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Breech births at term revisited: new contributions from Finland and Norway

In October 2000, the results of a randomized trial on the best mode of delivery for fetuses in breech presentation at term (1) were met with consternation in some quarters. In the controversial article, Hannah et al. (1) concluded that planned cesarean section is substantially better than planned vaginal birth. This was countered with the questions: ‘‘What is the external validity of these results?’’ and ‘‘Will we lose our dexterity in handling the occasional vaginal breech birth if we adopt a policy of more cesarean sections?’’ In the year 2000, approximately 40% of the term breech deliveries in Norway were vaginal. This is a strong tradition, not least because of the Løvset maneuver (2), which is still practiced regularly. Among the Nordic countries, centers in Denmark and Finland had participated in the trial, but Iceland, Norway and Sweden were absent. The perinatal mortality rates in the Nordic countries are much lower than in most of the countries represented in the Hannah trial. Two months after the results were published, Swedish perinatologists convened a Nordic meeting focusing on term breech delivery, but no consensus was reached. Halmesmäki wrote a commentary in Acta, pointing out that rigid monitoring in hospitals with high standards of care might have saved some of the babies who died in the group of planned vaginal births (3). In the same vein, Apuzzio et al. (4) from a respected US center defended their protocol with strict rules for vaginal breech births to continue and commented on longterm risks for mothers following cesarean section. Roosmalen and Rosendaal (5) commented on the causes of death and serious morbidity in the Hannah trial and did not accept the results at face value. Meanwhile, one observational study from Sweden (6) and another from Norway (7) had conclusions more in line with the Hannah trial. The new contributions