Canada's Obstetricians Release Updated Breech Guidelines: Informed Consent is Key

Introduction

The Society of Obstetricians and Gynaecologists of Canada (SOGC) has just released new guidelines for the Management of Breech Presentation at Term (No. 384).  These new guidelines were last updated more than 10 years ago.  The updated guidelines center informed consent shared decision making and appropriate provider trainer in order to be able to safely and routinely offer vaginal breech births for appropriate candidates. 

Three percent of babies are breech (not vertex/head down) at birth.  People with anatomical differences in their uterus or pelvis, multiples or too much/too little amniotic fluid are more likely to have a breech baby at term.  Currently, In the United States, almost all breech babies are delivered by a cesarean.  Other places around the globe also follow that trend.  In some countries, a breech baby may be born vaginally.  This may be the case in under-resourced countries where a cesarean delivery is often not available or cannot be performed safely.

As the vast majority of births moved into the hospital in the past century in developed countries, and traditional midwifery skills were replaced with deliveries done by obstetricians, the pendulum has swung between vaginal breech delivery and cesarean delivery for a breech baby.  If there are subsequent births after a cesarean, in the USA, more than 87 percent of those births are delivered by a planned repeat cesarean.  Reducing the first cesarean has a significant impact on the need for future cesareans in the same parent.

Change in Society of Obstetricians and Gynaecologists Updated Recommendations

The guidelines just released by SOGC include the following changes/information:

1. Evidence that perinatal mortality risk is between 0.8 and 1.7/ 1000 with planned vaginal breech birth and 0 and 0.8/1000 for planned Caesarean section. 

2. Cerebral palsy rates and long-term neurological outcomes are similar with planned vaginal breech birth and planned Caesarean section. 

3. There is modest evidence that home breech birth is associated with approximately 10-fold higher risk of perinatal mortality than well-supported planned vaginal breech birth in hospital. 

4. There is modest evidence that careful induction of labour may involve similar level of risk as planned vaginal breech birth. 

5. Changed to GRADE evidence ratings. 


The key messages from SOGC are:

1. In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a planned vaginal breech birth and planned Caesarean section, and informed consent should be obtained. A woman’s choice of delivery mode should be respected. 

2. Long-term neurological infant outcomes including cerebral palsy do not differ by planned mode of delivery, even in the presence of serious short-term neonatal morbidity. 

3. The risk of planned vaginal breech birth is acceptable to some women with a term singleton breech fetus. 

4. Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should be provided the best possible in-hospital care. 

5. Women will continue to ask for planned vaginal breech birth, and unplanned vaginal breech birth will occur in various settings; therefore, vaginal breech birth should remain a part of core and continuing obstetrical training/education. 

6. Appendix added: sample Patient Information Sheet and Consent Form

The entire Canadian guidelines are available for free and is downloadable to all for the next month here.  These new guidelines are detailed and identify recommendations for who is an appropriate candidate for a vaginal breech birth, and what criteria should rule out a pregnant person from having a vaginal breech birth.  Labor management recommendations during intrapartum are identified.  A suggested delivery technique is provided.  Throughout the guidelines, the GRADE evidence ratings for reach recommendation is included so that the reader can assess the weight of the recommendation.

Informed consent

There are clear and concise recommendations for consent including a sample consent form in the appendix of the guidelines.  SOGC also stresses that they are not supportive of community births (home or free-standing birth center) for vaginal breech birth and recommend that hospitals have an OR team in house.  There is also an acknowledgement that newer practitioners may not have the skills necessary to support vaginal breech births safely and encourage the “each one, teach one” model of mentoring to encourage skill development.

Conclusion

The Society of Obstetricians and Gynaecologists of Canada released new breech guidelines for the first time in 10 years. They recommend an external cephalic version if appropriate for a full-term breech baby.  After that, if baby is not head down, and the candidate is a good candidate for a vaginal breech birth, the provider should counsel the patient on the benefits and risks of both vaginal breech birth and planned cesarean and encourage shared decision making and support of the patient’s decision.  Here are the American College of Obstetricians and Gynecologists' (ACOG) Breech Guidelines.

Childbirth educators and other birth professionals working with expectant families can share the current SOGC recommendations and encourage dialogue between the family and their provider, even if they are not in Canada.  Reducing the number of unnecessary cesareans is a critical component of reducing maternal mortality and morbidity rates worldwide.  Vaginal breech birth with a skilled provider and full informed consent can help lower cesarean rates and the accompanying downstream impacts.

Have you had a chance to read these new guidelines?  What are your thoughts?  Do you believe that ACOG should consider encouraging similar recommendations? Please dialogue with us in the comments section below.

References

Kotaska, A., & Menticoglou, S. (2019). No. 384-Management of Breech Presentation at Term. Journal of Obstetrics and Gynaecology Canada, 41(8), 1193-1205.

Mode of term singleton breech delivery. ACOG Committee Opinion No. 745. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e60–3.

Published: July 26, 2019

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