How we went to routine cesarean for breech and back again in the era of evidence-based medicine

For further information, contact Melissa Maimann at Essential Birth Consulting. Link

The media is reporting that the Society of Obstetricians and Gynaecologists of Canada (SOGC) no longer recommends routine cesarean when the baby is presenting breech at term. The new clinical practice guideline entitled “Vaginal Delivery of Breech Presentation” concludes that “vaginal delivery is reasonable in selected women with a term singleton breech fetus.”

Automatic cesarean for breech has been the international standard of care since the results of the Term Breech Trial (TBT) ... the trial’s findings ... seemed to suggest that vaginal breech birth posed unacceptable risks to the baby. The results included:

combined stillbirth and neonatal mortality rate excluding lethal congenital abnormalities: 0.3% in the planned c-section group vs. 1.25% in the planned vaginal group combined perinatal mortality and serious neonatal morbidity: 1.6% in the planned c-section group vs. 5.0% in the planned vaginal group no differences in maternal mortality or morbidity between groups

There has not been another randomized controlled trial of term breech birth since the TBT. ... The journey to routine cesarean and back provides an important lesson in the nuances of evidence-based medicine. Let’s take a look at how the evidence has unfolded.

First, over the months and years following the trial’s publication, a flurry of responses poured in from clinicians and researchers ... pointing to flaws and irregularities in the trial ... Cracks in the evidence were already appearing.

Then ... the TBT research team tracked down the trial participants and reported long-term health outcomes. ... almost all of the babies with severe morbidity after birth in both trial groups survived without any long-term neurological compromise, and differences in combined mortality and morbidity between the cesarean and vaginal groups had disappeared ...

... Those randomized to a trial of labour had a 6% absolute lower chance ... of having a two-year-old child with unspecified medical problems, suggesting some lasting benefit of labour to the newborn immune system.

Meanwhile, several large non-randomized studies were released, consistently reporting excellent outcomes of planned vaginal breech birth. The largest, a prospective cohort study four times the size of the TBT ... [found] There was no difference in perinatal mortality (0.08% vs. 0.15%) or serious neonatal morbidity (1.6% vs. 1.45%) between planned vaginal and planned cesarean birth ...

... SOGC’s change of heart was ... also influenced by a vocal and persistent group of consumers and clinicians who pushed back against routine cesarean for breech. ... They also recognized the ethical problems inherent in coercing women to accept the risks of surgery in exchange for little if any benefit to their infants ...

... We do not yet know if the change in guidelines will translate to a meaningful change in practice, or for that matter, whether we will see a similar guideline revision south-of-the-border ...

It will be interesting to see how long it takes in Australia before vaginal breech birth is the norm. Or should I say - vaginal breech delivery. I'd like to see a ransomised controlled trial comparing the difference in outcomes between women having a breech birth and a breech delivery!!! See Lisa Barrett's Blog for info on vaginal breech birth.

Melissa Maimann, Essential Birth Consulting 0400 418 448