Saturday, May 1, 2010

Breech Vaginal Birth

Tired of birth posts yet? Sorry. :)

My mom works as a maternity nurse, as most of you know. We are visiting my parents right now and yesterday my mom called me from work to tell me there had just been the first planned vaginal breech delivery on her ward in over ten years!!! Since the SOGC changed its recommendations last July for breech births, the system has slowly been changing. My mom brought me home the SOGC clinical practice guideline on breech vaginal birth that is being used at her hospital for me to read. My review of it is a mixed bag: midwives who have continued to deliver breech births vaginally, in particular Ina May Gaskin in the U.S.A., have noted that the lithotomy position is particularly inappropriate for breech deliveries. Hands and knees position or upright position are recommended. The SOGC guideline has 11 illustrations in it that include the mother's pelvis/uterus/body, and in all 11 illustrations, the mother is in the lithotomy position. In one, her legs are in stirrups and her body is draped! Archaic! People are visual creatures, and if obstetricians only ever see or imagine delivering breech babies with women in the lithotomy position, they will automatically prefer and perpetuate this position. Which is not optimal.
Also, the SOGC guidelines do not mention the hands and knees position at all, though they DO mention an upright position for second stage of labor, ONCE, near the end of the guidelines.

Otherwise, it's pretty good. The guidelines discuss the inclusion/exclusion criteria for vaginal breech birth, but mention three times that parturient women have the right to refuse Cesarean sections and should NOT be abandoned if they choose vaginal births despite medical advice to the contrary. Referral to a institution or physician who has the experience and skill and comfort level to deliver breech vaginally, or (barring that) delivery in a hospital by the obstetrician on hand IS an option that MUST be given to women. This jives with my philosophy. Women have the right to refuse surgery. Period.

This is addressed in the guidelines:

"The 2001 ACOG and RCOG [American and British obstetrical societies] breech guidelines left little room for parturient autonomy. Since their publication, it has been routine practice in many jurisdictions for obstetrician-gynecologists to refuse women a breech TOL [trial of labor] in hospital. On occasion, women so denied have given birth unattended at home, and perinatal deaths have resulted. Also, the volume of midwife-attended breech home births appears to have increased. Even with the quality of care limitations of the TBT [major Canadian trail in 2000 that resulted in automatic cesareans for breech babies, which has now been peer reviewed and found to have MANY major flaws], the long-term outcome was equivalent in the planned vaginal birth and planned CS groups, and parturient autonomy takes precedence over practitioner concerns about small levels of fetal risk. WOmen should be informed of the safety of a TOL in a setting with experienced care providers.

Women who have a contraindication to labor or who are considered poor candidates for a TOL should be advised to deliver by CS. However, it is the patient's right to decline any recommended medical procedure or treatment. If a woman chooses to labor despite this recommendation, she should be cared for in hospital...A woman nust not be abandoned if she does not take medical advice."

It is mentioned in the guidelines that an infant's immune system is activated by labor, and that an elective cesarean results in higher rates of infant illness and infection. This is what is conjectured to counterbalance the increased risk of deoxygenation in the breech vaginal delivery. The vast majority of deoxygenated babies have no long term effects due to the existence of neonatal resuscitation evidence based protocols and standards. VERY INTERESTING! Short and long term outcomes in several trials and data studies are mentioned, and the conclusion is that:

"Sort term morbidity [injury that does not result in death] in vaginally born breech fetuses is often increased because of the cord compression that commonly occurs during the second stage and fetal expulsion. In countries like Canada with low perinatal mortality, the absolute difference in serious short term morbidity between the arms of the TBT was 5%. However, one half of the sample was followed beyond two years, at which time there was no difference in the combined perinatal death and abnormal neurological outcome: 3.1% in the planned CS group, and 2.8% in the TOL group...At two years of age, the only significant difference in infant outcome was fewer "medical problems in the past several months" in the TOL group (15% vs. 21%; P=0.02). The neonatal immune system is activated during labour, and associations between labour and reduced incidence of pediatric allergic and auto-immune disease may be causal.
With the limitations in the TBT, women had a 97% chance of having a neurologically normal two-year old, regardless of planned mode of birth. Those randomized to a trial of labour had a 6% absolute lower chance (or 30% relative risk reduction) of having a two-year-old child with unspecified medical problems, suggesting some lasting benefit of labour to the newborn immune system."

There are a bunch of criteria for including and excluding women from TOL for vaginal breech births, and recommendations for safe labour management of breech deliveries. If women are considered good candidates for breech birth, they are to be offered a trial of labour.
I think that the language should be changed to indicate that women should be encouraged, or recommended, to do a TOL. "Offered" is too weak. IMO.

Anyways, this is great! And I'm encouraged to hear of situations where vaginal breech deliveries are being DONE, following last July's change in SOGC recommendations.

For those of you who have read this far, congratulations! :D
For any who want to read more, you can read the entire recommentations HERE.


Keli Harrington said...

just a note to say that you have an exciting invite waiting for you on facebook!

Asheya said...

So awesome! I'm so glad that one more woman did not have unnecessary surgery!

I totally agree with you about images of women birthing in the lithotomy position. I went online to find an animated video of the cardinal movements of the baby when he is being born, for my childbirth education class, and the only video out there that I could easily find has the woman in the lithotomy position.

One more thing to add to the list for Mothers of Change projects...