Vaginal breech births: the debate continues

Abstract

British Journal of Midwifery • August 2015 • Vol 23, No 8 It is not unusual for me to receive a press release or two a day about a new midwifery study with a headline meant to catch my attention. Most of the time I skim read them for importance and file them away to be read more thoroughly at a later date. However, at the end of last month, my inbox pinged with news of new study published in BJOG about the risks of planned vaginal breech birth compared with planned caesarean section for breech presentation (Berhan and Haileamlak, 2015). The title of the press release—‘Caesarean birth “safest” for breech delivery, but the absolute risks of vaginal delivery remain small’—sparked my attention. At a time when the UK’s caesarean section rate is already too high, at 24.6% (Macfarlane et al, 2015; World Health Organization, 2015), will this study help to contribute to the rising numbers of caesarean sections and undo some of the work done to encourage normal births? The methods of breech birth have been hotly debated for many decades. Hannah et al’s (2000) Term Breech Trial (TBT) transformed breech practice, concluding that a planned caesarean section is better than a planned vaginal birth for a term fetus in the breech presentation: swaying the balance towards an increasingly ‘safer’ practice of caesarean section and away from vaginal breech births. However, the TBT was not what it seemed. Sanders and Steele (2012) discussed the TBT, highlighting the flaws in the design of the study. The authors themselves found that there were no differences in outcomes from mode of birth in their 2-year follow-up (Whyte et al, 2004). Despite this, the recommended method of breech birth remains via caesarean section. On initial reading, Berhan and Haileamlak’s (2015) study agrees with the TBT (Hannah et al, 2000). The results showed that the relative risk of perinatal mortality and morbidity was between two and five times higher in planned vaginal breech birth compared to planned caesarean section birth. However, the absolute risks were very small. It is so important that information on relative vs absolute risk is portrayed accurately to women. Neither vaginal breech birth, nor caesarean breech birth is riskfree. Therefore, a woman must be made fully aware of the risks and benefits of each, in order for her to make a truly informed decision about her care. Vaginal breech birth requires skilled management and continuing to deliver breech babies via caesarean section means that midwives are becoming deskilled in this area. Therefore, understanding these risks and chosing a vaginal breech birth is moot if midwives are not able to offer this service. If the options aren’t available because midwives don’t have the skills, where is the choice and how are we going to achieve the demedicalisation of birth? BJM