New Thoughts on Breech Birth?

In recent weeks, I have seen on various mommy-networks the new guidelines on breech birth from the Society of Obstetricians and Gynecologists of Canada (SOGC) trumpeted as a huge step towards better birth care. The most recent guidelines, published in 2009, recommend a trial of labor for some breech deliveries, and suggest that automatic cesarean sections for all breech deliveries is neither necessary nor necessarily safer.

Before we break out the red-raspberry leaf tea for a toast to natural birth, it's worthwhile to read the actual recommendations. The SOGC is definitely not Ina May Gaskin's midwifery practice.

The recommendations are available in pdf format, at SOGC.org. A few points worth noting follow.¹

-While the SOGC rejects Cesarean section as standard practice for all breech deliveries, the recommendations have a fairly stringent list of guidelines for which deliveries should be allowed even a trial of labor (TOL). To meet the criteria for vaginal delivery, both mother and baby must be in adequate health according to the guidelines. The mother's pelvis must be clinically examined to determine if there is any pathological abnormality that would prohibit safe delivery. The baby must be between 2000 and 4000 grams (4 lb. 6 oz. to 8 lb. 13 oz.), a singleton, frank or complete breech, with the head in a flexed or neutral position.

-If ultrasound is not available in order to determine that the situation meets the above criteria, cesarean section is recommended.

-The SOGC release contains recommendations for vaginal breech delivery that would make Dr. Michel Odent² shudder. It is advised that vaginal breech deliveries be done in a hospital, near or even in an operating room should something go wrong. The approach to the vaginal breech delivery recommended is very hands-on and proactive, quite the opposite of breech recommendations in natural birthing circles. Continuous fetal monitoring is mandated and active pushing is limited to 60 minutes, at which point the SOGC favors surgical delivery. "Failure to progress" is used several times in this publication and is cited as a reason for cesarean delivery.

-On the other hand, induction is not recommended for breech deliveries and the practice of total fetal extraction is considered inappropriate in most cases. The need for medical professionals trained in and comfortable with delivering breech babies vaginally is recognized, and training is recommended to make this more common.

-The recommendation states that women should be advised of the risks of breech delivery. It also states that if the considered medical advice is to have a cesarean, and the woman refuses, she should not be "abandoned" and should receive in hospital care during her attempted breech birth.

Far from being a complete reversal of common obstetrical view on breech delivery, these guidelines are a rather mixed bag. For natural birth advocates, any step away from automatic cesarean section is a step forward, but anyone who wants to cite this recommendation to bolster their particular position should read it thoroughly first.

¹Vaginal Delivery of Breech Presentation, Kotaska, Menticoglou, Gagnon, et al, SOGC
²Fetal Ejection Reflex and the Art of Midwifery, Michel Odent, WombEcology.com