A study of very big wingspan led in 26 countries by a Canadian team should offer a final solution in debates on the high or low way facing a presentation of the baby by the seat. Caesarian section divides by 3 - 4 deceases and serious pathologies of the newborn baby, without intervening on maternal forecast.  A policy of programmed Caesarian section is widely preferable for noveau-born coming by the si pe . This peremptory sentence of Mary Hannah (Toronto, Canada) is perhaps going to put an end to decades of debates on the necessity of this intervention facing a seat ".

Mr Hannah, in Trial on the presentations of the urgent seat whom she publishes with her collaborators in last "Lancet", estimate the advantage of the bistoury on the vaginal way: the babies born by Caesarian section risk 3 - 4 times less dying or introducing serious pathologies than those born by low way. This result seems so not very subject to contradiction as the study, conclusion of which it is, envisaged to last five years was interrupted prematurely at the end of two years.

26 countries and 121 hospitals

It is necessary to say that the Canadian team had put statistical power for his/her part to arrive at a result not very subject to deposit. Not less than 26 countries were solicited, regrouping 121 hospitals. 2083 births were so analysed, corresponding to the habitual frequency of breech births, on unique child, from 3 to 4 %.

The monitoring was performed over six weeks of the post - partum, recording deceases in the course of delivery, in continuation or serious affections. Of course, maternal deceases or serious affections were also notified.
The women were incidentally divided into two groups, those whose Caesarian section was programmed and those having to a priori give birth by the natural ways. In the second case, the presence of an experienced obstetrician was customary.

On 1 041 women dev nt to be done a Cesarean section, intervention really took place in 90,4 % cases (941 women). Caesarian section could not be practiced at 100 other parturientes because of the imminence of delivery, of the request of the patient, a modification of presentation in summit As regards their counterparts intended for the low way, only 56,7 % gave birth suchlike; others suffered a Caesarian section for narrow basin, stopping of job, anomalies of cardiac frequency f|tale, ask the patient, obstetrical complication, procidence the cord.

In the course of the programmed period of monitoring, of six weeks, deceases or serious pathologies were recorded to 1,6 % babies born by Caesarian section, against 5 % to those born by low way.

More important in the Western countries

An analysis according to industrialized character or not from the country of delivery was also pratiquce. It emerges that the advantage of Caesarian section is more important in the Western countries: in the group Caesarian section, 0,4 % of deceases or serious pathologies against 5,7 %; 2,9 % against 4,4 % in the group see low. Interpreted in another way, these figures show that it is necessary to practice 14 additional Caesarian sections in industrial countries to avoid a serious complication, and 39 in developing countries.

Regarding the maternal state in immediate, de facto continuation, I' study recorded no difference between both feminine groups. What seems contradictory with the general notion of a risk increased for the high way. The authors explain it by two probable biases. First of all, vaginal delivery gave no benefit to the women, probably because, in this group, 43 % of them have finalernent done a Cesarean section, in an urgent context, after the beginning of job. In the comparing, in the group envisaged for the high way, intervention was accomplished in a programmed way, before the beginning of job. The other bias can be allocated in the exclusive recognition of the heavy pathologies, and it over a delay of six weeks. The authors besides announce that new data will allow to appreciate better the state of health of the three-month-old mothers and in two years.
An authentic dilemma

In a leader accompanying publication, Judith Lumley (Melbourne, Australia) wants to add that if the result of study had been in favour of birth by vaginal way, would then have settled an authentic dilemma, since the protocol of trial was based on the presence of an experienced obstetrician who is not found everywhere. She finishes her comment by noting that the taking care of this common clinical situation can be clarified, at least in a large majority cases . The next stage will be the quick broadcasting of these recent jobs to the pregnant women, to their family and all practitioners implicated in care in motherhood.

Dr Guy BENZADON, the daily of the doctor, 10/24/2000 The Lancet, flight 356, October 21st, 2000, pp on 1368-1369 and 1375-1383