New breech guidelines from Canada

The Society of Obstetricians and Gynecologists of Canada has come out with new guidelines for breech birth, saying that the automatic c-section is not an evidence-based practice and that all breeches should be evaluated and offered vaginal delivery if appropriate. New guidelines are here. I was curious to read through the guidelines, but as I read them I thought “What doctor is going to be willing to go through this checklist when they could just schedule another c-section and be done with it?” That’s why I liked an article that accompanies the published guidelines, by Dr. Andrew Kotaska, called titled, “Breech Birth Can Be Safe, But Is It Worth the Effort?”: (all the emphasis is mine)

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. …

In the PREMODA study, the overall vaginal birth rate was only 23%. Is it important to mount the significant effort required to offer women breech birth if only one quarter will thereby avoid Caesarean section? … In North America, over 100 000 women have pregnancies that remain breech at term annually. With a success rate similar to that of the PREMODA study, some 25 000 could safely avoid Caesarean section.

…[T]he current practice of “not offering” women a trial of labour while providing ready access to Caesarean section is coercive, especially given the equivalency of long-term neonatal outcome. Now, with a more comprehensive understanding of the components required to make short-term outcomes of vaginal breech birth equivalent as well, it would be unethical not to provide this information to women. Although it may be difficult in some settings to offer vaginal breech birth routinely, its availability elsewhere should be disclosed and assistance offered to obtain it if requested. To offer only Caesarean section is ethically and legally difficult to justify if a reasonable alternative is available.

This is really the crux of it, and the guidelines even state that women who refuse a c-section recommendation must still be given care (why does this even need to be said?) Why is it OK to providers to offer one option and not the other? What if no c-sections were offered and all women were required to deliver breech vaginally, regardless of the risks – would anyone be ethically down with that?

I think the next big step is to change the attitude that offering women one choice (to be accurate, no choice at all) is acceptable. After some new evidence came out about Term Breech Trial and other breech trials in 2006, ACOG did a weak “we guess maybe you could try vaginal breech if you REALLY REALLY want to” policy change, and I think everyone would agree it didn’t change much here. The Canadian guidelines, on the other hand, are actual guidelines with specific recommendations on how to safely offer and assist breech deliveries, along with a recommendation to train more providers in breech skills. But without strong advocacy the status quo seems likely to persist there as it does here. Will there be loud enough voices in Canada demanding that those guidelines be applied?