Obstretricians debate whether Caesarean section is always best for breech babies

By Tracy Sutherland
Special to The Washington Post
Tuesday, January 5, 2010; HE01

About 32 weeks into her first pregnancy, Christie Craigie-Carter's obstetrician told her that the baby she was carrying was stuck in a bottom-down position -- a breech baby -- and that she'd have to give up her dream of a natural delivery and have a Caesarean section instead.

Desperate to avoid surgery, Craigie-Carter said she wanted to deliver the baby naturally anyway, but her doctor told her that such a procedure was simply too dangerous. "She said I wouldn't find a obstetrician on the East Coast who would deliver a breech baby vaginally," recalled Craigie-Carter. When she asked her obstetrician to try to turn the baby into a head-down position by manually manipulating her abdomen, Craigie-Carter was told that such a maneuver might endanger the baby's life by causing the placenta to separate from the uterine wall.

Craigie-Carter went into labor just before her due date and her son Joshua was delivered -- via C-section -- giving her an adored and healthy baby but also lingering regrets that she hadn't been able to even try to deliver him naturally.

Her experience highlights a debate over whether breech babies should always be delivered by C-section or whether there are cases where a natural delivery is a safe option.

In the United States, such babies are routinely delivered by C-section, in large part because of an international study, published in 2000, that found breech babies faced greater risks when delivered naturally. But the issue has received fresh attention following the decision last June by the Society of Obstetricians and Gynaecologists of Canada to reverse past opposition to natural deliveries and suggest that "planned vaginal delivery is reasonable in selected women."

The American College of Obstetricians and Gynecologists remains firmly opposed to vaginal deliveries of breech babies, warning of the dangers of the head's becoming trapped inside the mother; of neck injuries and paralysis if the baby is extracted incorrectly; and of pressure on the umbilical cord that could shut off blood supply to the baby.

Breech babies account for between 3 and 4 percent of full-term pregnancies worldwide, according to the 2000 study.

There are three typical ways in which a baby presents as breech: frank (with the bottom down and feet up near the ears); complete (with knees bent and feet near the bottom); and footling (with one or both feet pointing down toward the birth canal).

"You may get into a situation where the baby is stuck, and I've been there, and it is a true obstetric emergency," said Helain J. Landy, head of the department of obstetrics and gynecology at Georgetown University Hospital. Landy said she attempts to turn breech babies into a head-down position using external manual manipulation, but if that fails she "would probably recommend a C-section."

She said that she is "a proponent of what the patient wants as long as it makes sense in terms of her safety and the baby's safety." But because the majority of her patients are first-time mothers, often having had fertility treatments to get pregnant, Landy does not get much call for delivering a breech baby vaginally. She hasn't delivered a singleton breech baby naturally for 14 years, although she has delivered breech babies who were the second of twins where the first had come out in a normal head-down position, opening up the birth canal in the process.

"With experience comes a little bit of hindsight, and maybe I'm just not as much of a cowboy as I might have been when I was younger, but I really want to get a healthy baby and a healthy mom," Landy said. And given that breech births are trickier, concern about medical malpractice suits is a big factor behind the doctors' widespread reluctance to perform natural breech births, she said.

Yet some obstetricians believe that breech delivery is reasonable in certain cases and bemoan the loss of this skill among obstetricians trained today.

"When I started in residency [in the late 1970s] we did not do C-sections on breeches at all; it was normal to have a vaginal breech," said Michael Hall, 59, an obstetrician-gynecologist in Colorado. He has done about 300 vaginal breech deliveries in his career and continues to do them for carefully selected pregnancies: when labor has been normal, the baby is not too big or in the footling position, and the width of the mother's pelvis is adequate.

Dueling articles

The study that raised concerns about natural breech deliveries was published by the Lancet, a respected British medical journal. Known as the Term Breech Trial, it examined the cases of 2,088 women in 26 countries and found a significantly higher risk of death and injury for breech babies delivered naturally than for those delivered by C-section. "Planned [C]aesarean section is better than planned vaginal birth for the term fetus in the breech presentation," it concluded, though it also found that "serious maternal complications are similar."

Yet in recent years, the study's conclusions have been challenged by two papers published in the American Journal of Obstetrics and Gynecology.

In a January 2006 article, Marek Glezerman, head of obstetrics and gynecology at Tel Aviv University in Israel, argued that the study's recommendations should be withdrawn because most of the deaths or post-birth problems reported in the research "cannot be attributed to the mode of delivery." Glezerman reported that the study included cases of planned vaginal deliveries of breech babies when "there was no attendance of a clinician with adequate experience." (The 2000 study said, "Women having a vaginal breech delivery had an experienced clinician at the birth.")

The second article, published in April 2006, surveyed 8,105 breech births in France and Belgium where, it noted, vaginal delivery of breech babies is "a common practice." The study found that "when strict criteria are met before and during labor," planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women." The criteria for natural delivery included the mother's pelvic width, the position of the baby's head, the baby's weight, a frank breech position and a carefully monitored labor.

In response to the studies and to demand from patients, the Canadian obstetrics group adopted new guidelines in June approving natural deliveries for select cases.

The organization's executive vice president, André Lalonde, said in an interview that "there was no substantial evidence that C-section was very superior to breech vaginal birth in selected cases" with an experienced obstetrician.

Hal Lawrence, a vice president of the American College of Obstetrics and Gynecology, said that his organization routinely reviews its guidelines, but added that "our current recommendation is [that] the safest way for a breech delivery at term would be the abdominal approach" with a C-section.

Some American doctors still do breech deliveries if the mother requests it and the circumstances permit.

"If you select your breech patient carefully and thoughtfully, then it's as safe for the baby as having a Caesarean section, and in some cases may be safer," said Stuart Fischbein, a California obstetrician. He has delivered about 200 breech babies vaginally but in August was told by his hospital to stop. "The bottom line is litigation mitigation and economics," he said. Regardless of expert guidelines, the reality is that few doctors who graduated in the last decade have the skills to deliver breech babies naturally. Lawrence said American medical students are taught the theory behind vaginal breech deliveries and have access to computer simulation training, but exposure to real cases is limited to residents who happen to be on call when a mother presents with a breech baby in advanced labor and it is too late to perform a Caesarean.

Canada faces the same problem. Having changed its guidelines, Lalonde's group has put out a call to older physicians with the skills to deliver breech babies naturally to teach younger doctors. "The response has been good," he said. "We're going with the approach that this is something that has to be offered to all women, in all hospitals."

Craigie-Carter, for one, would approve of that approach. After Joshua was born, she went on to have two more breech babies. The first was delivered by C-section. But for the second one, she found a skilled midwife near her New York home who was willing to help her deliver naturally. Her son Ryan was born without complications.

Sutherland a Washington-based freelance writer.

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