In a recent Finnish population-based case-control study including all singleton deliveries from 1 January 2005 to 31 December 2014 and excluding preterm deliveries, antepartum-diagnosed stillbirths, placenta previa and infants with congenital malformations (499,206 foetuses at term), Macharey et al. [
22] evaluated the antenatal risk factors associated with adverse perinatal outcomes in planned vaginal breech labour at term. They found that the stillbirth rate was significantly higher in cases of planned vaginal breech labour than in cases of cephalic presentation (0.2 vs 0.1%, respectively), which was correlated with foetal growth restriction, oligohydramnios, gestational diabetes mellitus (GDM) and a history of CS. Furthermore, in another recent survey based on the same cohort of mother-neonate dyads that also excluded congenital malformations, placenta previa and prelabour stillbirths [
23], this same group showed that breech presentation at term was significantly associated with antenatal stillbirth and a number of individual obstetric risk factors for adverse perinatal outcomes, including oligohydramnios, foetal growth restriction, gestational diabetes, history of CS section and congenital anomalies. Among all planned singleton vaginal deliveries with the foetus in the breech presentation at term, a composite adverse perinatal outcome defined as umbilical arterial pH < 7.00, 5-min Apgar score below 7 and/or neonatal mortality during the first 6 days of life (excluding stillbirth) was associated with foetal growth restriction (aOR 2.94 [1.30–6.67]), oligohydramnios (adjusted OR 2.94 [1.15–7.81]), gestational diabetes (aOR 2.89[1.54–5.40]), and a history of CS (aOR 2.94 [1.28–6.77]).
In another recent population-based study based on perinatal data of all (650,968) children born in Norway from 1999 to 2009 [
24], the authors recognized the limitations of most registry-based studies, as the selection of women with breech presentation and planned vaginal delivery was based on criteria that might have identified pregnancies with a lower risk of adverse outcomes compared with those selected for CS delivery. Moreover, in this study [
24], the intrapartum conversion of some of the planned vaginal deliveries to an emergency CS delivery may have increased the risk for adverse outcome in the CS group. However, Bjellmo et al. [
24] conducted an innovative analysis comparing breech deliveries to vaginal cephalic births. Thus, they showed that singleton children born at term without congenital malformations had a higher risk for stillbirth and neonatal mortality if they were born in the breech presentation “regardless of whether they were born vaginally or by CS delivery” (0.9 per 1000 in those actually delivered vaginally and 0.8 per 1000 in those actually born by CS delivery) compared with those born by vaginal cephalic delivery (0.3 per 1000). Of note, among those children born in the breech rather than in the cephalic presentation, these authors [
24] found that a higher proportion of infants were born small for gestational age (SGA). However, these authors [
23] did not distinguish foetal growth restriction among SGA neonates. In their interpretation, Bjellmo et al. [
23] considered that “the overall higher risk for stillbirth and the higher proportion of infants born SGA among children born in the breech than in the cephalic presentation may suggest that foetuses with antenatal acquired risk factors for adverse outcomes are more likely to present in the breech than in the cephalic presentation at birth.” According to these authors, the findings were most likely explained by a combination of antenatal acquired risk factors for neonatal death with increased vulnerability to the birth process. Of note, in the TBT group, birth weights of less than 2.8 kg were also associated with adverse perinatal outcomes (
P = 0.003) [
10]. In fact, a limitation in the Norwegian study [
24] was that, unlike Macharey et al., the authors did not distinguish foetal growth restriction among these SGA neonates. Indeed, in a large cohort study conducted with the National Health Service region in England through a multivariable analysis of 92,218 normally formed singletons delivered during 2009–2011 from 24 weeks of gestation, including 389 stillbirths, Gardosi et al. [
25] showed that foetal growth restriction had the largest population attributable risk for stillbirth which was fivefold greater if it was not detected antenatally than when it was (32.0% v 6.2%). The above data suggest that some antenatal features associated with term breech presentation, notably foetal growth restriction, and some gestational disorders (such as uncontrolled gestational diabetes mellitus) could affect the prognosis in term breech cases. Previous data also support this conclusion; Luterkort M et al. [
26] had previously reported in a prospective follow-up of 228 pregnancies with the foetus in the breech presentation in the 33rd gestational week that the 96 foetuses (42%) who remained in the breech presentation at delivery weighed 4.9% less than their vertex controls after adjustments were made for gestational age and had an increased frequency of oligohydramnios. Krebs et al. [
27] later confirmed this association between breech presentation and foetal growth restriction from a register-based, case-control cohort of infants with cerebral palsy born between 1979 and 1986 in East Denmark.
In fact, as reported by Fox and Chapman [
28], up to 21% of all foetuses adopt a noncephalic presentation at 28–29 weeks of gestation, and this proportion progressively decreases to 5% from 37 to 38 weeks [
28]. Certain conditions, such as uterine malformation, can disturb both this continuous process of spontaneous cephalic version and normal foetal growth, thereby leading to increased term breech presentation rates in these cases [
29]. This point highlights the importance of estimating foetal weight and well-being in cases of persistent breech presentation at term. Furthermore, even some cases of controlled GDM may be associated with excess foetal weight during the last weeks of pregnancy, leading to possible dystocia due to this overgrowth, or with other GDM-related complications, such as preeclampsia; thus, foetal weight estimates should be monitored closely beginning in the 37th week of gestation, with regular reassessment as long as the patient has not delivered.