AFTENPOSTEN: Three out of four women who participated in a Norwegian study completed a vaginal breech birth. One out of four had to have an emergency caesarean.

For several years, doctors at Haukeland University Hospital in Bergen collected data about breech births and the children’s conditions. 625 of the women who had children in breech were chosen to give birth naturally (vaginally), not by planned caesarean section. Three out of four had a natural birth, while one in four had to have an emergency caesarean.

– The risk of oxygen deficiency was low and no greater than for children born with their head down, says Attending Physician Jørg Kessler at the Women’s Clinic at Haukeland University Hospital. – Most of the children were healthy at birth.

  – What is the reason that as many as one fourth still had an emergency Caesarean section, which is more risky than a planned C-section?

– We always inform parents that there is a slightly increased risk of emergency caesarean section at breech, even if you are planning vaginal birth. But also for babies born head first, ten percent are caesarean. In addition, suction or forceps are used in ten percent of all births, equipment we cannot use in breech delivery, Kessler points out.

The fetuses were monitored with STAN, a form of ECG to measure fetal heart rate and oxygen consumption.

The study was first published in July 2014 in the renowned journal BJOG: An International Journal of Obstetrics and Gynaecology.

Norwegians Are Pioneers

– We should be proud that we in Norway have chosen a different strategy than other countries when it comes to breech, says Kessler.

In 2000, a Canadian study showed that a vaginal breech birth was ‘three times more likely‘ to result in death or injury than for babies born with their feet first.

Thus, it was tempting for gynecologists in many countries to follow that instruction. Almost immediately, the number of caesarean sections exploded – with unintended consequences for many women. Morbidity and mortality at birth increased, especially in countries with poor health care. In May, a commentary article in the prestigious journal The Lancet debated the theme.

– For women who have had a caesarean problems can occur during the next birth. There is a risk that the scar in the uterus may open. In addition, there is an increased risk of bleeding, retained placenta or that the child suddenly dies in the womb, Kessler says.

Lost Knowledge

– We receive increasing numbers of data that children delivered by caesarean section have a higher risk of illness later in life. Now, several countries have acknowledged that the routine caesarean during breech was hasted, and some hospitals are about to change their practice. Unfortunately, there are many obstetricians who have lost the knowledge of vaginal breech delivery.

The Attending Physician believes that Norwegian hospitals are staring to notice this: Danish and Swedish specialists are not used to vaginal breech delivery, and find it safer to perform a caesarean. In Denmark, Sweden and Germany, nine out of ten breech deliveries happens through C-section. In the Netherlands, Belgium and France, obstetricians prefer vaginal birth when possible.

Tragic Death

In June, routines during risk birth at the Women’s Clinic at Haukeland University Hospital received harsh criticism from The Norwegian Board of Health Supervision after the death of a newborn baby in autumn 2012. The child was lying in breech position, but despite complications caesarean was not performed. The child died a few hours after birth due to injuries.

– Why do you choose to publish a study that says breech deliveries are safe after this incident?

– The study has been going on for many years and the date of publication has no connection with neither the report from the Board of Health nor the tragic event during a breech delivery in 2012. We have deeply apologized to the parents, says Kessler.

Listens to the Women

Also another child died during breech at the same clinic. The mother felt that she was not heard when she said she wanted a caesarean.

In an audit report from 2013, The Norwegian Board of Health Supervision in Hordaland County writes that patient safety at the clinic is not good enough, and that women are not allowed to participate in decisions concerning their delivery method.

– We always talk to the women in advance, more than we might have done previously. When they get satisfying information, most women with fetus in breech chose vaginal birth. If she still wants a caesarean, we come to the bottom of why they want it and make a birth plan that both we and the woman agrees, says Kessler.

Variations across the Country

There are major differences in how maternity wards perform breech deliveries. Many hospitals rely almost exclusively on caesarean breech births, especially in the districts.

At Østfold Hospital, 91 percent of breech deliveries are caesarean. Haukeland University Hospital in Bergen are “best in class” among the large hospitals with 58 percent, while at Ullevål University Hospital in Oslo 76 percent breech births last year were caesarean. Numbers are according to figures newspaper Aftenposten has obtained from the Medical Birth Registry at the Norwegian Institute of Public Health.

Requires the Best Emergency Response

– There will always be large differences in the maternity department’s staffing, expertise, and emergency caesarean when it comes to facilitating vaginal breech deliveries, says Jone Trovik, leader of the Norwegian Society for Gynecology and Obstetrics and Attending Physician at the Women’s Clinic at Haukeland University Hospital.

The Norwegian Society for Gynecology and Obstetrics “Veileder for fødselshjelp 2014” (Guidelines for Obstetrical Practice 2014) presents detailed recommendations for when vaginal breech delivery can be implemented.

Vaginal breech delivery is only performed where the emergency response is highest.

– The association works to maintain knowledge about vaginal breech deliveries among the gynecologists, says Trovik.

Acting Division Director for the Specialist Health Service, Kristin Cordt-Hansen, is concerned that patient safety is maintained in a proper and satisfactory manner.

– Most births are performed without increased risk for the mother or child. At about 4 percent of all births the baby is in breech position. When a thorough medical evaluation has found it safe to perform a vaginal breech delivery, it is regarded as a safe method. The Norwegian Directorate of Health does not have guidelines for which methods that are preferred during in uncomplicated breech deliveries.

FACTS:

* In the study period 2004-2008, 750 births (3.2 percent) of total 23,219 were breech deliveries at Haukeland University Hospital

* 625 of these (83 percent) were pre-selected for vaginal birth

* Around three-quarters were vaginal breech deliveries, while one in four had to have an emergency caesarean

* A breech birth is when a baby is born with buttocks or legs first as opposed to the normal head-first presentation

Text translated and modified by: Anette Broteng Christiansen, ThorNews

Source: Aftenposten, Merriam-Webster, Norwegian Society for Gynecology and Obstetrics

Photo: Ernest F/Wikimedia Commons

Categories: Sports & Health