I appreciate the valuable contribution of Drs de Leeuw, Verhoeven and van Roosmalen.1 They have addressed the downstream morbidity associated with caesarean section, a subject that has been largely ignored in the breech debate. This is of considerable interest to the individual woman who would like to have a large family. Placenta praevia percreta is becoming one of the plagues of our time, and it seems a great pity that a young woman who has delivered her first baby without difficulty would be exposed to such a risk because of a breech presentation in her next pregnancy, when the risk of neonatal death or of serious long-term morbidity is probably less than 2%.
Nonetheless, it is clear that a planned caesarean section is better for the breech baby at term. The fact remains that dozens of Dutch parents are perambulating a live healthy infant, thanks to the Term Breech Trial. The precision of the mathematics can be disputed, but there is no disputing that very hefty numbers of caesareans are required to avoid small numbers of very adverse outcomes. Furthermore, it is likely that once the caesarean section rate for term breech hits 80%, the law of diminishing returns applies. Franco-Belgian data showed low levels of adverse outcome for planned vaginal breech delivery, with an overall caesarean rate in the order of 80%.2 The difficulty is how to provide a safe service for women who are prepared to accept the 1–2% risk of perinatal death or serious infant morbidity. Caesarean section has a fairly short learning curve, about 15 cases,3 while the learning curve for vaginal breech delivery is unknown. Advocates of vaginal breech delivery have emphasised the importance of personnel skilled in the technique. The choice is simple: do we accept the long-term maternal consequences of high caesarean rates or the perinatal consequences of vaginal delivery conducted by doctors less experienced than in the past? It would be interesting to know how it is proposed to solve this conundrum in the Netherlands.
The risks of maternal death from caesarean section may have been understated heretofore. The authors report an unprecedented maternal mortality rate for elective caesarean section for breech presentation (1 per 2200). This exceptionally high rate is very disturbing, and their study will be of considerable interest. The recent population-based study of maternal mortality associated with caesarean section in France was among the most pessimistic:4 it suggested that the operation carried a 3.6-fold increased risk of maternal death compared with that of the vaginal delivery.
Dr de Leeuw et al.1 draw attention to the need to define acceptable levels of risk. This will not be done easily, given the difficulties of calculating long-term morbidity. Parents, and obstetricians for that matter, find it difficult enough to grapple with the particular circumstances and decisions of the current pregnancy, without having to consider also the consequences for future pregnancies. In the current fearful medico-legal climate, zero seems to be an acceptable level of risk.