Outcomes in vaginal vs. c-section breech birth

[Krutoi1978]

Hi everyone,
I am a soon to be father (on May 27) of a baby girl and I couldn't be more excited! For the majority of my wife's pregnancy the baby was head down and then she flipped at about 32 weeks and is now in a complete breech position by the latest ultrasound. After discussions with her OB/Gyn, she decided that she would proceed with a planned c-section birth. Unfortunately, she has been critized numerous times by many of her friends for not attempting a vaginal breech birth. According to some of these individuals, it is just as safe for the baby to attempt a vaginal birth and that this should definitely be attempted first.

As a physician with training in outcomes research I wanted to do my own research to determine what the actual statistics are on vaginal vs. caesarean delivery of breech infants. This is what I found:

The following is link to the results of a randomized clinical trial (i.e. the highest level of evidence possible) published in one of the foremost medical journals in the world (Lancet) addressing this question. To quickly summarize, 1.6% of the breech babies delivered by c-section either died during or shortly after delivery or had significant long-term, life-altering complications. In comparison, 5% of breech babies delivered vaginally either died during or shortly after delivery or had significant long-term, life-altering complications. In other words, breech babies delivered vaginally were at more that 3 times greater risk of death and other serious complications compared with those delivered by planned c-section.

I don't criticize those who elect to deliver their breech babies vaginally, I just found this information enlightening and it helps me and my wife to not feel guiltly about our planned c-section birth in the face of harsh criticism. I would imagine there are many couples in the same position and I wanted to help them feel a little better if they have been enduring the same type of critiques. The link to the study is below. Thank you all!

http://linkinghub.elsevier.com/retri...40673600028403

[*MamaJen*]

Congratulations on the pregnancy, and I hope your wife has a smooth delivery and a healthy baby.

One interesting thing I had heard about that study is that many physicians are very good at performing C-sections, because they do so very frequently (in one out of three births in America.) However, because they attend vaginal breech deliveries so infrequently, they've lost a lot of skills in performing breech births, along with other tools like forceps.

This was Henci Goer's response to that article.
http://www.lamaze.org/Research/WhenR...7/Default.aspx

"A critique of the Hannah (2000) trial reports that after eliminating mortality and morbidity arising from cases that should not have been enrolled or that should have been excluded from analysis, 16 cases remain of the trial’s 69: 11 in the planned vaginal birth group and 5 in the planned c/sec group (Glezerman 2006). When the corrected numbers are compared, the difference between groups is no longer significant."

[AlexisT]

Everyone here is aware of that study. However, I encourage you to research it further. There have been criticisms of its methodologies and the SOGC in Canada has changed its policy on breech from "Always a CS" as a result of further research.

So, your wife's friends are not ignoring the research at all.

On a personal note, I do believe that if you don't have a provider who is experienced in delivering breech, then a section is safer. I would certainly NOT want a resident delivering me! But this is a practical consideration.

[*MamaJen*]

This is just a side note, but I'm kind of obsessed with old obstetric texts -- I think they reveal a lot about how culture views women over the years. Anyway, I found one that was written by an obstetrician in the early 1950s. In between all the other cringe worthy comments about shaving, enemas and epesiotemies, he casually mentions that delivering breech babies isn't any harder than vertex births. I found it pretty amusing that in the twilight sleep era, one place where they were less interventionistic was breech births. (Which is all anecdotal and of course doesn't speak at all to the safety of breech vs c section, but I just found it really amusing).

[YvonneC-M]

I second AlexisT's comment that if your OB is not experienced with vaginal breech deliveries, then yes, c-section is safer. You need to make the choice that's best for your baby. My personal belief is that, because healthcare providers have come to depend on c-section for breech babies, most do not have a high level of competence with vaginal breech births. In other words, it's not that the latter is intrinsically unsafe, but that doctors are not as capable at handling them as they could be.

[*MamaJen*]

This is what Alexis was referring to -- the current The Society of Obstetricians and Gynaecologists of Canada (SOGC) Clinical Practical Guideline for breech births from June 2009: http://www.sogc.org/guidelines/docum...226CPG0906.pdf
It supports trials of vaginal birth for breech, as well as elective C-sections, and references flaws in the Hannah study (which was a Canadian study).

"The TBT is the largest randomized clinical trial ever undertaken on term breech mode of delivery, and it has provided a wealth of information about breech birth. Despite its strengths, however, a number of weaknesses have been identified since its publication.14–20 Based on the information available at the time, its findings may have been misinterpreted and may have led to premature changes in clinical practice."

[limette]

Wasn't there a Canadian study released recently that implied that vaginal breech had better outcomes and that they were recommending that ob's stop automatically going for c-sections?

[mediumcrunch]

I'd just like to ditto the comment re: provider experience. In this day and age the majority of OB's have little training and little to no experience in vaginal breech birth. That is the main issue, IMO. If you can find a provider experienced in vaginal breech birth and willing to do it THEN you actually have something to compare a ECS too. If you don't have an experienced provider a ECS is almost certainly the safest route.

[nikirj]

There were a lot of big problems with the Hannah study, but my favorites were:

- Centers chose for themselves who was a 'qualified' practitioner for the vaginal breech deliveries. Some of them had never even caught a breech baby before.

- Quite a few women in the planned vaginal delivery group should have been risked out and weren't; this is dramatically unsafe to begin with and certainly skewed the statistics.

Look to the Goffinet study (Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, et al.;
PREMODA Study Group. Is planned vaginal delivery for breech
presentation at term still an option? Results of an observational prospective
survey in France and Belgium. Am J Obstet Gynecol 2006;194:1002–11.), which was not an RCT but was prospective, for better data. That study was structured so that the statistics relate a lot more to what women who elect vaginal breech birth with a skilled professional will face than the statistics from the Hannah study did.

[MegBoz]

Originally Posted by nikirj

in France and Belgium.

yes, I was going to say try to get your hands on some stats from Western Europe - The Netherlands & Scandinavian countries in particular (I believe they have the lowest perinatal mortality rates in the world & HBs are about 33% of births in The Netherlands, vs. less than 1% here!)

That would be enlightening.

ETA: I'm surprised you're receiving criticisms though!! IMX, it's people who want natural birth (even with a regular old vertex, OA baby!) that get the criticisms! The good old, "Oh yeah, whatever, you'll be begging for that epidural!" comments. CS is the norm & certainly not criticized - at least in America today (not sure where you are).

[AlexisT]

The world's lowest PMR is Singapore. Netherlands is slightly higher than the USA in the last set of tables I saw (Singapore 4, USA 7, Netherlands 8). The report I saw was published in 2006, so the actual statistics will be older than that. France is 6, but everything I have heard about birth in France is super medical.

[soso-lynn]

I second that you should read carefully the socg's guidelines and look at the references. I think it gives an overall decent picture of the topic. The fact is that it is hard to get good large-scale research on the safety of breech birth since it would be very difficult not only to design an ethically sound research protocol but also to find a setting to carry it out in.

I believe, from the various existing studies, that vaginal breech delivery is safe in most cases. I also can understand why it would logically be safer to at least attempt a trial of labour. To me, the worst possible plan is a c-section without any labour. I would encourage you to consider waiting until a spontaneous onset of labour to do the c-section if you choose to not go for a vaginal delivery. The PREMODA study's 2-year outcome does show that it is best.

[stik]

People who make women feel guilty about their birth choices really, really suck. In this case, your wife and her doctor have considered the options before them, and have decided that a c-section is best. Now, everyone else should butt out.

If your wife is feeling iffy about the c-section, she should remember that babies sometimes flip late. spinningbabies.com has some great advice. And, if the baby's position genuinely is the *only* reason for a section, a late ultrasound to make sure the babe is still breach prior to surgery wouldn't hurt.

On the other hand, if your wife is comfortable with her decision to proceed with a c-section, the entire rest of the world should get comfortable with seeing this as her wise and sacred mama-intuition, which is absolutely not to be messed with. Your wife's critics are *not* friends.

[MeepyCat]

Originally Posted by Krutoi1978

Hi everyone,
Unfortunately, she has been critized numerous times by many of her friends for not attempting a vaginal breech birth. According to some of these individuals, it is just as safe for the baby to attempt a vaginal birth and that this should definitely be attempted first.

Unfortunately, you've just had your first encounter with one of the harsher realities of parenthood - everyone's got an opinion, usually a strong one, and they all want you to act on them. It doesn't end with birth.

Most of the rest of parenthood is pretty neat though, so it works out okay.

[caned & able]

The only reason breech deliveries are dangerous is because doctors are not have have not been trained to do them for nearly forty years.

A midwife at home has more experience than an ob/gyn in delivering sacrum presentations.

[AlexisT]

Not necessarily. HB MWs don't do breech everywhere, and because they do a low volume of births, it takes a long time for them to accumulate breech experience. There are MWs right here who have said they cannot or will not deliver a breech. Frankly, if my only choice was a HB MW who'd done one or two breeches, or a section--I'd choose the section.

Where I used to live, your best bet for a breech was a hospital OB. There was one in particular who was famous for attending breech deliveries.

Most OBs don't deliver breech any more, and the younger ones are unlikely to even know how other than in theory. (They are taught the concept, but most med students/residents today never get to attend a real one.) But the ones who do, have more experience than most midwives (The Farm would be an exception that comes to mind), simply because their volume of deliveries is so much higher, and they tend to have been practicing for a long time. That's a lot of babies.

[Belle]

One problem with the Hannah study being a randomized controled trial was exactly that. Women who would have not been a good candidate for vaginal birth were randomized to vaginal birth. Likewise, women who could have had a successful vaginal birth were randomized to c-section.

Many experienced breech birth providers refused to participate in this study for this reason.

[Kelly1101]

Originally Posted by stik

People who make women feel guilty about their birth choices really, really suck. In this case, your wife and her doctor have considered the options before them, and have decided that a c-section is best. Now, everyone else should butt out.

If your wife is feeling iffy about the c-section, she should remember that babies sometimes flip late. spinningbabies.com has some great advice. And, if the baby's position genuinely is the *only* reason for a section, a late ultrasound to make sure the babe is still breach prior to surgery wouldn't hurt.

On the other hand, if your wife is comfortable with her decision to proceed with a c-section, the entire rest of the world should get comfortable with seeing this as her wise and sacred mama-intuition, which is absolutely not to be messed with. Your wife's critics are *not* friends.

This, this, this all over.

I'd be fairly comfortable doing a vaginal birth if this baby turned out to be in a "good" breech position, because I've already had a vaginal birth. If it was my first time, I'd probably not be comfortable doing it.

It's up to your wife how she wants to deliver, and anyone else who has an opinion on it should be invited to keep it to themselves.

[caned & able]

Originally Posted by AlexisT

Not necessarily. HB MWs don't do breech everywhere, and because they do a low volume of births, it takes a long time for them to accumulate breech experience. There are MWs right here who have said they cannot or will not deliver a breech. Frankly, if my only choice was a HB MW who'd done one or two breeches, or a section--I'd choose the section.
.

As a third generation homebirther, I know plenty of home birth midwives with lots of breech delivery experience. Just because they do not advertise does not mean those midwives do not have breech experience. Those midwives are out there. Homebirth and midwives have always been with us.

These days, a midwife has more experience delivering breeches vaginally than an ob/gyn does.