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The Journal Gazette

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Sunday, December 18, 2016 4:16 pm

Rules tighter on breech births

Sherry Slater | The Journal Gazette

When Christopher Stroud trained as an obstetrician, he learned how to bring breech babies into the world.

It’s a skill the 52-year-old doctor has used numerous times over the years as a local OB-GYN whose patients include women in the Amish community. And it’s a skill he’d like to pass along to his medical partner, who is in the early years of her practice.

But it’s getting harder to find a hospital that will allow vaginal breech births for a single baby. Parkview Health and Lutheran Health Network now require cesarean section – or abdominal surgery – in those circumstances.

Although the American College of Obstetricians and Gynecologists has recently advised that breech deliveries are acceptable in certain circumstances, Parkview has taken a better-safe-than-sorry approach by banning them since October. Lutheran hospitals, which are owned by Community Health Systems Inc., has stopped allowing them while officials review their policy.

Stroud worries that if he tells Amish patients their only hospital-based option is a C-section, some might choose a risky at-home birth. He also worries that hospitals might next deny a planned vaginal birth to anyone who has ever had a C-section.

Even so, he understands that hospitals have to consider liability issues.

Upside up

Only a small percentage of pregnant women ever face a breech birth.

Just 3 percent to 4 percent of full-term babies are positioned so their buttocks or legs will enter the birth canal first, according to American College of Obstetricians and Gynecologists, or ACOG.

When a pregnant woman’s due date approaches, the fetus typically turns inside the womb so that its head is pointed downward.

Because the head is the largest part of a baby, the infant’s body tends to slip easily through the cervical opening after the head leads the way. That’s the common and best-case scenario. 

But some babies don’t turn on their own.

Doctors can press on the mother’s stomach during the latter weeks of pregnancy to coax the fetus into the traditional birthing position. Sometimes it works; sometimes it doesn’t.

The danger with a breech birth is that the baby could become stuck in the birth canal, prompting the doctor to perform an emergency C-section. That can put both the child and mother at higher risk.

Some hospitals require a planned C-section, which eliminates some risks but presents others. Some women have bleeding issues, the risk of infection is greater following a C-section, and recovery time is longer than after a vaginal birth.

Stroud worries about those increased risks, especially when the mother wants to give birth as naturally as possible. His practice, which includes three nurse-midwives, caters to such patients. Stroud’s responsibility extends to both patients, he said: mother and baby.

A natural process

Certain situations make it more likely that a full-term baby will be in breech position, according to ACOG. They include when the mother has given birth several times. Each pregnancy stretches the womb, which allows a later fetus to move around more freely.

First babies tend to remain upside down after they’ve turned because the tighter uterus holds them in place.

Stroud encounters more breech babies than most OB-GYNs because his practice, Fertility & Midwifery Care Center, serves numerous Amish women. Amish families average five or more children, according to Amish Studies, an academic website developed by the Young Center for Anabaptist and Pietist Studies at Elizabethtown College in Pennsylvania.

Martha King, a Ph.D. in the University of North Carolina’s anthropology department, said no specific religious beliefs prevent Amish women from undergoing C-section surgery. King wrote in an email that "attitudes toward medical technologies will vary depending on the level of conservatism of the patient’s church district."

"In general, it is true that Amish patients do tend to want only as much (bio)medical intervention as they must have," she added.

Stroud has found that Amish women he treats typically consider childbirth a natural process and question the need for a planned C-section birth when their previous children were born vaginally.

"My fear is that they’ll get up and walk out," he said about informing patients of local hospitals’ restrictions.

Holding out hope

Despite that fear, Stroud holds his ground when a C-section is the only safe option. But "in select circumstances," he said, a vaginal birth is viable.

Guidelines from ACOG dictate those circumstances. The baby can’t be too big. It must lie in an appropriate position. And the mother must have previously given birth vaginally.

"Those are all indications that this person might be a good candidate to deliver vaginally," Stroud said.

There’s one more thing.

"The experience of your health care provider in delivering breech babies vaginally also is an important factor," ACOG says in a list of questions and answers related to breech birth posted on its website.

Stroud gained his experience during a traditional residency at the University of Virginia and while starting out working with an experienced OB-GYN, who continued his training in vaginal breech birth. Stroud wonders whether he’ll be able to train others or the skill will fade away from lack of practice.

He is holding out hope that Lutheran’s parent company will choose to allow vaginal breech births as an option in select cases. It seems possible.

Tomi Galin, spokeswoman for Community Health Systems, said the Tennessee-based parent company doesn’t have a policy on vaginal breech birth for single babies. Those guidelines are developed and adopted by individual hospitals, she said last week in an email.

"In the course of Dupont Hospital’s recent evaluation of the American College of Obstetricians and Gynecologists published opinions regarding single breech delivery, they asked CHS for assistance in analysis of industry standards or best practices," she said. "Dupont’s draft policy was reviewed, and two large academic medical centers were contacted for additional perspective on current patient care practice programs.

"Comments were provided back to the hospital for local consideration. Those opinions are still under evaluation by the medical staff as they determine local standards of care," Galin wrote.

Geoff Thomas, Lutheran’s spokesman, provided this statement:

"When making health care decisions we turn to and enact evidence-based guidelines, such as those provided by the American College of Obstetricians and Gynecologists, when establishing standards of care. Breech deliveries are no exception," he said in an email. "Our physicians are prepared to handle vaginal singleton breech deliveries when it is imminent."

"The current standard of care in Fort Wayne is C-section for singleton breech in labor," Thomas wrote. "However, we always evaluate best practice and how we can be prepared to give the safest care possible as we embark on new guidelines."

ACOG’s committee opinion, which was reaffirmed this year, states many "reports of vaginal breech delivery that follow very specific protocols … note excellent neonatal outcomes."

Officials’ first recommendation in the written opinion states: "The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery."

The organization describes the option as reasonable under certain guidelines.

Liability issues

Parkview’s policy doesn’t allow discretion.

Spokeswoman Jessica Miller provided the following statement:

"Parkview’s policy on breech delivery is highly focused on the safety of mother and baby, is widely accepted in health care and was endorsed by an overwhelming majority of Parkview and independent OB-GYN physicians who have privileges at Parkview. It allows for vaginal birth delivery in emergency situations or for the birth of a second twin.

"The policy advocates for a cesarean section for breech births that are non-emergent, as a vaginal delivery in these situations can pose serious safety threats to the baby, such as head entrapment, developmental disabilities or even death."

In a letter to physicians dated Sept. 21, Dr. Judith Kennedy said she had recently been asked by a physician about the possibility of a planned single vaginal breech birth. In response, Parkview officials realized there wasn’t a policy in place, she wrote.

In the letter, Kennedy detailed concerns related to single vaginal breech births: An OB-GYN trained in the technique might not always be available, and nurses on duty might not be able to recognize unique distress signs when those patients are in labor.

Liability, she wrote, is also a significant issue. Parkview’s attorney, David Stach, has advised against offering the service because doing so could leave the health care system legally vulnerable if something goes wrong.

Stroud is slated to confront liability issues of his own. He has applied for tax breaks on a birthing center at 9823 Auburn Road, near the Dupont Hospital campus.

Construction and equipment costs are estimated at $855,000. The project is projected to be competed in June.

Despite being the boss, Stroud won’t be allowed to write the rules for what he offers to patients.

The Indiana Department of Health bars stand-alone birthing centers from serving women having breech babies, twins, C-sections, epidurals or induced labor, Stroud said. Also, they can’t treat a woman attempting vaginal birth after a previous C-section.

"You don’t do any high-risk things in a birth center," he said.

So Stroud – and his patients – will continue to rely on Parkview and Lutheran facilities for all breech deliveries. For now, at least, those deliveries will all be C-sections.