A Breech of Trust

Part 2

(See Part 1 in Issue 4 - Summer 2009)

Written by:
Robin Guy - CoFounder, Coalition for Breech Birth This email address is being protected from spambots. You need JavaScript enabled to view it. '; document.write(''); document.write(addy_text70980); document.write('<\/a>'); //-->\n This email address is being protected from spambots. You need JavaScript enabled to view it.
www.breechbirth.ca
Betty Anne Daviss - Registered Midwife, Prescott Russell Midwives, This email address is being protected from spambots. You need JavaScript enabled to view it.  

In Amy McKay's The Birth House, Miss Babineau, the village midwife, tells us "breech is a world of trouble for mother and baby."

Miss Babineau, of course, was referring to the medical issues associated with breech – often premies are breech, and premies often need extra help. Hydrocephalic babies (who have enlarged heads) tend to be breech. Downs Syndrome babies often choose to present breech. It's easy to see how, before the age of ultrasound, lore arose that breech was a dangerous situation.

What Miss Babineau didn't know, of course, is that breech does not cause these problems, and in fact, over 93% of breech babies are completely normal. But "common knowledge" is a powerful thing, even when it is merely group hysteria, and fear is contagious.

What is surprising is that in our age of ultrasound and diagnostic testing, the cultural fear of breech still exists. In fact, this fear exists so strongly that nearly all the obstetricians in North America took final licence to stop delivering breech babies vaginally based on a single study published in 2000, the Term Breech Trial. And even after:

serious flaws in the study's method and results were made public and brought the credibility of the study into serious doubt,

the study's own two year follow-up proved no difference in long-term health between breech babies born vaginally or by caesarean, and insignificant difference was found in neonatal deaths between cesarean and vaginal birth in countries like ours where the mortality is very low in the first place,

obstetricians still deliberately avoid offering vaginal breech birth to mothers whose healthy, term babies are presenting bum-first.

In Canada, we have sovereign rights over our bodies. A doctor cannot legally perform any procedure we decline. However, with breech (as in many obstetrical issues), our consent is often obtained by simply not giving us sufficient information to make our own judgement. Caesarean is presented as the superior choice – and from a surgeon's perspective, this is natural – however the risks of this major surgery have been proven in the scientific literature to increase the risk of death of the mother. Despite this, the surgeon's bias towards surgery, and our cultural fear of breech, cause most mothers to accept the recommendation of their trusted doctor that surgery is safest for them and their breech baby, and to accept this with very little question. Those mothers who do question it are rarely accommodated. There are some doctors and midwives who can and do "catch" breeches, but they are hard to find, and when one can be found, it is exceptionally rare for that doctor to agree to be on call for that mother, so that her reasonable desire to avoid a probably-unnecessary surgical birth can only be fulfilled if she goes into labour on the right day.

Breech presentation is not uncommon. 3-4 babies out of every 100 are breech, which means that in Ontario, about 13 breech babies are born every single day. About 95% of these are born surgically. Over 70% of them, based on international evidence, could be born vaginally, but the option is so rarely offered that we have no opportunity to learn that our fear of breech is little more than folklore.

However, we are making progress. In May 2009, the Association of Ontario Midwives passed a resolution to re-instate the midwife's place in offering and supporting vaginal breech birth. The SOGC recently published new breech birth guidelines which aim to re-establish the practice of vaginal breech birth across the country, and these guidelines will be coupled with initiatives to reinstate full training in obstetrical schools (which has been largely limited to "emergency" breech catching training since the TBT report in 2000, rendering younger doctors a liability to the safety of vaginal breech birth). Equally significant is a grassroots movement to support and encourage mothers of breech babies to openly demand vaginal breech birth, including referrals to the remaining experienced "breech catchers" for their births.

The second International Breech Conference is being staged in Ottawa in October 2009, hosted by the Coalition for Breech Birth, with the aim of bringing together those experienced in vaginal breech birth and those who need to gain the skills, along with the women who are so intimately affected by it. The CBB's goal is the "renormalization" of vaginal breech birth, and to ensure that complete information, and the choices, belong to those who live with the long-term ramifications of the birth - the family. Conference registration fees are on a sliding scale, rendering this a highly affordable opportunity for students and the public to weigh in on this important issue. More information and a link to registration can be found at www.breechbirth.ca/Conference.html.

The new SOGC breech guidelines can be summarized as follows: Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus.

Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section, however careful case selection and labour management in a modern obstetrical setting can achieve a similar level of safety.

With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1,000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. However many centres have better statistics, and recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols (eg. mother delivering upright instead of on her back) have noted excellent neonatal outcomes.

Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity.

The guidelines further state that women refusing cesarean for breech should not be abandoned but rather given the best possible in-hospital care.

The guidelines also suggest certain restrictions and protocols for offering vaginal breech birth. These include:

women should have an ultrasound prior to a breech birth (to rule out issues that could further complicate delivery, such as an extended neck or hydrocephaly),

that they be monitored with electronic fetal monitoring during labour,

that they be given a cesarean if progress is not considered adequate,

that the last part of the delivery take place in or near an operating room, and

that a practitioner skilled at neonatal resuscitation be available for delivery.

In addition, induction of labour is not recommended in a breech.

Among the instances that the SOGC recommends that a vaginal breech birth NOT be done are when there is a cord presenting before the rest of the baby, the baby is compromised by being too little (growth restricted) or too big, the mother's pelvis is considered "clinically" inadequate, or there is a fetal anomaly that does not make it safe to have a vaginal breech birth.

June 2009 Guideline to Vaginal Delivery of Breech Presentation can be found with the following link: www.sogc.org/guidelines/documents/gui226CPG0906.pdf

Since some of the new restrictions are based on more solid evidence than others (for example, fetal weight is notoriously difficult to estimate accurately in late pregnancy), and some are different from highly successful European protocols, it will be a challenge for women wanting a vaginal breech birth and their practitioners to understand how strictly these guidelines need to be enforced in each case. Miss Babineau may have been right about the "world of trouble," and we may be simply trading one set of rigid rules for another. However, to lay aside the assumption that a cesarean is needed as soon as a breech appears on the scene, comes as a breath of fresh common sense. v

Robin Guy, CoFounder, Coalition for Breech Birth.   www.breechbirth.ca

Coalition for Breech Birth:  www.breechbirth.ca

"The right to informed consent is meaningless where there is no access to informed refusal." - Henci Goer, author of "The Thinking Woman's Guide to a Better Birth"