Up against a wall: A patient and obstetrician’s perspective on the mode of breech delivery

At 41 weeks pregnant, I learned that my baby was in a frank breech position just hours before going into labor. I asked my care providers for an external cephalic version, and if that failed, an attempt at a vaginal breech delivery. Since I was so far past my due date, my attending obstetrician felt that the likelihood of success was too low to justify the risk of the version and thus did not feel comfortable attempting the procedure. Even at a large teaching hospital, there was no obstetrician available who was skilled at vaginal breech birth. As a result, my options were an unassisted breech delivery at home, a vaginal breech delivery at the hospital with inexperienced care providers, or an elective cesarean. I do not wish this situation on any pregnant woman. I felt enormous pressure to have a cesarean by my care team and concluded that given the circumstances, it would be reckless to not do the unwanted and potentially unneeded surgery. In retrospect, as I signed my informed consent document for the cesarean during the middle of a contraction, the risks of the cesarean were greatly downplayed compared with the risks of a vaginal delivery. I was not informed and did not realize at the time that I may be signing myself up for another cesarean if I have another child as many hospitals in the United States have outright banned VBAC or make VBAC extremely difficult to pursue through restrictive policies and practices. Instead, I was told that my baby's head was likely to become entrapped and she would likely die or suffer severe harm if I attempted a vaginal delivery. I was led to believe that head entrapment could only occur in a vaginal delivery and that this would be avoided if I did the surgery, even though I later learned that this complication can also occur in a cesarean.1 I also later learned that I was likely a candidate for a vaginal delivery under ACOG's guidelines2 for breech presentation, but the option was not available to me, and thus, I felt extremely cornered into a cesarean. I recognize that there are real risks and benefits to both a vaginal and a cesarean breech delivery, as there are with any health care decision. If I had been able to meet with a physician with experience in breech delivery, I would have expected that we carefully weigh the risks of cesarean delivery against the risks of a vaginal breech delivery. If we had decided the risks of a vaginal delivery were greater than the risks of a cesarean delivery given my individual circumstances, I would have felt the cesarean was justified. The issue at hand is not whether a cesarean should have been done; it is that I did not have access to a physician with this skill set, and thus, I felt cornered into a cesarean. As a birthing person, I expect to be given an unbiased view on the pros and cons of the treatment options available to me, and then make my own decisions that I feel are best for me and my baby. Unfortunately, I felt my care team made my decision for me by informing me the only way they knew how to safely deliver my baby was by a cesarean. Breech presentation at the end of pregnancy is a relatively common dilemma, as approximately 4% of babies will be breech at term.3 Historically, it has long been recognized that breech presentation poses a risk to the fetus and that some term breech babies are more safely delivered by cesarean.1, 4 However, in breech presentation cases that meet strict selection criteria set by ACOG2 vaginal delivery could be safer than ever as the modern obstetrician can more accurately know the fetal position, the size of the mother's pelvis, and the fetal status. Furthermore, neonatal resuscitation is available in the case of an unexpectedly depressed newborn, and when done while the cord is still attached has been shown to improve neonatal outcomes.5 Using careful case selection, skilled obstetric providers, and modern obstetrical care, as was done in a large study in France and Belgium, the neonatal outcomes are very similar between planned cesarean and planned vaginal breech delivery.6 Several professional organizations have evaluated the latest literature and updated their professional recommendations. In their 2018 Committee Opinion, ACOG states that “Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for eligibility and labor management. The decision regarding the mode of delivery should consider patient wishes and the experience of the health care provider.”2 The Society of Obstetricians and Gynecologists of Canada (SOGC) states “Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective caesarean section. Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus.”7 In addition, the Royal College of Obstetricians and Gynaecologists (United Kingdom) has made the statement that “Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.”8 Most importantly, RCOG notes that the risk of death to the baby of a vaginal breech birth (2 per 1000) should be compared with the risk to a vertex baby who is attempting vaginal delivery (1 per 1000), and not the risk of a scheduled cesarean at 39 week (0.5 per 1000).8 The limiting factor in providing women a choice with respect to the mode of breech delivery is a lack of skilled providers. The truth of the matter is that most midwives who attend home births make more of an effort to learn the skills to provide a safe vaginal breech delivery in an unplanned situation than most OB-GYN residents trained in the last 20 years. To train more providers in this skill set, several international education initiatives exist aimed at disseminating information on how to safely deliver a breech baby vaginally. The Coalition for Breech Birth, Shawn Walker in the United Kingdom, Betty-Anne Davis in Ontario, and the Frankfurt Breech at Term Study Group in Germany have made great efforts to ensure the art of breech vaginal delivery is not lost and to improve the safety of breech vaginal delivery.9-12 For instance, the Frankfurt Breech at Term Study Group has published research on the benefits of an upright positioning during a breech vaginal delivery to improve outcomes.13 The few physicians who attend vaginal breech births often face great pressure from their hospital administrations to discontinue offering this service to women.14, 15 For instance, I faced enormous pressure to stop attending vaginal breech births from my hospital administration. My hospital subsequently received many letters discouraging a vaginal breech delivery ban. After fighting for a year, I was once again allowed to offer this delivery option to women in my community, although at the local tertiary care center. I have had women travel as far as four hours away to have access to breech vaginal delivery under my care. Dr Stuart Fishbein faced a similar ban as well in his hospital in Los Angeles and decided to provide the service at home given no alternative.16 Hospital administrators and obstetricians are understandably concerned about litigation that may result in a vaginal breech birth gone awry. The United States, unlike many other developed countries, has a tort litigation malpractice system, which has resulted in astronomical medical malpractice insurance premiums for physicians.17 As a result, patients receive liability-centered care, as physicians cannot afford to take any risks they feel may jeopardize their career. To mitigate this problem, our medical malpractice system needs to be reformed using strategies suggested by Sakala et al,18 such as implementing quality improvement programs, embracing shared decision making, and reforming the liability insurance system. If malpractice suits were better controlled, more physicians may feel comfortable attempting vaginal breech deliveries. We recognize that breech vaginal delivery may not be able to be done safely in all hospitals across the country. However, even if a few hospitals in each state were to offer breech vaginal delivery, many more women would have more options in how they decide to birth their children. This is the situation in several European countries such as Germany and Norway.19, 20 Women expect their care teams to provide them with evidence-based care and want to make their own decisions with respect to their maternity care. Although maternity care professionals often state they support shared decision making with their patients,28 there is no real choice or decision making involved for expectant mothers if the only tool obstetricians have is a knife. Women need to be given choices in their care to give true informed consent and should never feel bullied or coerced into any medical decision. All too often women feel disempowered and sometimes traumatized by their children's births. Maternity care professionals can change this by giving women access to unbiased information with respect to the risks and benefits of their treatment options, and by offering all birthing options and informed choice for birthing women.

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