Doctors turning on breech caesarean trend

Courtney Hargreaves and her daughter Ava.
Courtney Hargreaves and her daughter Ava. Photo: Michael Clayton-Jones

More pregnant women are being given the option of vaginal birth for breech babies, as doctors question a decade-long trend of resorting to caesarean deliveries in such cases.

Recently revised guidelines by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists state vaginal breech births are possible for carefully selected patients in major hospitals where there are suitably experienced staff.

College vice-president Steve Robson said just 3 per cent of babies were in the breech position late in pregnancy and most of them were now delivered by caesarean section, meaning few young doctors were acquiring the skills to perform vaginal breech births.

Researchers have found that vaginal delivery of breech births in Australia dropped from 23 per cent in 1991 to 3.7 per cent in 2005, in an overwhelming shift towards caesareans.

Much of the change followed an influential study published in The Lancet medical journal in 2000 suggesting that caesarean sections posed fewer risks to breech babies than vaginal births. But many doctors have criticised the findings of the study, arguing its methods were flawed, and saying there is strong evidence that vaginal breech births are safe in certain circumstances.

Royal Women's Hospital director of birth suites Kobus du Plessis oversaw hundreds of vaginal breech births in his native South Africa, where doctors continued to perform them, and is now training junior doctors and midwives in what has become a ''lost art''.

He said doctors who had trained in obstetrics in Australia over the past decade were often scared to deliver breeches vaginally because they did not have the expertise.

''That's the problem we're sitting on now. The pendulum is swinging back to vaginal breech, but we haven't got the skills,'' he said.

Dr du Plessis said that by about 36 weeks' gestation about 3 per cent of births were breech, in which the baby was poised to exit the pelvis with the buttocks or feet first, rather than the head. He said that after confirming the breech position with ultrasound, doctors could perform a procedure to turn the baby using hands on the mother's stomach, which had a 50 per cent success rate.


If the procedure failed to turn the baby, Dr du Plessis said he counselled women about their options, including a vaginal birth in some cases.

He said a baby in the breech position could only be delivered vaginally if the head was flexed in labour, giving a smaller diameter than if it was extended.

Other important elements for vaginal breech birth were good progress in labour, continuous monitoring of the baby's heartbeat and an experienced doctor or midwife. ''Most deliveries are hands-off with breech births and if all the criteria is fulfilled, most of the time we don't have to do anything,'' Dr du Plessis said.

''The reason you need experience and the thing most people are petrified of is the head getting stuck.''

He said doctors and midwives could use forceps and other manoeuvres to assist in such cases.

Dr du Plessis said the Royal Women's Hospital was having success in slowly bringing down its caesar rate for breech births, from 87.5 per cent in 2011 to 85.1 per cent last year.

He said offering women the choice of a vaginal breech birth if they wanted it and where safe could avoid some of the complications of caesarean sections, including increased risk of bleeding and infection.

Courtney Hargreaves sought out Dr du Plessis to avoid a caesarean section for the birth of her daughter Ava Rose, now nine months.

''I had a feeling she wasn't going to turn. From about five months she just stayed sitting up,'' she said.

''For me it was really important she was born as naturally as possible."

Ms Hargreaves said her labour lasted just over half an hour and Ava Rose was born late in the afternoon. Both mother and baby were healthy and went home the next morning.