Monday, February 18, 2013

messages about breech births

 A couple of days ago I wrote about 'informed or mistaken'.

Although there are no guarantees in any life event, the truth is that when we make plans and decisions about giving birth to our children we want to avoid anything that could be harmful or lead to poor outcomes.

And although there are many mistakes occurring every day in health care, the first rule of medical ethics is 'First, do no harm': Primum non nocere.

The other 'rule' that applies in this matter is the basic principle of midwifery: "In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996. Care in Normal Birth: a practical guide)

Today I would like to collect a few messages about breech birth that are available in professional circles, and look at each of the messages from this high standard.  Just to be clear, my starting point for 'do'-ing, in the statement 'First, do no harm' is any form of intrusion, interruption, intervention, or altering of the natural process.  This can be something as obvious as induction of labour for social reasons, to more subtle matters, such as requiring a woman to be prone for the convenience of the accoucheur. 

1 Safety of vaginal breech birth
1.1 "The current practice of caesarean section for all breech presentations is not supported by the medical evidence.  Many breech babies can be born safely vaginally.[BBANZ]
1.2 "a caesarean section is lower risk than a vaginal breech birth"  Dr  
1.3 "Although it is common for obstetricians to advise that it has been proven that the outcomes of planned caesarean section (PCS) are better than the outcomes of vaginal breech birth (VBB), this is an oversimplification of the evidence and is misleading." [BBANZ] 
1.4 "... with the application of strict criteria before and during labour, planned vaginal delivery of the singleton breech at term remains a reasonable option to offer to selected women" [RANZCOG]
 2 Increased risk of complications for the baby
2.1 "Babies born in the breech position (bottom first) are at increased risk of complications at birth because of a delay in the birth of the head.  "  [Cochrane Summaries]
2.2 "OVERALL breech babies have lower Apgars than cephalic babies-REGARDLESS of how they are born"  [FB]

3 External cephalic version
3.1 "Turning a breech baby to head first in late pregnancy may reduce these complications. A procedure called external cephalic version (ECV) describes when practitioners use their hands on the woman's abdomen to gently try to turn the baby from the breech position to head first." [Cochrane Summaries]

3.2 "My preferred option is to turn the baby to head-first position in order to avoid a caesarean section." Dr

4 Moxibustion
4.1 "... moxibustion can be used for turning babies from breech presentation to cephalic presentation ... There is some evidence to suggest that moxibustion may be useful for turning babies from breech presentation (bottom first) to cephalic presentation (head first) for labour when used with either acupuncture or postural techniques of knee to chest or lifting buttocks while lying on the side.  [Source: Cochrane Summaries]

Comment: "First, do no harm"
These statements, taken from reliable sources, demonstrate a little of the current conflict in messages and advice about breech births.  

The principle of 'first, do no harm' is probably the driving force in the medical quest to follow what is called evidence based practice - all in the interests of safety and wellbeing for the 'patient'.  The rise and rise of the randomised controlled trial in the past couple of decades has reshaped and redefined the boundaries of many professional practices.  Perhaps none more so than breech births.  The Term Breech Trial (Hannah et al 2000) has led to the standardisation of elective caesarean for women with babies presenting breech, and the loss of skill and knowledge in the obstetric and midwifery communities, as to critical thinking about the safety of proceeding within physiological processes in particular situations.

Elective caesarean surgery can never be considered benign.  The potential for harm exists for both mother and baby.  Mothers who undergo major abdominal surgery face the physical risks of infection, haemorrhage, and iatrogenic causes such as retained surgical material.  Subsequent pregnancies face increased risk of placental abnormalities, which may lead to severe haemorrhage. The psychological impact of elective surgery cannot be ignored.  Babies delivered this way do not have the normal hormonal preparation that comes with labour, and may need hours or days of specialised care, which involves separation from their mothers, and frequently interferes with the establishment of bonding and breastfeeding.

First, do no harm?  Unnecessary surgery may result in maternal and newborn morbidity, with the potential for mortality.  Unnecessary surgery for any reason should be avoided.  The emergence of maternal deaths at the time of the primary caesarean, or subsequent births, is an infrequent, but serious aspect of potential harm.

When the need for caesarean surgery arises in pregnancy, or in labour, the potential to 'first, do no harm' is changed.  In the case of failure to progress, the likelihood of harm is greatly increased by not intervening.

In the past couple of decades the practice of external cephalic version (ECV) has been fine-tuned by obstetricians in teaching hospitals.  This has been promoted as a way to avoid elective caesarean - for the successful ones - while the default position for breech presentation is caesarean.  ECV does not, per se, prevent the need for caesarean.  Babies who would experience a failure to progress due to cephalo-pelvic disproportion will make this clear in labour, regardless of the presenting part.

In applying the 'first, do no harm' principle, every midwife and obstetric doctor needs to be ready and able to attend vaginal breech birth without fear.  The midwife or obstetric doctor who hides behind the 'de-skilling' banner of the Term Breech Trial (2000) may be delinquent in clinical situations that can arise without warning, when a mother presents in advanced labour, about to give birth to a breech baby, or when a mother intentionally proceeds with a spontaneous vaginal breech birth.
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