Cesarean delivery of the breech very-low-birth-weight infant: does it make a difference?

We evaluated the impact of cesarean section (CS) delivery on the outcome of breech very-low-birth-weight (VLBW) (500-1,499 g) infants. This retrospective study used data from a large perinatal data base with 109,428 consecutive deliveries including 1,564 VLBW infants born between 1982 and 1987. The study infants included 982 (62.8%) vertex and 582 (37.2%) breech presentations. The CS rate was higher for the breech group than for the vertex group (72.5% breech, 34.3% vertex, OR 5.1, 95% CI 4.0, 6.4). Breech infants delivered by CS were twice as likely to survive until discharge than those delivered vaginally (breech CS 71.7%, breech vaginal 36.5%, P < .0001). The increased survival with CS for breech presentation (mainly due to fewer deaths on day 1) was not seen with vertex presentation. The CS survival advantage for breech infants was seen in all 250g birth weight subgroups. However, breech VLBW infants delivered by CS had a mean birth weight 233 g more and gestational age 2.1 weeks more than those delivered vaginally. Further, breech infants delivered by CS were more likely to be intubated at birth than vaginally delivered breech infants (OR 4.2, 95% CI 2.0, 5.9). Central nervous system morbidity as measured by the occurrence of seizures and intraventricular hemorrhage was comparable for CS and vaginal infants. Cesarean birth of breech VLBW infants is associated with improved survival. However, breech CS infants were bigger, more mature, and more likely to be intubated at birth than vaginally delivered infants, indicating the presence of a strong selection bias. A prospective randomized trial is needed to evaluate the ideal delivery route for breech VLBW infants.