Breech Presentation
Caesarean operation versus normal birth
By Gina Lowdon
AIMS Journal Autumn 1998, Vol 10 No 3
There are widespread fears surrounding vaginal delivery of the breech
presentation and a lack of information generally available on safe
vaginal delivery of a breech. There is also a lack of honesty about the
risks of caesarean section and sparse knowledge of the post-caesarean
difficulties many mothers encounter. These factors, together with the
prevailing myths and beliefs that caesareans guarantee healthy babies,
more often than not leave the woman with no option but to blindly accept
the decisions made for her by her obstetrician.
Mothers may not be aware much earlier than 36-37 weeks that their
baby remaining in a breech position is a problem. The prevalence of
breech presentation decreases from about 15% at 29-32 weeks gestation to
between 3-4% at term.(1)
Many hospitals have a policy of elective caesarean section at 38
weeks gestation for all breech presentations. For many mothers,
particularly those who have made great efforts to maximise the chances
of 'as natural a birth as possible', such a position is extremely
confidence-shattering and desperately upsetting - loss of control of, or
involvement in, the delivery of her baby is often total.
In fact, a mother in such a position does have three main choices
although these are unlikely to be made known to her:
- Elective caesarean section
- Vaginal breech delivery or vaginal breech extraction using
forceps
- Natural, active breech birth
Despite the widespread acceptance that breech babies should be
delivered by caesarean section, it has not been proven to be safer for
the baby than natural active breech birth. An international multi-centre
Term Breech Trial is currently being undertaken to look at the question
of which is the better approach for management of the breech baby at
term: planned caesarean section or planned vaginal birth.
Estimates of the perinatal mortality attributable to vaginal delivery
of breech presentation have varied, but it is generally accepted to be
four times that for cephalic presentation when corrected for
abnormalities. However, in a review of over 10,000 breech births in
eighty-six hospitals world-wide, Fortney et al (1986)(2) found that the
neonatal mortality rate in breech births was about twice the overall
neonatal mortality rate.
The sad fact is that babies in the breech position are at higher risk
than cephalic babies. Unfortunately widespread use of caesarean delivery
for breech babies has not demonstrated an improvement in the outcome
statistics.
Caesarean operations do not guarantee delivery of healthy babies,
breech or otherwise. Neither are all the 'hazards' of vaginal delivery
always avoided. Breech presenting babies are still born bottom first
even when delivered operatively.
"It is incorrect to assume . . . that caesarean breech delivery
is never traumatic for the fetus. Several retrospective studies have
shown that brachial plexus injury, damage to soft tissues, fractures,
lacerations, and entrapment of the fetal head behind the uterine
incision followed by intracranial hemorrhage occur in caesarean breech
deliveries as well."(3)
Some obstetricians prefer to use a low vertical, rather than a
transverse, uterine incision when delivering a breech baby by caesarean
since vertical incisions can be extended with less risk to the mother
should the need arise. This, of course, has implications for future
deliveries since it is widely believed that vertical scars are at
slightly higher risk of rupture.
The main fears surrounding vaginal breech delivery are birth trauma
and asphyxia. With a breech, the after-coming head does not have an
opportunity to mould before passing through the birth canal. If the baby
is small or premature there is a danger that the body may deliver easily
leaving the head trapped behind an incompletely dilated cervix or an
inadequate pelvis.
However, Collea et al (1978) point out that "excessively slow
delivery of the head may result in fetal asphyxia, although found no
direct relationship between umbilicus-to-mouth delivery time and Apgar
score."(4)
As the rate of caesarean delivery of breech babies rises, fewer and
fewer midwives and doctors are learning the skills of vaginal breech
delivery. In cases where the baby's head does get trapped the birth
attendants may act inappropriately by forcefully extracting the baby
which may cause severe brain and spinal cord injuries, bruising
sufficient to cause hyperbilirubinemia, trauma to the liver, kidneys,
spleen and adrenals.
In the ICEA review Delivery Alternatives in the Term Breech Pregnancy
the views of Irwin Kaiser, an American ob/gyn are noted:
"I have never in my life had trouble with a breech. And I rarely
section for a breech. Now, of course there are some skills involved in
delivering breeches. And, many doctors trained today aren't learning
them. However, if doctors don't have the skills, maybe they ought to be
doing something else - perhaps administrative medecine."(3)
Although in theory breech babies are not benefiting from caesarean
delivery, they may well be doing so in practice, because the skills of
vaginal breech delivery are being lost.
Another much voiced fear in association with vaginal breech birth is
cord prolapse. Since the baby's bottom or legs do not fit the pelvis as
closely as the head there is more chance that the cord may slip through.
However, for the same reasons the pressure on the cord may not be as
great, therefore a cord prolapse with a breech may not be the
immediately life-threatening event that often presents with a head down
baby. Although Confino, et al found that umbilical cord prolapse was
much more common in breech presentations (3.7%) than in vertex
presentations (0.3%)(5), cord prolapse may not necessarily be as
devastating in breech presentations as it is in vertex presentations,
because the fetal legs may shield the prolapsed cord from compression.
There is literature which cites numerous instances of cord prolapse in
breech deliveries without any apparent untoward effect on the fetus.(3)
To those who express the doubt that the high rate of caesarean
section for breech presentations has improved outcome statistics,
quickly comes the response "but they don't do follow-up studies!". In
fact, there have been two widely quoted studies which found no
difference between breech infants delivered vaginally and breech infants
delivered by caesarean.(6,7)
It would appear that in the case of a healthy mother with a healthy
baby of normal size in a breech presentation, vaginal delivery at full
term ought to be an option to be given serious consideration 'Informed
choice' is very much the 'in' thing at present, but how often does this
happen with a woman whose baby is in a breech presentation?
It is rarely acknowledged, for instance, that there are two very
different 'types' of vaginal delivery. Generally speaking 'vaginal
breech extraction' would better describe what the majority of British
hospitals have to offer as a 'vaginal breech delivery' option. This
often involves some or all of the following:
- Getting to the hospital early in labour (in case of cord
prolapse)
- Continuous fetal monitoring
- Epidural (to avoid the mother pushing too early and of course it
can be topped up if a caesarean becomes necessary)
- Mother in lithotomy position (flat on back, legs in stirrups -
so the doctor has 'good' access)
- Large episiotomy (to accommodate the forceps)
- Complex manipulation with forceps
'Natural, active' breech birth is rarely the norm, although there are
some midwives and the occasional obstetrician who consider breech as
simply a variation of normal.
Michel Odent's natural protocol for breech birth involves no
intervention whatsoever in the first stage of labour, leaving the woman
free and 'naturally active'. In his book 'Birth Reborn' he writes that
his only intervention is to:
"insist on the supported squatting position for delivery, since it is
the most mechanically efficient. It reduces the likelihood of our having
to pull the baby out, and is the best way to minimise the delay between
the delivery of the baby's umbilicus and the baby's head . . . would
never risk a breech delivery with the mother in a dorsal or semi-seated
position."
"If, on the other hand, contractions in the first stage labour
are painful and inefficient and dilation does not progress, we must
quickly dispense with the idea of vaginal delivery. Otherwise we face
the danger of a last minute 'point of no return' when, after emergence
of the baby's buttocks, it is too late to switch strategies and decide
on a caesarean. However, although we always perform caesareans when
first stage labour is difficult and the situation is not improving, most
breech births in our clinic do end up as vaginal deliveries."(8)
Whether to opt for a caesarean, a trial of labour ending in a vaginal
breech extraction, or a natural active breech birth is a very difficult
decision for an individual mother, particularly if she is a first time
mother.
Even if she has full information she has to weigh the risks of
caesarean section to herself and her baby against the possible risks to
the baby of vaginal delivery. The mortality rates for breech babies are
at least two-to-four times higher than that for cephalic presentations.
High rates of caesarean section for breech presenting babies have not
been proved to improve outcome statistics, but the risks involved in
operative delivery remain largely unacknowledged, summarily dismissed
and are presented on the whole as being generally more acceptable.
Many women may well be content to go along with the medical advice
being presented to them and opt for an elective caesarean at 38 weeks.
They may consider the risks of an elective section more acceptable,
especially if their confidence that the medical profession 'know best'
is strong. The thought of a possibly long and difficult labour which
could still end in an emergency caesarean, perhaps under general
anaesthetic, may appear more frightening and seem pointless when they
could arrange to schedule an epidural section at a possibly more
'convenient' time. Although the current availability of spinal
anaesthetic should make use of a general anaesthetic unlikely.
Elective caesarean is also the option which encounters least
resistance and most support since few obstetricians today would refuse a
caesarean to a woman with a breech presenting baby. Other mothers too,
are much more likely to understand such a decision since many have heard
vague horror stories of breech births resulting in dead or brain-damaged
babies.
An additional disadvantage to an elective caesarean section is that
the baby does not benefit from experiencing contractions. It is believed
that the contractions of labour, together with the passage down the
birth canal, help prepare the baby's lungs for breathing air and
generally 'wake up' various systems in the body.(9) Babies born by
caesarean before the onset of labour have a higher incidence of lung
disorders.
Some mothers may find themselves being advised by medical
professionals at one of the small and ever diminishing number of
hospitals that do still offer a 'trial of labour' culminating in a
'vaginal breech extraction'. Such an option at least enables the mother
to go into labour spontaneously, enabling the baby's lungs to benefit
from contractions. It also gives the baby a longer opportunity to turn.
Major abdominal surgery can be avoided. What is more, provided the
woman manages to push the baby out - despite being in the most
mechanically unfavourable position for childbirth possible (bar being
hung upside down) - she will, at least, have had a 'normal' birth.
Amazingly some women do actually manage to give birth in such
circumstances, some so rapidly that there is no time for epidurals or
forceps. Women who have no deep-seated fear or dread of the lithotomy
position and good levels of confidence in both themselves and their
birth attendants can even have positive birth experiences, despite the
breech presentation.
One mother who managed to give birth under just such conditions
before her attendants were ready, commented to me that she found the
stirrups useful because they gave her something to push against and that
it would have been better if they'd been padded because they'd hurt her
feet.
Apart from the obvious advantages of avoiding surgery it is unlikely
that a woman planning to deliver a breech via the 'vaginal route' will
be attended by an inexperienced midwife - she should be cared for by
someone who is skilled in breech deliveries and who is conversant with
the problems and risks involved. Since breech presentations are
relatively rare such a person is likely to be one of the more
experienced midwives or doctors at the hospital. There is support too
for this option since it has medical sanction.
The disadvantages are that labour may be long and difficult and may
end, after all, in a caesarean. Women who have prepared during pregnancy
for a natural active birth may not be able to cope emotionally with the
prospect of epidural, lithotomy, and forceps. Even if delivery is
achieved under such circumstances some women may still suffer
emotionally due to 'loss of control' and feelings that they have not
'given birth' as they had hoped to do.
So, what of the woman who is fortunate enough to be well informed and
who takes the very unusual decision to remain 'naturally active' and
give birth to her breech presenting baby in a supported standing squat?
How much respect is such an 'informed choice' likely to engender? How
much genuinely interested co- operation is she likely to encounter?
The general reaction from the vast majority of our maternity health
professionals is very sadly likely to be at best unhelpful and at worst
downright threatening. It is an indictment of our maternity services
that if she steadfastly refuses to make the 'right' choice she is likely
to find herself trying to give birth alone, unassisted, unsupported,
surrounded by birth attendants oozing fear, with a ready-and-waiting
operating theatre down the hall, complete with surgeon, knife at the
ready, waiting for the errant patient to come to her senses.
Despite all the evidence pointing to the relative safety of natural
active breech birth a mother can't possibly be properly 'informed' if
she makes such a choice, can she?
Gina Lowdon
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References
- Enkin Murray, Keirse Marc J N, Renfrew Mary, and
Neilson James, A Guide to Effective Care in Pregnancy and
Childbirth, Second Edition, Oxford University Press (1995)
- Fortney, JA et al, Delivery type and neonatal
mortality among 10,749 breeches, Am J Pub Health, 1986; 76(8):
980-5.
- Cox Janice P, ICEA Review -Delivery alternatives in
the term breech pregnancy, November 1988
- Collea, JV et al, The randomized management of frank
breech presentation: vaginal delivery vs. caesarean section, Am J Ob
Gyn, 1978; 131:186-93
- Confino, E et al, Vaginal versus caesarean section
oriented approach in the management of breech delivery, Int J Ob Gyn,
1985; 23: 1-6.
- Hughcroft, SA et al, Late results of caesarean and
vaginal delivery in cases of breech presentation, Can Med Assoc J,
1981; 125: 726
- Rosen, MG et al, Long term neurological morbidity in
breech and vertex birth, Am J Ob Gyn, 1985; 151: 718-20.
- Odent, M, Birth Reborn, Souvenir Press, 1984 see also
Richards, Lynn Baptisti, The Vaginal Birth After Cesarean
Experience, Bergin and Garvey, 1987.
- Lagercrantz, H et al, The "stress" of being born,
Scientific Arena, 1986; April: 92-102.
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