Trial and error − Outcome of breech presentation depending on birth mode and root cause analysis of severe adverse events

•Successful VBB lowers blood loss but worsens UApH compared to elective CS.•Lower BMI and multiparity boost VBB success.•Failed VBB indicates worse UApH, but no difference in Apgar score or NICU transfer rates.•VBB: It’s worth a try taking into account predictors and strict birth management. The debate about the safest birth mode for breech presentation at term remains unresolved. The comparison of a vaginal breech birth (VBB) with an elective caesarean section (CS) regarding fetal outcomes favors the CS. However, the question of whether attempting a VBB is associated with poorer fetal outcomes is examined in this study. Additionally, the study evaluates factors contributing to a successful VBB and illustrates possible errors in VBB management. Study design: We performed a retrospective analysis of term breech births over 15 years in a Perinatal Center Level I regarding fetal, maternal, and obstetric outcomes by comparing successful with unsuccessful VBB attempt and all attempted VBB vs. CS including a multivariate analysis of predictors for a successful VBB. A root cause analysis of severe adverse events (SAE) was conducted to evaluate factors leading to poorer fetal outcomes in VBB. Of 863 breech cases, in 78 % a CS was performed and in 22 % a VBB was attempted, with 57 % succeeding. Comparing successful with unsuccessful VBB attempts, successful VBB showed significantly lower maternal blood loss (p