Vaginal breech birth - a statement
(This is a variation of a letter of complaint sent to an Australian tertiary-care hospital after it failed to make provision for a planned spontaneous vaginal breech birth)
(This is a variation of a letter of complaint sent to an Australian tertiary-care hospital after it failed to make provision for a planned spontaneous vaginal breech birth)
We have read the results of the Term Breech Trial (TBT),[1] as well as other medical studies and commentary on the relative risks of planned c/s and planned VBB, including the study by Rietberg et al[2] which backed up the change in obstetric policies subsequent to the TBT and the article by Burke summarising all the evidence in favour of a policy of elective c/s for breech.[3] We understand that the normal hospital policy on the management of breech presentation is informed by numerous factors, including medical research, international standards of practice, funding, staffing, and medico-legal considerations.
Nevertheless, we believe that obstetric policy should allow women who make an informed decision to attempt a VBB to be supported to do so. Here is why:
We understand that doctors have legal and ethical duties to advise patients of the risks associated with their options. However, having been fully informed, the decision should remain with the patient.
There is a difference between weighing up the options and electing a c/s and being presented with no other option. Women who elect a c/s are less likely to feel aggrieved if they did so having been offered full information and a real choice.
Whilst many women may be perfectly comfortable with an elective c/s, for others the denial of the opportunity to attempt to birth their babies is extremely distressing. Hospitals should support those women too, even if the obstetricians disagree with their choices.
Some women will always choose the 'least risky' option for their baby. For others, the starting point is a vaginal birth, unless the mother or baby is not coping with the labour. For those women, the relevant question is not 'which option is less risky' but 'how risky is VBB'. When viewed in absolute rather than relative terms, for good candidates and in the right conditions, VBB is not so risky that it should be banned.
Whilst various population studies showed that planned c/s is less risky than planned VBB, other centre-specific studies showed equally good outcomes for VBB. It therefore appears that the circumstances in which VBB takes place are important. Thus, rather than attempt to 'prevent' all VBBs, a better option would be to look closer at the factors which lead to safe vaginal breech birth and to offer VBB to carefully selected candidates under strictly controlled conditions and in the presence of a suitably experienced midwife or doctor.[4] This approach would be consistent with the guidelines of the RANZCOG, which state that “management should be individualised. The term breech trial did not have the statistical power to meaningfully analyse subgroups, some of which are likely to be pregnancies that do extremely well with breech vaginal delivery.”[5]
Consent to c/s for breech should not be treated as fully informed if women are only told of the conclusions of the authors of the TBT. Women should also be told:
◦ That the TBT has been criticised in terms of its methodology (including VBB in conditions which experienced obstetricians would consider too risky),[6] its conclusions (attributing neo-natal harm to mode of delivery rather than to inappropriate management),[7] and the way it has been applied to obstetric policy (leading to a policy of planned caesarean section rather than improving vaginal breech conditions).[8]
◦ That other studies have shown that for good candidates, the outcomes of carefully managed VBBs are usually as good as those of elective c/s.[9] For example, PRE-MODA, which had larger numbers and was better controlled, showed no significant difference between planned VBB and planned c/s.[10]
◦ Accurate information about the risks of VBB in absolute (rather than relative) terms. For instance, even in the TBT, “the risk in a multigravid patient of a normally-formed singleton breech presentation dying as a result of vaginal delivery was zero”.[11]
◦ That VBB is much less risky in the presence of an experienced care-provider and the likelihood of such a person being available.
◦ Where else a patient may turn if she is unhappy with her options.
It is impossible to prevent all VBB by a policy of elective c/s. It is therefore important that skills in VBB are retained for unplanned VBBs, so that those women and their babies are not put at additional risk.
A policy of elective c/s for all breeches takes insufficient account of:
◦ the long term obstetric implications of c/s for the mother; and
◦ the sociological and psychological aspects of childbirth for women.
These factors are extremely important to many women but they are underplayed by a focus on short-term risk-analysis alone.
The risks of c/s for mother and baby appear to be poorly understood by women. Anecdotally, it appears that many women see c/s as risk-free. This is clearly untrue.[12] In particular, the implications for future reproductive performance should not be underplayed, including the increased risks of uterine rupture and placental attachment abnormalities, particularly in the case of multiple c/s. These 'down-stream' effects of routine c/s for breech have not yet been properly analysed.[13] C/s also increases the chance of respiratory difficulties for the baby, especially if carried out pre-labour.[14]
Failing to offer women any other option but c/s may lead to an increase in unattended births and any resultant poor maternal or neonatal outcomes.[15]
These reasons may explain why the Society of Obstetricians and Gynaecologists of Canada has reverted to a policy of supporting VBB in certain circumstances, asserting that 'Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section'.[16] Similarly, the New South Wales Department of Health is currently implementing policy to make VBB more widely available.[17]
Even with a policy of elective c/s for breech, we believe that an acceptable alternative should be put in place for any women who decline.
As a last resort, if a hospital is truly unable to offer expertise in VBB, then we believe it should facilitate access to suitable alternative care for women who who do not elect a c/s. Even if a care-provider disagrees with a woman's decision, the woman should not be neglected during such a vulnerable time. The New South Wales Department of Health requires Area Health Services to 'provide women desiring a VBB access to clinicians that will support this choice'.[18] This obligation should rest on the head of all maternity-care providers.
Footnotes
[1] M Hannah et al, 'Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multi-centre trial' The Lancet (2000) 356: 1375–83
[2] C Rietberg et al, 'The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants' BJOG (2005) 112: 205–09
[3] G Burke, 'The end of vaginal breech delivery' BJOG (2006) 113: 969–72
[4] See, for example the protocol set out in J Taillefer and J Dubé, 'Singleton Breech at Term: Two Continents, Two Approaches' JOGC (2010) 32(3): 238-43
[5] RANZCOG College Statement 'Management of term breech presentation' (C-Obs 11) November 2009
[6] A Kotaska, ' Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery' BMJ (2004) 329: 1039-42
[7] M Glezerman, 'Five years to the term breech trial: The rise and fall of a randomized controlled trial' AJOG (2006) 194: 20-25, 22 and Turner (2006) above 492
[8] For example, Glezerman (2006) above and M Turner, 'The Term Breech Trial: Are the clinical guidelines justified by the evidence?' Journal of Obstetrics and Gynaecology (2006) 26(6) 491-94
[9] C Deans and Z Penn 'The case for and against vaginal breech delivery' The Obstetrician & Gynaecologist (2008) 10: 139-144, 141
[10] F Goffinet et al, 'Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium' AJOG (2006) 194: 1002-11
[11] Turner (2006) above 491
[12] See the example of a maternal death after a forced c/s when fully dilated from an unproblematic labour in A Kotaska 'Routine Cesarean Section for Breech: The Unmeasured Cost' Birth (2011) 38(2): 162-64
[13] See the comments in Deans and Penn (2008) above 143
[14] Nearly half of the c/s in the TBT were carried out in labour and thus in terms of infant morbidity, the c/s results may be biased in favour of the planned c/s group: Turner (2006) above 492
[15] See the example of a neo-natal death after an unassisted breech home-birth in Kotaska (2011) above
[16] SOGC Clinical Practice Guideline No 226 (June 2009) 1
[17] NSW Department of Health 'Maternity – Towards Normal Birth in New South Wales' Policy Directive (29 June 2010)
[18] NSW Department of Health (2010) above 19
Nevertheless, we believe that obstetric policy should allow women who make an informed decision to attempt a VBB to be supported to do so. Here is why:
We understand that doctors have legal and ethical duties to advise patients of the risks associated with their options. However, having been fully informed, the decision should remain with the patient.
There is a difference between weighing up the options and electing a c/s and being presented with no other option. Women who elect a c/s are less likely to feel aggrieved if they did so having been offered full information and a real choice.
Whilst many women may be perfectly comfortable with an elective c/s, for others the denial of the opportunity to attempt to birth their babies is extremely distressing. Hospitals should support those women too, even if the obstetricians disagree with their choices.
Some women will always choose the 'least risky' option for their baby. For others, the starting point is a vaginal birth, unless the mother or baby is not coping with the labour. For those women, the relevant question is not 'which option is less risky' but 'how risky is VBB'. When viewed in absolute rather than relative terms, for good candidates and in the right conditions, VBB is not so risky that it should be banned.
Whilst various population studies showed that planned c/s is less risky than planned VBB, other centre-specific studies showed equally good outcomes for VBB. It therefore appears that the circumstances in which VBB takes place are important. Thus, rather than attempt to 'prevent' all VBBs, a better option would be to look closer at the factors which lead to safe vaginal breech birth and to offer VBB to carefully selected candidates under strictly controlled conditions and in the presence of a suitably experienced midwife or doctor.[4] This approach would be consistent with the guidelines of the RANZCOG, which state that “management should be individualised. The term breech trial did not have the statistical power to meaningfully analyse subgroups, some of which are likely to be pregnancies that do extremely well with breech vaginal delivery.”[5]
Consent to c/s for breech should not be treated as fully informed if women are only told of the conclusions of the authors of the TBT. Women should also be told:
◦ That the TBT has been criticised in terms of its methodology (including VBB in conditions which experienced obstetricians would consider too risky),[6] its conclusions (attributing neo-natal harm to mode of delivery rather than to inappropriate management),[7] and the way it has been applied to obstetric policy (leading to a policy of planned caesarean section rather than improving vaginal breech conditions).[8]
◦ That other studies have shown that for good candidates, the outcomes of carefully managed VBBs are usually as good as those of elective c/s.[9] For example, PRE-MODA, which had larger numbers and was better controlled, showed no significant difference between planned VBB and planned c/s.[10]
◦ Accurate information about the risks of VBB in absolute (rather than relative) terms. For instance, even in the TBT, “the risk in a multigravid patient of a normally-formed singleton breech presentation dying as a result of vaginal delivery was zero”.[11]
◦ That VBB is much less risky in the presence of an experienced care-provider and the likelihood of such a person being available.
◦ Where else a patient may turn if she is unhappy with her options.
It is impossible to prevent all VBB by a policy of elective c/s. It is therefore important that skills in VBB are retained for unplanned VBBs, so that those women and their babies are not put at additional risk.
A policy of elective c/s for all breeches takes insufficient account of:
◦ the long term obstetric implications of c/s for the mother; and
◦ the sociological and psychological aspects of childbirth for women.
These factors are extremely important to many women but they are underplayed by a focus on short-term risk-analysis alone.
The risks of c/s for mother and baby appear to be poorly understood by women. Anecdotally, it appears that many women see c/s as risk-free. This is clearly untrue.[12] In particular, the implications for future reproductive performance should not be underplayed, including the increased risks of uterine rupture and placental attachment abnormalities, particularly in the case of multiple c/s. These 'down-stream' effects of routine c/s for breech have not yet been properly analysed.[13] C/s also increases the chance of respiratory difficulties for the baby, especially if carried out pre-labour.[14]
Failing to offer women any other option but c/s may lead to an increase in unattended births and any resultant poor maternal or neonatal outcomes.[15]
These reasons may explain why the Society of Obstetricians and Gynaecologists of Canada has reverted to a policy of supporting VBB in certain circumstances, asserting that 'Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section'.[16] Similarly, the New South Wales Department of Health is currently implementing policy to make VBB more widely available.[17]
Even with a policy of elective c/s for breech, we believe that an acceptable alternative should be put in place for any women who decline.
As a last resort, if a hospital is truly unable to offer expertise in VBB, then we believe it should facilitate access to suitable alternative care for women who who do not elect a c/s. Even if a care-provider disagrees with a woman's decision, the woman should not be neglected during such a vulnerable time. The New South Wales Department of Health requires Area Health Services to 'provide women desiring a VBB access to clinicians that will support this choice'.[18] This obligation should rest on the head of all maternity-care providers.
Footnotes
[1] M Hannah et al, 'Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multi-centre trial' The Lancet (2000) 356: 1375–83
[2] C Rietberg et al, 'The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants' BJOG (2005) 112: 205–09
[3] G Burke, 'The end of vaginal breech delivery' BJOG (2006) 113: 969–72
[4] See, for example the protocol set out in J Taillefer and J Dubé, 'Singleton Breech at Term: Two Continents, Two Approaches' JOGC (2010) 32(3): 238-43
[5] RANZCOG College Statement 'Management of term breech presentation' (C-Obs 11) November 2009
[6] A Kotaska, ' Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery' BMJ (2004) 329: 1039-42
[7] M Glezerman, 'Five years to the term breech trial: The rise and fall of a randomized controlled trial' AJOG (2006) 194: 20-25, 22 and Turner (2006) above 492
[8] For example, Glezerman (2006) above and M Turner, 'The Term Breech Trial: Are the clinical guidelines justified by the evidence?' Journal of Obstetrics and Gynaecology (2006) 26(6) 491-94
[9] C Deans and Z Penn 'The case for and against vaginal breech delivery' The Obstetrician & Gynaecologist (2008) 10: 139-144, 141
[10] F Goffinet et al, 'Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium' AJOG (2006) 194: 1002-11
[11] Turner (2006) above 491
[12] See the example of a maternal death after a forced c/s when fully dilated from an unproblematic labour in A Kotaska 'Routine Cesarean Section for Breech: The Unmeasured Cost' Birth (2011) 38(2): 162-64
[13] See the comments in Deans and Penn (2008) above 143
[14] Nearly half of the c/s in the TBT were carried out in labour and thus in terms of infant morbidity, the c/s results may be biased in favour of the planned c/s group: Turner (2006) above 492
[15] See the example of a neo-natal death after an unassisted breech home-birth in Kotaska (2011) above
[16] SOGC Clinical Practice Guideline No 226 (June 2009) 1
[17] NSW Department of Health 'Maternity – Towards Normal Birth in New South Wales' Policy Directive (29 June 2010)
[18] NSW Department of Health (2010) above 19