Another NICE Guideline that mentions care for breech presentation has been put out for comment. This time it is Inducing Labour. Many fine colleagues are collating responses to the guideline in general, but I would like views on the specific section related to induction of labour in breech presentation.
I have prepared a response, based on previous feedback from women and birthing people. Please let us know how you feel about this, and whether you would word anything differently.
Induction of labour is controversial, and even more controversial for breech presentation. I have tried to word the response in such a way that reflects the need for more informed choice, rather than more induction per se.
Some other resources:
- RCOG Management of Breech Presentation Guideline
- Sun et al 2017, Comparison of outcomes between induction of labor and spontaneous labor for term breech — A systematic review and meta-analysis
- A blog about one woman’s experience
Response to Draft Guideline:
p.10, line 6 “Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]” Cannot locate evidence for this recommendation in evidence review. This statement is vague. Not generally recommended by who? Why? Induction of labour for breech presentation is common outside of the UK.
p.10, line 14 “Discuss the possible risks of induction with the woman.” Also vague. What are the risks? A systematic review has been done, so women can be offered evidence-based information rather than general reluctance. https://www.ejog.org/article/S0301-2115(17)30578-X/fulltext
p.10, line 5 Suggest the section on ‘Breech Presentation’ is re-written to reflect the ethos of informed choice and discussion, in a similar manner to the section on ‘Previous caesarean birth.’ Otherwise, the service is inequitable. A guideline on IOL with breech presentation is only applicable to women who have chosen to plan a vaginal breech birth. The guideline should reflect and respect this, using neutral, non-judgemental language.
1.2.19 Advise women with a baby in the breech position, who have chosen to plan a vaginal breech birth, that:
- induction of labour could lead to an increased risk of emergency caesarean birth, compared to spontaneous breech labour
- induction of labour could lead to an increased risk of neonatal intensive care unit admission for the baby, compared to spontaneous breech labour
- the methods used for induction of labour will be guided by the need to reduce these risks. See the recommendations on Methods for inducing labour.
1.2.20 If delivery is indicated, offer women who have a baby in the breech position a choice of:
- an attempt at external cephalic version, immediately followed by induction of labour if successful
- caesarean birth or
- induction of labour in breech presentation
Take into account the woman’s circumstances and preferences. Advise women that they are entitled to decline the offer of treatment such as external cephalic version, induction of labour or caesarean birth, even when it MAY benefit their or their baby’s heath.
Current wording in Draft Guideline is:
1.2.19 Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]
1.2.20 Consider induction of labour for babies in the breech position if:
- delivery is indicated and
- external cephalic version is unsuccessful, declined or contraindicated and
- the woman chooses not to have an elective caesarean birth.
Discuss the possible risks associated with induction with the woman. [2008, amended 2021]