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Original Contribution |

Outcomes at 3 Months After Planned Cesarean vs Planned Vaginal Delivery for Breech Presentation at Term:  The International Randomized Term Breech Trial FREE

Mary E. Hannah, MDCM; Walter J. Hannah, MD; Ellen D. Hodnett, RN, PhD; Beverley Chalmers, PhD; Rose Kung, MD; Andrew Willan, PhD; Kofi Amankwah, MD; Mary Cheng, MD; Michael Helewa, MD; Sheila Hewson, BSc; Saroj Saigal, MD; Hilary Whyte, MD; Amiram Gafni, PhD; for the Term Breech Trial 3-Month Follow-up Collaborative Group
[+] Author Affiliations

Author Affiliations: Department of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre (Drs M. Hannah, W. Hannah, Kung, and Amankwah), Maternal Infant and Reproductive Health Research Unit, Centre for Research in Women's Health (Drs M. Hannah and Willan and Ms Hewson), Faculty of Nursing (Drs Hodnett and Chalmers), WHO Collaborating Centre, Centre for Research in Women's Health (Dr Chalmers), and Department of Paediatrics, Hospital for Sick Children (Dr Whyte), University of Toronto, Toronto, Ontario; Department of Obstetrics and Gynaecology, Centenary Hospital, Scarborough, Ontario (Dr Cheng); Department of Obstetrics and Gynaecology, St Boniface Hospital, University of Manitoba, Winnipeg (Dr Helewa); and the Departments of Clinical Epidemiology and Biostatistics (Drs Willan and Gafni) and Paediatrics (Dr Saigal), McMaster University, Hamilton, Ontario.


JAMA. 2002;287(14):1822-1831. doi:10.1001/jama.287.14.1822.
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Published online

Context The Term Breech Trial found a significant reduction in adverse perinatal outcomes without an increased risk of immediate maternal morbidity with planned cesarean delivery compared with planned vaginal birth. No randomized controlled trial of planned cesarean delivery has measured benefits and risks of postpartum outcomes months after the birth.

Objective To compare maternal outcomes of planned cesarean delivery and planned vaginal birth at 3 months post partum.

Design Follow-up study to the Term Breech Trial, a randomized controlled trial conducted between January 9, 1997, and April 21, 2000.

Setting and Participants A total of 1596 of 1940 women from 110 centers worldwide who had a singleton fetus in breech presentation at term responded to a follow-up questionnaire at 3 months post partum.

Main Outcome Measures Breastfeeding; infant health; ease of caring for infant and adjusting to being a new mother; sexual relations and relationship with husband/partner; pain; urinary, flatal, and fecal incontinence; depression; and views regarding childbirth experience and study participation.

Results Baseline information was similar for both the cesarean and vaginal delivery groups. Women in the planned cesarean delivery group were less likely to report urinary incontinence than those in the planned vaginal birth group (36/798 [4.5%] vs 58/797 [7.3%]; relative risk, 0.62; 95% confidence interval, 0.41-0.93). Incontinence of flatus was not different between groups but was less of a problem in the planned cesarean delivery group when it occurred (P = .006). There were no differences between groups in other outcomes.

Conclusions Planned cesarean delivery for pregnancies with breech presentation at term may result in a lower risk of incontinence and is not associated with an increased risk of other problems for women at 3 months post partum, although the effect on longer-term outcomes is uncertain.

Figures in this Article

Rates of cesarean delivery vary tremendously in different settings, and recent data suggest that rates are generally increasing.14 The procedure is usually undertaken to reduce the risk of adverse outcomes for the neonate, accepting that maternal risk of complications may be higher. The Term Breech Trial, a multicenter, international, randomized controlled trial of 2088 women, was undertaken to determine if a policy of planned cesarean delivery, compared with planned vaginal birth, would decrease the risk of adverse perinatal outcomes, a composite measure of perinatal or neonatal mortality or serious neonatal morbidity, for the selected fetus in breech presentation at term. The study found a significant reduction in adverse perinatal outcomes with planned cesarean delivery compared with planned vaginal birth (1.6% vs 5.0%; P<.001).5 Although the risks of maternal mortality or serious maternal morbidity during the first 6 weeks post partum were low in the Term Breech Trial and not significantly increased (3.9% vs 3.2%; P = .35), a Cochrane meta-analysis of this trial and 2 other small trials found a slightly greater risk of serious problems for mothers with planned cesarean delivery (relative risk [RR], 1.29; 95% confidence interval [CI], 1.03-1.61).6 Serious maternal morbidity in these trials consisted principally of postpartum bleeding; postpartum fever; and wound infection, dehiscence, or breakdown.

Other important adverse maternal outcomes that are thought to be related to the birth process, such as urinary or fecal incontinence, resumption of and comfort during sexual activity, pain, breastfeeding, and postpartum depression, have not been previously studied in a randomized controlled trial. Nonrandomized studies have consistently found that labor and vaginal birth increase the risks of urinary incontinence, fecal incontinence, and incontinence of flatus following delivery.711 The importance of urinary incontinence at 3 months post partum was recently emphasized in a report that found that 92% of such women continued to have symptoms 5 years after the delivery.12 Indeed, to avoid incontinence after birth, some women have indicated a preference for elective cesarean delivery.13,14

Other studies, however, have suggested that cesarean delivery may increase the risk of other problems, such as difficulties with breastfeeding, postpartum depression, and negative feelings about the childbirth experience.1517 Because none of these studies was randomized, the effects may be due to confounding factors or difficulties differentiating elective cesarean deliveries vs those performed during labor as part of a policy of planned vaginal birth. Also, the effects of cesarean delivery may differ depending on the indication.

The Term Breech Trial provided us with a unique opportunity to assess the effects of a policy of planned cesarean delivery compared with planned vaginal birth on these other maternal outcomes at 3 months following delivery.

Eligibility and Randomization

Women were eligible for the trial if they had a singleton live fetus in a frank or complete breech presentation at term (≥37 weeks' gestation). The study was approved by the research ethics committees at participating centers, and women gave informed consent before being enrolled in the study. Centers that were not confident in their ability to trace more than 80% of randomized women did not undertake the follow-up components of the study. Randomization was centrally controlled at the University of Toronto Maternal Infant and Reproductive Health Research Unit (Toronto, Ontario) with a computerized randomization program, accessible by means of a touch-tone telephone.

Treatment Protocol

Women enrolled in the study were randomly allocated to either the planned cesarean delivery group or the planned vaginal birth group. If randomized to the planned cesarean delivery group, a cesarean delivery was scheduled for 38 or more weeks' gestation. If the woman was in labor at the time of randomization, the cesarean delivery was undertaken as soon as possible. Immediately prior to cesarean delivery, the fetal presentation was reassessed and if it was cephalic, a vaginal birth was planned. We anticipated that more than 90% of women in this group would undergo cesarean delivery.

For women randomized to the planned vaginal birth group, management was expectant until spontaneous labor began, unless an indication to induce labor (eg, postterm pregnancy) or undertake cesarean delivery (eg, footling breech presentation) developed. The protocol for management during labor has been previously reported.5 Fetuses in breech presentation who were delivered vaginally were attended by a clinician experienced in vaginal breech birth. We anticipated that more than 50% of women in this group would actually deliver vaginally, but we recognized that many women in this group would appropriately require cesarean delivery because of fetal/maternal problems developing during labor/delivery.

Follow-up and Outcomes

Collaborators in participating centers contacted women at 3 months post partum and asked them to complete a structured questionnaire to obtain information regarding breastfeeding, health of the infant, sexual relations, pain within the previous 24 hours, urinary incontinence within the previous 7 days, postpartum depression, and likes and dislikes regarding the childbirth experience and participation in the Term Breech Trial (the questionnaire is available at http://www.utoronto.ca/miru/breech/3mpq). To determine the presence of urinary incontinence, women were asked if they lost or leaked urine when they coughed, laughed, sneezed, etc. Postpartum depression was defined as a score of more than 12 on the Edinburgh Postnatal Depression Scale (EPDS).18

The 3-month postpartum questionnaire was slightly revised shortly after the study was started (November 1997) to include additional questions concerning the mother's ease of caring for her new infant and ease of adjusting to being a new mother, happiness with her relationship with her husband or partner, happiness with sexual relations, how severe the pain was during sex (if sex was described as painful), fecal incontinence (lost or leaked feces/stool, fluid, or mucus unexpectedly from the bowels) or incontinence of flatus (passed gas/wind unexpectedly) within the previous 7 days, and how much of a problem incontinence was perceived to be (no problem at all, a little problem, or a big problem) whether it was urine, stool, or flatus. Aside from the EPDS, all questions were formulated following a review of the literature and discussions among members of the steering committee, and the questionnaire was pretested prior to its use. Questionnaires were mailed to women for completion. If this was not possible because of logistical problems, questionnaires were completed by telephone or during a personal interview. The questionnaires were either translated (and back-translated to ensure accuracy of the translation) into the mother's language or were administered by someone who could translate the questions for the woman. We used previously published translations of the EPDS when available.19

A 2-year follow-up of mothers and children is ongoing in participating centers.

Statistical Analysis

The results were analyzed according to treatment as assigned at randomization (modified intention to treat). Thus, we wished to determine the effect of the approach to delivery rather than the effect of the actual method of delivery. All women who delivered at centers participating in the follow-up component of the study and for whom we had completed questionnaires were included in the analysis. The groups were compared using the Fisher exact test for the analysis of binary outcomes and the χ2 test for linear trend for the analysis of ordered categorical outcomes. A 2-sided P value of <.05 was considered indicative of statistical significance. Relative risks and 95% CIs were also calculated. The P values reported herein should be considered descriptive because these were secondary outcomes of the study and we made no adjustments for multiple tests. Statistical analyses were carried out using SAS Version 8.0 (SAS Institute Inc, Cary, NC).

Subgroup Analyses

The following subgroup analyses, not planned as part of the original protocol, were undertaken: for the outcomes of no sex since the birth, pain, urinary incontinence, fecal incontinence, incontinence of flatus, and postpartum depression, we used multiple logistic regression analyses to determine the effect of the variables of parity at randomization (0 vs ≥1); the country's national perinatal mortality rate as reported in 1996 by the World Health Organization (low [≤20/1000] vs high [>20/1000])5,20; how the questionnaire was completed (received questionnaire by mail and answered the questions without help vs other methods); and their interactions with treatment group. We also tested for interactions between these baseline variables as well as whether a woman was planning to breastfeed (yes vs no or unknown) and treatment group on the outcome of continuing to breastfeed at the time the questionnaire was completed.

The Term Breech Trial enrolled 2088 women between January 9, 1997, and April 21, 2000, at 121 centers in 26 countries. Outcomes occurring within 6 weeks following birth among all randomized women have been previously published.5 A total of 1940 women enrolled at 110 centers were followed up to 3 months post partum and asked to complete a questionnaire. We received completed questionnaires for 1596 (82.3%) of these women, of whom 798 were randomized to the planned cesarean delivery group and 798 were randomized to the planned vaginal birth group (Figure 1).

Figure. Flow Diagram of the Term Breech Trial
Graphic Jump Location
Baseline Characteristics at Randomization and Completion of the Questionnaire

Baseline characteristics for those followed up were similar in both groups (Table 1). Seven hundred ninety women (49.5%) were from centers in countries with a low national perinatal mortality rate, and 806 (50.5%) were from centers in countries with a high national perinatal mortality rate.20 For both groups, the median time to completion of the questionnaire was 3.1 months, and the majority of women completed the questionnaire over the telephone or during a personal interview (70.6% in the planned cesarean delivery group and 70.7% in the planned vaginal birth group).

Table Graphic Jump LocationTable 1. Characteristics of Women and Their Pregnancies at Randomization and Method and Timing of Completion of the Questionnaire*
Mode of Delivery and Perineal Trauma

Of the 798 women randomized to the planned cesarean delivery group, 725 (90.9%) had cesarean deliveries. For the 73 women in the planned cesarean group who delivered vaginally, the reasons were: cesarean delivery not possible due to imminent vaginal delivery (n = 39 [53.4%]), patient request (n = 26 [35.6%]), cephalic presentation (n = 10 [13.7%]), and other or unknown reasons (n = 3 [4.1%]). Of the 798 women randomized to the planned vaginal birth group, 456 (57.1%) delivered vaginally. For the 342 who had cesarean delivery in that group, the reasons were: fetopelvic disproportion or failure to progress in labor (174 [50.9%]), fetal heart rate abnormality (100 [29.2%]), footling breech presentation (56 [16.4%]), patient request (48 [14.0%]), obstetrical or medical complication (32 [9.4%]), cord prolapse (10 [2.9%]), and other or unknown reason (6 [1.8 %]). The rates of cesarean and vaginal birth in the 2 groups were very similar to the rates for all women randomized.5 Women who had had a previous cesarean delivery (n = 44) had similar rates of cesarean delivery as other women in the 2 groups (87.5% in the planned cesarean delivery group and 50.0% in the planned vaginal birth group). Among the 456 women in the planned vaginal birth group who delivered vaginally, 107 (23.5%) had a forceps or vacuum delivery—either using forceps to deliver the after-coming head of a breech fetus (n = 104) or using forceps or vacuum to deliver a fetus in cephalic presentation (n = 3). For the 456 women in the planned vaginal birth group who delivered vaginally, 332 (72.8%) had some degree of perineal trauma. For 6 women, there was a tear involving the anal sphincter. The remaining 326 women had either a median episiotomy (n = 16), a mediolateral episiotomy (n = 290), or a tear not involving the anal sphincter (n = 20).

Breastfeeding, Infant Health, and Mother-Infant Relationship

Most women (1407/1592 [88.4%]) indicated that they had initiated breastfeeding, and 68.9% were breastfeeding at the time they completed the questionnaire, although these rates did not differ between the planned cesarean and planned vaginal birth groups (Table 2). Fewer women in the planned cesarean delivery group breastfed their infant within a few hours following the birth (571/779 [73.3%] vs 602/776 [77.6%]; RR, 0.94; 95% CI, 0.89-1.00; P = .05) (Table 2). Most women (922/1186 [77.7%]) found it easy or very easy to care for their new infant and 980/1196 (81.9%) found adjusting to being a new mother to be easy or very easy, and these rates did not differ between the planned cesarean and planned vaginal birth groups. For infants discharged home after the birth, 19.9% returned to a physician for medical care and 3.4% were readmitted to hospital. These rates did not differ between groups (Table 2).

Table Graphic Jump LocationTable 2. Breastfeeding and Health of Infant*
Sex and Relationship With Husband or Partner

There were no significant effects of planned method of delivery on sexual relations or the relationships with a husband or partner. At the time the questionnaire was completed, 15.3% of women had not had sex since the birth and 17.8% of women who had had sex since the birth had experienced pain on the most recent occasion (Table 3). Of those who reported on the severity of pain during sex, 18 (9.5%) of 190 reported the pain to be "quite a lot" and 4 (2.1%) of 190 reported the pain to be "severe or excruciating/terrible pain." Of the women who reported on their happiness with sexual relations with their husband or partner, most (858/914 [93.9%]) reported that they were very happy or somewhat happy. Irrespective of the sexual relationship, most women (1122/1181 [95.0%]) reported that their relationship with their husband or partner was very happy or somewhat happy. Compared with before the birth, most women indicated that their relationship with their husband or partner was about the same. However, 285 (24.1%) of 1182 indicated that the relationship was better and 32 (2.7%) of 1182 indicated that it was worse.

Table Graphic Jump LocationTable 3. Sex, Pain, Incontinence, and Depression*
Pain, Incontinence, and Depression

Pain of any kind within the previous 24 hours was similar for women in the planned cesarean delivery group (217/796 [27.3%]) and the planned vaginal birth group (199/797 [25.0%]) (Table 3). However, compared with the planned vaginal birth group, more women in the planned cesarean delivery group indicated that they had pain on the outside of the abdomen (79/796 [9.9%] vs 45/797 [5.7%]; RR, 1.76; 95% CI, 1.24-2.50; P = .002) or deep inside the abdomen (70/796 [8.8%] vs 37/797 [4.6%]; RR, 1.89; 95% CI, 1.29-2.79; P<.001), and fewer women in the planned cesarean group indicated that they had pain in the bottom or genital area (14/796 [1.8%] vs 44/797 [5.5%]; RR, 0.32; 95% CI, 0.18-0.58; P<.001) (Table 3).

Fewer women in the planned cesarean delivery group compared with the planned vaginal birth group indicated that they had lost or leaked urine in the previous 7 days (36/798 [4.5%] vs 58/797 [7.3%]; RR, 0.62; 95% CI, 0.41-0.93; P = .02). Among women who experienced urinary incontinence, there was no significant difference between groups in perceiving the incontinence as a problem (Table 3). Very few women indicated that they had lost or leaked feces/stool, fluid, or mucus unexpectedly from their bowels in the previous 7 days (5 women in the planned cesarean group and 9 women in the planned vaginal birth group). The risk of incontinence of flatus within the previous 7 days was not different between groups (66/616 [10.7%] in the planned cesarean group compared with 59/606 [9.7%] in the planned vaginal birth group). However, among those with incontinence of flatus, it was less likely to be perceived as a problem in the planned cesarean group compared with the planned vaginal birth group (P = .006) (Table 3). Of the 7 women having a tear involving the anal sphincter (1 in the planned cesarean group and 6 in the planned vaginal birth group), 2 reported fecal incontinence and 2 reported incontinence of flatus.

Postpartum depression as defined by the EPDS was not different between the 2 randomized groups (80/793 [10.1%] in the planned cesarean delivery group compared with 86/793 [10.8%] in the planned vaginal birth group) (Table 3).

Likes and Dislikes Regarding Childbirth Experience and Trial Participation

Women's likes and dislikes in relation to their childbirth experience are shown in Table 4. Women in the planned cesarean delivery group were more likely than those in the planned vaginal birth group to indicate that they liked being able to schedule their delivery, liked that the childbirth experience was not very painful, and felt reassured about their infant's health. Women in the planned vaginal birth group were more likely than those in the planned cesarean delivery group to indicate that they liked that it was natural, liked actively participating in the birth, and liked that recovering from the childbirth experience was not difficult. Similar numbers of women in both groups indicated that they liked the method of delivery that they had had or felt reassured about their own health, or indicated that there was nothing they liked about their childbirth experience. Regarding women's likes and dislikes relating to participation in the study, women in the planned cesarean delivery group were more likely to indicate that they liked being in the trial because they felt reassured about their infant's health (516/798 [64.7%] vs 472/798 [59.2%]; RR, 1.09; 95% CI, 1.01-1.18; P = .03) but were also more likely to indicate that they disliked being in the trial because they did not like the method of delivery (62/798 [7.8%] vs 31/798 [3.9%]; RR, 2.00; 95% CI, 1.31-3.04; P = .001). When asked whether they would participate in the trial if they had to do it all over again, there were no differences in responses between the 2 groups, with 37 (2.3%) of 1579 indicating definitely not, 167 (10.6%) indicating probably not, 595 (37.7%) indicating probably yes, and 780 (49.4%) indicating definitely yes.

Table Graphic Jump LocationTable 4. Likes and Dislikes Regarding the Childbirth Experience*
Subgroup Analyses

There were no statistically significant interactions between treatment group and baseline variables for any of the outcomes, indicating that the effects of planned cesarean delivery and planned vaginal birth were similar in subgroups defined by the baseline variables. Primiparous (vs multiparous) women were significantly more likely to report not having sex since the birth (odds ratio, 2.19; 95% CI, 1.65-2.92; P<.001). Women who delivered in countries with a low (vs high) national perinatal mortality rate and those who completed the questionnaire by mail without any help (vs other methods) were significantly more likely to report pain within the previous 24 hours (OR, 1.56; 95% CI, 1.19-2.06; P = .002 and OR, 1.43; 95% CI, 1.06-1.94; P = .02, respectively). Multiparous (vs primiparous) women and those who delivered in a country with a low (vs high) national perinatal mortality rate were significantly more likely to report urinary incontinence (OR, 2.66; 95% CI, 1.69-4.19; P<.001 and OR, 4.04; 95% CI, 2.47-6.63; P<.001, respectively). Women who delivered in a country with a low (vs high) national perinatal mortality rate and those who completed the questionnaire by mail without any help (vs other methods), were significantly more likely to report incontinence of flatus (OR, 2.56; 95% CI, 1.54-4.27; P<.001 and OR, 1.97; 95% CI, 1.23-3.17; P = .005, respectively). Women who completed the questionnaire by mail without any help (vs other methods) were more likely to report fecal incontinence (OR, 4.74; 95% CI, 1.63-13.8; P = .004). Women who delivered in countries with a low (vs high) national perinatal mortality rate were significantly less likely to report that they were continuing to breastfeed at the time of completing the questionnaire (OR, 0.20; 95% CI, 0.16-0.26; P<.001), whereas those who indicated they were planning to breastfeed (vs those not planning or not known to be planning to do so) were significantly more likely to report continuing to breastfeed (OR, 14.04; 95% CI, 7.02-28.06; P<.001).

This is the first report of a randomized controlled trial comparing the policies of planned cesarean delivery and planned vaginal birth in relation to maternal outcomes at 3 months following delivery. Overall, there was no increased risk of problems with planned cesarean delivery. We found that multiparous women were at greater risk of urinary incontinence than primiparous women and that, regardless of parity, planned cesarean delivery reduced the risk of urinary incontinence compared with planned vaginal birth. We also found that when incontinence of flatus occurred, it was less likely to be perceived as a problem if a cesarean delivery had been planned.

Although urinary incontinence was not the primary outcome of the Term Breech Trial and we did not adjust for the multiple statistical tests, we believe that the finding of a reduced risk of urinary incontinence with planned cesarean delivery in this study is likely to be true because it is consistent with the findings of numerous nonrandomized studies.711,21,22 Whether a policy of planned cesarean delivery can reduce the risk of problematic incontinence that interferes with a woman's quality of life is still not known, and this should be the focus of future randomized controlled trials of planned cesarean delivery.

Others have found higher rates of urinary incontinence at 3 months post partum than we found in this study.9,12 Using a postal questionnaire, Wilson et al9 found that 34.3% of all women who responded admitted to some degree of urinary incontinence at 3 months post partum; however, urinary incontinence was defined broadly, including that which occurred less (as well as more) often than once per week. The low rate of urinary incontinence found in this study may be because we required that there be symptoms of incontinence during the week prior to completing the questionnaire, thus excluding incontinence that was short-lived or that occurred less frequently. Also, the design of the Term Breech Trial required that there be a high rate of cesarean delivery for women randomized to planned vaginal birth to ensure the best outcome for neonates. If vaginal delivery is a major cause of urinary incontinence at 3 months post partum, the risk may have been reduced by the high rate of cesarean delivery in that group.

Although there were no differences between groups in reporting pain or amount of pain at 3 months post partum, not surprisingly, women allocated to planned cesarean delivery were more likely to report abdominal pain and less likely to report perineal pain than women allocated to planned vaginal birth. Women who delivered in more developed countries, as defined by the country's national perinatal mortality rate, were more likely to report urinary incontinence, incontinence of flatus, and pain. It may be that women in more developed countries actually experienced more of these adverse outcomes, tolerated them less well, or felt more at liberty to report them than the women in less developed countries.

Although we found benefits to planned cesarean delivery in terms of a lower risk of urinary incontinence and perceiving incontinence of flatus to be a problem, planned cesarean delivery did not have an effect on having sex, pain associated with sex, or happiness with sexual relations at 3 months post partum. This is not inconsistent with other studies; other factors such as depression, tiredness, and lack of interest have been found to be more associated with occurrence of and satisfaction with sexual relations than mode of delivery.23,24 In our study, 15% of women had not had sex since the birth, and close to 20% of women reported that the last episode of sex was painful. Robson et al,23 who followed up 119 primiparous women for 1 year after delivery, found that at 3 months post partum, approximately 30% of women had either not resumed sex or had received very little or no pleasure from it. Although the true impact of childbirth on maternal sexuality requires further study, our results of adverse outcomes following childbirth are consistent with other reports.23,24

The rates of continuing to breastfeed at the time the questionnaire was completed, a median of 3.1 months in both groups, were lower among women who delivered in more developed countries. However, in contrast with some reports that have linked difficulties with breastfeeding with cesarean delivery,15 we did not find that a policy of planned cesarean delivery had an influence on either the initiation of breastfeeding or likelihood of continuing to breastfeed, although women in the planned cesarean group were less likely to breastfeed during the first few hours following the birth compared with women in the planned vaginal birth group.

This study did not find planned cesarean delivery to be associated with higher rates of postpartum depression as measured by the EPDS. This is also in contrast to the findings of other, nonrandomized studies, which have found an association between cesarean delivery and postpartum depression.2527 One of the difficulties interpreting data from nonrandomized studies is that elective cesarean deliveries undertaken as part of a policy of planned cesarean delivery are often combined with emergency procedures undertaken as part of a policy of planned vaginal birth. It may be that the indication for the cesarean delivery, rather than the procedure itself, is more associated with adverse outcomes.

We found that women in the planned cesarean and planned vaginal birth groups were equally likely to respond that they liked the method of delivery and that if they had to do it all over again, they would participate in the trial. Satisfaction with the childbirth experience has been associated with involvement in decision making, having sufficient information from caregivers, perceiving caregivers to be helpful, and less obstetric intervention.27 Other randomized controlled trials, however, have found higher rates of satisfaction with more obstetric intervention, if the intervention has been aimed at preventing or treating a problem.28,29 Our findings suggest that in a pregnancy with a fetus in breech presentation at term, mode of delivery is not an important component of maternal satisfaction with care.

In summary, this large, international, randomized controlled trial of mothers with a breech presentation at term found planned cesarean delivery to be associated with a lower risk of urinary incontinence and perceiving incontinence of flatus to be less of a problem when it occurs, and has not found a policy of planned cesarean delivery to be associated with adverse consequences for the mother at 3 months post partum. Our findings must be interpreted with caution because women randomized to the planned vaginal birth group had a high rate of cesarean delivery, which would have reduced our ability of finding an association between cesarean delivery and adverse outcomes, if one existed. Caution should also be exercised in recommending a policy of planned cesarean delivery because serious maternal morbidity in the first 6 weeks is slightly increased with planned cesarean delivery, and because the much longer-term effects of a policy of planned cesarean delivery on future childbearing and complications associated with repeat cesarean delivery, such as infection, bleeding, thromboembolic problems, and surgical trauma, are a concern, particularly if women are planning to have many more children. However, recent data suggest that women with urinary incontinence at 3 months post partum are at high risk of continuing to have symptoms many years later,12 and maternal mortality data suggest that an elective cesarean delivery may be associated with a substantially lower risk of maternal mortality than if a vaginal delivery is planned when the likelihood of an emergency cesarean delivery is high.30

Therefore, although uncertainties remain, we believe it is reasonable to offer women the option of elective cesarean delivery, based on the available evidence, if such women are at high risk of needing an emergency cesarean delivery if vaginal delivery is planned.

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Astbury J, Brown S, Lumley J, Small R. Birth events, birth experiences and social differences in postnatal depression.  Aust J Public Health.1994;18:176-184.
Jolly J, Walker J, Bhabra K. Subsequent obstetric performance related to primary mode of delivery.  Br J Obstet Gynaecol.1999;106:227-232.
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression—development of the 10-item Edinburgh Postnatal Depression Scale.  Br J Psychiatry.1987;150:782-786.
Cox J, Holden J. Perinatal Psychiatry: Use and Misuse of the Edinburgh Postnatal Depression ScaleLondon, England: Gaskell; 1994.
 Perinatal Mortality: A Listing of Available Information . Geneva, Switzerland: World Health Organization; 1996. Publication WHO/FRH/MSM/96.7.
Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery.  N Engl J Med.1993;329:1905-1911.
Viktrup L, Lose G, Rolff M, Barfoed K. The symptom of stress incontinence caused by pregnancy or delivery in primiparas.  Obstet Gynecol.1992;79:945-949.
Robson KM, Brant HA, Kumar R. Maternal sexuality during first pregnancy and after childbirth.  Br J Obstet Gynaecol.1981;88:882-889.
Glazener CM. Sexual function after childbirth: women's experiences, persistent morbidity and lack of professional recognition.  Br J Obstet Gynaecol.1997;104:330-335.
Kendell RE, Rennie D, Clarke A, Dean C. The social and obstetric correlates of psychiatric admission in the puerperium.  Psychol Med.1981;11:341-350.
Hannah P, Adams D, Lee A, Glover V, Sandler M. Links between early post-partum mood and post-natal depression.  Br J Psychiatry.1992;160:777-780.
Brown S, Lumley J. Satisfaction with care in labor and birth: a survey of 790 Australian women.  Birth.1994;21:4-13.
Hodnett ED, Hannah ME, Weston J.  et al.  Women's evaluations of induction of labor versus expectant management for prelabor rupture of the membranes.  Birth.1997;24:214-220.
Lavender T, Wallymahmed AH, Walkinshaw SA. Managing labor using partograms with different action lines: a prospective study of women's views.  Birth.1999;26:89-96.
Hall MH, Bewley S. Maternal mortality and mode of delivery.  Lancet.1999;354:776.

Figures

Figure. Flow Diagram of the Term Breech Trial
Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Characteristics of Women and Their Pregnancies at Randomization and Method and Timing of Completion of the Questionnaire*
Table Graphic Jump LocationTable 2. Breastfeeding and Health of Infant*
Table Graphic Jump LocationTable 3. Sex, Pain, Incontinence, and Depression*
Table Graphic Jump LocationTable 4. Likes and Dislikes Regarding the Childbirth Experience*

References

Health Canada.  Canadian Perinatal Health Report, 2000Ottawa, Ontario: Minister of Public Health Works and Government Services Canada; 2000.
Martin JA, Smith BL, Mathews TJ, Ventura SJ. Births and deaths: preliminary data for 1998.  Natl Vital Stat Rep.1999;47:1-45.
 Department of Health statistical bulletin: NHS maternity statistics, England 1989-90 to 1994-95. Available at: http://www.doh.gov.uk/public/sb9728.htm. Accessed March 19, 2002.
 Department of Health statistical bulletin: NHS maternity statistics, England 1995-96 to 1997-98. Available at: http://www.doh.gov.uk/public/sb0114.htm. Accessed March 12, 2002.
Hannah ME, Hannah WJ, Hewson S, Hodnett E, Saigal S, Willan A.for the Term Breech Trial Collaborative Group.  Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial.  Lancet.2000;356:1375-1383.
Hofmeyr GJ, Hannah ME. Planned caesarean section for term breech delivery. In: The Cochrane Library, Issue 1. Oxford, England: Update Software; 2001.
Meyer S, Schreyer A, De Grandi P, Hohlfeld P. The effects of birth on urinary continence mechanisms and other pelvic-floor characteristics.  Obstet Gynecol.1998;92:613-618.
Højberg K, Salvig JD, Winsløw NA, Lose G, Secher NJ. Urinary incontinence: prevalence and risk factors at 16 weeks of gestation.  Br J Obstet Gynaecol.1999;106:842-850.
Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery.  Br J Obstet Gynaecol.1996;103:154-161.
MacArthur C, Bick DE, Keighley MR. Faecal incontinence after childbirth.  Br J Obstet Gynaecol.1997;104:46-50.
Peschers U, Schaer GN, DeLancey JO, Schuessler B. Levator ani function before and after childbirth.  Br J Obstet Gynaecol.1997;104:1004-1008.
Viktrup L, Lose G. The risk of stress incontinence 5 years after first delivery.  Am J Obstet Gynecol.2001;185:82-87.
Al-Mufti R, McCarthy A, Fisk NM. Obstetricians' personal choice and mode of delivery.  Lancet.1996;347:544.
Paterson-Brown S. Should doctors perform an elective caesarean section on request? yes, as long as the woman is fully informed.  BMJ.1998;317:462-463.
Chalmers BE, Meyers D. Adjustment to the early months of parenthood.  Int J Prenat Perinat Stud.1990;1:229-240.
Astbury J, Brown S, Lumley J, Small R. Birth events, birth experiences and social differences in postnatal depression.  Aust J Public Health.1994;18:176-184.
Jolly J, Walker J, Bhabra K. Subsequent obstetric performance related to primary mode of delivery.  Br J Obstet Gynaecol.1999;106:227-232.
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression—development of the 10-item Edinburgh Postnatal Depression Scale.  Br J Psychiatry.1987;150:782-786.
Cox J, Holden J. Perinatal Psychiatry: Use and Misuse of the Edinburgh Postnatal Depression ScaleLondon, England: Gaskell; 1994.
 Perinatal Mortality: A Listing of Available Information . Geneva, Switzerland: World Health Organization; 1996. Publication WHO/FRH/MSM/96.7.
Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery.  N Engl J Med.1993;329:1905-1911.
Viktrup L, Lose G, Rolff M, Barfoed K. The symptom of stress incontinence caused by pregnancy or delivery in primiparas.  Obstet Gynecol.1992;79:945-949.
Robson KM, Brant HA, Kumar R. Maternal sexuality during first pregnancy and after childbirth.  Br J Obstet Gynaecol.1981;88:882-889.
Glazener CM. Sexual function after childbirth: women's experiences, persistent morbidity and lack of professional recognition.  Br J Obstet Gynaecol.1997;104:330-335.
Kendell RE, Rennie D, Clarke A, Dean C. The social and obstetric correlates of psychiatric admission in the puerperium.  Psychol Med.1981;11:341-350.
Hannah P, Adams D, Lee A, Glover V, Sandler M. Links between early post-partum mood and post-natal depression.  Br J Psychiatry.1992;160:777-780.
Brown S, Lumley J. Satisfaction with care in labor and birth: a survey of 790 Australian women.  Birth.1994;21:4-13.
Hodnett ED, Hannah ME, Weston J.  et al.  Women's evaluations of induction of labor versus expectant management for prelabor rupture of the membranes.  Birth.1997;24:214-220.
Lavender T, Wallymahmed AH, Walkinshaw SA. Managing labor using partograms with different action lines: a prospective study of women's views.  Birth.1999;26:89-96.
Hall MH, Bewley S. Maternal mortality and mode of delivery.  Lancet.1999;354:776.

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