Re: Breech deliveries

Dr Krisman laments the end of the era of vaginal delivery of babies presenting by the breech.[1] His feelings are understandable, for few skills in the obstetrical armamentarium can equal those involved in the conduct of a breech birth and there is enormous satisfaction when it has been successfully accomplished.

The Piper’s forceps have joined the cephalotribe and cranioclast in the glass-enclosed museum of obstetrical curiosities, not on a whim, but based upon a carefully controlled study under the aegis of the respected Society of Obstetricians and Gynaecologists of Canada.[2] The trial chose only carefully selected cases for inclusion in the study. Whilst the experience of those involved is measurable, their technical dexterity and judgment in terms of timing and intervention is not. The trial involved 2088 cases in 21 countries. Half were assigned to vaginal birth and the other to elective cesarean section. It was abruptly terminated prior to its completion owing to the significant neonatal morbidity and mortality of those in the vaginal birth group. The report concluded, “…we found that the fetuses of women allocated planned caesarean section were significantly less likely to die or to experience poor outcomes in the immediate neonatal period than the fetuses of women allocated planned vaginal birth.” “…with a policy of planned caesarean section, for every 14 caesarean sections done, one baby will avoid death or serious morbidity.”[3]

The SOGC has recommended cesarean section for all cases of singleton breech presentation in labor, with the occasional exception of congenital abnormality, advanced labor, and prematurity.

Dr Krisman fails to mention that there is a readily available means of reducing the 14,000 primary cesarean sections which, if no steps are taken, will be performed annually for breech babies. External cephalic version, where there is no contraindication such as placenta previa or cord entanglement, should be successful in at least 50% of cases. My plea is that young obstetricians should be taught this procedure and in each centre a few skilled persons should be responsible for attempting an external cephalic version in all suitable cases. The advantages of having a few highly qualified individuals caring for less common complications—in this case, breech presentation at term occurs in about 4%—has been clearly demonstrated in other fields such as colposcopy and gynecologic medical oncology, to cite two obvious examples.

To encourage the acquisition of this useful skill, apart from its obvious benefit to the patient, might also assuage Dr Krisman’s sadness at the loss of one of the accoucheur’s arts.

—H.E. Woolley, MD 
Vancouver

References

1.  Krisman AM. Breech deliveries. BC Med J 2001;43:324. Full Text 
2.  The Canadian Consensus on Breech Management at Term. SOGC Policy Statement No. 31, November 1994. Full Text 
3.  Hannah ME, Hannah WJ, Hewson SA, et al. For the Term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term: A randomized multicentre trial. Lancet 2000;356:1381. PubMed Abstract