Canadian docs to stop automatic C-sections for breech babies

Unfortunately here in St. George, there are no providers at the hospital that will do a planned vaginal breech birth. Hopefully, the US will take notice of Canada's new stance on breech birth and follow.
Vaginal breech birth is possible and surgical birth should not be the only choice. Your best chance for a vaginal breech birth, if you find yourself in that position, is a homebirth midwife. Do your research.
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By Sharon Kirkey, Canwest News Service

In a major shift in medical practice and another assault on Canada's rising cesarean section rate, Canada's delivery doctors are being told to stop automatically scheduling C-sections for breech babies and attempt a normal delivery instead — something significant numbers of obstetricians aren't trained to do.

New guidelines issued Wednesday by the Society of Obstetricians and Gynaecologists of Canada say women carrying babies in the breech, or bottom-first, position should be given the right to choose to attempt a traditional delivery when possible.

The society says that women in Canada want the choice, and that some women with breech babies are delivering at home "because they knew if they went to hospital A, B or C it would not be offered," says Dr. Andre Lalonde, executive vice-president of the obstetricians' group and an adjunct professor of obstetrics and gynecology at McGill University and the University of Ottawa.

Lalonde says the group is working aggressively to ensure future specialists are trained in breech vaginal deliveries and is organizing courses across Canada for practising doctors to refresh their training.

"Paramount is the safe birth of the child," he said.

Most babies are positioned in the head-down position when labour starts. With breech babies, the feet or buttocks come out first during birth.

Breech babies account for about three to four per cent of all pregnancies in Canada, or about 11,000 to 14,500 pregnancies each year.

"Breech pregnancies are almost always delivered using a cesarean section, to the point where the practice has become somewhat automatic," Dr. Robert Gagnon, a principal author of the new guidelines and chair of The Society of Obstetricians and Gynaecologists of Canada's maternal fetal medicine committee, said.

"What we've found is that, in some cases, vaginal breech birth is a safe option and obstetricians should be able to offer women the choice to attempt a traditional delivery."

An international, Canadian-led study reported in 2000 that the safest way for breech babies to enter the world was via C-section. The study of more than 2,000 women found babies of mothers in the cesarean group were three to four times less likely to die, or have serious problems in the first six weeks of life, compared to those in the vaginal birth group (1.6 per cent versus 5.0 per cent).

The study had widespread influence worldwide. Many doctors stopped doing vaginal deliveries for breech babies, and many medical schools stopped training doctors in how to do them.

But the doctor who led the study said the risks, while different, were never huge. "The risks were still quite low," says Dr. Mary Hannah, a professor in the department of obstetrics and gynecology at the University of Toronto and Sunnybrook Health Sciences Centre.

More recent studies, including a study of more than 8,000 French and Belgian women carrying breech babies, found no significant differences in risks to babies whether they were born vaginally or via C-section.

Hannah says that a planned vaginal delivery of breech babies can be a safe and reasonable option. But, she said, most women she knows "will still want the option that is possibly safer, and that will be a planned cesarean section."

The main concern has always been delivery of the head — that the body will deliver, but that the baby's head will get caught.

"You can push the baby all the way back up into the uterus and do a cesarean section. But that's very traumatic," Hannah says. "And by the time that you are able to do that the baby may have suffered severe hypoxia," or lack of oxygen.

The new guidelines say that many breech deliveries will still require a C-section, and that a vaginal birth is not recommended for a "footling" breech, where the baby is positioned feet-first, with one or both feet pointing directly down toward the birthing canal.

Vaginal breech births also aren't recommended if the woman's pelvis is narrow or small, if the umbilical cord is likely to become entangled or compressed during delivery, or for babies that are too big (weighing more than 4,000 grams, or 8.8 pounds) or too small (less than 2,500 grams, or 5.5 pounds).

Breech deliveries are one of the main reason for C-sections, "and, if you do one (C-section), you increase the risk for another" in future pregnancies, Lalonde says. Repeat C-sections account for 30 to 40 per cent of all cesareans.

Breech Vaginal Birth is NOT an Emergency

This blog was written by a blogger friend. It was so good, I asked if she would mind me posting it here. Thanks Emily (http://jeremyscorner-grifter.blogspot.com) for letting me share this with my readers!

In my continuing crusade to shoot down OB myths, this week I am tackling breech vaginal birth. This post has taken a lot longer to write than I thought it would. At first I thought I was having trouble with the amount of information available about it, but that isn't the problem. The problem is that I can't really understand why breech vaginal birth is considered an emergency in the first place. Sure, I know that there are risks associated with breech vaginal birth, but I just can't shake the idea that babies are born breech all over the world with little fanfare or issue. Nevertheless, obstetricians continue to look for more and more excuses to avoid the topic entirely by just cutting the babies out. So, in the interest of being thorough, here is some food for thought.

According to this article, "Vaginal breech deliveries were previously the norm until 1959 when it was proposed that all breech presentations should be delivered abdominally to reduce perinatal morbidity and mortality." Typical of obstetric mentality, instead of looking at the cause of morbidity and mortality in the first place, they chose to focus on the correlative factor instead - that many babies who presented breech had a high rate of injury or death. But as far as I know, no one thought to ask if medications, managed, or instrumental delivery could have contributed to those injuries or deaths.

Fast forward to today, and more than 90% of all breech births in the U.S. are delivered by c-section. This has happened largely because of a study that was done in 2000 by Hannah, et al, that shows a higher rate of perinatal morbidity and mortality associated with breech vaginal birth, as compared to planned c-section. Consequently, the American College of Obstetrics and Gynecology (ACOG) has systematically condemned breech vaginal birth, and it is no longer offered as a choice to women today. Henci Goer does a good job here of explaining why the conclusions of that 2000 study are not valid.

However, the ACOG has a history of picking and choosing those studies that support its own position. They also prefer to ignore any studies not done in the United States, as those studies are often contrary to American obstetric practics. For example:

A study out of Sweden in 2003 in the European Journal of Obstetrics & Gynecology and Reproductive Biology showed no difference between elective cesarean vs. planned vaginal birth for term breech deliveries.

Another study actually published with the American Journal of Obstetrics and Gynecology in 2006 examined planned breech delivery in France and Belgium, and found no discernable difference in outcome with more than 8,000 breech patients studied.

A different study from France in 2002 and published in European Journal of Obstetrics & Gynecology and Reproductive Biology looked at more than 500 patients and found no difference in outcome.

The International Journal of Gynecology & Obstetrics published a study in 2004 from the United Emirates which found no clear difference in breech vaginal vs. cesarean, but did find more maternal morbidity associated with cesarean section.

The Malaysian Journal of Medical Sciences, published a study in 2007, which concluded, "Most of the perinatal mortality was due to IUD, congenital abnormality and prematurity and there
were no perinatal death related to mode of delivery or due to birth trauma."

and there have been other studies to support these findings.

Danell Swim writes in her article, A Breech of Trust,

So I ask you, what are the United States hospitals doing wrong for their vaginal breech deliveries?

It is NOT that cesarean section is safer for breech deliveries in this nation, it is that vaginal breech is more dangerous in this country. US hospital policy and procedure are killing more breech babies than their European counterparts.

And to remedy the situation, it’s been recommended that nearly all babies in a breech presentation be delivered via cesarean section. This is despite the study published with the American Journal of Obstetrics and Gynecology that discovered that France and Belgium are able to safely deliver them vaginally, and safely.

So rather than teach our doctors how to safely deliver a breech baby, the ACOG's answer to the breech problem is to simply take them by c-section at term.

This article describes how best to safely deliver a breech baby. Included in the highlighted points are:

• Spontaneous onset anytime after about the 37th week.
• No augmentation if labour is slow or there is poor progress - caesarean section.
• Mother encouraged to assume positions of choice during the first stage.
• Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
• Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
• Membranes not ruptured artificially.
• Vaginal examinations restricted to avoid accidental rupturing of the membranes.
• If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
• Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
• Mother encouraged to be in an all-fours position.
• No routine episiotomy.
• Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

Of that list, tell me how many of those are likely to occur in a medically managed birth in a US hospital today?

The most dangerous aspect of this trend is that American health care providers are losing, or have completely lost, the art of safely delivering breech babies. While some doctors may envision a 100% c-section rate for breech births, that will never be possible. The World Health Organization (WHO), in this publication about planned c-section for breech says,

It will be impossible to deliver all term breech pregnancies by caesarean section. The systematic review showed that 9% of women with breech presentation still have a vaginal breech delivery because the mother may insist on vaginal delivery, breech labour may be precipitate, or special situations such as the second fetus in twins. It is therefore imperative to continue providing expertise in vaginal breech delivery to all the intrapartum care providers.

This atmosphere of fear and foreboding surrounding breech births is leading women to choose dangerous options to avoid having a breech baby at all costs. The current recommendation is to attempt an external cephalic version (ECV), in which the care provider attempts to turn the baby from the outside into a head-down position. But ECV is not without risks. According to this publication:

The largest review which included 44 studies and 7377 patients found the most common complication of ECV to be transient fetal heart rate abnormalities (5.7%). The risk of placental abruption, emergency cesarean section, vaginal bleeding, and perinatal mortality were less than 1 percent combined. Because of the risk of alloimmunization, Rhogam is recommended for non-sensitised Rh negative women following ECV. There currently is not enough evidence from randomized controlled trials to assess complications of ECV.

In addition, in order to perform an ECV, tocolytics such as terbutaline, and epidural anesthesia are sometimes used. The risks of epidural anesthesia are well-documented. Risks of terbutaline to the baby include fetal tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, myocardial ischemia. Terbutaline not only does not have FDA approval but the FDA disapproves of its use as a tocolytic.

ECV is only successful 50-60% of the time (various sources). When ECV is unsuccessful, the only other option is to schedule a planned c-section for some arbitrary date. The problem with this is that breech babies can and do turn, up to, and even during labor. So planning a c-section may be taking a baby even before it is ready to be born, and without giving it a chance to get itself into a favorable position.

It is clear to me that breech birth, while carrying some risk, is not unreasonably dangerous in itself. The danger lies in breech birth in a highly managed hospital setting. For this reason, I would suggest that if a woman plans to birth in the hospital in the U.S, and her baby is breech, she should plan to have c-section. In fact, if a woman is planning a hospital birth and her baby is breech, she probably won't have a choice about it. If she does not want to have a c-section, she should stay home. But she should know a c-section for breech is not necessary! In fact, I don't even believe any undue concern should be attributed to breech presentation, especially if one has a midwife who is experienced and skilled in delivering breech babies.

If you find yourself pregnant, approaching term, and your baby is breech, please try these suggestions for gently encouraging your baby to turn. If you want to avoid unnecessary surgery, start now looking for a midwife who is experienced in breech delivery. Don't schedule a c-section - allow baby all the time it needs to turn itself. You can visit spinningbabies.com to learn how to tell whether your baby is head-down.