State of the breech in 2020: Guidelines support maternal choice, but skills are lost….

Are women desiring a planned vaginal breech delivery able to access that option? Twenty years ago, the publication of the Term Breech Trial's (TBT) short-term outcomes1 led the American College of Obstetricians and Gynecologists (ACOG) to state in a committee opinion that “planned vaginal breech birth may no longer be appropriate.”2 In 2020, we now have national obstetrical guidelines from Canada (Society of Obstetricians and Gynaecologists of Canada—SOGC), the United Kingdom (Royal College of Obstetricians and Gynaecologists—RCOG), and ACOG supporting the option of vaginal breech delivery based on maternal choice for woman meeting specified selection criteria.3 Despite these guidelines, few women are given that option and planned vaginal breech birth is a rare event. A common limiting factor is the lack of a provider skilled and willing to offer vaginal breech delivery.4 In this issue, two papers address the physiological approach to vaginal breech delivery using an upright birthing position and describe the use of birth videos to teach the technique5 and the use of maneuvers to resolve complications occurring in the upright position.6 Although rates of vaginal breech birth had declined before the TBT, the decrease after the 2000 publication was dramatic.7 The subsequent publication of the two-year outcomes from the TBT8 in 2004 and the large prospective cohort PREMODA study from France and Belgium in 20069 suggested that the increased rates of neonatal morbidity and mortality described in the initial publication of the TBT's short-term outcomes were misleading and led to a revised 2006 ACOG Committee opinion supporting vaginal breech birth using hospital-specific protocol guidelines for eligibility and labor management.10 A large proportion of the increased morbidity in the short-term outcomes was attributable to decreased fetal tone at 2 hours of life, and the 2-year outcomes demonstrated that tone at 2 hours of age was not a useful surrogate marker for long-term morbidity.8 Methodological critiques of the TBT include allowing prolonged labor before converting to cesarean birth for labor dystocia, not requiring continuous fetal monitoring in the second stage or a prerandomization ultrasound to rule out growth restriction, and having 18.5% of the vaginal breech births attended by obstetricians in training.11, 12 What are the risks of planned vaginal breech delivery? RCOG states 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.” The excess perinatal mortality of planned vaginal breech versus planned cephalic delivery is estimated by RCOG as 2/1000 compared with 1/1000,13 which is similar to the SOGC estimate of perinatal mortality with planned vaginal breech of 0.8 to 1.7/1000 compared with between 0 and 0.8/1000 with planned cesarean birth.14 Perinatal morbidity includes trauma during delivery because of nuchal arms or delayed delivery of the head, and neonatal acidemia because of cord compression during second-stage labor. Despite the national guidelines supporting the option of planned vaginal breech birth for women meeting selection and labor management criteria, the proportion of breech fetuses delivered vaginally continues to decrease in all countries. The national guidelines from ACOG, RCOG, and SOGC all describe the need for a skilled provider with ACOG stating “patient wishes and the experience of the health care provider”15 are the determining factors with respect to choice of mode of delivery. RCOG describes the presence of a skilled birth attendant as “essential,”13 and SOGC recommends that “an obstetrician skilled in vaginal breech birth should be present during the active second stage.”14 Unfortunately, few physicians or midwives are being trained in vaginal breech birth as demonstrated by 74% of fourth-year obstetrics and gynecology residents in the United States responding that they would not be comfortable with vaginal breech delivery16 in a 2019 survey. Interestingly, several of the clinicians and training programs that have continued to offer vaginal breech births have adopted a new physiological approach to vaginal breech delivery using the upright position.17-21 The cardinal movements of breech delivery and the maneuvers used to assist delivery in an upright position with the complications of nuchal arms or a difficult head delivery are unknown to most physicians and midwives as past training and current emergency obstetrics courses use the dorsal lithotomy position. The RCOG and SOGC estimates of perinatal mortality are based primarily on retrospective studies with almost all the vaginal breech births presumed to be in the dorsal lithotomy maternal position. A comparison of upright vaginal breech demonstrated significantly fewer delivery maneuvers (OR 0.45, 95% CI 0.31-0.68) and second stages that were on average 42% shorter compared with vaginal breech birth in the dorsal lithotomy position.19 An article in this issue demonstrates the potential for using videos of birth to teach the cardinal movements of physiological breech birth in the upright position and the indications and techniques for maneuvers when needed.5 A Delphi panel of 13 obstetricians, 13 midwives, and two consumer representatives choose 10-13 upright breech births as an appropriate number to achieve competence and 3-6 per year for ongoing maintenance of proficiency.22 They also advocated the use of videos for training in vaginal breech birth. Given the infrequent occurrence of nuchal arms and delayed delivery of the fetal head, the use of videos and simulations will be essential to achieve adequate experience in observing the management of these complications. Piper Forceps can be taught for emergency use for head entrapment with simulations and pelvic mannequins given the rare need for their use. Efforts to train or retrain physicians and midwives have been limited in the United States and the United Kingdom to national conferences and regional workshops held on an irregular basis.17 The Advanced Life Support in Obstetrics (ALSO)23 and Emergencies in Clinical Obstetrics (ECO)24 courses in the United States both teach emergency vaginal breech birth, but include minimal focus on the skills of patient selection and labor management required for planned vaginal breech delivery. The Become a Breech Expert (BABE) course, developed in Australia, is a one-day course that includes patient selection, labor management, and delivery skills, and a strong emphasis on counseling woman with a breech fetus at term on their options for mode of delivery.25 Maintaining access to vaginal breech includes addressing unplanned and planned vaginal breech birth. RCOG counsels that all maternity care units must be able to provide “skilled supervision” for vaginal breech birth when a woman presents in advanced labor and suggests that “women near or in active second stage of labour should not be routinely offered cesarean section.”13 This aligns with the SOGC statement that women presenting in advanced labor do not appear to have increased perinatal risk.14 Despite these recommendations, women presenting in advanced active or second-stage labor may be routinely told that they should have a cesarean because of increased risks of vaginal breech birth as the provider present at the time of diagnosis lacks adequate experience. According to an informal survey of breech providers and consumers on the Coalition for Breech Birth, a Facebook group with over 6000 members, women in many states have little or no access to providers offering planned singleton vaginal breech hospital birth. There are at least 12 states with no known provider, 12 states with one provider, 11 states with 2-4 providers, two states with 5-10 providers, and no available data on the remaining 13 states. Many of the providers included will only attend births for their own patients and will not accept transfers for a planned vaginal breech birth. The lack of access to planned vaginal beech in hospitals in the United States may be increasing the likelihood that women desiring planned vaginal breech delivery choose to birth at home, a setting associated with substantially higher perinatal mortality, compared with a hospital setting with a trained clinician.26 How can the availability of vaginal breech birth in the United States and other areas with a rapidly decreasing pool of trained physicians and midwives be increased? One potential model is to establish regional centers of excellence that maintain access to trained physicians and midwives, guidelines for appropriate patient selection and labor management, and resources to address uncommon complications including use of Piper Forceps and symphysiotomy for head entrapment. One example at an academic center, the George Washington Hospital, is the Vaginal Breech Initiative.27 This center had 47 women with trials of labor over 6 years with 34 successful vaginal breech births. Given the number of midwives and physicians who are part of the GW breech initiative team, it is clear that even in a major metropolitan area, few vaginal breech births are being attended each year by most clinicians. It will be difficult for clinicians to achieve the number of vaginal breech births recommended by the Delphi study for ongoing experience to ensure excellence in the provision of breech birth. Training using videos of vaginal breech births and simulations will need to be an important part of developing and maintaining competency even at a regional center. Midwives have been leaders in teaching vaginal breech in England, Australia, and Canada including developing the physiological breech approach.25, 28 Given the small number of providers who are experienced and supportive of the option of planned vaginal breech, the option of labor induction may increase access. Although there have been concerns with respect to the safety of breech induction and the potential to increase the likelihood of cesarean, the results of four retrospective studies comprising 608 induced vaginal breech deliveries did not demonstrate increased perinatal morbidity in any of the studies.9, 29-31 The risk of cesarean was not increased in three of the four studies.9, 29-31 Based on these studies, the 2019 SOGC recommendations state that induction of labor does not appear to be associated with poorer outcomes, although evidence is limited based on study size.14 Cautious use of induction appears reasonable.32 Malpresentation is the indication for 17% of primary cesarean births32 in the United States. With a 2018 vaginal birth after cesarean (VBAC) rate of 13.3%,33 preventing primary cesarean will have a large downstream effect on the overall cesarean rate. External cephalic version (ECV) can potentially prevent about half of these cesareans34, 35 and appears to be more readily available than planned vaginal breech delivery; however, its use is limited by maternity care providers failing to diagnose approximately one-third of breech presentations until labor or after 38 weeks.36, 37 After diagnosis, success rates appear dependent on provider experience,36 and exclusion of women from being offered ECV based on non–evidence-based criteria may limit the use of ECV.38 If an initial attempt is unsuccessful or the woman is unable to tolerate an attempted external cephalic version, then the use of regional anesthesia (spinal or epidural) should be offered as this has been shown to increase the likelihood of successful ECV and subsequent vaginal birth.39 Providers who are reluctant to use regional anesthesia because of concerns about applying excess force should be reassured by a study demonstrating less pressure was used after regional anesthesia presumably because of relaxation of the abdominal musculature.39 There needs to be a cultural change in our maternity care training programs and birthing units if we are to make the support expressed in national guidelines for women's autonomy to choose planned vaginal breech birth a reality. This includes addressing how to improve training for all maternity care providers in the prenatal diagnosis of breech presentation and emergency vaginal breech delivery to decrease the likelihood of unplanned vaginal breech deliveries occurring with untrained providers. The additional training for planned vaginal breech birth will likely require the use of simulations and videos demonstrating maneuvers, attendance at focused training workshops, and time at regional centers to obtain enough experience in management of breech labor and “hands-on” deliveries. The effort to institute this training process will be substantial, but the alternative of women lacking the option to choose vaginal birth because of provider inexperience is an unacceptable disservice to women.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.