Tag Archives: inducing breech labour

NICE Guideline consultation on Induction of Labour

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:

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.

For example:

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:

Breech presentation

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]

Induction of breech labour?

Thank you to the woman who provided permission to re-post this exchange, in case others are looking for similar information. Emma and I respond to many requests for information like this. Hoping that sharing this response helps others looking & those who are caring for them. Shawn’s replies in blue.

I’m P2+0, ventouse in first and normal birth on the second. In all of my pregnancies I’ve had Gestational diabetes and been induced. I’ve been well controlled on insulin with no complications for the babies either antenatally or in the neonatal period. Same is the plan for this one. Previous two babies weighed 2.8kg And 2.82kg. All went well for both mother and babies on both births.

Sounds good.

This time round I’m currently 34+4 weeks and baby is firmly breech for the last 8 weeks. So far I’ve tried spinning babies, homeopathy, acupuncture and moxa sticks to encourage baby to turn. Not budging one bit. I know there is still time for it to turn but I’m getting myself educated as to options. 

ECV is a potential option at 37 weeks and if that fails obstetrician has suggested that I go for an induction of labour with breech as he knows I really don’t want a c/s. 

He has said himself as I’m a midwife I know what’s involved, I don’t have big babies and there is only 18mths between each of my babies so I should labour well.

Agreed.

Only breech births I’ve seen over my career are either second twins or unexpected fully dilated breech in labour on arrival. I’ve never seen one induced.

Yes, this is one of the things that causes problems for planned breech births. Most people are most familiar with the ones what progress quickly and ‘just fall out’ before a CS can be performed. This can give a false impression, and though people may be ‘experienced,’ they may lack experience of more challenging breech births that take a little longer, such as people giving birth for the first time and inductions. [See No more ‘hands off the breech.’]

I’ve been doing reading & research on the topic but it’s hard to find current evidence. As you know historically from previous research c/s has been recommended instead of induction. I have found some more current evidence suggesting that with the right maternal candidate induction is possible and long term outcomes for both mother and baby are of no significant difference to those that have elective c/s. Am I right in this?

In experienced centres, the balance of evidence does not indicate increased risk from induction compared to spontaneous breech birth. In fact, in experienced centres, induction is sometimes used to increase the likelihood of a good outcome by ensuring a birth occurs when significant experience is available – not ideal, but nothing to do with vaginal breech birth is currently ideal.

Most recent published systematic review is Sun et al (2017) in EJOG. https://www.ejog.org/article/S0301-2115(17)30578-X/fulltext

One of my talented midwifery students just repeated this review with the addition of the most recent evidence, and the results showed not one significant difference. However, all of these studies would have been done in centres that are experienced enough to be confident inducting breech births. Given what I have said above, I feel it is likely that in centres who do not regularly do this, there is some increased risk. But this would be more applicable to people giving birth for the first time, in my opinion.

Also my baby is currently in a complete breech position flexed knees and feet above the buttock. Again I know this could change but I have read conflicting information on if this is a suitable position for induction of breech.

Breech babies dance until they can’t dance no more. So the position could change to head down or feet up or knees down or something else at the time of labour or even in labour. Non-frank breech presentations are at slightly higher risk of cord prolapse, so you may want to consider labouring with a cannula if this is the case at the time of induction. I have no further research-based information to offer. 

It’s hard to find current information for parents on options using recent research so that is why I am contacting yourself. I’ve been following your twitter and some of the work the breech team is doing. I think as a midwife it’s a great idea and desperately needed to give real options to parents and expand skill set in health professionals. Do you have any patient information that you give to parents on induction of breech that I might benefit from reading?

Agreed, it’s hard. We have a leaflet, developed by Emma Spillane, which was developed based on the current RCOG guidelines.  https://breechbirth.org.uk/2019/07/18/new-information-leaflet/ Because the RCOG guidelines currently ‘do not recommend’ induction of labour for breech births, we have chosen not to go there. Working in a controversial area like breech birth, one has to choose one’s battles. I’m very happy to support this as an individual choice myself, but in the wider context of re-establishing effective breech services, it hasn’t been the priority. Given increases in induction across the service, and evidence of the potential benefits of offering induction, this will eventually need to be addressed in any contemporary breech service. ‘Not going into labour,’ either by the date considered optimal, or following waters breaking, is the biggest reason that people who plan a vaginal breech birth do not end up having one.

Finally – Would you be happy for me to publish this e-mail exchange as a blog, with names and any other identifiable information removed, or not if you prefer? It helps me to be able to provide a link when people ask similar questions, which I expect will happen more with this topic.

Wishing you all the best,

Shawn