Evidence-based practice is based on more than research; it brings together knowledge from a number of sources, research being one of them, clinical and personal experiences another. It may be worth asking the midwife or obstetrician who is providing you with advice on your breech options what the source of their knowledge is. There are Royal College of Obsterics and Gynaecology guidelines that are commonly referred to by health professionals and all maternity services will have local breech guidelines that you may want to ask to see.
Breech presentation and breech birth has not always been seen as a high-risk or abnormal event. At nearly every breech skills session I teach there are midwives and obstetricians who recall breech babies being routinely born vaginally, usually cared for by midwives and not uncommonly at home. Over the last 20-30 years, however there has been increased anxiety around breech. This is partly to do with the general increase in medical impact on childbirth and the risk focus of healthcare, partly to do with breech presentations association with congenital abnormalities (see ‘what is breech section’) and partly to do with influential research studies.
The research studies on breech are limited compared to other childbirth subjects, however in the last 10 years there have been a number of helpful studies and recently a meta-analysis (a review of all the breech data collected in studies over many years) has been published.
The research study that made the most comprehensive change in how breech babies are born today was undertaken by a group of Canadian obstetricians led by Dr Hannah and published in 2000. This research compared women who planned to have an elective (planned) caesarean section for breech and women who planned to have a vaginal breech birth. They concluded it was safer for breech babies to be born by planned caesarean section. No other research study has changed practice in such a short space of time in maternity care. Within just a few years caesarean section for breech presentation in the western world became the overwhelming practice and vaginal breech was considered a risky and unsafe option for the baby. The research had some strong points; it was a large study with over 2000 women involved and women were randomised into 2 groups to reduce the risk of bias. Further studies have agreed with these findings, however there have been many criticisms of the study too. Critics raised concerns about how the study was undertaken, the inclusion of women and babies who already had ill health prior to joining the study, the different skills of the clinical staff providing care and the different care approaches. These criticisms call into question how reliable the study is to be used to inform clinical practice and guide care.
The authors of the study did follow up many of the children born at 2 years of age and found that the outcomes for babies at 2 years was similar regardless of how they were born, suggesting whilst there may be some concerns about how well they were around the time of birth, this did not affect them longer term.
Since this study there have been several other research studies; some studies agree that it is safer for breech babies to be born by planned caesarean section and others conclude that by selecting cases carefully the outcomes are similar for the baby regardless of how they are born.
In 2016 a large review was undertaken that included all the breech data that has been collected over the years. They concluded that there were some risks to the breech baby of vaginal birth when compared to caesarean section, but that these risks are low. The study supports the continued practice of individualised decision making for women to support their choice of how to give birth. These large reviews are helpful as they compare large amounts of information, but as the approach, skills, interventions (such as epidurals and induction) are different between the data reviewed it does make full comparison difficult. Childbirth is a very complex phenomenon with many elements that can impact on the mother and baby which is why research knowledge and clinical knowledge are used together to develop evidence-based practice.
Below I have put the references to the research studies and commentaries that are commonly used to help develop clinical guidelines and practice. Please note this is not a comprehensive list. These articles may not be easily accessible or you may have to pay for them. Institutions such as hospitals and universities will often have subscribed access.
Hannah M, Hannah W, Hewson S Saigal S, M, Hodnett E, Willan A et al. 2000. Planned casarean section verses planned vaginal birth for breech presentation at term: a randomised multicentred trial. The Lancet. 356: 9239:1375
Whyte H, Hannah M, Saigal S, Hannah W, Hewson S, Amankwah K, Cheng M, Gafni A, Guselle P, Helewa M, Hodnett E, Hutton E, Kung R, McKay D, Ross S, Willan A. 2004. Outcomes of children at 2 years after planned caesarean birth verses planned vaginal birth for breech presentation at term: the International Randomised Term Breech trial. American Journal of Obstetrics and Gynaecology. 191:864-71
Reitberg, C., Elferink-Stinkens, P. & Visser, G., 2005. The effect of the Tern Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35, 453 term breech infants. BJOG: an International journal of Obstetrics and Gynaecology. 112, pp. 205-209.
Uotila J, Tuimala R, Kirkenen P. 2005. Good perinatal outcomes in selective vaginal breech delivery at term. Acta Obstetricia et Gynaecologica. 84:578-583.
Goffinet F, Carayol M, Foidart J, Alexander S, Uzan S, Subtil D and Breart G. 2006. Is planned Vaginal Breech Delivery at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynaecology. 194:1002-11
Pradhan P, Mohajer M, Deshpande S. 2005. Outcome of term breech births: 10 years’ experience at a district general hospital. BJOG. 11:218-222
Borbolla Foster A, Bagust A, Bistis A, Holland M, Welsh A. 2014. Lessons to be learnt in managing the breech presentation at term: a 1 year single centre retrospective study. Australian and New Zealand Journal of Obstetrics and Gynaecology. 54: 333-339
Berhan Y, Haileamlak A. 2016. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies. BJOG;123:49–57
Kierse M. 2002. Evidence Based Childbirth Only for Breech Babies? Commentary on the Term Breech Trial. Birth 29:1
Kotaska A. 2004. Inappropriate use of Randomised trial to evaluate complex phenomena: case study of vaginal breech delivery. British Medical Journal. 329:1039-1043
Lawson G. 2012. The Term Breech Trail Ten years on: Primum non Nocere? Birth. 39:1
Banks M. 2001. Commentary on Term Breech Trial. http://www.radmid.demon.co.uk/breechbanks.htm
Royal College Obsterics and Gynaecology greentop guidelines on breech (note these are under review and a revised guideline is expected very soon)
Women’s experiences of breech
In 2011 a group of midwives undertook a study exploring women’s experience of finding out their baby was breech and how they made decisions regarding how to give birth. The researchers’ found that this was a really complex experience where women drew on their life experiences, how they saw themselves as mothers and their own values and personality. They also found there were strong external influences such as social pressures from those around them and from medical people. They concluded that there needed to be better communication and respect for women’s views and values.
Guittier MJ, Bonnet J, Jarabo G, Boulvain M, Irion Oand Hudelson P. 2011. Breech presentation and choice of mode of childbirth; a qualitative study of women’s experiences. Midwifery 27 e208-e213
Founds S. 2006. Women’s and provider’s experiences of breech presentation in Jamaica: a Qualitative study. International Journal of Nursing Studies. 44: 1391-1399
My research, which also explored the breech experience, will be shared in the very near future, so watch this space!