Running head: VAGINAL BREECH BIRTH 1

Vaginal Breech Birth- Still a Controversy

Atoosa Benji

Midwifery College of Utah

VAGINAL BREECH BIRTH 2

Abstract

Vaginal breech birth has been a hot topic for many years in the field of obstetrics. Up until the

year 2000, obstetricians performed vaginal breech deliveries to varying degrees, dependent upon

their level of expertise and comfort. In the year 2000, a study published in The Lancet, rippled

the world of obstetrics, and left women with less options for a vaginal breech birth. Hannah et

al., (2000) conducted a worldwide study of 2033 women randomly assigned to a planned vaginal

birth or a planned cesarean section for a baby in the breech position at birth. Both mothers and

newborns were followed up at 6 weeks. The research showed that both perinatal and neonatal

mortality as well as serious neonatal morbidity were less in the planned cesarean section group

than the planed vaginal birth group. The researchers concluded that a planned abdominal

delivery is safer for the term fetus than a planned vaginal birth. In response to the findings of the

Term Breech Trial (TBT) of 2000, The American College of Obstetrics and Gynecology (ACOG)

published a committee opinion in 2001 recommending that all babies in the breech position be

delivered by cesarean section. In the years following the TBT of 2000, many studies proved the

TBT erroneous in its findings due to problems with the methodology of the study. As a result of

these findings, in 2006, ACOG replaced its original recommendation. ACOG revised the

statement now recommending that vaginal breech birth may be considered a safe option if certain

parameters are in place for proper candidate selection, as well as protocols for the positions of

the term fetus and the expertise of the care provider in attendance. However, the damage caused

by the 2000 TBT may never be repaired. Many obstetricians have stopped offering vaginal

breech birth as an option to women, thus increasing cesarean rates worldwide.

Keywords: breech vaginal delivery, cesarean section, trial of labor, singleton, vertex
VAGINAL BREECH BIRTH 3

In the past half-century, we have made advances in the field of obstetrics, and consensus

has been reached on the management of many obstetrical complications. However, with regards

to vaginal breech delivery of the term singleton fetus, the controversy continues worldwide. Up

until the year 2000, obstetricians were trained in delivering babies in the breech position

vaginally. However, in 2000 the findings of the Term Breech Trial (TBT) study published in The

Lancet resulted in a drastic reduction of vaginal breech deliveries both in the US and in other

countries. The study concluded that vaginal breech birth was not a safe option and that babies in

the breech position would be safer born by cesarean section (Hannah et al., 2000). In the years

following the 2000 TBT, researchers found flaws in the TBT study, pointing to problems in the

sample selected for analysis. The problem lay wherein selection criteria were not in place for the

mothers and babies who participated in the study. Additionally, standard protocols were not in

place for the clinician in attendance nor for the delivery itself. While a vaginal breech birth is

not being offered as an option to many women and being outright refused to others, the evidence

shows that with careful selection of candidates and with the right parameters in place at the time

of birth, a vaginal breech delivery is a safe option for both mother and baby.

Breech presentation at term occurs in approximately 3-4% of all pregnancies (Hickok et

al., 1993). While some obstetricians are trained, skilled and confident in performing vaginal

breech deliveries, others refuse anything but a cesarean section for babies in the breech position

at birth. In the year 2000, a worldwide study of 2088 women pregnant with babies in the breech

position at term was conducted. Half of the women were randomly selected for a planned

cesarean section (C/S), the other half for a planned vaginal birth (VBB). When the mothers and

babies were followed up at 6 weeks, researchers found a higher rate of both perinatal and
VAGINAL BREECH BIRTH 4

neonatal mortality and serious perinatal morbidity in the C/S group. The research published in

The Lancet concluded that a planned cesarean section is safer than a planned VBB for the fetus

in the breech position at term (Hannah et al., 2000). As a result of the findings of the TBT,

ACOG published committee opinion number 265, recommending that patients with breech

presentation at term with a singleton fetus should undergo cesarean section. They also stated that

as a result of the findings of the study (2000 TBT), planned vaginal delivery of a term singleton

breech may no longer be appropriate (ACOG, 2001).

In the years following 2000, the TBT research came under heavy scrutiny. Upon deep

analysis, critics found flaws in the studys methodology, thereby deeming the conclusion

erroneous. The focus of the criticism centered on the fact that the minority of perinatal deaths

were related to the actual mode of delivery. Additionally, some of the clinical practices were

questionable, the definitions of neonatal morbidity were loosely defined and the countries in

the study already had widely varying perinatal outcomes (Alarab et al., 2004). Other errors in

methodology included no inclusion criteria for the sample of women, the clinician in attendance

did not have enough training by the standards of institutions in the Western world, and there was

no consistency required for the position of the fetus at the time of delivery. In addition, there

were twins included in the sample, whereas C/S has always been the preferred mode of delivery

for twin delivery. There were also more babies in the planned VBB group weighing more than

4000g. Most professional societies as well as medical literature advises against VBB for a baby

more than 4000g at term (Glezerman, 2005).

VAGINAL BREECH BIRTH 5

In 2002, Hanna et al., conducted another study to determine if any of the babies from the

original 2000 TBT had died or experienced neurodevelopmental delays at 2 years of age. In

research published in the American Journal of Obstetrics and Gynecology in 2004, the study

concluded that a planned cesarean delivery is not associated with reduction in risk of birth or

neurodevelopmental delay in children at 2 years of age (Whyte et al., 2004 p. 864). The 2-year

outcome of death or neurodevelopmental delay is conceptually more relevant than the immediate

primary outcomes found for serious neonatal morbidity or perinatal death (Joseph et al.,

2015).

At the George Washington University Hospital in Washington DC, the Breech Vaginal

Initiative, a collaboration of nurse midwives and physicians experienced in vaginal breech

deliveries is working to reduce the hospitals C/S rates. By improving access to VBB, and by

training their health care providers with skills for safe vaginal breech deliveries, the hospital has

not only reported fewer C/S, but increased patient satisfaction. In 2015, the Breech Vaginal

Initiative reported an 89% vaginal breech delivery rate. In a paper published in Obstetrics and

Gynecology, the team concluded that breech vaginal births are feasible in an academic medical

center through careful diagnosis, patient selection, counseling, and collaboration (Marko et al.,

2015).

A 3-year study women in Ireland presenting with babies in the breech position at term

highlighted the importance of proper selection criteria for vaginal breech delivery as well as

criteria for both pre-labor and intrapartum. Of 641 women sampled, 54% had a scheduled C/S,

46% were given the chance to labor with hopes of delivering vaginally. Of the 46% who were

given a trial of labor, 49% delivered vaginally. There were no incidents of significant trauma,

neurological dysfunction or perinatal deaths associated with the VBB (Alarab et al., 2004).
VAGINAL BREECH BIRTH 6

Considering the harsh criticism of the 2000 TBT and subsequent worldwide studies showing

positive birth outcomes for vaginal breech birth with certain protocols in place, ACOG replaced

its 2001 statement. The 2006 ACOG committee statements states that a planned VBB of a term

singleton fetus may be reasonable under hospital specific protocol guidelines for both eligibility

and labor management (p. 236). ACOG also recommends that a cephalic external version be

offered and performed wherever possible, and that detailed patient informed consent must be

documented. The ACOG recommendation does not include recommendations for twins at this

time (ACOG, 2006).

The original TBT was the source of many changes in the field of obstetrics and

particularly influenced the preference of obstetricians to perform vaginal breech deliveries. In

2006, an American study concluded that simulation training with a basic obstetric model and

instruction improved resident performance in the management of vaginal delivery of breech

babies (Deering et al. 2006). In an Australian study of 303 registered trained obstetricians, there

was a dramatic increase in experience with just one year of training in vaginal breech delivery.

However, of the 65% of the OBs who participated in the study, although 53% of final-tear

trainees reported feeling confident with their skills in VBB, only 11% reported planning to

perform VBB in their future practice (Chinnock & Robson, 2007). It requires less expertise to

deliver a breech baby by cesarean section than it does by vaginal delivery. It is also easier to

plan. More litigation occurs with poor outcomes from vaginal birth than with cesarean section

(Glezerman, 2005). This may well be the motivation behind refusing VBB as an option to

women by many OBs.

Researchers in Finland conducted research to analyze the experience of mothers who had

a VBB in comparison to mothers who gave birth vaginally to a baby in the vertex positions. In
VAGINAL BREECH BIRTH 7

Finland, women are given the option of a VBB if there are no medial contraindications.

However, the most important factor is a mothers wish for a VBB. The researchers concluded

that while a negative birth experience was associated with birth trauma or extended hospital stay,

the birth experience of mothers experiencing a normal vaginal breech birth is just as positive as

the mother delivering a vertex baby vaginally (Toivonen et al., 2014).

In conclusion, the findings of the 2000 TBT study have caused long-lasting ripples in the

world of obstetrics, and more so to the disappearing art of vaginal breech delivery. With

litigation rates high and insurance companies breathing down the necks of obstetricians, it is no

wonder OBs welcomed the recommendations of ACOG in 2001 with open arms. Many

programs stopped teaching breech vaginal delivery to residents altogether and many OBs already

in practice stopped offering VBB to women in their practice. Consequently, the rate of planned

C/S increased and remains high even in light of the 2006 ACOG statement which replaced the

2001 recommendation of performing only cesarean sections for breech babies at term. Vaginal

delivery of a breech baby by midwives is currently illegal in most states. The TBT has been

described as an example of a randomized trial that was impeccable as regards to its

methodological design, but questionable as regards to its clinical design (Grant, 2002). Despite

multiple findings in favor of VBB with certain parameters in mind such as fetal size, fetal

position, mode of delivery, intrapartum interventions and most importantly, exact standards for

the level of training the clinician in attendance has undergone, the authors of the TBT continue to

reiterate their conclusions in all subsequent publications (Glezerman, 2005). It is difficult to

predict whether a trial of labor for a breech singleton fetus at birth will ever become protocol.

However, it is evident from the research presented in this paper that with careful selection of
VAGINAL BREECH BIRTH 8

candidates and with the right parameters in place at the time of birth, a vaginal breech delivery is

a safe option for both mother and baby.

References
VAGINAL BREECH BIRTH 9

ACOG Committee Opinion No. 265: Mode of Term Singleton Breech Delivery. (2001)

Obstetrics & Gynecology, 98, 1189-1190. Retrieved from

http://ovidsp.ovid.com/ovidweb.cgi?

T=JS&PAGE=reference&D=yrovfte&NEWS=N&AN=00006250-200112000-00045

ACOG Committee Opinion No. 340: Mode of Term Singleton Breech Delivery. (2006)

Obstetrics & Gynecology, 108, 235. Retrieved from

http://ovidsp.ovid.com/ovidweb.cgi?

T=JS&PAGE=reference&D=yrovfth&NEWS=N&AN=00006250-200607000-00058

Alarab, M., Regan, C., OConnell, M.P., Keane, D.P., O Herlihy, C., & Foley, M.E. (2004).

Singleton vaginal breech delivery at term: Still a safe option. Obstetrics & Gynecology,

103, 407-412. doi:10.1097/01.AOG.0000113625.29073.4c

Chinnock, M., & Robson, S. (2007). Obstetrics trainees experience in vaginal breech

delivery. Obstetrics & Gynecology, 110, 900-903.

doi: 10.1097/01.AOG.0000267199.32847.c4

Deering, S., Brown, J., Hodor, J., & Satin, A.J. (2006). Simulation training and resident

performance of singleton vaginal breech delivery. Obstetrics & Gynecology, 107, 86-

89. doi:10.1097/01.AOG.0000192168.48738.77

Glezerman, M. (2005). Five years to the term breech trial: The rise and fall of a randomized

controlled trial. American Journal of Obstetrics and Gynecology, 194, 20-25. doi:

http://dx.doi.org/10.1016/j.ajog.2005.08.039

Grant, J.M. (2002). Obstetric conundrums. British Journal of Obstetrics and Gynecology.

109, 968-999.
VAGINAL BREECH BIRTH 10

Hannah, M.E., Hannah, W.J., Hewson, S.A., Hodnett, E.D., Saigal, S., & Willan, A.R.

(2000). Planned cesarean section versus planned vaginal birth for breech presentation

at term: A randomized multicenter trial. The Lancet, 356, 1375-1383.

doi: http://dx.doi.org/10.1016/S0140-6736(00)02840-3

Hickok, D.E., Gordon, D.C., Milberg, J.A., Williams, M.A., & Daling, J.R. (1993). The

frequency of breech presentation by gestational age at birth: A large population-based

study. American Journal of Obstetrics and Gynecology, 82, 605-618. doi:

http://dx.doi.org/10.1016/0002-9378(92)91347-D

Joseph, K.S., Pressey, T., Lyons, J., Bartholomew, S., Liu, S., Muraca, G., & Liston, R.M.

(2015). Once more unto the breech: Planned vaginal delivery compared with planned

cesarean delivery. Obstetrics & Gynecology, 125, 5.

doi: 10.1097/AOG.0000000000000824.

Marko, K.L., Lewis, L., Kapner, M.D., Clausen, M., Casillas, S., & Pinger, W.A. (2015).

Cesarean delivery prevention: The vaginal breech initiative at the George Washington

University Hospital. Obstetrics & Gynecology, 125, 42-43.

doi:10.1097/01.AOG.0000463058.52967.86

Toivonen, E., Palomaki, O., Huhtala, H., & Uotila, J. (2014). Maternal experiences of

vaginal breech delivery. Birth 41:4 316-322. doi: 10.1111/birt.12119

Whyte, H., Hannah, M.E., Saigal, S., Hannah, W.J., Hewson, S., Amankwah, K.,

Cheng, M., Gafni, A., Guselle, P., Helewa, M., Hodnett, E.D., Hutton, E., Kung, R.,
VAGINAL BREECH BIRTH 11

McKay, D., Ross, S., & Willan, A. (2004). Outcomes of children at 2 years after

planned cesarean birth versus planned vaginal birth for breech presentation at term:

The international randomized Term Breech Trial. 191, 864-871.

doi: http://dx.doi.org/10.1016/j.ajog.2004.06.056
VAGINAL BREECH BIRTH 12