Yesterday’s post about the breech birth books brought this study from 2004 to mind. I’ve known of its existence for several months, but haven’t blogged about it yet, so far as I can remember.
I have mixed feelings about it, as the conclusion perhaps will show:
Safe vaginal breech delivery at term can be achieved with strict selection criteria, adherence to a careful intrapartum protocol, and with an experienced obstetrician in attendance.
While this implies that any breech birth that goes outside of these parameters is “unsafe” (which may or may not be synonymous with “deadly”), it does not mean that these things must be observed for a breech baby to safely be born vaginally. This is why I have mixed feelings about the study — as long as a woman meets the selection criteria and consents to the “careful intrapartum protocol”, she may wish to present the study to her doctor in an effort to lobby him to allow her to have a vaginal breech birth. But it may be a death knell to her desires to attempt a vaginal birth if she or her baby lies outside of these parameters, or if she does not want to have her baby’s head manipulated or pulled out of her with forceps, instead of being allowed to birth it naturally.
The selection criteria were as follows (my comments in italics):
If breech presentation persisted or recurred, patients were offered a trial of vaginal delivery if the following criteria were fulfilled: 1) estimated fetal weight of 2,500–3,800 g13; 2) deepest amniotic fluid pool 30 mm or more; 3) normal fetal morphology and normal placental location; 4) absence of hyperextension of the fetal head (an angle exceeding 90°) [this head position is also called “star-gazing”]; and 5) flexed (complete) or extended (frank) breech presentation. Management of fetal anomaly depended on the type of malformation identified. Elective prelabor cesarean was advised, based on the following fetal indications; estimated fetal weight more than 3,800 g [about 8.5 lb.], footling breech, hyperextension of the fetal head or when fetal compromise was suspected (oligohydramnios or intrauterine growth restriction). Maternal indications for elective cesarean included maternal preference, previous cesarean, significant preeclampsia and placenta previa. [Also, no woman was allowed to go past 41 weeks.]
The study defined “careful intrapartum protocol” thusly:
Oxytocin was not used to augment labor in either the first or second stage; failure to progress in labor was considered an indication for intrapartum cesarean. If fetal distress was suspected, cesarean delivery was effected without fetal blood sampling; meconium staining of amniotic fluid alone was not deemed an indication for cesarean delivery [it is common for breech babies to pass meconium due to the buttocks presenting and being birthed first; while meconium staining may indicate a problem in vertex babies, it does not necessarily indicate a problem in breech babies]. Epidural administration was based on maternal request. An experienced obstetrician (senior resident with at least 4 years experience or consultant) conducted all vaginal breech deliveries, and a pediatrician was also in attendance. Breech delivery was spontaneous with active maternal pushing, but no intervention by the attending obstetrician, until the fetus was delivered to the level of the umbilicus. Lovset’s maneuver was used to deliver the shoulders if required, and episiotomy was performed routinely. Delivery of the head was then controlled with Mauriceau-Smellie-Veit maneuver or with Neville-Barnes obstetric forceps, depending on the obstetrician’s preference.
But many breech births which did not fall within these protocols — in babies whose feet were the presenting part, or who weighed more than 8 and a half pounds, or in women who did not have an episiotomy or forceps — have happened and the babies were perfectly fine. There have been good outcomes in women whose doctors and midwives had little or no experience in attending a breech birth, and even in women who have given birth unattended.
There was no allowance for the woman to give birth spontaneously — forceps or manipulating the baby’s head was done on every baby, whether it was needed or not. Because the woman was on her back, I have no doubt that these interventions were “needed” with some regularity or frequency; but I wonder how often they would have been needed — really needed — had the woman given birth in a squatting position, which allows her pelvic outlet to open widest, and also allowing gravity to assist in the baby’s birth.
I’m also concerned with the rather strict criteria for “progress” in labor:
When the diagnosis of labor was confirmed, amniotomy was performed to augment labor, provided the presenting part was fixed in the pelvis and continuous electronic fetal heart rate monitoring was initiated. Subsequent progress was assessed vaginally every 2 hours. Cervical dilatation at a rate of 1 cm/h or more was deemed acceptable. In the second stage, 1 hour was allowed if required for adequate descent of the breech to the pelvic floor; delivery of the fetus was completed within 1 hour of active pushing for nulliparas and within 30 minutes for multiparas.
Apparently, at the slightest derivation from these rules, the woman was wheeled off to the operating room for a C-section, as was evidenced by the number of women who actually had a vaginal birth: 23%. But we know that just because a woman does not dilate 1 cm every hour, that that indicates a problem, or is problematic in and of itself. And allowing only 1 hour for a first-time mom to push seems rather strict, as well.
So, all in all, while the study shows that vaginal breech birth is safe under certain parameters, and is therefore a benefit to some women who want to attempt to give birth to their breech babies vaginally, it seems far too quick to run off to the OR for a C-section. My hope is that by using this study, vaginal breech birth will become more normalized, and as it does so, that more women will be allowed to have a breech birth (at least an attempt!), and that the parameters will be more defined and refined to allow more and more women to have a vaginal birth, to save them from the trauma (if only medically and anatomically speaking, not necessarily mental or emotional) of a C-section or being given a big episiotomy and having forceps inserted; and also to save babies from being dragged out of the birth canal with cold steel or a doctor’s manipulating hands unnecessarily. My goal is for the fewest interventions as safely possible.