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Is breech vaginal delivery safe?

Between 3-4% of babies begin labor in the breech (bottom first) position, increasing the risk of neonatal morbidity and mortality. Pre-emptive C-section has become the preferred method of delivery for breech babies, but now some are questioning this recommendation. The controversy is fueled by differing appraisals of the danger and by differing assessments of the whether any risk of neonatal death can be justified in the age of the safe Cesarean.

The best conducted and most important study comparing breech vaginal delivery with elective C-section is the Term Breech Trial (TBT) conducted by Mary Hannah and colleagues. It is the only randomized control trial of its kind.

… [W]e 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. Although some of the deaths in the planned vaginal birth group were related to difficulty with vaginal breech delivery, others were clearly associated with problems during labour. Thus the avoidance of labour and vaginal breech delivery could have contributed to better outcomes with planned caesarean section…

A more recent trial, the PREMODA (PREsentation et MODe d’Accouchement: presentation and mode of delivery) study produced different findings and as a result, some obstetricians have been calling for a re-evaluation of the standard recommendation for C-section delivery of a breech baby.

The groups [planned vaginal delivery vs. planned C-section] did not differ significantly for the combined outcome of fetal or neonatal mortality or serious morbidity (odds ratio [OR] = 1.10, 95% CI [0.75-1.61]. Of the criteria included in this combined variable, only a 5-minute Apgar score less than 4 was significantly more frequent in the planned vaginal group (n = 4 vs n = 1, OR = 8.9, 95% CI [1.00-79.8]). Of the other individual outcomes, the following were significantly more frequent in the planned vaginal than in the planned cesarean group: 5-minute Apgar score less than 7 (OR = 3.2, 95% CI [1.9-5.3]), total injuries (OR = 3.9, 95% CI [2.4-6.3]), and intubation (OR = 1.8, 95% CI [1.08-3.1]).

The authors of the PREMODA study acknowledge that their trial was not randomized and that the results must applied with caution. Nonetheless, the authors concluded:

In centers where planned vaginal delivery remains a widespread practice and in complying with rigorous conditions before and during labor, we did not find a significant excess risk associated with planned vaginal delivery compared with planned cesarean for women with a singleton fetus in breech presentation at term. There may be a slightly higher neonatal risk associated with planned vaginal delivery but it is very different from that reported in the only published large randomized trial….

In light of the PREMODA study, some obstetricians have been calling for a return to breech vaginal delivery. The NNT to prevent neonatal death from breech is 111. That translates to 110 unnecessary (in retrospect) C-sections for every baby saved. What are the risks of those C-sections? They include hemorrhage, transfusion and possible hysterectomy. Maternal mortality after elective C-section is so rare that many contemporary studies of C-section focus exclusively on morbidity.

So why not simply explain the controversy to patients, as well as the differing findings and let them choose? Putting aside the issue of the magnitude of the risk, are patients capable of giving informed consent to a procedure that will, if widely offered, lead to preventable neonatal deaths? Obviously consent ultimately rests with the patient, but can it be truly informed consent?

Let’s assume for the moment that The Term Breech Trial is correct and the excess risk of neonatal mortality in breech vaginal delivery is 9/1000. That sounds like a small number and many women will reason that the number is so small that they need not worry that their babies will die.

However, 9/1000 means that approximately 9 babies per 1000 WILL die. In the US approximately 140,000 babies each year present as breech at the onset of labor. Not all will meet the eligibility criteria for vaginal delivery (approximately 35% of breech babies are in an unfavorable position for vaginal delivery, and others will exceed the weight criteria or have other contraindications), but even if only half were eligible, that would mean 70,000 attempted breech vaginal deliveries. At an excess rate of neonatal mortality of 9/1000, we could expect that 630 babies would die from preventable neonatal deaths each year.

This is a relatively small number. Indeed, it would barely impact overall neonatal mortality figures (approximately 18,000 neonatal deaths per year), since the bulk of neonatal mortality is due to prematurity and congenital anomalies. On the other hand, that is quadruple the number of deaths we would expect in an otherwise low risk group. Most importantly, that number represents 630 sets of bereaved parents who would have had a healthy baby had they opted for elective C-section. Would those parents accept a preventable death philosophically, or would they be shocked and bewildered that the baby actually died? Would they simply try again or will they look for someone to blame?

Can the excess risk of neonatal mortality can be reduced somewhat by making the eligibility criteria more strict as the authors of the PREMODA study suggest? Only a randomized trial can provide that information, and unless the excess neonatal mortality rate could be reduced dramatically, we would still anticipate the preventable death of hundreds of babies per year.

C-section is not a trivial procedure, but it is an extremely safe surgery, reducing risk to the baby and only slightly elevating risk to the mother. Even though the risk of breech vaginal delivery is small, the outcome can be catastrophic. A lot of unnecessary (in retrospect) C-sections are being done. Do we think that is too high a price to pay to save several hundred babies each year?

Posted in: Obstetrics & gynecology, Science and Medicine

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184 thoughts on “Is breech vaginal delivery safe?

  1. BillyJoe says:

    It sounds wrong.
    Surely it should be “vaginal breech delivery”.

    I googled it:
    “breech vaginal delivery”: 156,000 hits
    “vaginal breech delivery”: 404,000 hits

    Also your first quote contains “vaginal breech delivery” twice

    I win.

  2. BillyJoe says:

    But seriously….

    There are two questions here:
    1) Can mothers really give informed consent?
    2) How should you present the information.

    I think these two questions are related.
    If the information is presented in the wrong way, the legitimacy of the informed consent will be compromised.

    Telling the mother that every year 630 mothers in America who choose vaginal instead of C-section in her circumstances end up with a dead baby would be the wrong way to present the information.

    Telling the mother that if she chooses vaginal delivery there is a 110 in 111 chance that her baby will survive and a 1 in 111 chance that her baby will not survive would be the correct way to present the information.

    The risks of C-section would need to be put in similar terms for her to make a proper risk-benefit assessment.

    Finally, if the patient defers to the obstetrician’s opinion, the obstetrician must be ready and prepared to offer her advice.
    So, Dr. Amy, what would you advise your patient in this scenario?

  3. “There are two questions here:”

    There are a few more. The threshold questions are:

    1. What is the true magnitude of the additional risk? (I lean in the direction of the Hannah study showing excess risk in the range of 9/1000).

    2. What is the real world risk? It’s possibly even higher because the both studies were conducted in conditions that would be difficult to recreate in the real world, and because even the strictest criteria depend on subjective estimates like fetal weight.

    “Telling the mother that every year 630 mothers in America who choose vaginal instead of C-section in her circumstances end up with a dead baby would be the wrong way to present the information.

    Telling the mother that if she chooses vaginal delivery there is a 110 in 111 chance that her baby will survive and a 1 in 111 chance that her baby will not survive would be the correct way to present the information.”

    I strongly disagree. The information should be presented BOTH ways.

    The goal of informed consent is that the information be presented in a way that the patient can understanding the options she has before her.

    Telling the mother that 110/111 C-sections will be unnecessary is important, but telling the mother that 630 babies WILL die and that one of those babies might be hers is equally important.

    As a general matter, lay people have trouble quantifying risk. They often conclude that low risk is the same as no risk, and that is entirely untrue. It is critically important that a mother choosing a very real, though low risk of neonatal death understands that the baby really could die.

  4. TimMills says:

    In areas where C-sections are already routine, there may be nobody experienced in delivering breech babies vaginally, while other areas may have much more experience. I imagine that the degree of experience that obstetricians or midwives have with vaginal delivery of breech babies would have a significant impact on outcomes. Could this be a factor in the difference between the two studies cited above? (If so, that would complicate any attempt to merge them in a meta-analysis.)

    If the difference is largely due to practitioner experience, the next question is this: Do we spend money trying to give people expertise in vaginal breech deliveries (in order to facilitate patient choice), or do we spend that money making C-sections as safe as possible?

  5. “Could this be a factor in the difference between the two studies cited above?”

    No, all the births in both studies were attended by providers experienced in delivering breech babies.

    An uncomplicated breech vaginal delivery requires very little experience. The provider should support the bottom of the baby (so it won’t hand down between the mother’s legs) and let the mother’s body do all the work. Experience is only necessary when the head does not deliver spontaneously and the baby’s life is in danger. Even then, if there is a significant mismatch between the size of the baby’s head and the largest diameter of the mother’s bony pelvis, the baby will be long dead before it has been freed.

    “Do we spend money trying to give people expertise in vaginal breech deliveries ”

    The issue is not money. The issue is a mother’s willing to have a vaginal breech delivery. You can’t get experience unless you attend a fair number of breech deliveries with serious complications. But every one of those babies is at significant risk of dying and some definitely will die. How many infant lives is it acceptable to sacrifice in order to reduce the number of C-sections?

  6. BillyJoe says:

    “Telling the mother that 110/111 C-sections will be unnecessary is important, but telling the mother that 630 babies WILL die and that one of those babies might be hers is equally important.”

    That’s not exactly what I said though.
    I said that the correct way to deliver the information is to tell her that there is a 110 in 111 chance that her baby will survive and a 1 in 111 chance that her baby will not survive.

    She needs to know the risk to her child right?
    How does telling her that there is a 1 in 111 chance of her child not surviving not accurately convey that risk?

    Seems to me that saying 630 babies will die and that one of them may be hers is a way of almost guaranteeing that she’ll opt for the C-section.

    I imagine there must be situations when the mother is unable to decide and defers to your opinion. What would you recommend in that situation?

  7. “Seems to me that saying 630 babies will die and that one of them may be hers is a way of almost guaranteeing that she’ll opt for the C-section.”

    But isn’t that the truth? Doesn’t she need to understand that 630 babies will die and one of them really might be hers?

    “I imagine there must be situations when the mother is unable to decide and defers to your opinion. What would you recommend in that situation?”

    It rarely happened when I was practicing. Most women immediately opted for a C-section. But if there is any doubt, I would want to be absolutely, completely sure that the mother understood the fact that some babies will die and that one of them could be hers.

    Most women simply cannot fathom the idea of a healthy baby dying in childbirth. It is so rare nowadays that women have never seen it and may have never heard of it. Then when it happens, mothers are shocked and outraged; they never envisioned it as a real possibility.

  8. windriven says:

    “Putting aside the issue of the magnitude of the risk, are patients capable of giving informed consent to a procedure that will, if widely offered, lead to preventable neonatal deaths?”

    Why would patients not be capable of giving informed consent? Patients give consent every day to procedures that are far more arcane than C-sections.

    And how can one “put aside the issue of the magnitude of the risk” is assessing whether or not to give consent?

    The primary difficulty, it seems to me, is weighing the risk of neonatlal mortality versus maternal morbidity when choosing section.

    I also question how the French study reported the neonatal outcomes of failed vaginal deliveries. If the baby was in sufficient distress during vaginal to require emergency section and subsequently expired, I suspect that the French (results simply reported by mail) study would count that as a C-section mortality thereby giving a quite distorted picture as the baby might well have lived had the section been elective.

  9. provaxmom says:

    What about other complications for breech? I mean, what would scare me away from a c/s is the sutures/staples, recovery time, etc. That would factor heavily in my decision. I don’t mean that to imply that my comfort takes precedence over a dead baby…..but I would hate for women to opt for the vaginal breech, thinking that the recovery will be as easy as a traditional vaginal delivery, when in fact there may be additional risks such as severe tears, greater chance for uterine/bladder prolapse, etc. What are those additional risks, are there any?

    What about turning? What situations preclude moms from not being candidates for turning the baby? Although I understand this is not a comfortable procedure.

  10. “Why would patients not be capable of giving informed consent?”

    Obviously, the mother is the only person able to give consent, informed or not. The question I am raising is based on my personal experience (and that of many other obstetricians) that patients don’t seem to understand that a low risk of catastrophic outcome means that the catastrophic outcome may very well happen to them.

    Obstetrics has become so successful at handling the inherent dangers of childbirth that parents assume that a baby that starts labor perfectly healthy will be perfectly healthy when it is is born. More importantly, if it isn’t perfectly healthy, they often think that it must be someone else’s fault.

    In reality, an approximately 1% risk of death of an otherwise health baby is actually a large risk, not a small risk. Yet lay people tend to view even a 1% risk as something not likely to happen.

    I think BillyJoe’s comments illustrate that point, by suggesting that the risk is not that high, and that the information should be presented so as to emphasize the fact that most babies won’t die. However, in the US today, the death of any otherwise healthy baby is considered virtually inexcusable. If a mother believes that the chances of death are so small as to be negligible, is she really giving an informed consent?

  11. “If the baby was in sufficient distress during vaginal to require emergency section and subsequently expired, I suspect that the French (results simply reported by mail) study would count that as a C-section mortality thereby giving a quite distorted picture as the baby might well have lived had the section been elective.”

    The authors said they used an “intention to treat” analysis, which means that groups were assigned based on the intended mode of delivery at the start of labor.

  12. rork says:

    I’m not clear where you get 9/1000. Might not the result of perinatal/neonatal mortality of 3/511 cases with “low national perinatal mortality rate” be the one to talk about from the Lancet (TBT) paper? (Unless you are advising a person from a random country.)

    I really don’t see how, after that estimated risk is given, that the figure of 630 deaths/year adds any information about the risk.
    Instead, I would think that one should be obliged to say something about the uncertainty of the point estimate of the risk, and mention what other studies find, if you consider them any good.

    From that Lancet paper, it seems rather likely that experience of the doctors really does matter. The paper failed to perform the statistical tests of that – which I found interesting. It fails to give the summary for mortality alone, but they do present tests for mortality + morbidity, and there the difference between C-section and vaginal intended birth gets smaller and smaller as they look at the more experienced subsets of docs. They only get p=.03 when they reduce to docs with 20 years experience. I suspect that for mortality alone they failed to get p<.05 for those docs (difference small, sample size getting small), which may be why they don't present that. That may have resulted from the usual troubles with getting competent reviews. Is the data-set actually available is another question to be ask of studies that we might actually want to act on – it did not fall in my lap, and I finally gave up trying to find it. Is it acceptable to not cough up the data here?

  13. Scott says:

    If a mother believes that the chances of death are so small as to be negligible, is she really giving an informed consent?

    As informed as most consent, I’d say. How often do patients really understand the risks in any field of medicine? “A 1% chance couldn’t happen to me” is not unique to this situation, or even this field.

    A very worthy discussion to have, certainly – but IMO it’s a much bigger discussion than is immediately evident, because this situation is but one example of a much broader issue.

  14. edgar says:

    But isn’t that the truth? Doesn’t she need to understand that 630 babies will die and one of them really might be hers?

    No, it is not the truth, it is a point estimate based on extrapolation of a single number (number of births per year). This number will change, obviously.

    While using the 1 in 111 is a statistical probability.

    Also, as I have not read the study, no mention is made about types of breech.

    (and Billy is correct, it is vaginal breech delivery, not breech vaginal delivery. The vagina isn’t breech, the delivery is).

  15. “A 1% chance couldn’t happen to me” is not unique to this situation, or even this field.”

    I would argue that it is, for a number of reasons, but most importantly because of expectations.

    If you tell someone that the chance of death from brain surgery is 1%, he or she expects that brain surgery is dangerous and takes that 1% number seriously. On the other hand, because people believe (erroneously) that childbirth is not dangerous, they will discount the chance of 1% that a baby will die.

    We know that lay people have a very difficult time assessing risk. People “feel” that flying on an airplane is more dangerous than driving in a car even though all available data shows that auto travel is far more dangerous.

  16. TsuDhoNimh says:

    A lot of unnecessary (in retrospect) C-sections are being done. Do we think that is too high a price to pay to save several hundred babies each year?

    Reverse it: how many babies are we willing to kill to decrease the C-section rate for breech position deliveries?

    Decreasing the C-section rate to 0 would kill ____?

    And, I think presenting it as 1 of 111 mothers who choses this option buries her baby gets the statistics to a graspable figure.

  17. Calli Arcale says:

    The main problem with the informed consent question is that the mother may need to make the decision at a very difficult time. My last baby was breech, and we did a c-section. My situation was a little different, in that it was intended initially to go for TOLAC. My first baby had been an emergency c-section due to fetal distress. What is the risk of vaginal breech delivery after a prior c-section? Hard to say, and in the end, even the c-section ended up being difficult — she got stuck in the bottom of the uterus, forcing the doctor to make a lengthwise incision. If I ever get pregnant again, attempted vaginal delivery is now out of the question.

    More relevant to this discussion, my baby had been vertex during an exam just a couple of days before. She’d been turning a lot during the last month. It was quite a surprise, therefore, when after my water broke and I went to the hospital, the OB nurse reached in and found a foot. I wasn’t in active labor yet; contractions had started, but were not at all organized. Had I been in active labor, would I have been in the best frame of mind to objectively analyze the situation and give truly informed consent? Hard to say. But that’s probably the best we’re gonna get. It’s probably something that should be discussed with patients about a month before the due date, so they can process the information outside the heat of the moment.

    Medical science tends to be very risk-averse when it comes to delivering babies. That’s not a bad thing, really; nobody wants to hurt moms or babies. But it has restricted science from critically examining whether our fears are well-founded or not, and whether we’re really taking the path of least risk. I’m not sure how to change that situation, because I wouldn’t want to hurt moms and babies either.

  18. Kylara says:

    I had to make this decision, actually. I don’t remember how the risks were presented, exactly — I recall that we discussed that C-section was very safe and that complications were a bigger concern than death; that breech delivery was only slightly less safe but carried a risk of emergency C-section, which would be less controlled than a scheduled C. I don’t think there were numbers, but I don’t think I asked for them. I did ask what “most” women did, and my doctor gave me percentage estimates for his patients.

    I did try CEV (turning the baby from the outside), which didn’t work; he was quite stuck (see below). I think this *slightly* influenced my decision to have a scheduled C section; I felt like I’d done “everything I could” to create an uncomplicated vaginal delivery so I was more comfortable choosing the C section. What was a much larger impact was that delivery breech would have required going to my non-preferred hospital. My preferred hospital was very small, intimate, friendly; the other hospital handled high-risk cases but was much more medicalized and assembly-line. I’m sure it would have been fine, but I was emotionally prepared to deliver in the Small Hospital and had done my classes there and everything there; switching to Big Hospital at 38 weeks seemed very, very stressful and emotional.

    In retrospect the C-section was a good idea; the baby was wedged in my pelvis (with adorable little bruises on his little butt) and wouldn’t have delivered. I think after the attempted CEV the doctors had an idea he wouldn’t deliver, but they couldn’t be sure, of course. (They couldn’t be sure he wouldn’t just flip on his own anyway.)

    Anyway, when I finally made the decision, which was very emotional, particularly because I have an absolute horror of surgery (and being AWAKE for it — that struck me as unimaginably horrific), I made it because I was convinced the C-section would be much safer for my baby and I was afraid of what might happen to him if I tried to labor and it went wrong. I was fairly irrationally afraid that I would die from the surgery; I knew it was irrational, but I was still very frightened. However, I felt like I made the best decision for my baby.

    Now, I teach medical ethics, and we talk a lot about informed consent (of course); was my decision process informed consent? I was certainly informed; I was certainly legally able to consent; but I was also certainly deeply emotionally influenced, and certainly very irrational about surgery. I also didn’t have every study and all the numbers in front of me (though I’ve done that from time to time), and I relied heavily on the expertise of my trusted ob/gyn. It’s a much more complicated issue than just presenting the statistics.

  19. Emma B says:

    Telling the mother that if she chooses vaginal delivery there is a 110 in 111 chance that her baby will survive and a 1 in 111 chance that her baby will not survive would be the correct way to present the information.

    Have you ever had a 1-in-100 condition, and if so, how did you feel about it? If someone had told you before you’d gotten sick that you were at a 1:100 risk, would you have considered it as a likely possibility?

    About two years ago, one of my daughters developed ITP, a blood disorder that occurs in children at a rate of 1/20,000. I’m a math person and computer scientist, so I KNOW that even 1/20,000 is not trivial across a large population, but on the drive to the children’s cancer center, I still felt like we’d been hit with the proverbial lightning strike. When we got there, the staff told me they had two other kids there for ITP treatment and followup, and it immediately made me feel like it was a lot less unusual. When I calmed down and did the math that about 200 kids a year in the US get ITP, it again made me realize that while ITP is unusual, it does happen to a non-negligible number of kids.

    It was all completely psychological, but it shows that even someone who has some formal and professional experience with risk assessment can make an incorrect evaluation in their own personal situation.

    A year after that, a pregnancy ultrasound revealed my son had a potential marker for a fatal genetic condition, and the quad-screen bloodwork came back showing a 1:100 risk. My OB was a little puzzled when I completely freaked out on her — “there’s a 99% chance he will be just fine!”. Fortunately, he was, but that time I understood the magnitude of the risk at a more visceral level. If I’d been just an ordinary parent, though, without my professional background or my prior experience with K’s ITP, I think I would have been a lot more cavalier, and correspondingly more surprised and devastated if A had been affected.

  20. latenac says:

    The problem is all of pregnancy and labor is about statistical probability. Starting with Down’s Syndrome testing. Every first time mother I know freaked out when they got a “positive” back which really could have translated for some of them to a 1 in 500 risk rather than 1 in 1000. And then when the second test came back with proof it wasn’t the case you begin to question everything that involves probability.

    After my test came back with increased risk an ultrasound was done that showed no Down’s Syndrome but an increased risk that dd would be a dwarf. Unfortunately the table that led to this only had 50 kids in it and wasn’t very statistically viable. One doctor said it was something to watch and I went back for ultrasounds every 2-3 weeks. Another OB decided it meant dd wouldn’t survive outside of the womb. It became apparent very quickly that medicine is less of a definite science in some ways than I had thought and we were overwhelmed with information that no one knew what to do with or even how to truly assess the risk.

    In the end it was that the umbilical cord was attached to the side of the placenta. DD is fine and not a dwarf. None of it was discovered until after dd was born. According to the chart I was shown I think dd had at least a 5% risk of being a dwarf with her foreshortened limbs with no other markers for dwarfism.

    DD wasn’t breech but after going through the emotional rollercoaster of statistical probability for most of my pregnancy if any OB had told me I needed to have a c-section b/c dd was breech b/c of a less than 1% chance of her dying I probably would have strangled that OB. I probably would have decided to have the c-section anyway but I was so tired of absolutes being presented that weren’t actually anywhere near absolutes when I asked questions about them that I just wanted dd out.

    OBs would do well to find a better way to present information and explain risks to expectant mothers and make them a partner with what’s going on and respect them. To me, that’s the better way to combat woo. Telling a woman 630 babies will die from the choice they’re making and theirs could be one of the 630 is not the way to do it.

  21. edgar says:

    OBs would do well to find a better way to present information

    I don’t think it is limited to OB, this is something all HCP’s struggle with And actually, IMO, it leads to a larger discussion of healthy literacy, and maybe even a uniform way of describing risk.

  22. crazyred says:

    I think that people sometimes forget that the ultimate goal of pregnancy is a healthy living baby.

    When c-sections were not an option (or where they are still not really an option), so many more babies and mothers were dying in labor. Modern obstetrics has increased happy outcomes and reduced tragic ones.

  23. Kylara says:

    @provaxmom: “What about turning? What situations preclude moms from not being candidates for turning the baby? Although I understand this is not a comfortable procedure.”

    I had cephalic external version done, where they attempt to turn the baby by manipulating the belly (as opposed to reaching in via the birth canal, which I guess is DURING delivery?). This is done some time in advance of delivery in the hopes the baby will then stay head down. (And you stay in the hospital for a couple hours after to make sure there’s no distress to the fetus and it doesn’t need to be delivered immediately.) Mine was done at 38 weeks, which is when the little twit turned sunny side up, so there wasn’t a lot of room to move him.

    It was literally the most painful thing I have ever experienced in my life, and I’m including the entire C-section recovery.

    I’m not sorry I did it, and I would do it again for my baby, but uncomfortable definitely understates it! And I would certainly understand a woman choosing a C-section rather than turning the baby with CEV (even if, let us imagine, she had foreknowledge that the turning would work). It was utterly excruciating … and of course carried its own risks to the fetus.

    I imagine it’s less painful a little earlier (36 weeks, say), or if it’s a second baby and the uterus is more stretchy, or if you’re taller than me, or whatever, but even “somewhat less painful” would still be “worst pain ever” for me!

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  25. Dawn says:

    @Provaxmom: cephalic version can be successful, but, as Kylara points out, is usually very uncomfortable/painful to the mom, and you still risk the baby going back to breech. I have seen it done several times. Most of the time, if there is enough room and the umbilical cord is free (not wrapped around baby anywhere), it works. However, the room to turn the baby also means they have the room to turn back. And, of course, it doesn’t always work – the doc can’t rotate the baby, trying to rotate the baby causes fetal distress, or mom can’t tolerate the pain.

    Usually, in the cases I saw, it was most successful when the mom went in to labor soon afterwards. Height of the mother, size of the baby, etc all do effect the ability to do the version.

    @Kylara: you are again correct, that internal version is done to rotate a baby from breech to vertex during delivery, with the provider inserting their hand into the uterus to rotate the baby. Again, VERY painful to the mother. I’ve seen it done only once, with preterm twins (twin 2 went from breech to lateral, decided to crash his heartrate and the doc pulled him out quickly because we didn’t have in house OR staff for a stat section. He did fine, except for the usual premature baby issues.)

  26. “…based on my personal experience (and that of many other obstetricians) that patients don’t seem to understand that a low risk of catastrophic outcome means that the catastrophic outcome may very well happen to them.”

    Well, you’ve just summed up a fundamental problem with human beings in general. I think that’s a big part of what caused the current financial crisis.

    There’s many ways to say it; take your pick:

    Low risk is not risk free.
    Low risk is not no risk.
    Low risk is not zero risk.
    Low risk still means risk.
    Things can still go very, very badly in a low risk situation.
    A situation can go from low risk to SHTF in the blink of an eye.
    etc…

    People play the lottery every day with far lower odds of winning in the belief that they have some realistic chance of winning.

    Some of it does have to do with framing, such as how you present the information. Some of it also has to do with what the person wants to believe. We want to believe we will win the lottery, but we also want to believe our babies will be fine.

  27. dulcinea says:

    “telling the mother that 630 babies WILL die and that one of those babies might be hers is equally important.”

    I don’t disagree that it would be important to stress that babies DO die from vaginal breech delivery in order to make consent as informed as possible; however, shouldn’t we also have a denominator in that statement? Not being an obgyn, I have no idea how many babies are born each year (i’m sure my guess would be off by an order of magnitude, at least), nor what percentage of those are breech. Without those values as well, it seems like simply saying 630 babies die each year is bordering on scaremongering at an already stressful time.

  28. “I would hate for women to opt for the vaginal breech, thinking that the recovery will be as easy as a traditional vaginal delivery, when in fact there may be additional risks”

    A successful breech vaginal delivery does not have additional risks compared to a successful vertex (head first) delivery, so mothers don’t need to worry about that.

  29. “as opposed to reaching in via the birth canal, which I guess is DURING delivery?”

    Although it sounds similar, an internal version is very different from an external version and is used in an entirely different situation.

    External version is used to turn a breech baby to the vertex (head first position). Internal version is for delivery of a second twin high in the pelvis after the first twin is born. It involves turning a floating baby by the feet to the double footling breech position (feet first) and extracting the baby.

  30. “Medical science tends to be very risk-averse when it comes to delivering babies.”

    Doctors are merely responding to patient expectations. Patients expect (rightly or wrongly) that any baby who starts labor perfectly healthy should be perfectly healthy at birth. It is this belief that drives the skyrocketing C-section rate for breech and for all other indications. It is simply unacceptable to deliver a dead baby.

  31. “I have no idea how many babies are born each year”

    Approximately 4 million.

  32. BillyJoe says:

    Dr. Auteur.

    “But isn’t that the truth? Doesn’t she need to understand that 630 babies will die and one of them really might be hers?”

    It is the truth, yes, but what I’m saying is that it is not the information on which she should base her decision. She needs to know what the risk is for her. That risk is 1 in 111.
    if you were “not completely sure that the mother understood the fact that some babies will die and that one of them could be hers”, then the more honest response would be to say that the risk is 1 in 111 and that her child could be that 1 child in 111.

    “It rarely happened when I was practicing. Most women immediately opted for a C-section.”

    I imagine they would have with the information you provided.

    “Most women simply cannot fathom the idea of a healthy baby dying in childbirth. It is so rare nowadays that women have never seen it and may have never heard of it. Then when it happens, mothers are shocked and outraged; they never envisioned it as a real possibility”.

    That gets back to the question of whether the mother can really give informed consent.
    In my opinion, the way you present the information you have practically guaranteed that the mother will have a C-section. The question is, is this informed consent?

    “I think BillyJoe’s comments illustrate that point, by suggesting that the risk is not that high, and that the information should be presented so as to emphasize the fact that most babies won’t die.”

    Actually no. I think the 1 in 111 risk IS high, but I’m concerned about how this risk is presented. My underlying theme is actually the question of informed consent. In my opinion, if you want informed consent you must present the information that gives the true risk for the patient. That risk is 1 in 111. Or, if you want to use the 630 figure you would have to put it in terms of 630 out of a total of 70,000, which brings us back to the more manageable and honest figure of 1 in 111.

    If you don’t think there should be informed consent in this situation – in other words, if you think the mother should have a C-section – it would be more honest to say something along the lines of “your baby is breech, so we need to do a C-section” and then prepare her for surgery. Her signing of the consent form would then be mere formality.
    It seems to me that effectively is what’s happening in any case.

    regards,
    BillyJoe

  33. BillyJoe,

    I completely understand what you’re saying. In mathematical terms, a numerator without a denominator tells us nothing.

    The problem is that most people are terrible at math. Trying to communicate the meaning of a number as well as the number itself is a challenge in informed consent.

    Many women will translate 1/111 as “1/111th of a baby,” which is meaningless. Giving the absolute number of 630 makes the point that these are real babies, whole babies, and they aren’t flukes.

    I think one of the things that obstetricians struggle with is communicating what statistics mean for them. Obstetricians deliver many babies, so something that is a “1 in 100″ event for an individual mother could be a yearly event for her doctor. And if the “event” we’re talking about is a dead baby, the doctor will be extremely distressed about it. Trying to ethically and accurately communicate “Yes this really could happen, in fact it happens every day, and if it did it would be really terrible” to someone who is thinking “1/111th of a baby – somebody else’s problem” must be frustrating.

  34. Tom S says:

    Just one brief observation for Amy. As I scanned the comments, I found 4 or 5 instances in which she says “lay people have trouble understanding risk” or the like. The fact is that ALL HUMANS struggle with it, not just the laity, as I think all these comments will testify.

  35. BillyJoe says:

    Alison,

    “Obstetricians deliver many babies, so something that is a “1 in 100″ event for an individual mother could be a yearly event for her doctor. And if the “event” we’re talking about is a dead baby, the doctor will be extremely distressed about it.”

    Yes, I haven’t been looking at this from the point of view of the obstetrician. But lets see how that actually works out:

    The average obstetrician performs 150 deliveries per year.
    The breech rate is about 1 in 25, which is 6 per year per obstetrician.
    The death rate for vaginal breech delivery is 1 in 111
    So, if obstetricians delivered all breech births vaginally, they would see one death roughly every 18 years.

    So this is not a yearly event for the obstetrician, but something that occurs every 18 years on average.
    I’m not saying that’s acceptable, but I think we need to get the statistics right.

    “I think one of the things that obstetricians struggle with is communicating what statistics mean….”

    That may be, but I don’t think the way to do that is to distort the statistics. Are patients (or obstetricians, or anyone) capable of understanding them? I think it must be at least possible. The one thing for certain is that you won’t increase their understanding of statistics by distorting them.

  36. Zoe237 says:

    Dr. Tuteur:

    “The NNT to prevent neonatal death from breech is 111. That translates to 110 unnecessary (in retrospect) C-sections for every baby saved. “.

    Where did you get this number? It was not in TBT, at least I didn’t see it. Not arguing, just curious what I missed.

    “Putting aside the issue of the magnitude of the risk, are patients capable of giving informed consent to a procedure that will, if widely offered, lead to preventable neonatal deaths? Obviously consent ultimately rests with the patient, but can it be truly informed consent?”.

    Interesting question. What is the alternative? Court orders for c-section?

    “Let’s assume for the moment that The Term Breech Trial is correct and the excess risk of neonatal mortality in breech vaginal delivery is 9/1000. “.

    Where did you get this number? What section or table (I didn’t look at all the tables)?

    Dr. Tuteur:

    “Telling the mother that 110/111 C-sections will be unnecessary is important, but telling the mother that 630 babies WILL die and that one of those babies might be hers is equally important.”.

    Yes, I agree with Billy Joe and Edgar. This number is irrelevant without a denominator. It’s also another way of saying the same thing, except it is designed to elicit a reaction- a scare tactic. I’m all for more information, so you could also report the number of babies that would be alive (69,370) as well. Reminiscent of the mammography guidelines and everybody going nuts about risks with little understanding that the alternative has risk as well.

    The study also reported that maternal mortality and morbidity were not different for c-section and vaginal either. However, the p value was something like .3, not significant. 2000 births is not a big enough group to look for maternal mortality. My main concerns with c-sections (in general, not necessarily breech) were breathing problems in my baby, as well as risks to future pregnancies. Avoiding unnecessary c-sections is not about the “experience,” contrary to popular belief.

    Tim Mills:

    “Could this be a factor in the difference between the two studies cited above?”

    Dr. Tuteur: “No, all the births in both studies were attended by providers experienced in delivering breech babies.”.

    No, that is a major criticism levied against the TBT, if you read the medical literature. All of the births were not attended by experienced breech providers. But you wouldn’t know that just by reading the abstract. They also weren’t double blinded, and the vaginal birthers were also subjected to certain interventions that can lead to iatrogenic complications.

    “The issue is not money.”.

    Money is an issue, particularly in resource poor countries who may not have the facilities for cesarean section. In fact, there are many issues in the TBT regarding this very topic and how money and resources (or lack thereof) in certain countries could have influenced the results.

    Calli Arcale:

    “Medical science tends to be very risk-averse when it comes to delivering babies. ”

    Dr. Tuteur: “Doctors are merely responding to patient expectations. Patients expect (rightly or wrongly) that any baby who starts labor perfectly healthy should be perfectly healthy at birth. It is this belief that drives the skyrocketing C-section rate for breech and for all other indications. It is simply unacceptable to deliver a dead baby.”.

    Aren’t you contradicting yourself here? Are patients risk averse or are they incapable of calculating risk? Or is it only pregnant women (who disagree with you) who may not be giving informed consent?

    Allison Cummins:

    “Obstetricians deliver many babies, so something that is a “1 in 100″ event for an individual mother could be a yearly event for her doctor.”.

    Not likely. An OB would have to do 2775 (or 53/week) deliveries/year to get one breech baby death as delivered vaginally (if Dr. Tuteur’s numbers are correct). Or 111 breech deliveries in a year. Some people tend to underestimate risk, definitely, but some also tend to overestimate it. The truth is somewhere in the middle.

    There is probably some magnitude of increased risk to vaginal breech delivery… I’m not sure how much based on my very cursory glancing at the studies tonight. If I were in that position, I’d read a lot more, but would probably elect for a c-section.

  37. Zoe237 says:

    In case anybody else is interested:

    1.
    Andrew Kotaska
    Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery
    BMJ 2004; 329: 1039-1042 [Full text]

    http://www.bmj.com/cgi/reprint/329/7473/1039

    Rapid response (love this part of the BMJ- very interesting!)
    http://www.bmj.com/cgi/eletters/329/7473/1039

    2.
    RESULTS: Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies. CONCLUSION: The original term breech trial recommendations should be withdrawn.

    Citation:

    Five years to the term breech trial: the rise and fall of a randomized controlled trial.
    Glezerman M – Am J Obstet Gynecol – 01-JAN-2006; 194(1): 20-5

    (Sorry! No idea how to embed a link).
    http://www.mdconsult.com/das/citation/body/178380796-2/jorg=journal&source=&sp=15934583&sid=0/N/15934583/1.html?issn=0002-9378&issue_id=18187

    3.The TBT after two years (same authors):
    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.
    Whyte H, Hannah ME, …

    CONCLUSION: Planned cesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age.

    http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Search&term=Am%20J%20Obstet%20GynecolJour+AND+191Volume+AND+864page

  38. I’m sorry, I should have been clearer. My own quick-and-dirty math had an obstetrician attending the vaginal births of one or two dead breech babies per career. But I had to make too many guesses to get there, so I gave up on trying to invent a number.

    Instead, I just put the problem in general terms, because the problem of frequency is not restricted to breech births.
    “Obstetricians deliver many babies, so something that is a “1 in 100″ event for an individual mother could be a yearly event for her doctor. And if the “event” we’re talking about is a dead baby, the doctor will be extremely distressed about it.″

    If something is a “1 in 100 event″ for all deliveries – something like, I don’t know, a breech presentation, or twins, or an extra finger – then an obstetrician will see a lot of them. (One piece of advice I heard was never to accept an obstetrician who attends fewer than 50 births a month. Rates clearly vary.)

    The “1 in 111 event″ we’re talking about here only applies to the 1 in 28 breech births, and then only to those women who are eligible and then only to those who choose it. Once we get into subsets of subsets, even a busy doctor won’t see that many.

    Still, even one is traumatizing for the doctor. It’s not routine for them.

  39. Plonit says:

    A few things on this…

    Firstly, this trial was designed to compare outcomes between planned caesarean section and planned vaginal delivery for breech. It does not tell us, directly, what to do when someone arrives in advanced labour with a previously undiagnosed breech on board. The results of the Hannah trial have been extrapolated to this situation, though the outcomes may be different (because caesarean in advanced labour had different risks from elective caesarean, and because good labour progress may be associated with better outcomes.

    Secondly, the trial protocols themselves may have biased the trial towards those providers who regarded these particular protocols as safe (and therefore ethical). Several centres in Europe with experience in vaginal breech delivery chose not to participate in the trial either because they were not equipoise about the research question (that is, there own audits had found their practice to be safe and they saw no reason to change it) and/or because they felt the trail protocols were unsafe with regard to selection criteria or labour management (in particular, the rate of 0.5cm dilatation/hour in first stage, length of second stage deemed acceptable, and the possibility augmentation). As a result, the study did not include centres with different approaches to vaginal breech delivery, which may have had better outcomes.

    Thirdly, many providers had to massively increase their rate of vaginal breech delivery in order to participate in the trial. This would have been achieved by changing their normal (i.e. pre-trial) selection criteria and hence practising outside their experience and comfort zone.

    Fourthly, some trial participants were outside the trial selection criteria, including participants whose babies died.

    Finally (for now), the outcome measures were combined (grouping mortality and morbidity) and short-term, which exaggerated the effect. At two years out from the trial the differences in neonatal morbidity found in the initial outcomes were no longer statistically significant.

    These are all well known criticisms of the Hannah trial in the obstetric literature, for example by Marek Glezerman, who was one of the trial centre leads. Dr Tuteur should at least have mentioned the concerns that have been raised about the trial, if only to refute them.

  40. BillyJoe says:

    Plonit,

    Thanks for the information you provided on the drawbacks of this trial.

    There is also the Premoda Study mentioned by Dr. Auteur which “did not find a significant excess risk associated with planned vaginal delivery compared with planned cesarean” (though they acknowledge that the results must be applied with caution because it was not randomised.

    Of course that feeds into the problem of informed consent which has been my focus here. How could you possibly present all this to the patient in such a way that she could make an informed choice?

    I think there is a lot of disingenuity on the question of informed choice. If I was the obstetrician and had come to a conclusion about what should be done in any particular situation based on the available evidence, I’d make pretty sure in the way I presented the information, that the patient would reach the same conclusion.

    Of course, the next problem is that the patient cannot make an informed choice of obstetrician. What on Earth would she base decision on? Where would she get the relevant information?

    Perhaps, unless we are prepared to do a whole lot of work and develop some expertise ourselves (is that even possible?), we have no choice but to trust the professionalism of the various specialists that become involved in our medical care to do what is in out best interests.

  41. BillyJoe says:

    Alison:

    Thank you as well.
    I missed your contribution before.

    Dr Auteur:

    Scary isn’t it.
    We’ve not done a thorough search for all the available information and have come to the wrong conclusion and then we misuse statistics to get the patient to agree!!!
    There has to be a lesson in there somewhere.

    (And what did I just say about trusting specialists to do what is in our best interests!!! – Only joking of course. We’re all human and we all make mistakes, but I’m sure we all try to do the best we can)

    regards,
    BillyJoe

  42. Zoe237:

    “Where did you get this number?”

    By dividing. If the excess rate of neonatal death is 9/1000, you must treat 111 women to avoid one death.

    “This number is irrelevant without a denominator.”

    Irrelevant to what? We’re trying to make sure that a woman understands that her baby could die.

    Even better is TsuDoNihm’s formulation up thread of “presenting it as 1 of 111 mothers who choses this option buries her baby.”

    “that is a major criticism levied against the TBT, if you read the medical literature. All of the births were not attended by experienced breech providers.”

    No, the criticism is that not all the births were attended by obstetricians. Some of the providers were midwives who had equivalent experience delivering breech babies. If the criterion is experience, I don’t see why midwives should be excluded.

    “Are patients risk averse or are they incapable of calculating risk?”

    Patients are implacably opposed to any neonatal deaths, AND they often do not understand the true magnitude of the risk of neonatal death.

    “An OB would have to do 2775 (or 53/week) deliveries/year to get one breech baby death as delivered vaginally (if Dr. Tuteur’s numbers are correct).”

    And that’s why the concept of an “experienced” practitioner is wishful thinking. Some obstetricians are more experienced than others but even obstetricians who deliver breech babies have very, very little experience dealing with a complicated breech delivery.

    In the “old days” obstetricians would gain experience by practicing on patients who didn’t need the maneuvers. For example, an older doctor might teach a younger doctor how to apply Piper forceps to an after-coming head (used to extract a trapped head) of a breech baby who wasn’t stuck. You can’t do that nowadays (thankfully), so an obstetrician can practice for a decade or decades without every having put Piper forceps on. The only time he or she will be called to do so is in the midst of a life threatening emergency.

    There is one area in which experience is valuable. A hasty practitioner can actually CAUSE complications by trying to rush the delivery of the baby once the breech is out. Doing lots of breech deliveries teaches the best way to avoid complications.

    It is almost impossible, however, to get much, if any, experience managing those complications if you make sure they are very rare.

  43. Zoe237:

    “Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery”

    Dr. Kotaska has always been an enthusiastic proponent of vaginal breech delivery and the results of various studies have been accepted or rejected by him based on whether they supported the safety of vaginal breech delivery.

    His criticism of RCTs falls into that category. Of course RCTs have important limitations, but that doesn’t make non-randomized trials superior.

    “Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies.”

    Yes, but the most severely injured babies were already dead, and therefore were not included in a study of outcomes at 2 years of age.

  44. “These are all well known criticisms of the Hannah trial in the obstetric literature”

    Yes, they are, and they have been addressed by Mary Hannah and others.

    It is important to keep in mind that the supposed “safety” of vaginal delivery applies to only a small group. Even in the PREMODA study, the non-randomized trial with the best results, only 23% of patients with a breech baby went on to have a vaginal delivery. The vast majority were excluded based on the very stringent criteria and others had intrapartum C-sections for failure to progress (etc.)

    So the issue is not whether vaginal breech deliveries are safe. For most cases, they are not. The only outstanding issue is whether deaths can be kept to a minimum by utilizing extremely stringent eligibility criteria.

  45. Zoe237 says:

    I get that Alison- that makes more sense.

    Be nice to see Plonit’s (and forks) points addressed- Dr. Tuteur would rather argue about philosophy about informed consent rather than the actual science.

    “By dividing. If the excess rate of neonatal death is 9/1000, you must treat 111 women to avoid one death.”

    Where does the 9/1000 come from? You chose to ignore that question. I also saw no NNT or excess rate in the study- just from the TBT, it is actually much lower than that, as far as I can tell. But I’m no expert.

    “Even better is TsuDoNihm’s formulation up thread of “presenting it as 1 of 111 mothers who choses this option buries her baby.””

    You seriously don’t know why a denominator might be needed to give informed consent, and why emotional language like “buries her baby” is intended to scare rather than inform? Oh well. Thank goodness you retired. Btw, the thinking on breech does seem to have changed since the 2000 study- ACOG has changed their policy from no breech vaginal to “it is an option for EXPERIENCED providers” in 2006. Absolutely it is dependent on stingent criteria- nobody is arguing that it isn’t.

    “No, the criticism is that not all the births were attended by obstetricians. Some of the providers were midwives who had equivalent experience delivering breech babies. If the criterion is experience, I don’t see why midwives should be excluded.”

    I suggest you read the Glezerman review I posted in AJOG. Hilarious you jump to that though (midwives vs. obstetricians), but I’ll explain it you. The key issue in breech in a provider who has delivered a certain number of breech babies and has practiced a certain number of years. These providers often have very stringent criteria for what women should attempt vaginal breech birth. Part of having that experience is NOT JUST the complicated obstetrical maneuvers required in case of head entrapment, but also the *selection* of good candidates for a TOL through the use of u/s and other skills to avoid complications to begin with. There are serious questions in the study that the requirements lead to more breech vaginal births than should have been done, as well as obstetricians claiming they were experienced who might not have been. As you mention, level of experience is difficult to acquire and judge.

    Be nice if you could address Kotaska’s points rather than saying he supports breech vaginal birth, therefore his opinions are worthless. Same with Plonit’s points- yes Hannah has responded, and I read those responses. They’re not all that cogent on some criticisms. Like I said above, you would rather argue about philosophy about informed consent than actual science. Understandable, I suppose.

    More counterpoints to Dr. Tuteur’s view of informed consent, patient choice, and breech birth and VBAC(with rapid response):

    http://www.annfammed.org/cgi/content/full/4/3/265

  46. Calli Arcale says:

    Amy Tuteur:

    “Medical science tends to be very risk-averse when it comes to delivering babies.”

    Doctors are merely responding to patient expectations. Patients expect (rightly or wrongly) that any baby who starts labor perfectly healthy should be perfectly healthy at birth. It is this belief that drives the skyrocketing C-section rate for breech and for all other indications. It is simply unacceptable to deliver a dead baby.

    I’m not quite sure what you’re getting at here. I wasn’t intending to imply that it was any particular party’s *fault* that medical science is risk-averse in obstetrics. If there is a fault (and I’m not sure there is; there are good reasons for being risk-averse in this area), then I’d say it’s society as a whole. That includes not just patients but also their families, doctors, nurses, hospitals, lawyers, policy-makers, insurance companies…. It’s everybody. I think very few people alive, in any context, want to risk a dead baby or a dead mother.

    I do agree that many patients aren’t clear on the risks of labor and delivery. If the baby was fine before labor, why was he born dead? Lots of reasons, and most of them, there really isn’t a good person to point the finger at. I suppose it’s a bit like the autism thing; they want to blame somebody, even if there’s really no fair basis for that. I think this is what you’re alluding to — that obstetricians are risk-averse because of the fear of lawsuits. This is true, but is smaller than what I had in mind.

    Medical science as a whole is risk-averse when it comes to mothers and babies, and this has profound influences on the whole process that go beyond an OB deciding to do a c-section just in case. In particular, this risk aversion makes it harder to do scientific research because it’s tough to answer some of the critical questions in ways which will satisfy an ethics IRB. Pharmaceuticals are seldom tested in pregnant women and small children for this reason. There’s good reason for this — nobody wants to hurt a kid. But it means that doctors and pharmacists have to extrapolate from inferior data when deciding how to treat pregnant women and newborn babies. And it means that you have to do other, less rigorous types of research if you want to improve risk estimates for obstetric procedures. This means that the estimates for the risk of c-section are probably not accurate, and neither are the estimates for the risk of breech delivery. It’s something we all have to live with — these are the best estimates we have. But we can’t know how close they are to reality, and that can be disquieting, especially in a high-stakes situation like pregnancy and birth.

    So to cut a long story short, the risk-aversion in medical science goes far beyond simply OBs afraid of being sued for delivering a dead or injured baby. We’ll never know how many c-sections were really unnecessary, nor how many breech deliveries were unnecessary — we have an estimated NNT, but that’s not exactly the same thing. It’s close; closest we can get in science, probably. But not the same, and the existence of uncertainty will inevitably make a lot of people nervous.

    (BTW, for the record, I favor c-section over vaginal breech delivery, even in a woman with no prior c-sections. But I’m a software engineer, so take that opinion for what it’s worth.)

  47. rork says:

    Thankyou Zoe237. Those pointers were excellent!

    The Kotaska article was a good read. I am also quibbling about the actual facts rather than the theory of consent, and some might find that quibbling uninteresting by comparison, sorry.

    Perhaps Kotaska has an agenda, but that doesn’t make what was written wrong. Plonit’s summary (above) of Kotaska didn’t point out that in that half of the data that were for countries with low perinatal mortality, that intended vaginal deliveries gave death 3/511 times, and this was not significantly more than zero (of about 500) in the C-section group. It questions one of those 3 deaths as well. Kotaska (surprisingly) doesn’t point to the fact that even in the Hannah data there seems to be a strong experience effect, which Hannah also essentially weasels out of, as I mentioned earlier.

    So perhaps 2-3 out of 500 seems like more realistic risks around my area, assuming semi-aggressive inclusion criteria, and that the doc is merely as good as the average from this study. Docs informing the patient of their skill and experience seems important.

    PS: I advocate better math education in my particular country (U.S.), and much better math/stats education for docs (I have horror stories both as a patient, and a researcher). This blog is helping I hope. Thanks for that.

  48. Dacks says:

    Dr, Tuteur,
    This post seems to have a hidden agenda, as do most of your posts, but it is difficult to tease it out. Here are the points I’ve gathered so far:

    -The risks of vaginal breech delivery may be lower than we thought, but are not zero.
    -Laboring women, like the rest of us, can’t comprehend risk very well, and therefore can’t give truly informed consent.
    -C section for breech babies lowers the risk of neonatal complications
    -Doctors are only responding to patient demand when they recommend C section for breech births

    You seem to feel that C section IS a better choice for breech births, so why not come right out and say it – “If a baby is in breech position I would recommend a C section.”?
    Or are there cases where you would recommend a vaginal birth? If not, is it you who is risk averse, or is it the patient?

    You say that people look for someone to blame when something goes wrong during delivery, and I don’t doubt that for a moment. But I’m hearing a bit of the same here – if a patient chooses the riskier procedure, well, it’s their fault if something goes wrong.

  49. Basiorana says:

    Many universities are introducing courses for prospective scientists in how to present complicated research findings to the public. While doctors already have instruction in talking to patients, I’ve long wondered if a course specifically in how to present statistics and risks to patients would be beneficial to the medical community.

    Statistics are confusing, particularly when they’re mixed up in emotions. Creative and effective ways to present them to laypeople would be a very useful thing.

  50. BillyJoe says:

    Dacks,

    “I advocate better math education in my particular country (U.S.), and much better math/stats education for docs (I have horror stories both as a patient, and a researcher)”

    I take it that you mean that denominators are important.
    How about the dispassionate presentation of the facts?

    And I would love to hear some of your “horror stories” (provided they are also instructional).

  51. Dacks says:

    BillyJoe,
    That was rork, not me.

  52. There are women who claim to be fine with the risk. I read a first-person account of a UC delivery in Mothering magazine… maybe ten or twenty years ago. The baby was born limp, apparently infected, and died within a couple of days. I was fascinated to realize that her logic was completely consistent. She didn’t use birth control, this was her fifth child, her next oldest was only about a year old, and she was exhausted. Maybe this baby dying wasn’t the end of the world. She was living a life in which she allowed nature to take its course. That meant that when she was too spent to carry a healthy pregnancy to term that she allowed the baby to die as nature intended,* instead of actively seeking care to ensure the baby lived. (Reading between the lines, if the baby was born infected, presumably she’d been bleeding quite some time before labour started and she didn’t seek medical care.) If she was too drained to deliver a healthy baby, she was too drained to raise the child.

    While this isn’t the logic I would use to make my choices, I have to respect the internal consistency. I can completely imagine this woman fully appreciating the risk that a breech baby would die and finding that risk acceptable on the grounds that if it didn’t live then it wasn’t supposed to.

    *Yes I am perfectly aware that nature doesn’t “intend” anything.

    *** *** ***
    On another note, have we all read Atul Gawande’s classic New Yorker piece on the place of c-section in modern obstetric practice?
    http://www.newyorker.com/archive/2006/10/09/061009fa_fact

    There’s also a related nice little blog post by an obstetrician talking about her mission to learn to use forceps in an age of c-sections.
    http://mwwak.blogspot.com/2007/08/forceps-are-your-friends.html

    … and about what it’s like to deliver a breech baby. http://mwwak.blogspot.com/2006/11/do-or-do-not-there-is-no-try.html

    None of these articles address the science, but I thought that people who are enjoying this exchange might also enjoy these other ones. If they don’t already know them.

  53. “You seem to feel that C section IS a better choice for breech births, so why not come right out and say it – “If a baby is in breech position I would recommend a C section.”?”

    It would be more accurate to say that if a baby is in the breech position I feel compelled to recommend a C-section and to emphasize the dangers. Basically I’m expressing the frustration that most obstetricians feel with the current situation.

    Obstetricians are held to an impossible standard: any baby that starts labor healthy must be healthy when delivered. We dropped the neonatal mortality rate approximately 90% in the past 100 years (and the maternal mortality rate 99%), yet perfection is the standard.

    As the neonatal mortality rate has dropped to a very low level, the pressure exists to save the few babies who still will die. Therefore, the indications for C-section keep growing; first it was for all breech babies, now it’s for all women with a previous C-section.

    It seems that the law of diminishing returns applies in obstetrics. As we asymptotically approach the lowest possible neonatal mortality rates, we are doing more and more C-sections to save fewer and fewer babies. But, I for one, don’t see any alternative.

    I find the debate on the safety of vaginal breech delivery (as well as the debate on the safety of VBAC) to be disingenuous in the extreme. Those who are promoting vaginal breech delivery and a liberal VBAC policy are not honest about the fact that some babies WILL die. Unless patients understand that, they cannot make an informed decision.

    I personally am in favor of vaginal breech delivery with strict criteria, and VBAC for any woman who wants one, BUT it is only a feasible policy if women understand and ACCEPT that some babies WILL die as a result.

  54. Horror stories.

    Here’s one that happened at a homebirth. It might not have happened in the hospital since the patient would have been counseled emphatically to have a vaginal delivery, but it gives people a sense of the situation. A trapped breech is horrific in the extreme.

    This account is from the Oregon Register-Guardian:

    “The call to paramedics came at 8:10 p.m., the instant midwife Anita Rojas realized the head of the breech baby she was delivering was stuck.

    Twenty-one-year-old Kelsie Koberstein was swept up by medics in a blur of pain and fear.

    Rojas rode in the front of the ambulance, with Koberstein’s mother and best friend rushing behind in their car…

    On her back, her legs pushed up as high as they could go, she clutched the hand of a paramedic as if he were her only anchor to reality.

    Those minutes, so frantic for so many, ticked by slowly for her. As paramedics tried to wrest the baby out, Koberstein said she could sense the small life, still partially within her, beginning to fade. She began “letting him go, in a way.”

    At Sacred Heart Medical Center, the on-call emergency room obstetrician-gynecologists, Drs. Elizabeth McCorkle and Brant Cooper, wasted no time…

    When medics pulled up to the doors, the doctors leapt into the back, refusing to squander precious seconds bringing Koberstein inside. The doctors had to turn Lucian’s head 180 degrees in order to free him, a move that took at least 20 minutes.

    By then it was too late.

    The infant was dead.”

  55. BillyJoe says:

    Zoe,

    http://www.annfammed.org/cgi/content/full/4/3/265

    “The American College of Obstetricians and Gynecologists has released a formal opinion supporting obstetricians who perform elective primary cesarean delivery, citing the ethical premise of patient autonomy and informed consent”
    “[The authors of this article] are pleased at the emphasis on preserving women’s medical choices”

    Is it the “ethical premise of patient autonomy and informed consent” and the “preservation of women’s medical choices”? Or is it the abrogation of responsibility by the specialist collleges and their members?

    “The primary investigator of the TBT has stated that a woman’s choice for vaginal breech delivery should be respected”
    “opinions from professional societies in Australia and the United Kingdom acknowledge a woman’s right to choose vaginal breech delivery”

    Is this “respect for patient choice” and the “patient’s right to choose” or a surrogate for “don’t blame me. you made the choice”

    Patients even have the right to choose a PRIMARY caesarean section – in other words, for no medical reason at all!

    The irony is that the point of this paper is that women seem not to have the choice any more of delivering vaginally with a breech presentation or after previous C-section because obstetricians are no longer prepared to give that choice to the patient.

    Patient choice and autonomy indeed!

  56. Dacks says:

    Dr Tuteur,
    Thank you for clarifying your position. Your frustration with the current state of affairs is certainly understandable. We are a risk averse society, and that is nowhere more true than when it comes to our children. Yet it is hard to make the case that we should take more risks.

  57. BillyJoe says:

    Dr. Auteur,

    Thank you for your continued reponses in the face of strong opposition (and the occasional gratuitous insult). You sound like a true professional in that regard, so thank you (and I know you cannot resppond to everyone).

    I appreciate the frank summary of your views on VBAC and vaginal breech delivery in the second last post above as well as for this perpective”

    “As we asymptotically approach the lowest possible neonatal mortality rates, we are doing more and more C-sections to save fewer and fewer babies. But, I for one, don’t see any alternative.”

    I think, though, that we must be certain that more lives ARE being saved as we approach that asymptotic point.

    I am interested in your view on patient autonomy and informed choice but perhaps that is for a future article?

    regards,
    BillyJoe

  58. Calli Arcale says:

    As the neonatal mortality rate has dropped to a very low level, the pressure exists to save the few babies who still will die. Therefore, the indications for C-section keep growing; first it was for all breech babies, now it’s for all women with a previous C-section.

    This is very true, and gets to another area that I’ve always had some unease about: the heroic efforts to save very ill newborns and the increase in high-risk pregnancies which, in retrospect, could probably have been avoided. (Higher order multiples during fertility treatment, for instance.) You’ve talked of how there is an expectation that a healthy fetus should be delivered as a healthy baby; what about unhealthy fetuses, and high-risk pregnancies? Though it’s wonderful to save a baby’s life, I admit to some discomfort when I hear about new records set in smallest baby to survive, or youngest. Second-trimester preemies, nursed back to life at great expense and often great pain, with a tendency (at least in the media and the public eye) to consider “mortality” the only significant factor for these babies. Are we trying *too* hard to save some babies? A thorny question indeed; it’s sort of the flip side of the abortion debate, but far less commonly discussed — we discuss whether it’s always okay to kill a fetus, but we don’t discuss whether it’s always okay to save one, because our instinct screams “hell yes”.

    I would be interested to someday hear your thoughts on that, though I bet that would be another thread that would get an excruciatingly long comment section. ;-)

  59. “You’ve talked of how there is an expectation that a healthy fetus should be delivered as a healthy baby; what about unhealthy fetuses, and high-risk pregnancies?”

    Those situations raise very serious ethical issues, although different issues. In the case of high risk pregnancies, those mothers are desperate for any baby, and it doesn’t have to be healthy. Plus, in the past two decades the age of viability has been dropping constantly, giving people hope that even the most hopeless cases can work out… I’ve been surprised on a couple of occasions.

    It is extraordinarily difficult to counsel patients appropriately in those situations since there are times when no one really knows what what the odds are.

  60. BillyJoe says:

    Here is an point of view I can relate to:

    http://www.annfammed.org/cgi/eletters/4/3/265#4003

    “Cesarean Delivery: a choice, a demand, or a request?

    A mother may request [as opposed to "choose" or, god forbid, "demand"] a cesarean, but it is the caregiver who must use their knowledge of medicine and the patient to provide guidance. The decision should respect both the patient’s autonomy and the provider’s obligation to optimize the health of both the mother and the fetus”

  61. manixter says:

    Thank you for covering this topic.
    I was persistent breech, even after attempted external version. Even if my group was still doing elective breech deliveries, I would have not been a good candidate as a primapara (an elderly one, at that).
    I have seen one (1) elective breech delivery; it was done in the OR, with anesthesia (me) in the room throughout to provide for emergency uterine relaxation or crash c-section if needed. Given the amount of sphincter tone associated with this elective delivery, I can understand the reluctance to go with a vaginal birth over a c-section.
    However, there always will be “surprise” breech births that must be managed– how are OBs going to gain experience in this? I would not advocate resuming elective vaginal breech births just for the experience, but if the main determinant of a safe(er) breech delivery is the experience of the OB (and the anesthetist), how can we train the next generation? It seems to be an extreme of the “elective forceps” problem.
    I would argue that most patients can NOT give informed consent regarding this issue– phrases like “head entrapment” (baby can’t breathe and the cord is compressed in the birth canal against its body= asphyxia) give me the screaming willies. Unless a practicioner can create the kind of visceral fear that is appropriate in that scenario, I don’t think “informed” consent is possible.
    Just the fact that some women feel that delivering a breech infant with a midwife at home is OK would imply that there is a serious gap in understanding.

  62. Zoe237 says:

    Rork, thanks.

    BillyJoe:

    “”The irony is that the point of this paper is that women seem not to have the choice any more of delivering vaginally with a breech presentation or after previous C-section because obstetricians are no longer prepared to give that choice to the patient.”..

    http://www.annfammed.org/cgi/content/full/4/3/265

    Yep. The recommendation in 2000 after the TBT was NO breech delivery, patient choice be damned. After further studies came out, particularly those finding no difference at two years in TBT, the recommendation was revised (2006) to allow women the option of breech delivery vaginally. I believe there is ONE provider about an hour north of me willing to do breeches, and has many years of experience. Many other OBs don’t have the skills and are extremely risk averse. Obviously their lack of confidence/experience/skill should not be tested, and these patients should be referred to another doctor.

    Alison, THANKS for those links to midwife with a knife (yes, she’s an ob for those not familiar)- I had never read that one before. As I’ve been reading Dr. T’s stuff on here for a few months, and newly reading a bit on the online blog world, I’m pleasantly suprised to be coming across many OBs who realize c-sections have risks, mothers ARE capable of informed consent (as much as any other human being anyway), and that obstetrics should be based on evidence not emotion. Oh, not to mention that midwives are an underutilized resource, not evil witches!

    http://mwwak.blogspot.com/

    “”Those who are promoting vaginal breech delivery and a liberal VBAC policy are not honest about the fact that some babies WILL die. “..

    Baloney. Every OB and FP who promotes those (a significant number) acknowledge the risks to VBAC and vaginal breech delivery. In fact, it seems to me it is you who is incapable of acknowledging the risks of (unnecessary) c-sections to mother and neonate.

    This is the exact reasoning promoted by those against the mammography guidelines, and they are correct. If we don’t screen every mother between the ages of 40-49, some WILL die of undetected breast cancer. This simplistic evaluation of risk ignores other factors- resource allocation, cancer statistics, and risks of biopsies, etc. The anti-vaccine camp uses a similar risk analysis- a one in a million risk of encephalopathy is catastrophic (and yes, some babies WILL die from vaccination), never mind the millions of lives saved. Doctors are also often not very good at making statistical inferences- they see many anecdotes and assume that every case must be too risky to allow few interventions. Like 630 vs. 69,000.

    There are the OBs who are honest about the fact that med mal *forces* them to be more risk averse than they would otherwise be. Then there are the OBs who truly believe, in a religion like way, that mothers are stupid and any neonatal risk is too be avoided, and that iatrogenic complications don’t exist.

    The complete (desire of) avoidance of risk, paricularly when it comes to children in general, is a very new phenomenon (and definitely moreso in the U.S.) Interesting to consider the ethical implications as we expand and extend the human life span. How we are born and how we die are the big question marks on this. Even if increasingly complex technology allows us to extend life, at what point is it not worth it/ too painful? Should we be saving micropreemies who will need 24-7 care for the rest of their lives? How about the capacity for IVF and giving birth to eight babies? I have no idea what the answers are, but I do know that they are not simplistic and that we HAVE to allow people to make their own decisions with informed consent, even if we don’t like/agree with the risk analysis.

    Ugh, must work on being concise!

  63. “The recommendation in 2000 after the TBT was NO breech delivery, patient choice be damned.”

    And what about those 630 babies? What do you say to the parents who exercised “patient choice” and their babies are now dead after a truly horrific disaster in the delivery room, one that has emotionally scarred them for life, not to mention the grief of losing a baby who would otherwise be healthy and flourishing?

    It is easy, oh so easy, to pontificate about patient choice. Try counseling parents who have buried a baby and then get back to me about the relative value of “patient choice” vs. a live baby.

  64. Note that mwwak can offer a forceps-assisted vaginal delivery as an alternative to a c-section: when an intervention of some kind is needed to deliver the baby safely, she has a wider armamentarium than many. Forceps are very difficult to use safely without hurting the baby and she happened to be very motivated to learn to master them.

    She also acknowledges the risk.

  65. Zoe237 says:

    “It is easy, oh so easy, to pontificate about patient choice. Try counseling parents who have buried a baby and then get back to me about the relative value of “patient choice” vs. a live baby.”

    Gee, Dr. Tuteur, I thought you supported patient choice for vbac and vaginal breech delivery if the patient understood the risks (both ways). I thought we were pretty much in agreement. Risky choice, varied study outcomes, dependent on provider experience, should be available with *truly* informed consent. You sound a little bit hysterical, although I can understand why if you’ve been an ob to mothers who’ve lost their neonates to head entrapment in a breech delivery. Anecdotes can be very powerful.

  66. “I thought you supported patient choice for vbac and vaginal breech delivery if the patient understood the risks ”

    But anyone who is cavalier about the babies who will die doesn’t understand the risk. That’s been my point all along.

  67. J_ says:

    Amy’s hysterical finger-pointing approach on this topic and several others does not help the call for rational, science-based medicine. Giving birth has risks, and in the U.S. those risks are among the lowest in the world, even for home-births, and parents who decline the muscular medical interventions Amy is pushing so hard in this article and others. Babies die in hospitals too, and sometimes because of medical mistakes. My son’s hospital birth was far from perfect: nurses whisked him away because they said his O2 levels were low. When I tried to follow they informed me it was against the rules. I ignored them. They put him under a mask with lots of tubes and sensors, and to my amazement, as these women chattered and laughed, his O2 levels kept dropping. Finally I realized they hadn’t connected a large blue tube that delivered O2. When I pointed it out, they just laughed and connected the tube, and went back to their conversation. God knows what damage was done, but I’m sure this was recorded this as another successful hospital birth with no complications. The vitamin K injection, severe jaundice, heel puncture, and relentless unwelcome demands to circumcise him added insult to injury. At least he got out with all his penis intact. Not a very good advertisement for the medical industry.

    I’m jealous of my friend who has given birth to two healthy sons at home, with no beeping monitors, c-section pushing doctors, circumcisers, injections, O2 machines that did more damage than good, and careless nurses.

    -John Kuehne, Ph.D.

  68. Fifi says:

    Dr Tuteur – “Try counseling parents who have buried a baby and then get back to me about the relative value of “patient choice” vs. a live baby.”

    Do you equally inform mothers about the dangers of c-sections? And the differences between a vaginal birth and c-section? Do you advise against elective c-sections? I’m certainly not against c-sections and they can be life saving for both mother and child, once again I question your neutrality on this issue Dr Tuteur (and how you’ve chosen a controversial topic – c-sections – and yet again seem to be trying to use science merely to prop up a personal position).

    Dr Tuteur, you seem to be making this about you and your feelings, which is fertile ground for personal bias to creep in. While I’m sure that delivering healthy babies (and being given full credit and praise for doing so) is more satisfying than the more difficult aspects of your job, dealing with the hard parts of being an OB/GYN is also part of your job. Some women do have hard choices to make about keeping a baby or ending a pregnancy (due to both physical or life complications and birth defects). Women do lose babies – both during pregnancy and childbirth, and after birth as well.

    An upset parent may not be very rational, even if they were properly informed about benefits vs risks of a procedure, but that doesn’t mean you should be taking away the opportunity for parents to assess risks and make their own choices simply because you find it hard to deal with a distraught parent who may blame you after the fact (or even sue you). All one has to say is “the risks are 1 in whatever, that may not seem too bad but remember that you may be that one in whatever”. It really isn’t nearly as complicated as you make out to get people to understand risk. There’s no need for the emotional manipulations and fear mongering approach you seem to prefer, a simple personalization works very well to personalize risk without manipulative dramatics. In fact, by being emotionally manipulative you’re making it harder for parent to make a rational decision about a highly emotionally charged matter.

    It’s interesting that you chose to approach a generally controversial topic – c-sections – from this angle and are making an argument from emotion that you’re dressing up as SBM. An interesting article about the controversial topic of unnecessary c-sections (slightly off topic but relevant considering the high rate of elective c-sections in the US)…
    http://www.scientificamerican.com/blog/post.cfm?id=elective-cesarean-sections-are-too-2010-01-11

  69. Funny thing about the WHO study you referenced: the authors were so anxious to condemn elective C-sections that they ignored the fact that THEIR study showed that the safest form of delivery (for babies and mothers) is elective C-section WITHOUT medical indications. Their data show it to be safer than vaginal delivery!

  70. BillyJoe says:

    This may be my last comment here but I have to agree with Zoe on the question of emotionally laden information:

    If you are going to present information on which a patient is to make an “informed choice”, it must be a dispassionate presentation of the facts.
    Once emotional content is added, the patient is no longer making an “informed choice” but a “forced choice”. Yes, that is an oxymoron – you are effectively telling the patient what to do.

    I do understand that a mother with a dead baby is necessarily an extremely emotional situation for both the mother and her doctor, but that is no excuse for an unscientific approach to this question.

    The best summary I have seen is this (slightly paraphrased):

    “A mother may request a caesarean, but it is the doctor who must use her knowledge of medicine and the patient to provide guidance. The decision should respect both the patient’s autonomy and the doctor’s obligation to optimize the health of both the mother and her baby”

  71. “Do you equally inform mothers about the dangers of c-sections?”

    Of course I do; that’s part of my job. Interestingly, women seem to have a much better grasp of the risks and consequences of surgery than they do of the risks of neonatal death. I suspect that is because most people think of surgery as inherently dangerous and (erroneously) think of childbirth as inherently safe.

    “once again I question your neutrality on this issue”

    Neutrality on what issue? I am decidedly not neutral on the subject of neonatal death. I am unabashedly committed to the notion that it is a tragedy of major proportions and that all reasonable measure should be taken to prevent it.

    The key criterion of informed consent is being informed. Anyone who dismisses the possibility of neonatal death out of hand or as too negligible to consider seriously cannot possibly make an informed decision.

    Those who are commenting in this thread supporting the notion of patient choice refuse to make the acknowledgment that would justify their support of such choice. They need to acknowledge that they find it acceptable that some babies will die needlessly in order for other women to avoid surgery that was unnecessary in retrospect.

    I am all in favor of patient choice, but I can tell you as an obstetrician that it is extraordinarily difficult to obtain informed consent in the current climate when women are told that obstetricians merely want to rob them of their “birth experience” and make extra money (they don’t make extra money) on promoting C-sections instead of blissful, “empowering” vaginal births.

    I always found it much easier to obtain informed consent for hysterectomies and other GYN procedures than to obtain informed consent for obstetric procedures where a baby’s life may be placed at risk, because it often seemed to me that patients discounted the possibility of neonatal death.

  72. Zoe237 says:

    I’m assuming you are pro-life Dr. Tuteur? That is the only reason I can see for putting a fetus’ life ahead of a woman’s right to informed consent?

    I am probably in the politically incorrect minority, but not only am I pro-choice, I also would not sacrifice my own life for my fetus’s. If an ob told me, it’s your life or your 38 week fetus, I would say “save mine.” I have other children to take care of.

    Again, I have said repeatedly that I realize neonates are at risk of dying with a vaginal breech birth (630 of them every year, if I believe your numbers, which the more you refuse to give a source for them, the more I doubt them). They are also at risk every time we put them in the car. Mothers and grandmothers are at risk of death from cancer every time we scan every other year rather than every year. We could also probably cut down on neonatal death if we put women in the hospital for their entire pregnancies. And yes, I believe the risks of breech are probably more significant than these examples, but so are the risks of surgery.

    I also stated that I myself would most likely choose a cesarean for breech. But I realize that women are smart, diverse, and capable of making their own decisions, with their own risk analyses.

    You are no different than those who seek to limit a woman’s right to choose elective cesarean section, saying they don’t “truly” understand the risks.

  73. J_ says:

    Anyone who dismisses the possibility of neonatal death out of hand or as too negligible to consider seriously cannot possibly make an informed decision.

    I hope Dr. Tuteur remembers to inform her patients when discussing or before doing a circumcision that every year some boys die from the complications of this surgery and that this circumcision might be the next death. Seems in her recent circumcision post she forgot to mention the possibility, or thought it too negligible to consider seriously.

    This whole thread is surreal: millions of women in the U.S., and most of the women on earth, can’t even afford to buy a C-section. It’s only a choice for the wealthy, or those who are fortunate to be covered by that peculiar social medicine known as Health Insurance. There’s no obligation for a hospital to perform a C-section that patients elect to have but can’t pay for. There’s no legal obligation for a hospital to do a C-section at all unless the woman or baby are in the process of dying.

  74. BillyJoe says:

    “This whole thread is surreal: millions of women in the U.S., and most of the women on earth, can’t even afford to buy a C-section. It’s only a choice for the wealthy, or those who are fortunate to be covered by that peculiar social medicine known as Health Insurance. There’s no obligation for a hospital to perform a C-section that patients elect to have but can’t pay for. There’s no legal obligation for a hospital to do a C-section at all unless the woman or baby are in the process of dying.”

    That’s because your health system is ******

    And it’s all because of ideology.
    What do you call it? Libertarianism?
    Hey, people are more important than ideology.

    And there’s finally been a chance to fix it but you missed it.

    In some parts of the world, it doesn’t depend on whether you are wealthy or not, if you need a caesarean you get one.

  75. “I’m assuming you are pro-life Dr. Tuteur? That is the only reason I can see for putting a fetus’ life ahead of a woman’s right to informed consent?”

    Your assumption is wrong.

    Moreover, I’m not putting a fetus’ life ahead of a woman’s right to refuse a C-section. I’m saying that refusing to acknowledge the risk or minimizing the risk makes it impossible for a woman for to give consent that is informed.

    When someone says to me (and it has happened): I’d rather take the risks that the baby dies than to do X, they’ve acknowledged that risk. I am both legally and ethically obligated to accept the patient’s decision even if the baby does die, which did happen in one case.

    The issue of informed consent for procedures that put the baby at risk extend far beyond the issue of breech delivery. The assumption that every baby who starts labor healthy will be healthy at birth drives the rising C-section rate.

    Americans say to obstetricians, “Give me a perfect baby or I will try to destroy you professionally and economically by suing you” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.

    If we wish to control the rising C-section rate, we must confront the expectations of patients, including those who refuse to acknowledge that liberal policies for vaginal breech delivery or VBAC will mean that some babies will die.

  76. Zoe237 says:

    “That’s because your health system is ******

    And it’s all because of ideology.
    What do you call it? Libertarianism?
    Hey, people are more important than ideology.

    And there’s finally been a chance to fix it but you missed it.

    In some parts of the world, it doesn’t depend on whether you are wealthy or not, if you need a caesarean you get one.”

    That’s right. If a hypothetical person truly cares about babies, they’d work on lobbying for universal health care. Poverty issues, race issues, and prematurity for social reasons is what is ***killing*** babies in this country. Not the very rare woman opting for vaginal breech delivery or homebirth.

    “Americans say to obstetricians, “Give me a perfect baby or I will try to destroy you professionally and economically by suing you” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.”

    Is that where your passion comes from and why you retired? There are some who wonder why you’ve gone off the deep end on this subject.

  77. Fifi says:

    Dr Tuteur – “Neutrality on what issue? I am decidedly not neutral on the subject of neonatal death. I am unabashedly committed to the notion that it is a tragedy of major proportions and that all reasonable measure should be taken to prevent it.”

    Neutrality about c-sections, of course, since that’s the issue being discussed. Not only are you erecting a strawman by making it all about neonatal death, you’re once again doing so by making a potentially inflammatory emotional appeal (and once again in a way that invokes a very inflammatory subject in the US, though a woman’s right to choose isn’t controversial in Canada, Australia or Europe).

    Dr Tuteur – “The key criterion of informed consent is being informed. Anyone who dismisses the possibility of neonatal death out of hand or as too negligible to consider seriously cannot possibly make an informed decision.”

    You’re erecting another emotionally laden strawman, nobody here is dismissing the possibility of death out of hand or pretending babies don’t die. What you’ve been called on is using unnecessarily emotionally loaded language when relating the risks/benefits of c-sections and not actually presenting the evidence in a neutral manner (others have called you out on misrepresenting the statistical risk, not being a statistician I don’t know about that – however I do know about communication and you clearly try to use emotionally charged language to manipulate both patients and readers of your posts here).

    Dr Tuteur – “I am all in favor of patient choice, but I can tell you as an obstetrician that it is extraordinarily difficult to obtain informed consent in the current climate when women are told that obstetricians merely want to rob them of their “birth experience” and make extra money (they don’t make extra money) on promoting C-sections instead of blissful, “empowering” vaginal births.”

    Ahhh, so it’s all about you and your personal ideological battles again and not actually about SBM. I’m confused – are you actually a working OB/Gyn or retired? You seem to have a personal resentment that some women choose other options and once again are just grinding some ax rather than actually discussing this as SBM. You seem to have some kind of weird resentment against vaginal birth. For someone who keeps claiming to have an interest in science, you don’t seem at all interested in some of the current research that’s being done. It’s not conclusive by any means, and only a beginning, but it does point out a lack of knowledge in this area and something that mothers should potentially be aware of if they’re going to make a truly informed choice. Now, clearly c-sections can save both babies and mothers lives when they’re truly necessary and no one here seems to be disputing that, what is being disputed is your emotionally charged language and your very obvious personal bias in this matter which you’re trying to float as SBM. The other thing you seem to be totally ignoring is just

    The inconclusive but interesting first forays into the neurobiology of childbirth.
    http://sciencebasedparenting.com/2008/09/13/vaginal-birth-vs-c-section-the-interview/

    Just so you know, I’m sympathetic to just how difficult it can be for doctors to practice medicine in the anti-medicine climate (both my parents are doctors). However, your tactic of personalizing and using emotionally loaded language (and admitted desire to be sensationalist to get attention) serves neither SBM nor women’s health. In fact, it makes you appear to be an ideologue and someone willing to use emotional bullying and abuse professional power/authority, not to mention willing to abuse science, to enact your own personal/ideological agenda.

    Dr Tuteur – “Americans say to obstetricians, “Give me a perfect baby or I will try to destroy you professionally and economically by suing you” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.”

    You are aware that there’s a whole world beyond America and you’re writing on the internet? Once again, it’s not all about you. Of course I’m shocked that a physician would put their own economic well being before their patient’s health, it’s highly unethical! I find it interesting that you don’t take issue with this. Trying to blame patients for your actions is pretty unethical too. This constant refrain of yours – that doctors are being victimized (particularly American doctors since you seem to disregard the rest of the world, except when ideologically useful) – is a bit pathetic. Having a c-section is no guarantee someone will have a perfect baby, do you tell your patients this as a means to encourage c-sections? All this “perfect baby” nonsense seems to be coming from you and some of your American colleagues. It’s interesting that you even use this terminology – “perfect” – when one would hope the goal is to have a healthy baby and mother.

  78. I rather think that you are proving my point for me.

    I’ve presented the scientific evidence that shows that vaginal breech delivery involves real risk of neonatal death and have made the argument that those who promote vaginal breech delivery ignore or elide that risk.

    And in this thread those who are promoting vaginal breech delivery ignore or elide the risk to babies. I don’t notice anyone saying what must be said: The preventable deaths of 630 babies is worth it to reduce tens of thousands of unnecessary (in retrospect) C-sections.

    If you think it is worth it, then say so. If you are not willing to say so, then you are ignoring the real risks.

  79. Zoe237 says:

    “The inconclusive but interesting first forays into the neurobiology of childbirth.”
    http://sciencebasedparenting.com/2008/09/13/vaginal-birth-vs-c-section-the-interview/

    Thanks for the link.The study author is Dr. Swain, MD, PhD, a Yale psychiatrist with a neuroscience Ph.D. Sample size 12.

    I’m skeptical of the findings that c-section moms may show less response to crying in their brains from MRIs. But I know almost nothing about MRI research either.

    But I do think Dr. Tuteur glosses over the risks of c-sections because of her ideological war.

  80. Fifi says:

    Dr Tuteur – “If you think it is worth it, then say so. If you are not willing to say so, then you are ignoring the real risks.”

    Once again you erect a strawman because all you can do is think in black and white terms (a la “you’re either for me or against me” and that anyone who actually calls you on something must be an advocate of whatever you’re against…it’s a telltale sign of an ideologue that you can’t get beyond binary thinking). I’m for informed consent and think it should be the mother’s choice (with input from her partner when appropriate) – not mine, not your’s…do you understand this? What you’re being called out on here is promoting your own personal agenda using emotionally loaded language rather than presenting the information in a neutral way. You’re using exactly the same tactics as the people you’re all up in arms about. All that a mother needs to be told is what the information is and reminded that even though the odds may seem good that she may be the unlucky one in however many. For myself and my baby, that’s a decision I’d make at the time and according to the evidence and my particular situation, not due to some predetermined ideological position. I respect the right of other women to make their own choices, particularly without being emotionally bullied or having the evidence misrepresented by someone in a position of power.

    Zoe – I totally agree that it’s a small sample size and not at all definitive. My point was to prove anything, it’s that we don’t know and more research needs to be done. Clearly all the repercussions of having a c-section instead of a natural birth aren’t known yet (and even if natural childbirth does end up being preferable it doesn’t mean that c-sections won’t need to be done, I’m not anti-c-section, I’m anti-emotional rhetoric and ideological positioning trying to pass itself off as SBM). And, obviously, c-sections aren’t risk free for the mother (even if they do reduce the risk of being sued for doctors in America).

    This is an interesting article that looks at ways to reduce the need for c-sections and the role of technology in the increase. Since the rates have been rising astronomically around the world, it’s worth considering why and if this is really in the mother and child’s best interests. There are some very interesting discussions to be had around this issue, particularly if we look at this rationally and not from an emotionally charged and ideological starting place.

    http://www.research.utoronto.ca/behind_the_headlines/what%E2%80%99s-behind-canada%E2%80%99s-rising-c-section-rate/

  81. Fifi says:

    That was meant to read…

    “My point WASN’T to prove anything, it’s that we don’t know and more research needs to be done.”

    Actually, I guess my point was to prove that there are still many unknowns and things to be considered and that c-sections aren’t a simple black and white issue.

  82. Fifi says:

    If anyone is interested, the official position of Canadian OB/GYNs is that c-sections shouldn’t automatically be done for breech births.

    [excerpt]

    “No more automatic C-section for breech births, says Ob/Gyn Society

    Halifax – June 17, 2009 – Physicians should no longer automatically opt for caesarean sections in the event of breech birth, according to new guidelines for Canadian health professionals released today by the Society of Obstetricians and Gynaecologists of Canada.

    The guidelines are based on a comprehensive review of research and clinical evidence regarding the safety and outcomes of vaginal breech births compared with that of caesarean sections.”

    http://www.sogc.org/media/advisories-20090617a_e.asp

  83. Plonit says:

    On Tuteur’s point that “the most severely injured babies were already dead, and therefore were not included in a study of outcomes at 2 years of age.”

    It should be noted that in subgroup analysis, for low-perinatal mortality countries, there was no statistically significant difference in perintatal mortality between the planned vaginal and planned caesarean delivery groups.

    In the low-perinatal mortality countries, the recommendation of planned caesarean over planned vaginal delivery was therefore based entirely on the difference in morbidity, either alone or when aggregated with a non-significant difference in perinatal mortality. In the two-year follow-up, the difference had disappeared calling into question the initial definitions and judgments about serious morbidities (as well as the fact that paediatricians were not blinded as to which group – vaginal or CS – the neonates they assessed belonged).

  84. BillyJoe says:

    Plonit,

    “It should be noted that in subgroup analysis, for low-perinatal mortality countries, there was no statistically significant difference in perintatal mortality between the planned vaginal and planned caesarean delivery groups. ”

    If that is true, then the actual information that Dr Auteur gives her patients is actually false.

    This is another reason to present the information in a neutral manner: if the information you have presented to the patient is false, flawed, or incomplete, you won’t have unnecessarily aggravated your error by driving the patients decision in the wrong direction.

    Dr Auteur,

    “If we wish to control the rising C-section rate, we must confront the expectations of patients, including those who refuse to acknowledge that liberal policies for vaginal breech delivery or VBAC will mean that some babies will die.”

    You seem to be in two minds about C-section. You both blame patient expectation of a perfect baby for the rising C-section rate and, at the same time, you are advocating more C-sections to reduce the infant death rate.
    So, which is it, are there too many C-sections because of unrealistic patient expectation or do there need to ber more C-sections to reduce the infant death rate?

  85. laursaurus says:

    Dr. Amy, I couldn’t agree more with your prudent approach to breech deliveries. When things go wrong in obstetrics, it happens rapidly. And not only that, there are 2 patients at risk, not just one. I personally was glad not to be recovering from abdominal surgery while caring for my newborn. But why risk the baby getting “stuck” in the middle of delivery? Breech doesn’t just mean bottom first. It can be a footling or even worse, a shoulder presentation (which if I remember, is impossible to deliver vaginally).
    Post C/S, the number of patients is decreased back to one, the post-op mother. Most complications, should they arise, post-op are generally of lower acuity. Infection or other complications to healing, can often be managed thru homehealth nursing care, even though care may need to be initiated in a hospital setting. Yes, in a perfect world, babies would gently emerge despite which end comes first. But once the body is delivered and the head is stuck, it’s too late to then op for a C/S.
    It seems your blog attracts women who’s ideology trumps practicality. Big Birth is another medical conspiracy to earn $, and the dirty little secret is that child birth is a completely natural and safe occurrence. Human beings are at physical disadvantage compared to other animals. If the fontanels were closed, the head would not fit thru the birth canal. If our female pelvises were any wider, we could not walk upright. Considering all the amazing advantages our species is endowed with, it’s a fair trade off, IMO.
    I don’t recall you ever mentioning the horrible reality of litigation. Any poor outcome for the neonate, means a lawsuit. Not to imply that dr’s perform C/S just to cover their butts. But people don’t realize how devastating an impact a neonatal death makes on the attending md. It just seems plain reckless to run the incredible risk of attempting a vaginal breech delivery. The patient may completely assume the potential for serious problems, but a dead child is automatically be the doctor’s fault.

  86. laursaurus says:

    “I’m assuming you are pro-life Dr. Tuteur? That is the only reason I can see for putting a fetus’ life ahead of a woman’s right to informed consent?”
    This is just so wrong on so many levels. The woman who has carried her child to term, not only chose life, but is counting on it.
    This comment is clearly not about appropriate medical care, but a battle of ideology.
    The whole point of labor and delivery is a healthy, living child. It’s horrifying to imagine conceiving a child (not easily for many), enduring 9+ months of pregnancy, the intense pain of labor, and during the middle of delivery, you helplessly see your baby die.

    Bang that feminista drum on a political blog, not a medical one.

  87. Zoe237 says:

    “It should be noted that in subgroup analysis, for low-perinatal mortality countries, there was no statistically significant difference in perintatal mortality between the planned vaginal and planned caesarean delivery groups. ”

    Do you mean in the TBT at two years? I’m looking at the tables now for the first one, and Plonit is correct. The bulk of the mortality/morbidity in low PMR countries comes from morbidity. IOW, it was only by combining the two that they got statistically significant results, probably because of lower sample size. I initially accepted Dr. Tuteur’s “630 babies will die” but now I’m starting to wonder if that’s correct. particularly in the U.S.

    Fifi, I know you weren’t trying to prove anything. Those were just my disjointed thoughts as I read the link. I totally agree on binary thinking being a sign of an idealogue. Some natural child birth advocates do it, and Dr. T definitely does it.

  88. laursaurus says:

    While I’m on the subject, can I ask a question, Dr T?
    Isn’t the standard of care to deliver the baby prematurely in the 3rd trimester if the mother’s health is threatened as opposed to a late term abortion?
    I developed what appeared to pre-eclampsia during my 2nd pregnancy. When protein was detected in my urine, I gained 7lbs of water-weight in one week, my ankles and feet were too swollen to wear shoes, and my blood work revealed a elevated alk phos, my OB admitted me for MgSo4 gtt and an insertion of Cytotec. Early the next am, Pitocin gtt was started. By 3:30 pm, I was holding my son. Granted his gestation age assessment indicated 38 weeks. I recall doing a C/S for a woman with toxemia/severe eclampsia at just 26 wks. I’m an OR RN, and because of the acuity of the patient, anesthesia insisted on doing the case in Surgery, rather than OB (those nurses aren’t experienced at assisting an anesthesiologist). The NICU team was present to manage the infant, who was immediately intubated. Even though she was a micro-preemie, the overall prognosis was good and she was eventually discharged to home with her mother (several weeks in NICU).
    When late term abortion is discussed in reference to saving the mother’s life, how often does this occur in reality? Note, the viability of the infant is a separate, but obviously significant issue-meaning I see no ethical conflict with a late term abortion for fetal demise, anacephaloly, etc.

  89. Fifi says:

    “I don’t recall you ever mentioning the horrible reality of litigation. Any poor outcome for the neonate, means a lawsuit. Not to imply that dr’s perform C/S just to cover their butts. But people don’t realize how devastating an impact a neonatal death makes on the attending md. It just seems plain reckless to run the incredible risk of attempting a vaginal breech delivery. The patient may completely assume the potential for serious problems, but a dead child is automatically be the doctor’s fault.”

    Actually Dr Tuteur did mention litigation as a defense for her position, while also blaming her patients for having unrealistic expectations (though it can be easily argued that the commercial nature of American medicine – and the almost pathologically heroic way commercial medicine is often practiced – is at least partially responsible for creating those unrealistic expectations). She did acknowledge that in the US doctors perform c-sections to cover their butts financially (while simultaneously claiming there’s no commercial/monetary interest informing the frequency of c-sections). And, really, it’s not about the MDs feelings when they lose a patient (not to trivialize how sad death can be) and putting patients through procedures to spare the MDs feelings. Most MDs will lose patients over the course of their careers (both my parents are doctors), it comes with the territory. It’s unrealistic for an MD, including an OB/Gyn, to think they’ll never lose a patient so I’d suggest, once again, that some of the unrealistic thinking that patients end up with actually originates with doctors who have unrealistic heroic visions of themselves.

    As it stands, I’m an advocate for informed choice and not ideologically against c-sections. What I object to is the emotionally charged language Dr Tuteur uses to persuade women towards what she prefers and the pretense that doing so is somehow SBM. Each woman should be able to decide for herself without being bullied in that way, and it’s something that should be discussed well before a woman starts giving birth. Women should know that childbirth carries risks, as well as the potential complications from c-sections and potential risks for future pregnancies if you have a c-section. Trying to scare women about natural childbirth OR c-sections with emotionally charged language is emotional bullying and manipulation, it’s not practicing SBM.

    A c-section can be a necessary and lifesaving procedure for both mother and child. However, to routinely do c-sections so a doctor can protect him or herself from being sued is highly unethical (and seemingly a particularly American thing to do). That this has twice been used as a defense of routinely doing c-sections doesn’t do much to dispel accusations that it’s about money in the US. In other countries with non-commercial medical systems the rising rates of c-sections are due to other factors (so it didn’t actually occur to me that it was about money).

    I’ll continue to look to policies in Canada, Australia and Europe to inform and guide my own decisions about any medical treatment I may require simply because of the commercial nature of American medical practice and the lack of focus on SBM and rational public health policies.

  90. Plonit says:

    @ laursaurus

    “Breech doesn’t just mean bottom first. It can be a footling or even worse, a shoulder presentation (which if I remember, is impossible to deliver vaginally).”

    You are right, not possible to deliver vaginally with shoulder presentation, but the TBT was not about this presentation – and no one is doing planned vaginal deliveries with shoulder presentation.

    “But once the body is delivered and the head is stuck, it’s too late to then op for a C/S.”

    That’s true. It is also true that once the head is delivered and the shoulders are stuck (shoulder dystocia), it’s really too late to then opt for a CS. But we don’t use that argument as the basis to institute 100% CS, because as you rightly point out there is maternal health to consider also.

    Head entrapment is operating more as spectre than science in this debate – from the discussion you would think that the deaths in the TBT were mostly caused by this very rare complication of breech, which is simply not true. In fact, some of the deaths – I forget what proportion, and don’t have access to the paper right now to check – were not caused directly by the mode of delivery. At least one baby in the planned vaginal delivery died before onset of labour, so the death was certainly not due to head entrapment or any other complication of the delivery itself. TBT was intention to treat analysis, so it is right to include these sorts of death – especially as planned CS were inevitably delivered earlier (on average) and this may have some effect on outcome regardless of presentation.

  91. Plonit says:

    Do you mean in the TBT at two years?

    ++++++++

    I mean that in the initial findings, there is no statistically significant difference in perinatal mortality alone in the low perinatal mortality countries. However, in the low-perinatal mortality countries there was a statistically significant difference in what was termed “serious” neonatal morbidity. The aggregated mortality+morbidity also showed statistically significanct difference.

    At two-year follow-up, in the low perinatal mortality countries, there was no longer any statisically significant difference in morbidity. There was still no difference in perinatal mortality, because there never had been. Aggregated, the mortality and morbidity in low-perinatal mortality countries showed no difference at two years.

  92. rosemary says:

    Fifi, “What I object to is the emotionally charged language Dr Tuteur uses to persuade women towards what she prefers and the pretense that doing so is somehow SBM. Each woman should be able to decide for herself without being bullied in that way, and it’s something that should be discussed well before a woman starts giving birth.”

    Fifi, “Beauty is in the eye of the beholder.” Maybe emotion is in the ear of the reader because I find your posts to be full of “emotionally charged language”. I definitely agree that people should be able to decide for themselves what is best and in this instance it goes for patients and their doctors. Neither should be able to force the other to do something they are not comfortable with.

    I also think people should be able to stand up to bullies and that they should prepare themselves ahead of time for life’s major events – like childbirth. Most people know when they are quite young whether or not they want to have children. If they do, they should start educating themselves early on about the procedure and start looking for practitioners they feel comfortable and compatible with, be that a witch doctor, a practitioner of evidence-based medicine or anyone in between, so that when the hour arrives, they are well prepared.

    Fifi, “Actually Dr Tuteur did mention litigation as a defense for her position, while also blaming her patients for having unrealistic expectations (though it can be easily argued that the commercial nature of American medicine – and the almost pathologically heroic way commercial medicine is often practiced – is at least partially responsible for creating those unrealistic expectations).”

    “Blaming her patients” for unrealistic expectations” or stating that people in the society where she has practiced have unrealistic expectations? I most certainly believe that that the majority of people today have very unrealistic expectations about medicine and that the main reason is that given the improved health care that we enjoy, compared with that of even our parents or grandparents, very few people today ever experience serious illness or death until, often quite late in life, they or someone they love are afflicted. At that point they do not have the experience necessary to deal emotionally with it in an appropriate way. And please don’t tell me that these things don’t have to be experienced that they can be taught from a book or a lecture.

    It may be quite easy to argue about the commercial nature of American medicine and about American culture as compared to the practice of medicine in other countries, but it is very hard to get evidence to support those arguments that can’t be refuted with evidence from the opposing side simply because of the great complexity of the problem. If you want to trade anecdotes, you can also find many supporting each of the opposing positions. I lived in Quebec for 10 years and was on your system and now live in Vermont 1.5 miles south of the border. I’ve also lived, worked and studied in Italy, Germany, Mexico and Spain.

    You may look to health policies in Western countries other than the US to help you make informed medical decisions. I look at the scientific evidence.

    I would guess that there are very few people in any western society, even doctors, who face, and I do mean face as look in the eye, the life and death decisions that obstetricians face on a regular basis. In their field things can go very bad very fast. It is very emotional for them and for their patients. So much so that I find it amazing that there are still people willing to practice in the field and it astonishes me to hear the way so many people here who never are in those situations attack Dr. Tuteur.

  93. Plonit says:

    I would guess that there are very few people in any western society, even doctors, who face, and I do mean face as look in the eye, the life and death decisions that obstetricians face on a regular basis. In their field things can go very bad very fast. It is very emotional for them and for their patients. So much so that I find it amazing that there are still people willing to practice in the field and it astonishes me to hear the way so many people here who never are in those situations attack Dr. Tuteur.

    +++++++++++++

    I don’t think anyone is attacking Dr Tuteur. Her presentation of the issues is being questioned.

    Also, I agree with you that obstetricians and midwives have more of their fair share of looking death in the face – and it is emotional. However, the issue is not whether childbirth presents dangers (it is a given that it does) but whether interventions (such as CS) can reduce those dangers. This is one of the things need science-based medicine for: to overcome our emotional drive to do “something” regardless of the efficacy of that intervention. In the findings of the TBT, in countries with already low perinatal mortality, CS for breech at term did not reduce perinatal mortality, and intitially large differences in neonatal morbidity were not sustained over time.

  94. Zoe237 says:

    Thanks for the explanation Plonit. That was my take as well, but it does seem to invalidate every argument Dr. Tuteur has made thus far, at least the fact based ones. That’s informed consent… how?

    “If they do, they should start educating themselves early on about the procedure and start looking for practitioners they feel comfortable and compatible with, be that a witch doctor, a practitioner of evidence-based medicine or anyone in between, so that when the hour arrives, they are well prepared.”

    Rosemary, I agree with you. I also do not agree with Fifi that *some* doctors are promoting c-sections for financial reasons. Medical mal being what it is, these doctors are simply trying to continue practicing. I know way too many good obs who have gone out of practice because of the insurance rates. For their education level, OBs don’t seem to be raking in the dough either. So the financial argument may be valid, but only on a system wide level, not an individual OB level.

    My own OB was very honest that a lot of hospital policies were CYA and not evidence based, and that she was perfectly willing to let me labor without intervention. I trusted this OB that when she said (hypothetically speaking) I needed a c-section, it was for a damn good reason, not just because the baby was 10 pounds or I’d been laboring for 24 hours. (CPD and Friedman’s curve). I also asked for her rates- and they were around 15%, despite her fairly high high risk caseload. Because you really do need that trust- if you are in the middle of pushing, doing extremely hard work, it’s rather hard to give informed consent, stop the episiotomy, or refuse a c-section.

    Then there are the obs who are defending the system and asserting that c-section for everything is justified by the evidence. Which it’s not. Just because the technology is there doesn’t mean it’s beneficial in every circumstance. Some obs, out of idealogy, fear, or emotion, assume that their interventions are always necessary. But it is not that simple, and research has reflected that. Again, that false dichotomy.

  95. The Term Breech Trial and the PREMODA study are not the only two papers on the subject. I chose to present them because they represent the two poles of the debate.

    Since the publication of the TBT study, there have several large studies of breech vaginal delivery in real world populations.

    Rietberg et al., The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35 453 term breech infants, BJOG 2005;112:205–9):

    “Within two months after publication of the Term Breech Trial, the overall caesarean rate increased from 50% to 80% and has remained stable thereafter. In the group of infants less than or equal to 4000g this was associated with a significant decrease of perinatal mortality from 0.35% to 0.18%, a decrease of the incidence of 5-minute Apgar score less than 7 from 2.4% to 1.1% and a decrease of birth trauma from 0.29% to 0.08%. In the (small) group of infants greater than 4000g a similar trend was observed.”

    Gilbert et al., Vaginal versus cesarean delivery for breech presentation in California: a population-based study. Obstet Gynecol 2003;102:911-17:

    “More than 3.2 million singleton term newborns were identified during the study period, with 100,667 (3%) in breech presentation at the time of delivery. Of these, 4952 women (4.9%) had vaginal breech delivery, whereas 60,418 women delivered by cesarean without labor, and 35,297 women underwent cesarean in labor. Breech vaginal delivery in nulliparous women was associated with increased neonatal mortality (odds ratio [OR] 9.2, 95% confidence interval [CI] 3.3, 25.6) and morbidity (asphyxia: OR 5.7, 95% CI 4.5, 7.3; brachial plexus injury: OR 33.9, 95% CI 15.2, 76.1; and birth trauma: OR 5.8, 95% CI 4.7, 7.1) compared with breech delivery by prelabor cesarean in nulliparous women. In breech-presenting women with one prior vaginal delivery, neonatal mortality was not different between groups, but morbidities (asphyxia: OR 3.9, 95% CI 3.0, 5.1; brachial plexus injury: OR 22.4, 95% CI 9.9, 50.5; and birth trauma: OR 4.2, 95% CI 3.4, 5.3) remained increased for vaginal compared with cesarean delivery. CONCLUSION: The “normal” term breech fetus, when delivered vaginally, had significantly increased neonatal mortality (in nulliparous women) and morbidity (all breech deliveries), when compared with the breech fetus delivered by cesarean, which suggests that these patients might best be delivered by cesarean to avoid these adverse outcomes.”

    Collaborative Breech Study Group. Term breech delivery in Sweden: mortality relative to fetal presentation and planned mode of delivery. Acta Obstet Gynecol Scand 2005;84:593–601:

    “The study comprised two parts. Study A is a national cohort study for the period 1991–2001, including 22 549 breech presentations and 875 249 cephalic presentations born at ≥38 completed weeks. Study B is a case–control study, including all 164 breech deliveries with perinatal or 1-year infant death (during 1991–1999 in Sweden) and controls.

    Results. Study A: Among non-malformed infants, the total mortality rate was 0.46% in breech and 0.28% in cephalic presentations [adjusted odds ratio (OR) 1.6; 95% confidence interval 1.3–1.9]. Non-malformed breech babies were at an increased risk of antenatal death (breech versus cephalic hazard ratio: 2.7, 2.1–3.6). The infant mortality among non-malformed breech deliveries was higher in vaginal birth than in delivery by CS before labor (OR 2.5, 1.2–5.3). The perinatal + infant mortality among non-malformed breech babies was higher at delivery after 39 completed weeks than at CS delivery at 38 weeks (0.53% versus 0.14%; OR 3.5, 1.9–6.4). The estimated needed number of CS to avoid one death was 400. Study B: In breech presentations without malformations, OR for perinatal or infant death was 3.1 (1.7–5.8) at planned vaginal delivery compared with planned CS delivery, and when breech presentations not diagnosed at 37 gestational weeks were excluded, OR was 3.7 (1.6–9.2).

    Conclusions. These large population-based and case‐control studies both show a significant reduction of perinatal and infant mortality with planned CS in term breech pregnancy.”

    Even the authors of the PREMODA study acknowledge that vaginal breech delivery leads to an increased risk of death. They merely claim that the risk can be reduced by limiting eligibility with very strict criteria.

    In other words, claiming or implying that vaginal breech delivery can be extended to tens of thousands of women without resulting in preventable neonatal deaths is simply false. If we wish to consider a policy of promoting vaginal breech delivery, we inform women of the risk and make sure they understand that their babies could die and some will die.

  96. Fifi says:

    Rosemary – “I would guess that there are very few people in any western society, even doctors, who face, and I do mean face as look in the eye, the life and death decisions that obstetricians face on a regular basis.”

    We actually agree about more than we disagree about Rosemary – where we mainly disagree are our opinions of how Dr Tutuer presents her arguments on both this topic and others she’s written about here, and on how heroic OB/GYNs are in relation to other doctors and people. You are aware that Dr Tuteur tries to be inflammatory on purpose and has said so?

    Sorry but your guess is not a particularly good guess. Anyone who works in an ER/trauma/emergency medicine faces life and death decisions frequently, as do lots of surgeons. Many other doctors deal with these kinds of decisions and even harder ones (as do nurses – while for obvious reasons there aren’t good statistics, voluntary/requested euthanasia and assisted-suicide aren’t as rare as the general public tends to think). Psychiatrists also face life and death decisions all the time – perhaps just not in a form you’d considered. You seem to be forgetting that a great deal of medicine is about treating dying and suffering people. The main reason why so many people think having a baby doesn’t hold many dangers anymore is because the risks actually have been greatly reduced. Nothing is risk free, of course, and people do have a tendency to believe that medicine can fix anything and is magic (and that bad things won’t happen to them and to blame their doctors when they do, this isn’t an area where OB/GYNs get singled out).

    As for making decisions purely on the science…that’s a snappy answer but you’re a fool if you think you have the expertise and don’t need any input from a doctor. I mean, sure I’m quite well informed, I read up on things and grew up around medicine and research but I’m not a doctor, let alone a specialist. Even doctors rely upon other doctors who are specialists, they don’t presume to be specialists in every field (and it’s generally not a great idea for doctors to be treating themselves for anything but minor ailments, it’s a little matter of appropriate detachment).

    Even if someone can weigh the evidence on their own, specialists have clinical experience as well as specialized education and can also judge each of our cases based on who we are as individuals. Studies are great but at the end of the day we’re all an N of 1. I ask my parents – who are doctors – for their opinions if it’s their field but they’re wise enough to refer me to a specialist when it’s outside of their field of expertise (or inappropriate for them to be treating me). I go to see a specialist because, if I have found them trustworthy, I value their opinion and expertise – specialists exist for a reason. If a doctor is trying to impose either their personal ideology or morality on me – and I have had this happen – I simply find another doctor. Not everyone is equipped to do this though and many people see doctors as authorities they can’t question or aren’t comfortable enough with science to even start weighing the evidence. The fact remains that many people rely upon their doctors to help them make decisions. Adding emotional content to sway a patient one way or the other is unethical, particularly if it’s under the pretense of being neutral and simply SBM. Offering a professional opinion, which can most definitely include the physician’s biases, is an entirely different thing than pretending to be merely presenting the scientific facts (particularly if not all the facts are being presented due to a professional/personal bias).

  97. Fifi says:

    zoe – “I also do not agree with Fifi that *some* doctors are promoting c-sections for financial reasons.’

    I didn’t originally make this claim and I highly doubt it’s relevant anywhere but in America. It was Dr Tuteur who said that doctors were making decisions to perform c-sections for fear of being sued and brought the idea of the “perfect baby” into the conversation (I’d think the goal would be a healthy baby AND mother). The financial incentive didn’t even occur to me until Dr Tuteur brought it up in defense of c-sections, it seems to be something specific to America. I’m still unclear why she believes that people shouldn’t be shocked or dismayed by her assertion.

    Dr Tuteur – “Americans say to obstetricians, “Give me a perfect baby or I will try to destroy you professionally and economically by suing you” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.”

  98. StatlerWaldorf says:

    Amy said, “In other words, claiming or implying that vaginal breech delivery can be extended to tens of thousands of women without resulting in preventable neonatal deaths is simply false. If we wish to consider a policy of promoting vaginal breech delivery, we inform women of the risk and make sure they understand that their babies could die and some will die.”

    Yes, this is fair to say. However, for many women, especially those in a first pregnancy, avoiding a c-section is an important consideration for future fertility, healthy pregnancies and births. What are the stats about the risks of c-section for mothers, babies and future reproduction? Currently in an increasing number of US hospitals, one c-section means all future births must be c-section. Do you think that these other factors should be factored in when parents are deciding to risk their baby being that 1 in 111 that doesn’t survive a vaginal breech birth?

  99. BillyJoe says:

    Informed choice again.

    Rosemary,

    “I also think people…should prepare themselves ahead of time for life’s major events – like childbirth. Most people know when they are quite young whether or not they want to have children. If they do, they should start educating themselves early on about the procedure and start looking for practitioners they feel comfortable and compatible with…so that when the hour arrives, they are well prepared.”

    You’re living in cloud cuckoo land!

    What percentage of woman, when they decide they will have children, have the inclination, intelligence, wisdom, and investigative skill to do this. My estimate is <10%
    Of those, what percentage could attain a level of knowledge to be able to effectively argue against what their obstetrician recommends. Again, my estimate is <10%

    So we effectively have <1% of mothers who have anything that could reasonably be called "informed choice".

  100. rosemary says:

    BillyJoe, if your estimates about women are correct, and if the other side of the coin is also correct, that doctors are highly intelligent almost always right superior beings, then in the interest of society, I think we had better return immediately to the old paternalistic society of our ancestors.

    If your estimates about women are correct, but you do not believe that doctors are all knowing, then I think instead of fighting with doctors and demanding that they hand feed and take responsibility for the total education of their patients as I feel people here are doing, I think we should just give up on women and let them suffer the consequences of their inferiority.

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