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Background: Preterm breech delivery is associated with a higher perinatal mortality rate compared with preterm vertex delivery, and some studies suggest caesarean section leads to lower mortality rates. Few studies include infants delivered less than 26 weeks gestation, and where included, results are often not stratified by gestational age. There is also a lack of consistent reporting on neonatal and maternal morbidity outcome measures. Aims: To determine if mode of delivery for singleton extreme preterm breech fetuses is associated with a difference in perinatal mortality, neonatal and maternal morbidity. Materials and Methods: Retrospective cohort study of breech deliveries from 23 + 0 to 27 + 6 weeks gestation (extreme preterm) between 2005 and 2014 at a tertiary obstetric facility. Results: One hundred and fifty deliveries met the selection criteria. Perinatal mortality was reduced in the caesarean section group (20% vs 55.5% P < 0.001). Apgar scores ≥ 7 (P = 0.008) and cord pH ≥7.1 (P = 0.025) were more likely for neonates delivered by caesarean section, with lower rates of birth trauma (P = 0.003). Caesarean section was associated with higher nursery admission rates (P < 0.001), longer intensive care nursery admission (P = 0.006), continuous positive airway pressure times (P = 0.008) and increased use of surfactant (P < 0.001). Maternal morbidity was increased with caesarean section including longer hospital stay (P < 0.001), higher postpartum haemorrhage (P < 0.001) and wound infection rates (P = 0.034). Conclusion: Caesarean section for singleton extreme preterm breech delivery is associated with reduced perinatal mortality, improved neonatal condition at delivery, and increased short‐term maternal morbidity. [ABSTRACT FROM AUTHOR]