By Georgia Ragonetti-Zebell, MD
I knew she was completely dilated the moment I opened the door to the exam room. I was halfway through my intern year. I was still green and slow, but this much I knew. She was writhing in the bed, gripping the side rails. Her face was frantic as she looked to me for help. I was calm as I put on my glove to check her cervix. My fingers swept around searching for cervix. There was none. Suddenly, a gush of warm fluid covered my hand. Her water had broken. And that’s when I felt it. Not the hard overlapping plates of bone I was used to. A squishy baby tush had plopped right down into my hand.
Vaginal breech births, while always a controversial topic, have come to attention again with two hospitals recently banning vaginal breech deliveries. In Atlanta, Dr. Bootstaylor, an MFM heading SeeBaby Midwifery, had his vaginal breech delivery privileges suspended and quickly reinstated after community protests. In Los Angeles, Glendale Adventist Hospital has banned vaginal breech deliveries despite concerns voiced by another local physician.
So what’s the big deal with breech birth?
Prior to the late 1950’s, vaginal breech birth was standard. The risks of a cesarean were felt to outweigh the risks of vaginal delivery. In 1959, Wright published a paper in Obstetrics and Gynecology noting a decrease in perinatal mortality from 4.7 to 1.6 percent when breech infants were delivered by cesarean section. The rate of vaginal breech deliveries began to decrease, and small studies confirmed these findings. The nail in the coffin of vaginal breech delivery came in 2000 with the publication of the Term Breech Trial by Hannah et al in the Lancet.
The Term Breech Trial (TBT) followed 2083 women at 121 facilities in 26 countries across the globe. While there was no difference in maternal complications and death rates, the rate of complications for babies, including death, was significantly lower in the planned cesarean group (1.6% compared to 5.0% in the vaginal breech group). There were 16 deaths, 6 of which were determined to be from difficult deliveries. ACOG (the American Congress of Obstetricians and Gynecologists) and RCOG (the Royal College of Obstetricians and Gynaecologists in the UK) both quickly came out with statements against vaginal breech delivery and almost overnight vaginal breech deliveries were abandoned. The breech cesarean rate rose to well over 90%. Doctors in training no longer were taught vaginal breech delivery skills, and instead honed their surgical abilities. Of course, this limited their abilities in situations of cesarean refusal, or when breech deliveries occurred too fast to allow for a c-section to be performed.
I looked at the nurse as I began counseling my patient. “Ma’am, your baby is in the breech position. It is recommended that you have a c-section because sometimes the baby’s head can become trapped and that can be dangerous.” I continued to rattle on about the risks of surgery as we wheeled down the hall to the OR. I doubt she heard a word I said. She was shifting around on the stretcher, grunting with the involuntary surges that come at the end of labor. My chief resident was waiting in the operating room.
The attending physician in charge came in behind the stretcher and the patient was moved to the OR table. She was bearing down, instinctively, without much thought to the chaos around her. The attending examined her, the baby now almost crowning. “Why don’t you just deliver her vaginally?” he asked my chief resident.
“I don’t want to deliver her vaginally!” she yelled back at him. I can vividly remember the fear in her voice.
In the years following the Term Breech Trial, more analyses came out. One reviewed outcomes for the children. 76.9% of the children from the original study were followed for two years. There were no differences in deaths or neurodevelopmental disabilities at two years between the two groups. Another study reviewed maternal outcomes. There were no differences in breastfeeding rates, pain, incontinence, bonding, subsequent pregnancy, depression, or distressing memories of birth experience.
The original study came under scrutiny. Was there too much variation among centers? The baseline complication and death rates among the 126 countries varied significantly, as did the experience of the providers. 13% of vaginal deliveries were not attended by a licensed obstetrician. 18.5% of deliveries were attended by physicians in training, and 2.9% were attended by student midwives. Though supervised, these two groups accounted for 32% of infants with significant morbidity. Eliminating the providers with little experience seemed to improve outcome, though vaginal delivery was still associated with higher risk. Due to the varied resources available at the centers, ultrasound and continuous fetal monitoring were not required. Of the 16 perinatal deaths recorded in the trial, seven were in growth restricted babies. There were also more very large babies weighing more than 4000g in the vaginal delivery group (5.8% vs 3.1%).
Should the authors of the study have combined short term complications and deaths? It is common for vaginally delivered breech babies to have short term issues due to the inevitable cord compression that occurs with vaginal breech delivery. A normally grown fetus in no distress will tolerate this in the long run without difficulty. But, the longer the cord is compressed, the longer it will take to recover, and the higher the risk of long term complications. The follow up study showed that despite initial morbidity, there were no differences at two years. Combining the short term morbidity with the mortality rate may have overstated the risks of vaginal breech delivery.
Is a randomized controlled trial the most appropriate means to evaluate a complex process such as breech birth? Not all candidates are created equal. We see similar complexity in vaginal births after c-sections (VBACs). While some patients are great VBAC candidates, others are not. Randomizing women to VBAC would not make sense, and it stands to reason that it does not make sense in breech birth either. Several retrospective trials have been published since the Term Breech Trial discussed above. Of note, the PREMODA study reviews the outcomes of 8105 breech deliveries in France and Belgium, where practices were unchanged after the Term Breech Trial. 31% of women with a breech baby underwent a trial of labor. The same outcomes as the Term Breech Trial were examined, but strict criteria were used to select candidates, ultrasound was standard and continuous monitoring was used. In this study, there were no differences in between the two groups.
Another piece missing from the Term Breech Trial is analysis of the outcomes in future pregnancies. In a letter published in the British Journal of Obstetrics and Gynecology, De Leeuw estimates that in the Netherlands, 327 cesareans were needed to prevent one short term complication, more if you consider the uterine rupture, placenta previa and stillbirth rate of previous cesareans. Between 2001-2005, he estimates 39 additional postpartum hemorrhages (>3 L) and 39 additional uterine ruptures occurred. Four of those uterine ruptures are expected to lead to neurologically injured children. Four additional maternal deaths. A total of 7500 extra cesareans, costing 35 million Euros. Despite these compelling numbers, De Leeuw also admits an increased morbidity in vaginally delivered breech infants. The question remains: is it worth the costs?
My attending was exceedingly calm. “No, just deliver her vaginally.” I cradled her left leg in my arms as she pushed, my chief resident positioned between her legs. My heart was pounding. She lifted her hand as she pushed, sweat matting her hair to her forehead. It was maybe one or two pushes before the breech emerged. Meconium was squeezed out and the baby was a girl. No pulling, just momma pushing her baby out, out to the belly, cord loosened, out to the shoulders, arms gently swept across the body. Flex the head, the Mauriceau-Smellie-Veit maneuver I’d read about now come to life, fingers guiding the face down and the head- out. She did it!
I was elated. High on oxytocin, I giddily said to my chief, “We should do that more often!” My chief had no time for me. “They aren’t all that easy. Dr. Smith had a healthy baby die during a breech birth.”
Any mother I know would have a cesarean to save her baby’s life without hesitation. I know I would. Would you? And would you have a cesarean to save your sister’s baby? I bet you would, and your sister the same for you. Would you and your sister have a cesarean to save a friend’s baby? How about a stranger’s? This is what we mean when we talk about “number needed to treat”. How many women will have to undergo a cesarean to save the life of one baby? Of course, we don’t know which baby it will be that needs the cesarean. And when is that number too many? 327 as De Leeuw described? More? Less? These are not easy answers.
ACOG has since updated their guidelines. From Committee Opinion #340, “The decision regarding the mode of delivery should depend on the experience of the health care provider. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.” The Society of Obstetricians and Gynaecologists of Canada (SOGC) has a wonderful guideline on vaginal breech birth, including appropriate candidate selection. From Clinical Practice Guideline #226, “In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman’s choice of delivery mode should be respected. 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.”
A word about the bans. I have only the details the hospitals have released, but I suspect the bans came on the heels of bad outcomes. We know they will happen, and when they do, we must always reevaluate. Even when the providers are beloved. We must review, with fresh eyes. We must revise, if needed, policies and procedures that contributed to the outcome. Sometimes, we learn nothing. Bad outcomes will always happen despite our best efforts. But sometimes, there is a clear issue and hospitals may need to institute policy changes. However, I am not sure that a hospital ban on a procedure endorsed by ACOG is entirely appropriate, especially given that it is the natural course of pregnancy. Women have the right to refuse any treatment, including a recommended cesarean, and thus, vaginal breech delivery cannot effectively be banned.
As physicians, our own experiences, for better or worse, guide our care. I’ve delivered very few singleton breech babies vaginally. I rarely have mommas ask about vaginal breech birth, and I am always honest with them. There is a small but significant increase in morbidity and mortality in vaginal breech birth. My experience is limited and that deficit increases the risk more. I can handle a cesarean. I have experience with those complications- hemorrhage, infection, placenta accreta, and yes, uterine rupture. I have experience with those, enough to know what a baby floating in a belly outside the uterus feels like. I have no experience with head entrapment. Sure, I have read and practiced on plastic models. I have gone over the steps for cervical incisions and Piper forcep application in my head. It’s not the same. I want to give you my best and my best is a cesarean for your breech baby. But, in the words of the SOGC, you have the right to choose a trial of labor. While I will try to find someone with more experience to also attend your delivery, I will not abandon you. You deserve the best possible in-hospital care.
Georgia Ragonetti-Zebell, MD is an OB/GYN practicing in Upstate South Carolina, and is mommy to four (yes, FOUR) boys. She is a graduate of the Women’s Health Pathway at Drexel University College of Medicine in Philadelphia, Pennsylvania and completed her residency in Obstetrics and Gynecology with the Greenville Health System in Greenville, South Carolina. She has a special interest in natural childbirth, breastfeeding, and alternative methods in labor and delivery. She enjoys yoga, crochet, and reading, but spends most of her free time cleaning up poop while trying not to step on Legos.