[Mode of Delivery for Breech Presentation in Cases of Very or Extremely Preterm Birth]

The mode of delivery in cases of very preterm or extremely preterm breech presentation remains a matter of debate. Available randomized trials are too few and underpowered to provide a definitive answer, and most of the evidence comes from observational, hospital-based or population-based studies, often limited by bias, particularly indication bias. Practices vary widely depending on teams and institutional policies. Analyses from different cohorts, including EPIPAGE 1 and 2, show no clear superiority of planned cesarean section over planned vaginal delivery with respect to neonatal mortality, severe morbidity, or long-term sequelae, although a rare but documented risk of death due to entrapment of the aftercoming head is described, especially in low-birth-weight infants. A meta-analysis published in 2024 reported, for breech singletons, a significant reduction in mortality with cesarean delivery, whether performed or planned, a result largely driven by two retrospective studies with a high risk of bias. These findings highlight the need to balance neonatal risks against maternal complications (and neonatal risks in subsequent pregnancies) related to cesarean section at such an early gestational age, without any delivery mode being clearly recommended.