Andrew Kotaska

Vaginal delivery of breech presentation

To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth.

Commentary: Routine Cesarean Section for Breech: The Unmeasured Cost

Historically, partial breech extraction under maternal sedation was accompanied by high perinatal mortality rates (1). With the safety of modern cesarean section techniques, many deemed the avoidance of this fetal risk worth the maternal risk of cesarean section, and the proportion of breech fetuses delivered by cesarean section steadily increased. This trend reached its peak after publication of the term breech trial in 2000 (2). This trial implied that cesarean section was safer than vaginal birth for all breech fetuses at term. Professional obstetrical associations in the United Kingdom, United States, and Canada issued guidelines mandating cesarean section for term breech presentation. Across much of the world, vaginal breech birth is no longer ‘‘offered’’ to women. A new generation of specialist obstetricians lacks the skill and confidence to attend even the most straightforward vaginal breech birth, and maternal and perinatal deaths have resulted. The conclusions of the term breech trial were simplistic and erroneous. An overly liberal selection and labor management protocol allowed poorly selected infants to labor without adequate attention to progress. Half of the perinatal deaths in the trial were in growth-restricted fetuses, and infants born after prolonged labor had poorer outcomes compared with those whose labor was shorter (1,3). Inclusion of multiple centers with disparate levels of in-house specialist and surgical capability provided an inconsistent safety net. These factors led to fetal and neonatal harm attributed erroneously to breech presentation rather than to inappropriate management. Use of short-term surrogate outcomes overestimated the long-term risk of the questionable level of care provided. Breech birth technique has evolved. Particularly in Europe, centers with consistent specialist backup and cautious protocols convincingly demonstrated that a significant proportion of breech babies can be delivered safely vaginally (4,5). The professional obstetrical associations of the United Kingdom, United States, and Canada have reversed their restrictive stances and are supportive of selected vaginal breech birth (5‐7). Given the tenuous efforts to reestablish systems to provide safe breech birth, it is important to recognize the dangers of a system that is unwilling to do so.

Guideline‐Centered Care: A Two‐edged Sword

Most maternity care providers have heard of (and some will remember) the days of physician-dictated obstetrical care: routine perineal shaves, enemas, twilight sleep, prophylactic forceps, and mandatory postpartum bed rest. Although based on medical opinion at the time of what was best for women (beneficence), these interventions were derived from dogma rather than evidence. Happily over the last several decades, we have moved away from physician-directed care (based on real or perceived beneficence) defined by evidence, dogma, or anecdotal experience. Maternity care has evolved. Our goal has now become patient-centered care, based on a woman’s informed understanding of her clinical options and her autonomous consent. Practitioners have discarded most interventions based solely on dogma and have moved into the era of evidence-based medicine. As evidence accumulates, its translation to front-line clinicians has become a logistical challenge. In response, guidelines based on evidence and drafted by experts have become a welcome mainstay of clinical practice in the 21st century. With the advent of evidence-based medicine, however, there is a danger of straying into guideline-centered care; and guidelines vary considerably in their quality, tone, and directivity. The pedantic, simplistic 2001 breech guidelines of the American College of Obstetricians and Gynecologists (ACOG) (1) and the Royal College of Obstetricians and Gynaecologists (RCOG) (2) are examples of poor guidelines—poor because they accepted the term breech trial (3) hook, line, and sinker without adequate scientific skepticism, but more importantly, poor because they ignored external validity and parturient autonomy. In the term breech trial, all women with all breech fetuses in all settings were deemed to have the same intrinsic risk in labor, when this is not the case. Poor results from centers with inadequate resources following a liberal protocol do not have external validity in settings with better support and more cautious protocols. In a Kafkaesque perversion of informed consent, ACOG stated that if a woman refused a cesarean section, informed consent should be obtained (1). Clearly, any modern understanding of parturient autonomy and informed consent involves an up-front discussion of all options, including doing nothing, as part of the consent process. Thankfully, many clinicians are beginning to look more carefully at the relevance of evidence in their own settings (external validity), and are becoming conversant with quantifying small risks, informing women of these risks, and letting them decide what is the right decision based on their own values (parturient autonomy). Sometimes, honoring parturient autonomy means consciously defying a guideline—either because the setting differs from the evidence on which the guideline is based or the interpretation and woman’s acceptance of a particular risk-benefit balance differ from those of the authors of the guideline. Guidelines are due for (and are undergoing) a quantum leap by:

Informed consent and refusal in obstetrics: A practical ethical guide

The ethical principle of autonomy gives women a fundamental right to security of person. The principles of beneficence and nonmaleficence are caregivers’ duties to “do what is best,” and “do no harm.” Usually, women and caregivers agree on the best course of action and informed consent is straightforward. Occasionally however, a woman declines recommended treatment or requests treatment that a clinician believes is unsafe. When this occurs, the historical adage: “the doctor knows best” is no longer valid. Ethical tension between autonomy, beneficence, and nonmaleficence may cause conflict between a woman and her caregivers that can impede communication, compromise care, and contribute to poor outcomes. In these situations, negotiating informed consent or refusal can be challenging. By accepting a woman’s refusal, caregivers commonly believe they incur ethical and legal liability. Accordingly, they may withdraw care or coerce women to accept intervention. However, coercion negates consent and abandonment is unprofessional. This commentary explores how practical knowledge of the ethical and legal basis of informed consent and refusal can build trust, preserve the therapeutic alliance, and minimize risk when women refuse medical advice.

Two-Step Delivery May Avoid Shoulder Dystocia: Head-to-Body Delivery Interval Is Less Important Than We Think

A belief that prolonged head-to-body delivery interval endangers the newborn underpins the common obstetrical practice of delivering the babys trunk immediately after the head is born. Without intervention, however, birth typically occurs in two steps: once the fetal head is delivered there is usually a pause, and the rest of the infant is born with the next contraction. Allowing a two-step delivery does not increase the risk of fetal harm, and may lower the incidence of shoulder dystocia. A two-step approach to delivery should be considered physiologically normal. This has implications for the definition of shoulder dystocia.

L’accouchement du siège peut être sûr, mais le jeu en vaut-il la chandelle?

La surete de l’accouchement du siege par voie vaginale n’est plus remise en question. L’etude PREMODA a clairement indique que, en presence d’une selection et d’une prise en charge rigoureuses au sein de la plupart des unites de maternite, l’accouchement du siege pouvait etre sur1. Nous avons donc maintenant deux tâches a accomplir. Premierement, nous devons definir, aussi clairement que possible, les parametres qui permettent l’accouchement du siege par voie vaginale en toute surete. Deuxiemement, nous devons determiner, individuellement et collectivement en tant que profession, s’il s’avere indique de deployer les efforts necessaires a l’offre de l’accouchement du siege par voie vaginale.

Roundtable Discussion: “No One Can Condemn You to a C‐Section!”

The stories in this Roundtable Discussion are related by two women whose babies were born recently in Canadian hospitals. Each woman had undergone a cesarean delivery for her first child, and whereas Sophia delivered her second baby by vaginal birth after a cesarean (VBAC), Marie was unable to find a practitioner or hospital that would allow her to have a VBAC for her second birth. The women describe how they feel about their choices and experiences. Their two accounts and the issues that they raise are discussed in commentaries by a family physician, midwife, doula, and obstetrician.

Breech Birth Can Be Safe, But Is it Worth the Effort?

Whether term vaginal breech birth is safe is no longer a question. The PREMODA study has clearly shown that with careful selection and management by average maternity units, breech birth can be safe.1 We are now left with two tasks. The first is to define, as clearly as possible, what parameters make vaginal breech birth safe. The second is to decide, individually and collectively as a profession, whether to make the effort required to offer vaginal breech birth.

Female Genital Cutting

this document reflects emerging clinical and scientific advances on the date issued and is subject to change. the information should not be construed as dictating an exclusive course of treatment or procedure to be followed. local institutions can dictate amendments to these opinions. they should be well documented if modified at the local level. none of these contents may be reproduced in any form without prior written permission of the sOGC. this clinical practice guideline has been prepared by the social sexual issues Committee and the ethics Committee, and reviewed by the Clinical Practice Gynaecology Committee, the Canadian Paediatric and adolescent Gynaecology and Obstetricians Committee, and the Family Physicians advisory Committee, and approved by the executive and Council of the society of Obstetricians and Gynaecologists of Canada.