C-Section Not Best For Breech Birth

The Society of Obstetricians and Gynecologists of Canada will launch program to teach physicians breech vaginal delivery

from Globe Life Health and Fitness

by Carla Wintersgill

"Physicians should no longer automatically opt to perform a cesarean section in the case of a breech birth, according to new guidelines by the Society of Obstetricians and Gynecologists of Canada.

"Released yesterday, the guidelines are a response to new evidence that shows many women are safely able to vaginally deliver babies who enter the birth canal with the buttocks or feet first. Normally, the infant descends head first.

“Our primary purpose is to offer choice to women,” said André Lalonde, executive vice-president of the SOGC.

“More women are feeling disappointed when there is no one who is trained to assist in breech vaginal delivery,” he adds.

"Since 2000, C-sections have been the preferred method of delivery in breech births. Studies suggested that breached births were associated with an increased rate of complication when performed vaginally.

"As a result, many medical schools have stopped training their physicians in breech vaginal delivery.

"The problem now, according to Dr. Lalonde, is that there is a serious shortage of doctors to teach and perform these deliveries.

"With the release of the new guidelines, the SOGC will launch a nationwide training program to ensure that doctors will be adequately prepared to offer vaginal breech births .

"The new approach was prompted by a reassessment of earlier trials. It now appears that there is no difference in complication rates between vaginal and cesarean section deliveries in the case of breech births.

"News of the change is a boon for the Ottawa-based Coalition for Breech Birth.

“We're really, really pleased,” said Robin Guy, co-founder of the coalition.

"Ms. Guy started the group after the birth of her second child in the fall of 2006. Although she had given birth to her first child at home with a midwife, Ms. Guy delivered her daughter in the hospital because of the baby's breech position.

“I was cornered into an unneeded and unwanted C-section because the obstetrician that I had didn't have the experience to catch her,” said Ms. Guy.

"The aim of the coalition is to ensure that women know what their options are when it comes to breech birth. Ms. Guy believes that many women don't realize that vaginal breech births are even possible.

“Educating women is our primary goal because it takes more than just a guideline change,” she said.

"The SOGC stresses that because of complications that may arise, many breech deliveries will still require a cesarean section.

"Breech presentations occur in 3-4 per cent of pregnant women who reach term. That translates to approximately 11,000 to 14,500 breech deliveries a year in Canada.

"The new decision to offer vaginal breech birth aligns with the SOGC promotion of normal childbirth – spontaneous labour, followed by a delivery that is not assisted by forceps, vacuum or cesarean section. In December of 2008, the society release a policy statement that included its recommendation for a development of national practice guidelines on normal childbirth.

“The safest way to deliver has always been the natural way,” said Dr. Lalonde.

“Vaginal birth is the preferred method of having a baby because a C-section in itself has complications.”

"Cesarean sections, in which incisions are made through a mother's abdomen and uterus to deliver the baby, can lead to increased chance of bleeding and infections and can cause further complications for pregnancies later on.

“There's the idea out there in the public sometimes that having a C-section today with modern anesthesia and modern hospitals is as safe as having a normal childbirth, but we don't think so,” said Dr. Lalonde.

“It is the general principle in medicine to not make having a cesarean section trivial.”

"The SOGC believes that if a woman is well-prepared during pregnancy, she has the innate ability to deliver vaginally.

"The national average for babies delivered via cesarean section in Canada is 25 per cent."

Breech Baby (Breech Position or Presentation)

What is Breech?
Breech presentation is when a baby is in a position other than head-down. There are three types of breech presentation. Frank breech is the most common, with the baby's buttocks down and legs straight up toward the face. Complete breech is when the baby is in a sitting position with legs crossed. Footling breech is when the the baby has one or both feet down. The baby's position is checked at each prenatal visit in late pregnancy. By 34 to 36 weeks most baby's have assumed the position they will birth in.

Why is a breech presentation risky?

• The chances of a prolapsed cord increase with a breech baby because the buttocks or feet don't prevent the umbilical cord from being swept below the baby or into the vagina.
  
• When the baby's feet or buttocks are delivered first there is a possibility the head can press on the cord at the cervix and possibly reduce the baby's oxygen supply.
  
• Sometimes the baby's feet or buttocks are small enough that they can be born before the cervix is fully dilated, and the head doesn't have enough room to come out. This could lead to fetal distress and delay the birth of the head.
• Spinal cord injury is also a risk if the baby's head is hyperextended (bent back).

What can be done about a baby in a breech position?
If by 36 weeks your baby is in a breech position, you can try one of the following:

• The breech tilt position: The idea behind this is to tilt your body so that your hips are higher than your head. Ask your caregiver if this is safe for you to do. If you are healthy and the baby is doing well, most caregivers encourage this position. Lie on your baby with your feet flat on the floor. Raise your pelvis and slide firm cushions underneath your buttocks, enough to raise them 10-15 inches above your head. You may need help from your partner or a family member or friend with the pillows. You can also use a flat surface like an ironing board or plank, tilt it by putting one end on a chair and the other end on the floor. Lie down on the board with your head toward the bottom. If it's unsteady at all, have someone help steady it for you. Lie in this position for 10 minutes, 3 times each day at times when your baby is active. It helps encourage the baby to move up away from the birth canal so the baby can move to get into a more favorable head-down position. It's not the most comfortable position, but if you empty your bladder and make sure you don't have a full stomach, it will help ease some discomfort. While you lie in the tilt position, try to relax your abdominal muscles as much as possible and imagine your baby turning a somersault so the head turns toward the cervix. The baby will probably squirm as the head presses into the fundus. There is no medical proof that this method helps turn a baby, but many women swear by it, and it doesn't do any harm. After lying in this position, it's a good idea to assume an upright position to encourage the baby to move back down after being pulled up be gravity.
• Knee-chest position: This position uses the same principles as the breech tilt position, and you may want to try it and see if it's more comfortable for you. For this position, assume a hands and knees position with your knees about shoulder-width apart. Place firm pillows under your pelvis to help hold your hips and pelvis up in that position, and then lower your head and shoulders to the floor. You may want to use a blanket or thin pillow to soften the surface for your head, but be sure to keep your head and shoulders as low to the floor as possible to allow gravity to help pull your baby out of the breech position. Once you're support by enough pillows to keep your pelvis up, you should be able to maintain this position comfortably for 10 minutes or so, also 3 times a day just like the tilt position.
• Use of sound: You can try this by either placing earphones from a music player just above the pubic bone and playing music for the baby when the baby is active. You can also have your partner place his or her head in your lap and talk to the baby. The idea is that babies can hear outside sounds while in the womb, and the baby may reposition itself so that his or her head is down toward the comforting or familiar sound. This method is also completely harmless and comfortable, and many women have reported that it helped turn their baby.

What's the medical approach to turn a breech baby?
If your efforts at home haven't been successful in turning your breech baby, your caregiver may want to try external version. This is done at 37 to 38 weeks. An ultrasound is usually done to determine the exact position of the baby, check how much amniotic fluid is present, and see where the placenta is attached to the uterus. A non-stress test may be done to check the well-being of the baby before or after the version. You may be given a drug to relax your uterus, and some caregivers like to use an epidural to reduce any discomfort. The caregiver uses ultrasound as a guide while he or she presses on your abdomen and tries to manually turn the baby into a head-down position. If the baby shows fetal distress, the procedure is stopped. If the placenta starts to detach from the wall of the uterus, a cesarean section must be done to deliver the baby. Sometimes the version is unsuccessful and the baby does not turn at all. Some babies will turn from the version and then resume a breech position afterward. Studies have shown that external versions are safe and successful about 60% of the time. It can be quite uncomfortable because of the amount of pressure that's used to turn the baby. It can be helpful to have your partner or doula with you to help with breathing techniques and relaxation to give you comfort and allow the caregiver the time needed to turn the baby during the procedure.

Vaginal Birth versus Cesarean Birth for a Breech baby.
It used to be that vaginal breech births were done all the time. Even though there are complications with a vaginal breech birth, it can still be done safely with the right expertise. After the 1970's the overall cesarean section became increasingly common, and doctors began to abandon vaginal breech delivery and use surgery more and more to deliver breech babies. As vaginal breech births declined, fewer doctors learned the techniques to perform a vaginal breech birth. It can be difficult now to find a physician who is willing and has the skills to allow you to birth your breech baby vaginally.

Personal note: I know a woman who interviewed her physician before the birth of her second child. She showed him her birth plan and asked specifically that if the baby were to present in a breech position she be allowed to attempt a vaginal delivery. Her wonderful doctor (who happened to be an older man who had assisted in a multitude of vaginal breech births and has the necessary skills to do so) said that he would love to help her do that. This is rare, and I think it emphasizes the importance of interviewing your caregiver and being clear about your wishes for birth! If your baby is presenting breech and all efforts to turn the baby have been unsuccessful, you may need to prepare yourself for a cesarean birth, as that is the most common method of delivery for breech babies today.

My midwife recently assisted in a vaginal breech birth at a home. She did not have experience with breech delivery, so she called in a senior midwife who knew what to do, and the baby was delivered safely and vaginally. I find it truly amazing what can be done with the right knowledge and approach.

*Information presented can also be found in Pregnancy, Childbirth and the Newborn by Penny Simkin, Janet Whaley and Ann Keppler. This is a fantastic book that I would recommend to all expectant parents.