For as long as women have been having babies, a small percentage of those babies have been born breech. Breech presentation means the baby emerges with the head last, and foot, leg, or bottom first. Twenty five percent of babies are in the breech position at 32 weeks, and only three percent remain in that position at full term. Premature babies are therefore at a greater risk of breech presentation than term babies, since not all of them will have had a chance to flip to the vertex, or head down position.
There are different types of breech presentations, including:
Frank Breech (50 to 70% of breech presentations), with hips flexed and knees extended, like this:
Complete breech (5 to 10%), Hips flexed, knees crossed, like this:
Footling or Incomplete breech (10 to 30%) One or both feet first, like this:
In past decades breech babies were delivered vaginally. Techniques for dealing with breech birth varied, and it was acknowledged that breech presentation carried more potential for complications than vertex delivery. My grandmother gave birth to five children, two of whom were breech, and her physician cut a large episiotomy and used forceps for both babies.
A research study at the University of Toronto called the Term Breech Trial was begun in 1997 to determine the best approach to breech births. It was intended to span five years but results appeared to be conclusive in favour of planned cesarean section by 2000, so the study was stopped and published before the five years was finished. Over 2000 women were included in this study, from twenty six countries. This study dramatically changed the obstetrical approach to breech births around the world, resulting in thousands of women undergoing scheduled cesarean section to deliver their babies. In Canada alone between 2000 and 2009, it is estimated that between 11, 000 and 14, 000 women per year underwent surgical delivery based on the published results of this study.
Criticism of this study and its results included:
- the radical change of the international approach to breech births based on a single, randomized controlled trial which was stopped before its completion
- the reduced skill set of obstetricians in dealing with inevitable precipitous breech births or for women who choose vaginal birth, or for whom cesarean section surgery is contraindicated
- constraint in women’s choice in mode of delivery
- reduction of the role of midwives in the care and continuity of care for women with breech babies
- and the results themselves which carried a large number of variables based on the size and international nature of this trial.
Nevertheless, cesarean section for breech presentation became widespread, and in Canada the vast majority of breech births were delivered surgically starting in 2000.
The breech birth guidelines published by the Society of Obstetricians and Gynecologists of Canada (SOGC) underwent review in 2009 as a result of continued analysis of the Term Breech Trial including the original study follow up results and mounting criticism of its methodology and conclusions. The Globe and Mail published an article in June of 2009, shortly before the SOGC published new breech birth guidelines in August of 2009. The Globe and Mail stated,
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 (entire article available here).
Since then it has been considered safe to deliver breech babies vaginally in Canada. The new Breech Birth Guidelines released in 2009 state that
In light of recent publications that further clarify the lack of long-term newborn risk of vaginal breech delivery and the many cohort reports noting excellent neonatal outcomes in settings with specific protocols, it is acceptable for hospitals to offer vaginal breech delivery.
Breech births are more physiologically complex than vertex births, and so it is recommended that a practitioner experienced in breech delivery techniques be in attendance, and that physicians across the country recieve training or retraining as Canadian hospitals move back to offering women vaginal delivery of their breech babies as a reasonable and safe option. Breech vaginal birth is proven safe for babies in the frank breech position, whose estimated weight is less than 4000 grams, and not suspected to have Intra-Uterine Growth Restriction (IUGR).
It is now July of 2011, two years after this change in guidelines, yet very little has changed as far as options for women with persistent breech babies. Many women are simply told they must have a cesarean. Others are presented the option of a breech vaginal birth but discouraged from doing so for safety reasons, which is not supported by research. Very occasionally, an obstetrician will be comfortable and experienced with breech vaginal births and present it as an option. If an obstetrician is not comfortable and experienced with breech vaginal births, they should refer women to someone who is, but this rarely happens.
What do you think? The answer is surely complex…