 22 Urinary incontinence at 3 months.

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Analysis 1.23

Comparison 1 Planned caesarean section for term breech presentation, Outcome 23 Flatus incontinence at 3 months.

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Analysis 1.24

Comparison 1 Planned caesarean section for term breech presentation, Outcome 24 Faecal incontinence at 3 months.

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Analysis 1.25

Comparison 1 Planned caesarean section for term breech presentation, Outcome 25 Headache at 2 years.

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Analysis 1.26

Comparison 1 Planned caesarean section for term breech presentation, Outcome 26 Perineal pain at 2 years.

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Analysis 1.27

Comparison 1 Planned caesarean section for term breech presentation, Outcome 27 Back pain at 2 years.

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Analysis 1.28

Comparison 1 Planned caesarean section for term breech presentation, Outcome 28 Sexual problems at 2 years.

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Analysis 1.29

Comparison 1 Planned caesarean section for term breech presentation, Outcome 29 Painful intercourse at 2 years.

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Analysis 1.30

Comparison 1 Planned caesarean section for term breech presentation, Outcome 30 Urinary incontinence at 2 years.

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Analysis 1.31

Comparison 1 Planned caesarean section for term breech presentation, Outcome 31 Flatus incontinence at 2 years.

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Analysis 1.32

Comparison 1 Planned caesarean section for term breech presentation, Outcome 32 Faecal incontinence at 2 years.

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Analysis 1.33

Comparison 1 Planned caesarean section for term breech presentation, Outcome 33 Constipation at 2 years.

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Analysis 1.34

Comparison 1 Planned caesarean section for term breech presentation, Outcome 34 Haemorrhoids at 2 years.

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Analysis 1.35

Comparison 1 Planned caesarean section for term breech presentation, Outcome 35 Subsequent birth or pregnant at 2 years.

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Analysis 1.36

Comparison 1 Planned caesarean section for term breech presentation, Outcome 36 Subsequent caesarean section at 2 years.

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Analysis 1.37

Comparison 1 Planned caesarean section for term breech presentation, Outcome 37 Painful menstrual periods at 2 years.

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Analysis 1.38

Comparison 1 Planned caesarean section for term breech presentation, Outcome 38 Heavy menstrual periods at 2 years.

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Analysis 1.39

Comparison 1 Planned caesarean section for term breech presentation, Outcome 39 Depression at 2 years.

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Analysis 1.40

Comparison 1 Planned caesarean section for term breech presentation, Outcome 40 Difficulty caring for child at 2 years.

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Analysis 1.41

Comparison 1 Planned caesarean section for term breech presentation, Outcome 41 Relationship with partner unhappy at 2 years.

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Analysis 1.42

Comparison 1 Planned caesarean section for term breech presentation, Outcome 42 Unhappy with sexual relations at 2 years.

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Analysis 1.43

Comparison 1 Planned caesarean section for term breech presentation, Outcome 43 Estimated cost of intervention (in Canadian dollars).

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Summary of findings for the main comparison. Planned caesarean section for term breech delivery

Planned caesarean section for term breech delivery
Patient or population: women with term breech delivery Settings: 3 studies (2 in the USA, 1 international multicentre trial: 121 centres in 26 countries) Intervention: planned caesarean section
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Planned caesarean section
Perinatal/neonatal death or severe neonatal morbidity ‐ Low national perinatal mortality rate	Study population		RR 0.07 (0.02 to 0.29)	1025 (1 study)	⊕⊕⊕⊝ moderate¹
	57 per 1000	4 per 1000 (1 to 16)
Perinatal/neonatal death or severe neonatal morbidity ‐ High national perinatal mortality rate	Study population		RR 0.66 (0.35 to 1.24)	1053 (1 study)	⊕⊕⊝⊝ low^1,2
	44 per 1000	29 per 1000 (15 to 54)
Birth trauma, as defined by trial authors	Study population		RR 0.42 (0.16 to 1.1)	2062 (1 study)	⊕⊕⊝⊝ low^1,2
	14 per 1000	6 per 1000 (2 to 15)
Death or neurodevelopmental delay at age 2 years	Study population		RR 1.09 (0.52 to 2.3)	920 (1 study)	⊕⊕⊝⊝ low^1,2
	28 per 1000	31 per 1000 (15 to 65)
Caesarean section	Study population		RR 2.04 (1.91 to 2.17)	2396 (3 studies)	⊕⊕⊝⊝ low^3,4
	448 per 1000	843 per 1000 (717 to 986)
	Moderate
	522 per 1000	981 per 1000 (835 to 1000)
Short‐term maternal morbidity	Study population		RR 1.29 (1.03 to 1.61)	2396 (3 studies)	⊕⊕⊝⊝ low⁵
	86 per 1000	111 per 1000 (89 to 139)
	Moderate
	391 per 1000	504 per 1000 (403 to 630)
Any pain after at 3 months	Study population		RR 1.09 (0.93 to 1.29)	1593 (1 study)	⊕⊕⊝⊝ low^1,2
	250 per 1000	272 per 1000 (232 to 322)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ One study with design limitations. ² Wide confidence interval crossing the line of no effect. ³ Statistical Heterogeneity (I² > 40%). Direction of effect consistent but size of effect variable. ⁴ Studies contributing data had design limitations. ⁵ Studies contributing data had design limitations, with more than 40% of weight from studies with serious design limitations (‐2).

Summary of findings for the main comparison. Planned caesarean section for term breech delivery

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Comparison 1. Planned caesarean section for term breech presentation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Perinatal/neonatal death or severe neonatal morbidity Show forest plot	1	2078	Risk Ratio (M‐H, Random, 95% CI)	0.23 [0.02, 2.44]

1.1 Low national perinatal mortality rate	1	1025	Risk Ratio (M‐H, Random, 95% CI)	0.07 [0.02, 0.29]
1.2 High national perinatal mortality rate	1	1053	Risk Ratio (M‐H, Random, 95% CI)	0.66 [0.35, 1.24]
2 Death or neurodevelopmental delay at age 2 years Show forest plot	1	920	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.52, 2.30]

3 Perinatal/neonatal mortality (excluding fatal malformations) Show forest plot	3	2388	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.10, 0.86]

3.1 Low national perinatal mortality rate	3	1335	Risk Ratio (M‐H, Fixed, 95% CI)	0.26 [0.03, 2.00]
3.2 High national perinatal mortality rate	1	1053	Risk Ratio (M‐H, Fixed, 95% CI)	0.30 [0.08, 1.09]
4 5 minute Apgar < 7 Show forest plot	3	2375	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.12, 1.47]

5 5 minute Apgar < 4 Show forest plot	1	2062	Risk Ratio (M‐H, Fixed, 95% CI)	0.11 [0.01, 0.87]

6 Cord blood pH < 7.0 Show forest plot	1	1013	Risk Ratio (M‐H, Fixed, 95% CI)	0.15 [0.03, 0.67]

7 Cord blood base deficit =/> 15 Show forest plot	1	899	Risk Ratio (M‐H, Fixed, 95% CI)	0.30 [0.10, 0.92]

8 Birth trauma, as defined by trial authors Show forest plot	1	2062	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.16, 1.10]

9 Brachial plexus injury Show forest plot	3	2375	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.08, 1.47]

10 Infant medical problems at 2 years Show forest plot	1	843	Risk Ratio (M‐H, Fixed, 95% CI)	1.41 [1.05, 1.89]

11 Neurodevelopmental delay at age 2 years Show forest plot	1	920	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [0.69, 4.37]

12 Caesarean section Show forest plot	3	2396	Risk Ratio (M‐H, Random, 95% CI)	1.88 [1.60, 2.20]

13 Short‐term maternal morbidity Show forest plot	3	2396	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [1.03, 1.61]

14 Woman not satisfied Show forest plot	1	1596	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.64, 1.56]

15 Postnatal depression at 3 months, as defined by trial authors Show forest plot	1	1586	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.70, 1.24]

16 Not breastfeeding at 3 months Show forest plot	1	1557	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.90, 1.21]

17 Perineal pain at 3 months Show forest plot	1	1593	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.18, 0.58]

18 Abdominal pain at 3 months Show forest plot	1	1593	Risk Ratio (M‐H, Fixed, 95% CI)	1.89 [1.29, 2.79]

19 Backache after at 3 months Show forest plot	1	1593	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.71, 1.22]

20 Any pain after at 3 months Show forest plot	1	1593	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.93, 1.29]

21 Dyspareunia at 3 months Show forest plot	1	1329	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.72, 1.14]

22 Urinary incontinence at 3 months Show forest plot	1	1595	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.41, 0.93]

23 Flatus incontinence at 3 months Show forest plot	1	1222	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.79, 1.53]

24 Faecal incontinence at 3 months Show forest plot	1	1226	Risk Ratio (M‐H, Fixed, 95% CI)	0.54 [0.18, 1.62]

25 Headache at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.88, 1.25]

26 Perineal pain at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	0.65 [0.36, 1.15]

27 Back pain at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.88, 1.20]

28 Sexual problems at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.62, 1.48]

29 Painful intercourse at 2 years Show forest plot	1	830	Risk Ratio (M‐H, Fixed, 95% CI)	1.48 [0.53, 4.12]

30 Urinary incontinence at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.63, 1.06]

31 Flatus incontinence at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.81, 1.61]

32 Faecal incontinence at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	1.11 [0.47, 2.58]

33 Constipation at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	1.34 [1.06, 1.70]

34 Haemorrhoids at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.85, 1.43]

35 Subsequent birth or pregnant at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.71, 1.24]

36 Subsequent caesarean section at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	1.24 [0.60, 2.55]

37 Painful menstrual periods at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.71, 1.15]

38 Heavy menstrual periods at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.78, 1.52]

39 Depression at 2 years Show forest plot	1	917	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.62, 1.29]

40 Difficulty caring for child at 2 years Show forest plot	1	873	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.72, 1.29]

41 Relationship with partner unhappy at 2 years Show forest plot	1	856	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.63, 1.66]

42 Unhappy with sexual relations at 2 years Show forest plot	1	702	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.51, 1.50]

43 Estimated cost of intervention (in Canadian dollars) Show forest plot	1	1027	Mean Difference (IV, Fixed, 95% CI)	‐877.0 [‐894.89, ‐859.11]

43.1 Low national perinatal mortality rate	1	1027	Mean Difference (IV, Fixed, 95% CI)	‐877.0 [‐894.89, ‐859.11]

Comparison 1. Planned caesarean section for term breech presentation

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