I was reminded via twitter this week of my clumsy attempt at comedy when speaking at the fabulous CCSU MidSoc conference earlier this year: “I am, like many others, a little frustrated at how long we have been waiting for the RCOG to revise and update its guidelines; they are so overdue if they were a baby they would have been born by emergency caesarean section by now” (don’t worry I’m keeping the day job…).
The current RCOG breech guidelines were published in 2006, a whole 10 years ago. Only 1 other green top guideline is older (Tubal Pregnancy, 2004) so why is the breech guideline taking so long when there have been several good pieces of research and mounting evidence that a change of guidance is required?
We all know that change in healthcare can be really slow; like a massive ship trying to change course with a reluctant captain who rather likes the view as it is. But there are rather telling examples where change has been rapid. When the Term Breech Trial (Hannah et al, 2000) published their controversial results of their breech research in 2000 the number of vaginal breech births declined dramatically across the world. In the Netherlands, caesarean section for breech rose from 50% to 80% within 2 months of the publication of the research (Reitberg et al, 2005) and it has been said that no other research has impacted an area of clinical practice in such a short period of time.
It appears that the good captain had already plotted the course and was just waiting for the green light to turn hard right, full steam ahead. My obstetric colleague whispered that it was a relief that they would not be called for the odd ‘difficult’ vaginal breech in the middle of the night again; much easier the planned caesarean at 10am.
The move to surgical delivery for all breech babies at the turn of this century could not be more neatly presented as an example medicalisation of childbirth. Breech was redefined in a moment as the abnormal, dangerous and in need of obstetric intervention and rescue. And women’s birth choices were effectively removed.
The ship needs steering back on course; vaginal breech is a safe option for some women according to the current evidence, but I fear there is some reluctance in some quarters. Medicine, who advocates the authority of research to guide clinical practice, appears distracted and unconvinced when presented with current research that supports vaginal breech birth as an option. Local breech clinical guidelines reviewed and updated with the most up to date evidence, are not signed off as they don’t align with the 10year old breech RCOG guidelines. And I continue to hear that women are still being told they are ‘not allowed’ a vaginal breech birth or that there ‘aren’t staff with the skills’ to support their choices.
In this age of medical dominance the RCOG is a powerful and influential body which can make a difference. The draft RCOG breech guidelines I was able to review and comment on earlier this year were a huge improvement and will be a game changer for women and advocates for women’s birth choice (surely this is everyone??).
So I look forward in anticipation to these overdue breech guidelines. I know there are stirrings and that labour is imminent; not normally one to interfere, in this case I would offer these breech guidelines a stretch and sweep to move it along a little swifter – just give me a call.