Are Cesareans for Breech Worth the Cost in Maternal Death?

By: Gail Tully |

2019-04-09 |

Provider Tips

In my early days of attending breech births, I met a family I will forever be honored to have met. Their very experienced midwife helped them with a late in life baby and now they were having a second late in life baby to add to a large family. Because the baby was breech, they were planning a home birth. There were two reasons: a lack of vaginal breech options and the father had a very specific reason not to agree to the routine plan for breech babies to be born by the cesarean operation.
This wasn’t the father’s first breech baby. His first wife had their first child by cesarean due to the baby being in a breech position. Their second baby came along two years later born by repeat cesarean due to the previous cesarean, not because of the baby’s position, the pregnancy or the labor. A clot formed during the routine, second cesarean and entered the mother’s circulation. The clot lodged in a critical spot and in spite of immediate attempts to save her life, the mother died during the operation.
The labor of the second wife slowed and because the amniotic fluid had released, the lack of normal progress for the breech labor was good reason to transfer to the hospital. By the time we arrived in the hospital the baby had flipped! A head down baby was born vaginally later that day.
The topic of maternal morbidity due to policies around breech birth has ever been in my mind as a very real motivation to continue breech skills and a more open policy about first births and breech position.

Maternal Mortality From Cesarean Is A Factor in Choosing Breech Vaginal Birth

Andrew Kotaska, MD, of Canada is concerned that “women have been coerced, both overtly and covertly, into having cesarean sections” for birth of their breech babies. Research warns doctors to expand options for vaginal breech birth. Parents and providers want to protect the baby but we must also protect the birth giver. Better skills in breech birth for term or late preterm babies are being met by doctors like Andrew Kotaska, and Anke Reitter and Frank Louwen of Germany.

The Dutch State the Issue

The cesarean section rate for term singleton breech babies in the Netherlands rose from 57 to 81% in the first six years after the Term Breech Trial report concluded cesareans were safer for breech births. The Dutch Maternal Mortality Committee took a look and found 7% of total direct maternal mortality due to breech motivated cesareans. Two women died due to massive pulmonary embolism, the same reason as the first wife in the family I met and assisted. The other two women died from sepsis, one had not received prophylactic antibiotics during the operation (before the infection took hold). No women died after emergency cesarean section for breech presentation in this period of time. So waiting for labor to begin, or changing from a plan for vaginal birth to cesarean did not cause a mother to die. The skills for breech birth in the Netherlands (Holland) in this time period were in general better than the same period in the USA. Choosing to go straight to cesarean section does not guarantee the improved outcome of the child, or the mother, but may increase risks for the mother, compared to vaginal delivery, reports the Dutch Maternal Mortality Committee.

Another study by Mehta finds that maternal morbidity was increased because of anesthesia and operative interference. I suspect interference may mean complications due to human error. Even in preterm breeches, in the next pregnancy, 1.1% (3/259) of women died with a planned caesarean section in their first pregnancy whereas 0.5% (6/1284) of women died if they had a planned vaginal delivery in the first pregnancy (aOR 1.8; 95% CI 0.31–10.1). The average risk of perinatal mortality over two pregnancies was 1.9% (10/518) for planned caesarean section and 2.0% (51/2568) for planned vaginal delivery, (OR 0.98; 95% CI 0.49–1.9).
Risk of death after cesarean section was 21.9 per 100.000 cesarean sections (86/393,443) versus 3.8 deaths per 100.000 vaginal births. Of course, for many women, having a cesarean is because they are already quite sick. Having a cesarean because a baby is breech and no other reason can cause women injury or even death, either at that time and in a future birth. So the choice around having a cesarean shouldn’t be decided without the knowledge that the birthing person’s life is at risk.

Maternal Mortality in the U.S.

WHO says, “Between 1990 and 2013, the maternal mortality ratio for the USA more than doubled from an estimated 12 to 28 maternal deaths per 100 000 births1 and the country has now a higher ratio than those reported for most high-income countries and the Islamic Republic of Iran, Libya and Turkey.2 About half of all maternal deaths in the USA are preventable.2
Each year an estimated 12001 women in the USA suffer complications during pregnancy or childbirth that prove fatal and 60 0003 suffer complications that are near-fatal – even though costs of maternity care in the USA in 2012 exceeded 60 billion United States dollars.4
Three factors are probably contributing to the upward trend in maternal mortality and morbidity in the USA. First, there is inconsistent obstetric practice. Hospitals across the USA lack a standard approach to managing obstetric emergencies and the complications of pregnancy and childbirth are often identified too late. Nationally endorsed plans to manage obstetric emergencies and updated training and guidance on implementing these plans is a serious and ongoing need.5”

Conclusion

Breech position at the time of birth is a fact of life. We can’t hide from the risks by pushing all parents to surgical birth. Some breech babies can be born relatively safely by natural means when the provider knows simple methods of freeing trapped arms or heads. See our Breech Birth Guide for examples of methods and solutions. Cesareans will always be a safe choice for some breech births. But vaginal breech birth is a safe choice for many babies and birth givers as well.

References:
Kallianidis, A. F., Schutte, J. M., van Roosmalen, J., & van den Akker, T. (2018). Maternal mortality after cesarean section in the Netherlands. European Journal of Obstetrics & Gynecology and Reproductive Biology, 229, 148-152.
Bergenhenegouwen, L., Ensing, S., Ravelli, A. C., Schaaf, J., Kok, M., & Mol, B. W. (2016). Subsequent pregnancy outcome after preterm breech delivery, a population based cohort study. The Journal of Maternal-Fetal & Neonatal Medicine, 29(15), 2539-2543.
Mehta, S., Chauhan, J., Raval, B., Yadava, P., & Lilhare, V. (2017). Study of Feto-Maternaloutcome of Breech Presentation With Singelton Pregnancy At Tertiary Care Hospital. National Journal of Integrated Research in Medicine, 8(6).

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