Recently I have been reviewing the variety of opinions regarding the birth of term babies in breech positions. In my community, the obstetrical standard of care offers routine cesarean section for breech presentation. It is interesting to read ACOG's opinion from 2006, Mode of term singleton breech delivery, and to see the following recommendations:
* The decision regarding the mode of delivery should depend on the experience of the healthcare provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery.
* Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.
A dilemma exists in the US due to the lack of physicians who possess expertise in vaginal breech delivery. A prior ACOG committee opinion from 2001 recommended that vaginal breech births were not appropriate following the publication of the Term Breech Trial in the Lancet in 2000. Many physicians stopped offering vaginal breech delivery as an option for mothers. Medical schools stopped teaching new physicians vaginal breech skills. By the time a follow-up study found the "risk of death or neurodevelopmental delay was no different in the planned cesarean delivery group compared with the planned vaginal delivery group," few physicians remained who were willing to permit a trial of labor for a known breech presentation. Cesarean birth for the term breech baby has become routine, and ACOG states that 86.9% of breech presentations were delivered via cesarean in the year 2002.
Interestingly, ACOG's counterpart in Canada, the SOCG, has taken a stronger stance in support of vaginal breech birth at term. The SOCG now recommends revising their undergraduate and postgraduate training requirements to include theoretical and hands-on vaginal breech skills, and to promote training of current health care providers in those skills as well. In their 2009 clinical practice guidelines titled, Vaginal Delivery of Breech Presentation, labor selection criteria, contraindications, and labor management guidelines are offered. However, most impressive is SOCG's perspective regarding a woman's autonomy and the expectation of how the facility and staff should honor her wishes.
Interestingly, ACOG's counterpart in Canada, the SOCG, has taken a stronger stance in support of vaginal breech birth at term. The SOCG now recommends revising their undergraduate and postgraduate training requirements to include theoretical and hands-on vaginal breech skills, and to promote training of current health care providers in those skills as well. In their 2009 clinical practice guidelines titled, Vaginal Delivery of Breech Presentation, labor selection criteria, contraindications, and labor management guidelines are offered. However, most impressive is SOCG's perspective regarding a woman's autonomy and the expectation of how the facility and staff should honor her wishes.
"Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care."
There is a need for true shared decision-making in American maternity care. Health care providers should recognize that their obligation is to offer the patient their experience and evidence regarding term breech birth, and then to allow the mother her right to make an informed decision of either consent or refusal to the provider's recommendation. There is a need for laws to allow for health care providers to document the informed discussion and the mother's decision, without requiring the health care provider to abandon care for her. The time has come to stop pitting the perceived best interests of the baby against those of the mother, and to begin to treat MotherBaby as one, acknowledging that the mother has the right to self-determination about the health care she chooses to receive.
Stuart Fischbein, MD Even though they are few and far between, it is encouraging to discover birth attendants who continue to provide mothers with vaginal breech birth options. Ina May Gaskin and other Farm midwives are renowned for providing the Midwifery Model of Care to healthy women who travel from other states for a trial of labor with term breech babies. In Atlanta, Dr. Joseph Tate accepts referrals for women seeking a vaginal breech birth in the hospital. Dr. Stuart Fischbein in southern California is a strong believer that collaboration between doctors and midwives provides clients with the best care. He has left his former hospital-based practice to work along side a licensed midwife, and is willing to provide a trial of labor for term breech mothers who are good candidates for a vaginal birth. In this interview with Progressive Parenting's Gena Kirby, Dr. Fischbein discusses the issues surrounding vaginal breech birth and the importance of patients' rights to informed consent and refusal.
Breech presentation is considered by some to be a variation of normal, and for others as a high-risk scenario. Evidence shows that it does carry more risk than vertex presentation and it is vital to address those risks during the informed choice discussion. According to SOCG, even with careful case selection and labor management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. However since long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity, it is reasonable for some women to seek a trial of labor. No suitable candidate should be forced to birth via major abdominal surgery without offering a trial of labor. Neither should a woman be forced into a lower resource birth setting (giving birth out-of-hospital) due to a lack of a higher resource setting permitting a trial of labor.
It is wise for all birth attendants to seek training to facilitate vaginal breech birth because it is not uncommon to experience an unexpected breech presentation. In order for training opportunities to exist, the ability for health care providers to offer safe breech birth options should be revived for the women who would seek them.
Many thanks to Jodie Myers for capturing such lovely video of a home breech birth attended by Dr. Fischbein titled, "Aurora's Birth."
Breech presentation is considered by some to be a variation of normal, and for others as a high-risk scenario. Evidence shows that it does carry more risk than vertex presentation and it is vital to address those risks during the informed choice discussion. According to SOCG, even with careful case selection and labor management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. However since long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity, it is reasonable for some women to seek a trial of labor. No suitable candidate should be forced to birth via major abdominal surgery without offering a trial of labor. Neither should a woman be forced into a lower resource birth setting (giving birth out-of-hospital) due to a lack of a higher resource setting permitting a trial of labor.
It is wise for all birth attendants to seek training to facilitate vaginal breech birth because it is not uncommon to experience an unexpected breech presentation. In order for training opportunities to exist, the ability for health care providers to offer safe breech birth options should be revived for the women who would seek them.
Many thanks to Jodie Myers for capturing such lovely video of a home breech birth attended by Dr. Fischbein titled, "Aurora's Birth."
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