Wednesday, June 17, 2009

Canada does a 180!

The Society of Obstetricians & Gynecologists of Canada (SOGC) has made a dramatic about-face this week. In a reversal of its earlier prohibition of vaginal breech birth, the SOGC just announced its new recommendations: to offer vaginal breech birth and to establish nationwide training programs so that physicians can learn the necessary skills. From The Globe and Mail: C-section not best option for breech birth:

Physicians should no longer automatically opt to perform a cesarean section in the case of a breech birth, according to new guidelines by the Society of Obstetricians and Gynecologists of Canada.

Released yesterday, the guidelines are a response to new evidence that shows many women are safely able to vaginally deliver babies who enter the birth canal with the buttocks or feet first. Normally, the infant descends head first.

“Our primary purpose is to offer choice to women,” said André Lalonde, executive vice-president of the SOGC.

“More women are feeling disappointed when there is no one who is trained to assist in breech vaginal delivery,” he adds....

The new approach was prompted by a reassessment of earlier trials. It now appears that there is no difference in complication rates between vaginal and cesarean section deliveries in the case of breech births....

This article also highlighted the SOGC's position on normal birth:

The new decision to offer vaginal breech birth aligns with the SOGC promotion of normal childbirth – spontaneous labour, followed by a delivery that is not assisted by forceps, vacuum or cesarean section. In December of 2008, the society release a policy statement that included its recommendation for a development of national practice guidelines on normal childbirth.

“The safest way to deliver has always been the natural way,” said Dr. Lalonde.

“Vaginal birth is the preferred method of having a baby because a C-section in itself has complications.”

Cesarean sections, in which incisions are made through a mother's abdomen and uterus to deliver the baby, can lead to increased chance of bleeding and infections and can cause further complications for pregnancies later on.

“There's the idea out there in the public sometimes that having a C-section today with modern anesthesia and modern hospitals is as safe as having a normal childbirth, but we don't think so,” said Dr. Lalonde.

“It is the general principle in medicine to not make having a cesarean section trivial.”

The SOGC believes that if a woman is well-prepared during pregnancy, she has the innate ability to deliver vaginally.

Another article in The Vancouver Sun, Canadian docs to stop automatic C-sections for breech babies, covers much of the same information about the change in breech policy:

In a major shift in medical practice and another assault on Canada's rising cesarean section rate, Canada's delivery doctors are being told to stop automatically scheduling C-sections for breech babies and attempt a normal delivery instead — something significant numbers of obstetricians aren't trained to do.

New guidelines issued Wednesday by the Society of Obstetricians and Gynaecologists of Canada say women carrying babies in the breech, or bottom-first, position should be given the right to choose to attempt a traditional delivery when possible.

The society says that women in Canada want the choice, and that some women with breech babies are delivering at home "because they knew if they went to hospital A, B or C it would not be offered," says Dr. Andre Lalonde, executive vice-president of the obstetricians' group and an adjunct professor of obstetrics and gynecology at McGill University and the University of Ottawa.

Lalonde says the group is working aggressively to ensure future specialists are trained in breech vaginal deliveries and is organizing courses across Canada for practising doctors to refresh their training.

I am somewhat stunned at this dramatic shift in policy. The ACOG could definitely take some hints in listening to women and looking closely at the evidence from their friendly northern neighbors...This makes me want to go outside and sing "O Canada" at the top of my lungs!

ps--I love Unnecesarean's illustration!


  1. How awesome! For once its not all doom and gloom in the world of OB/GYN news. I doubt the ACOG will think seriously about their position on surgical birth, but a girl can hope.

  2. Wow! Thats such awesome news!

  3. Wow, that's very good. I hope it's the start of many such positive changes. (gotta be optimistic, right?)

  4. well, hopefully they will truely be trained in the art of breech birth and not just creating a "vaginal cesarean" through piper forceps and massive episiotomis.. when I had my baby (suprise breech) I thankfully birthed before the nurse could retrieve what the OB was requesting.. my baby slipped out..practically my easiest birth.. but some OBs just can't sit on their hands.. they need to learn to understand BIRTH. I still suspect breech in the hospital will remain risky if they can't learn to be more hands off..perhaps more risky than scheduled cesarean.

  5. as a woman who had a c-section because of breech presentation...yea!!!! I would have gone for natural but neither doctors or my midwives were comfortable with it because they had no experience with them. the fact that Canada is promoting natural, unassisted childbirth alone is awesome. but this stance on breech birth IS something to sing about.

    as a side note, I had a wonderful HBAC with my second, and though I don't plan on having any more kids, will refer friends with breech babies to Canada from now on.

  6. fantastic news. wow. almost

  7. Very interesting. Now, do you think the Doctors will actually do it? I wonder what literature they reviewed to come to this conclusion?

  8. Lots and lots of problems with the term breech trials. And common sense.

    They have been promising this policy shift for over a year (it's about time).

    As someone who lives in the city with the highest c/s rate in Canada (37% and rising), let's hope this makes a difference. Docs have been scared into c/s for breech for too long - that fear won't go away overnight.

  9. Yay Canada! my husband is Canadian and we are often trying to figure out a way to move back there. And despairing over having #2 here in the States. Maybe I'll go live with his parents and give birth there!

    On the American side of the debate, I don't know if you've been following any of the buzz swirrling around the New Yorker article by the surgeon & prof of public health - the expose on the high cost of US health care. Not just about the cost, but about the DANGER of high rates of interventions. It's basically the EXACT same information as you and others have been promoting about C-sections (after a certain critical mass of c-section per population, they actually become MORE dangerous rather than helpful). I'm hopeful that the wider issues of expense and safety will get people talking about unnecessary Cesareans in this country.

  10. How interesting! It's certainly a step in the right direction and is exciting to see! I wonder what this will translate into as far as midwifery care goes ...

    It's hard to believe, though, that the SOGC really believes that spontaneous labour and spontaneous vaginal birth are normal and the safest when you look at induction, instrumental delivery and c/s rates ...

  11. Yes, I read that article in The New Yorker a few days ago and have been meaning to post about it. Really interesting stuff, especially about how the Mayo Clinic model decreases costs, decreases utilization of procedures and technology to more prudent levels, and has better health outcomes--all by focusing foremost on the patient using a collaborative physician-led model.

  12. =)

    Steal it! That's what I did while nursing yesterday morning.

  13. I'm glad, but I am concerned that actual vaginal breech training has gone the way of the dodo. It's all well and good to say that it's better to do things this way, but when no one knows HOW to do them, well...that's not really progress. Two steps forward and one step back, I guess?

  14. Go ahead and sing, we won't mind! lol
    I have to admit, it does make me rather glad to be Canadian at this moment, hopefully we're moving forward!

  15. Oh good! Maybe ACOG will jump on this bandwagon! One can certainly hope! In my state, breech is an automatic section, period. NOBODY does vag breech here. In fact, the closest ob that will "trial" one will only do it for multiparas, in the or, WITH a mandatory episiotomy.

  16. This was on the news here today (I'm in Canada) and it was largely a positive piece. They did talk about how dr's would need to build skills. The one thing I didn't like is that at the end of the segment they showed a woman "purple pushing" to the nurse's count and made it seem like the desired way to birth. We've still got a long way to go I suppose.

  17. SO so good. OH CANADAAAAAA!

  18. I am betting Robin's conference had a lot to do with this. Go Robin!

  19. We're at a breech birth right now - in Wisconsin. So far so good!

  20. Pinky, I blogged about the evidence that led to the guideline change here:

    Spinning Babies Lady - sending good birthing energy your way. I hope all goes well!

    Rixa, if you blog about the New Yorker article, I'd love to hear your take on the fact that the same brilliant author wrote a completely backward analysis of industrial childbirth just a few years ago. Henci Goer deconstructed it on You can read the original article here and Henci's response here. Henci and I have wanted to contrast Gawande's two articles on Science & Sensibility but can't find the time...I'd love to see an analysis on Stand & Deliver.

  21. And now of course, they will need midwifery skills to actually assist a natural breech birth. How long has it been?

    Very good news though! The internet is buzzing.

  22. Its a girl! Went beautifully! 8 1/2 pounds. I could write more here, but I wrote a little at the Spinning Babies blog.

  23. I loved the piece in the New Yorker, but having given birth at the Mayo and attending births there as a doula, it is a TERRIBLE place to look to for birth practices. Nothing about the Mayo model of care is good, and they have the same rates of interventions at birth as anyone else. In some ways, they have higher rates. As late as 2002 or so they had episiotomy rates in the40% range (if I remember that correctly!). From everything I know, they don't have the cesarean rates and VBAC rates and inductions rates to back up the idea that their model of care would improve maternity care.

  24. I think this just goes to show you that the approach that yields optimal outcomes in medical and surgical specialties is not going to be the same approach that will get you optimal birth outcomes. It continues to fascinate me that the smartest people working on health care reform can still be blinded by their medical medical biases and not see the crisis we have in maternity care (or how to fix it).

  25. I guess people have already forgotten about the mother/infant mortality rates not so long ago. Also, if I was considering a vaginal breech birth, I would want to know all about the long term effects on my pelvic organs and my reproductive health in general.

    Take care, Elli

  26. Eli,

    The US maternal mortality rate was lower back in the 70s when vaginal breech birth was the norm. Infant mortality may have been higher (I don't know), but we have made great strides in saving babies that previously would have died, and ending vaginal breech birth played little to no role in the lower mortality rates for babies (whether stillbirth, perinatal death, neonatal death, or infant mortality). In fact, considering the higher morbidity and mortality of babies and mothers due to unnecessary C-sections, it might even be argued that it's worse now than it was then.

    The "worst" study shows that VBB would cause a mortality or severe morbidity rate of 6/1000, and there were significant problems with that study... which is why the SOGC has reversed its position... because the evidence doesn't suggest 100% C-section is actually safer than VBB.


  27. Three cheers for those providers who go to the extra effort to learn the art of breech delivery. Most must still go "outside the system" to learn. I was shocked when, at 8 cm with good progress and no problems, my homebirth mw said we had to go to the hospital to have a cesarean because the baby was presenting breech (frank). Next time, a midwife who has breech delivery on her list of competencies. Didn't know to check on that the first time around. I hope the art isn't too long lost in Canada as trainings are organized... thanks for the good example, neighbors to the north!

  28. Rixa,

    I'm trying to find the time to organize a letter-writing campaign to ACOG.

    I at least want them to know that there are women who want the option of breech vaginal birth.

    I really have no idea how many it would take to get their attention, but I'm collecting names of anyone willing, and trying to draft a sample letter.

    If anyone is interested, feel free to write me at craigiecarter at


    A breech mama x 3, the last an amazing homebirth


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