Various Professional Opinions from Around the World
- ACOG Committee published its opinion in 2006 that if a competent physician (trained and experienced in breech birth) can be found, a vaginal delivery would be appropriate under certain circumstances. It certainly does not encourage vaginal breech birth, but it admits that this is mostly because they know almost no one knows how to do it. Here is the abstract of the statement.
In light of recent studies that further clarify the long-term risks of vaginal breech delivery, the American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider Cesarean delivery will be the preferred mode 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. Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient’s informed consent should be documented. (Obstet Gynecol. 2006 Jul;108(1):235-7.)
- Commentary on the Canadian change by Andrew Kotaska, MD, FRCSC. A portion is reprinted below because it is especially worth reading, and because SOGC appears to have removed it from their files. Dr. Kotaska says it is unethical not to offer vaginal delivery or encourage patients to find it elsewhere.
The principles of patient autonomy and informed consent suggest that women with persistent breech presentation at term should have information about and access to an alternative to pre-emptive Caesarean section. Even using the Term Breech Trial alone as a basis for a consent discussion, the current practice of not offering women a trial of labour while providing ready access to Caesarean section is coercive, especially given the equivalency of long-term neonatal outcome. Now, with a more comprehensive understanding of the components required to make short-term outcomes of vaginal breech birth equivalent as well, it would be unethical not to provide this information to women. Although it may be difficult in some settings to offer vaginal breech birth routinely, its availability elsewhere should be disclosed and assistance offered to obtain it if requested. To offer only Caesarean section is ethically and legally difficult to justify if a reasonable alternative is available.
- Here is a great, long, comprehensive article on breech birth by an OB with a lot of credentials.
- Richard Fischer, MD points out that before the TBT, about 50% of breech mamas were considered candidates for vaginal delivery and up to 82% of them delivered just fine. He also quotes studies that show that the increase in cesarean has not led to safer outcomes for breech babies compared to the old days when many women delivered vaginally. He also discusses risks of both vaginal and cesarean birth, and shows pictures of maneuvers for vaginal delivery. Note the tabs on the left side to skip to a certain topic.
- Canadian OBs routinely suggest trying for a vaginal delivery. You can see their selection criteria on page 561 of this document.
- This is a mainstream news report about the 2009 breech-birth friendly change in Canada.
- Here an Australian midwife discusses normal breech birth, a caregiver’s skills, and what the birth is like, including (graphic) pictures.
- Maggie Banks, NZ midwife, on the Term Breech Trial. She emphasizes that for vaginal breech there should be no augmentation, induction, anesthesia.
- Ronnie Falcao is a California midwife who maintains gentlebirth.org, a website for helping families have the best, safest birth possible. She says:
The reason that breech birth is a concern is that the head is usually the biggest part of the baby, so it’s possible that the rest of the body could be born before the cervix is fully dilated. This is only a problem because once the umbilical cord contacts room conditions, it tends to congeal, and stops bringing oxygen to the baby. If this happens before the baby’s head is born, the baby isn’t getting oxygen through the cord and can’t breathe because the mouth isn’t out yet.
- Two very important things to know. If you have a waterbirth, the baby’s body will be born into conditions that simulate the uterus, and the cord is no more likely to congeal than if it were still inside. There are concerns that the cord could be pinched between the baby and the pelvis, so you don’t want this condition to last very long, but a waterbirth buys you a lot of safety margin.
- If it does appear that the baby’s oxygen supply is compromised, for whatever reason, they can still establish an airway even before the head is born. Obviously, they need to drain the water quickly and/or get you out of the tub, but then they can hold the vaginal tissues away from the baby’s face to establish an airway while waiting for the cervix to finish dilating and the baby’s head to mold appropriately.
- Ideally, you get the whole baby out in a relatively quick process, but the above can help protect against the most common problems of breech delivery.
- A frank breech is the most favorable breech position because those feet are safely tucked out of the way and won’t try to come out and bring the cord with them. Also, that nicely rounded hindquarters is still a very good aid in dilating the cervix, so it’s much more likely that the cervix will dilate fully before the baby begins to be born.
- In any breech delivery, you need someone who is experienced in all aspects of breech delivery, believes that it is safe, and whom you trust implicitly. The classic solution to avoiding having the head get stuck is what’s called the “hour of patience”. After it’s believed that your cervix is fully dilated, you all sit around and wait an hour to make absolutely sure. You need to have a caregiver who is very skilled at assessing dilation, who will be alert to the time when you’re fully complete before the baby’s butt starts to descend and then will assist you in getting in a good position to weather the next hour, which can be trying because you may be starting to experience an urge to push. A skilled caregiver will do as much as possible to minimize the urge to push through position changes and working with you through each contraction.
- The good news with a breech birth is that you’re guaranteed that the head will not be posterior because they can turn the head as the body is being born. [Very Big Grin]
- Check out these archives pages on breech birth from gentlebirth.org.
- Discussion of risks of vagninal breech birth: http://www.gentlebirth.org/archives/breechbr.html
- Lots of breech information: http://www.gentlebirth.org/archives/breech.html
- Turning: http://www.gentlebirth.org/archives/breechtn.html
- Here Gina Lowdon, who is an AIMS committee member and runs the website cesearean.org.uk, discusses your choices for breech birth Read the full article below in the AIMS journal.
There are widespread fears surrounding vaginal delivery of the breech presentation and a lack of information generally available on safe vaginal delivery of a breech. There is also a lack of honesty about the risks of caesarean section and sparse knowledge of the post-caesarean difficulties many mothers encounter. These factors, together with the prevailing myths and beliefs that caesareans guarantee healthy babies, more often than not leave the woman with no option but to blindly accept the decisions made for her by her obstetrician.