Hospital Breech Birth: The Illusion of the Lack of Choice

In the year 2000, a poorly performed Term Breech Trial (TBT) was suspended. Its results changed the way obstetrics saw breech birth to this day. In retrospect, we now know that the (TBT), even with all of its flaws, actually showed vaginal breech birth (VBB) to be equally safe to planned cesarean birth (PCB) for mother and baby. Of course, this excludes maternal sequelae of morbidity and mortality for subsequent pregnancy and birth outcomes related to cesarean birth. It also doesn’t take into account other long term health benefits of being born vaginally for the baby.

Right now 3-4% of women are breech at term. Most of these women will be told that they must birth by cesarean. Many of them are told that it is the safest option. Many are told that no one is trained to deliver breech babies vaginally. However, many older doctors who delivered hundreds of breech babies still practice. Some doctors with VBB experience who are willing to deliver breech are told by the hospitals that they cannot practice.

In the case of Dennis Hartung, MD of Minnesota, Hudson Hospital cited a change in policy for vaginal breech delivery. Hartung had participated in offering women options for vaginal breech delivery. Many women would even travel from out of state for his assistance and his experience. Having had no adverse outcomes, the hospital announced that it was changing its breech policy so that all breech women would be given a cesarean. They cited hospital “standardization” as its reason. This seems to be the standardization of lack of choice. The lack of choice is the choice of the institution itself.

Such incidences like this one highlight the illusion of informed choice. It highlights the fact that even though the excuses of hospitals rely on the lack of “trained physicians” that such may not even be true. And even if it is true in many institutions, very little is being done to rectify “lack of training” leading to “the lack of options.” One solution that has been discussed is creating centralized breech training centers where physicians with training can attract higher volumes of breech delivery by region-wide referrals. Doctors would apprentice, intern, and after a certain number of deliveries and skills could return to their own area and create a similar pilot program retraining physicians.

One of the many flaws of the TBT was that “skilled providers” were self-defining. There were no basic skill-sets required for one to call oneself skilled or experienced. Trainee physicians and trainee midwives were some of these attendants. At this point in time, there are still no basic breech birth protocols that define a physician as “trained” or “untrained” for breech birth. I also cannot argue that an attendant who unexpectedly deals with a breech birth in a hands-on fashion may also do more harm than good. Knowing the basic cardinal movements of breech birth as well as when to intervene and not intervene is essential.

I have talked to women feeling the pressure of a PCB who were considering going into the hospital as the baby is about to emerge. They were thinking of laboring at home and then showing up ready to push and refusing a cesarean birth. If a skilled provider was receiving her it could be quite a positive situation, the unfortunate circumstance would be when a scared provider may cause iatrogenic consequences by pulling or manipulating a baby in an unnecessary fashion. And if an adverse outcome occurred, it could be chalked up to the dangers of breech birth.

We are now at a crossroads of breech birth. Information from Frankfurt, Germany shows methods of approaching VBB using less manipulations and having better outcomes. Frank Louwen and Anke Reitter have discovered what midwives have known for quite some time: gravity with use of the hands and knees position and hands-off deliveries (without signs of complications) is the safest mode for VBB. The Frankfurt Study has a definite set of maternal protocols used to qualify for the option of a vaginal breech birth, and the outcomes are quite impressive. Preliminary data has been released, and the official published results are pending.

However, for many doctors, hands-off, upright, breech delivery may be a bit difficult to swallow. Despite evidence, physicians could be quite skeptical of the hands and knees position due to differences in how manipulations, when needed, could be employed. But if these physicians are not trained, wouldn’t it be the perfect time to facilitate the learning of these emergency maneuvers using the evidence we have at hand?

One of the challenges lies in shifting medical and obstetrical education. As with many other challenges of integrating evidence based practice and management, changing any institutional habit can be difficult. But especially when there is such a void of any understanding of breech cardinal descent using gravity, its dependence on the hormonal interplay of labor, or how interventions can illicit reflexes from both mom and baby that may complicate things further… When there is this void, it seems like an ideal time to start over. Educating doctors should not be optional for the medical establishments.

It is time to reframe the discussion of breech birth. Typically, the breech baby or the mother’s body is seen as a problem as far as vaginal breech birth. But most of the time the problem lies with the illusion of the lack of options. Omitting the choice by not implementing training programs is an illusion that perpetuates the myth. In a similar way, hospital policy to eliminate vaginal breech birth where there are qualified and willing providers enforces it.

Freeze, Rixa. . March, 2013.

Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol.2006 Jan;194(1):20-5.

Gray R et al. “Caesarean delivery and risk of stillbirth in subsequent pregnancy: a retrospective cohort study in an English population.BJOG. 2007 Mar;114(3):264-70.

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. “Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial.” Term Breech Trial Collaborative Group. Lancet. 2000 Oct 21;356(9239):1375-83.

Kotaska, Andrew. Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery. BMJ 2004;329:1039-1042 (30 October), doi:10.1136/bmj.329.7473.1039

Evans, Jane. “Understanding Physiological Breech Birth.” Essentially MIDIRS, February, 2012, Volume 3, Number2. 17-21.

Louwen, Frank. Klinik für Gynäkologie und Geburtshilfe, J. W. Goethe-Universität, 2013.

Schutte JM et al: “Maternal deaths after elective cesarean section for breech presentation in the Netherlands.” Acta Obstet Gynecol Scand. 2007;86(2):240-3. Maternal Mortality Committee Of The Netherlands, Society Of Obstetrics.

Smith GC, Pell JP, Dobbie R, “Caesarean section and risk of unexplained stillbirth in subsequent pregnancy.” Lancet. 2003 Nov 29;362(9398):1779-84

Tully, Gail. March, 2013.

Whyte H, Hannah ME, Saigal S,Hannah WJ, Hewson S, Amankwah K, Cheng M, Gafni A, Guselle P, Helewa M, Hodnett ED, Hutton E,Kung R, McKay D, Ross S, Willan A; Term Breech Trial Collaborative Group. “Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial.”: . Am J Obstet Gynecol.2004 Sep;191(3):864-71. Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada. Comment in:
Am J Obstet Gynecol. 2004 Sep;191(3):872-3.