More on Breech and Informed Consent

For those interested, the Royal College of Obstetrics & Gynecology has put out revised parameters supporting an option of vaginal breech delivery. Based on research that debunked a lot of the information in the earlier Term Breech Trial that organized medicine originally jumped on to recommend c/section for all breeches. The RCOG is way ahead of ACOG in the strength of their statement and the commitment to try to reeducate practitoners in the art of breech delivery. If you are breech or have a client who is breech at 35-36 weeks this would be an excellent educational, calm reasonable website to refer to families who want to know more. Might keep them from surfing the interent in unfiltered and sometimes hysterical sites.

When considering a home breech delivery, as that may be the only option left in many areas, it is important to give true informed consent. The most significant difference in a home birth with a skilled practitioner is the lack of ability to use Piper forceps for my midwife colleagues since this is out of their scope of practice. Trained physicians can use these helpful aids and I carry them in my birth supplies. Once again, showing the collaborative approach of midwife and doctor teaming up can provide optimal care. Of course, we all know how few doctors there are willing to collaborate with the midwife community and the pressure those few are under from their peers. Also, the diminishing number of doctors skilled in breech delivery is concerning. Lastly, home birthing also lacks the immediate availability of general anesthesia in the extremely rare case where complete uterine relaxation is necessary to assist in delivery of an entrapped head. Women need to know these things but they must be presented in the light of the reality that the likelihood of this frightening problem is extremely rare when proper selection criteria labor management for breech delivery are used. In my opinion, the risks of a complication that is life threatening is more common from a surgical birth and these should be discussed as well. Then, whatever decision is accepted by the family should be respected. Where vaginal breech delivery is the preference but not an option, an ethical practitioner should refer that patient to someone who can honor her request.

From the AMA's Code of Ethics:
The patient should make his or her own determination on treatment. The physician's obligation is to present the medical facts accurately to the patient ... and to make recommendations for management in accordance with good medical practice ... Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment

Dr. F