No, in a Randomised Control Trial, you randomise into arms on the basis of intention to treat. So, for previous CS you have two groups: one having repeat elective CS, the other attempting VBAC. Then you look at the outcomes (maternal and fetal) of both groups, regardless of whether they were successful in achieving VBAC. This is the best simulation of what happens in 'real life', since not every woman who embarks on VBAC will get one (some will have an in-labour CS). The maternal benefit of attempted VBAC over repeat elective CS remains, even after accounting for the % of women who will attempt VBAC but end up having CS. (And some of the risks associated with previous CS are not mitigated by planned elective CS, since planned elective CS is not completely protective against rupture).

Similarly, with comparison of breech vaginal delivery, you have to compare planned CS for breech, and planned vaginal delivery for breech, then look at outcomes (maternal and fetal) taking into account that not all plans (CS or vaginal) will, in real life, go according to plan. Thus some *planning* a CS doesn't mean you will get one, nor does *planning* a vaginal delivery mean you will get one. Since no one can guarantee CS or vaginal, the only meaningful comparison is the intention. Now, if you have a big cross-over then you have to account for that. Maybe the threshold for in-labour CS was too low (or too high) in the vaginal breech group? Maybe that effects the outcomes?

Yes I realise I have just completed my midwifery training as it happens, and have taken part in audit and am about to do an RCT for the Cochrane library so I realise all too well how to conduct research, but this is a breech thread, and it would be great if you could start a thread on VBAC.

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Sorry, it was an analogy (with attempted VBAC, and planned home birth) to show why it is not inherently wrong to do analysis by intention to treat in an RCT, since this most closely models 'real life'. People may not 'get' this in relation to the TBT, but seem to easily appreciate this in relation to home birth and VBAC. Not sure how this is off topic?

I think perhaps, Tracy means the OP concerns Vaginal breech, Wannabe.

Interesting debate, keep it coming we're all learning from it.

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A friend from uni has done her diss on this I must blag her to join us and add to the post, I'm sure she is bang up to date, and has had I believe 3 breech deliveries as a student, so she may have an interesting side to it x

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Yes, do Tracy! That would be great, always good to hear personal experiences from experienced students (well, almost qualified, now!)

I am intrigued to read up on this subject, not having had chance to think about it particularly yet....

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Yes, my posts also concerned vaginal breech (specifically Hannah TBT). Was trying to show that concern over intention to treat analysis in Hannah TBT is no more warranted than concern over analysis of *planned* place of birth or *planned* VBAC. Maybe it's a poor analogy. Maybe there is some specific reason why intention to treat is a bigger problem with breech than other interventions/circumstances being studied. (I alluded to some reasons: the threshold for doing in-labour CS for breech after attempting vaginal may be either too low or too high..)

LITIGATION!!! end of as far as I'm concerned our c/s rates are so high thanks to that trial!!!! I have heard a SPreg' in practice tell a woman that the head WILL get trapped and there will be nothing she can do.. Can you guess which mode of delivery she opted for?????? Statistics are worthless in this case they constantly quote from this trial ethics committees ( I believe you already mentioned) would not allow for another trial end of, some of our researchers have tried and failed, but there is one ongoing in another country at present (though I cannot remember which one TBH) this may throw out some interesting results, but then no doubt the argument will then be "It isn't geographically transferrable" Rock, hard place brickwall etc.... poor poor women, poor midwives, and disillusioned NHS and Doctors!!

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I was talking about whether ethics committee would allow a trial of 'upright' position for breech. I don't think they would allow a trial of an 'untested' position of unknown safety vs. CS, when consensus (yes, I know!) is that CS is safest.

But, if you could show genuine equipoise between dorsal/lithotomy and upright for breech (both with skilled practitioners), then you could randomize women who wanted vaginal breech delivery/birth - the difficulty would be in recruiting the numbers needed to have sufficient power. It would have to be a study with a lot of centres, and over several years I would think - to get the numbers needed.

The other trial much needed is on course of action on breech diagnosed in labour. TBT compared planned CS vs. planned vaginal delivery. But even if you accept the results (and there are plenty of arguments for not doing so) that isn't a good guide to action when you first diagnose breech in well established labour.

Maybe it's not the way the data is treater per se that is the problem, but rather the way the results iof the trial have been jumped on by the obstetric brigade. We need to remember than evidence based practice is the 'judicious and appropriate' application of research evidence to practice. In this case, the conclusion of the TBT has been interpreted as 'the outcomes show that CS is safer than vaginal delivery' rather than it being interpreted as 'the intention for CS' being compared with the 'intention for vaginal delivery' I know that you could say that this is just semantics, but the two things mean entirely different things.

There seems to be a tendency to misapply research to practice, without considering whether both the robustness of the research, and whether it is a valid application (look at all the research inappropriately applied to found the active management of labour movement..)

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