Head's up ~~~ A breech baby has their buttocks coming into the pelvis before the head. Usually the buttocks will be born first, less often the feet or knees emerge first.
Is breech presentation a malposition or a normal variation? What are the types of breech positions? When is vaginal birth safer than surgery and when is a cesarean better? Read more to learn the Spinning Babies view of breech fetal position.
Spinning Babies techniques do not include manual cephalic version or any manipulation of the baby.
Left: The doll is in a frank breech position- bottom coming first, but the doll's legs aren't able to fold as well as real babies fold at the hips. The frank breech baby legs emerge straight upward, close to their trunk.
Right: The doll is feet first. This is a footling breech position.
The uterus is designed to have the baby in a vertical position in late half of pregnancy. The head becomes heavy enough, between 5 and 7 months, for gravity to bring the head down in a symmetrical womb.
Until about 24-26 weeks most babies lie sideways in the Transverse Lie position. During the second trimester most babies settle head down in the womb. Between 24 and 29 weeks many babies will be breech and by 30-32 weeks most babies flip head down.
Spinning Babies view on the common cause of breech presentation
Some midwives will say that breech babies may be breech because they want to be. Hmmm. That may be, but I suggest we address a possible asymmetry of the uterus. I believe the baby will get in the best position possible given the space in the womb. Its not that any woman isn't perfect inside, but uterine symmetry depends on pelvic alignment and ligaments of equal length.
A twist in the pelvic joints (called torsion by body workers and Chiropractors) will pull the supporting ligaments of the womb off balance. The lower uterine segment gets a twist and the head doesn't fit down nicely. Babies can get left in a posterior position or a breech position as a result. A twist in the pelvis causes a twist in the uterus and can lead to a breech position occasionally.
One side may be tightened. For instance, the round ligament on the left may spasm. This can be felt during palpation by the midwife or doctor as a cable-like tension in the ligament. The mother will feel pinchy twinges under their fingers when they feel for the head (or butt in the case of a breech presentation). A tight broad ligament can hold the baby in a breech position. Tightness or looseness refers to uterine tone. Tone can effect fetal position.
The tone of even a symmetrical womb will influence fetal position.
Too tight or loose in the muscle tone, or too much amniotic fluid or too little amniotic fluid and the baby may not be able to get head down. Read Flip a Breech for ideas on how to work with these maternal variations to help the baby flip head down.
Sometimes a baby or babies grow larger than the available room to flip head down. Try to make more room. Drink 3 qts of water and herbal teas a day to increase amniotic fluid, as well as eat a good, balanced (!) diet, and get body work and/or do the forward-leaning inversion daily and the Rebozo Sifting (Manteado) to soften the broad ligament, making big motions inside the womb easier. Use Pulsatilla with professional supervision. Having twins? Go to Spinning Babies and... Twins.
Some babies may flip late in pregnancy. This may be because previously too tight womb and uterine ligaments are relaxing better with the hormones of late pregnancy and give the baby room to flip. Or, it may be that a baby flips after a long car ride or really terrible news that effects the mother's sense of safety around parenting this child.
Spinning Babies view: Bring balance and tone to the womb and the baby will move spontaneously into the best position they can in the time they have between balance and birth.
Other reasons for breech
Another reason for breech is that the anatomical shape of the womb is unusual and tends to hold a baby a breech position. Some women have uteri that have a center membrane (septum) or a heart shape at the top (bicornate) that makes breech position more likely. If the baby can get head down very early in pregnancy then the baby will be all set within the side of the uterus they are growing in and stay head down. But if breech as they grow bigger may not be able to flip later.
The septum is a wall of tissue that divides the womb into two smaller pockets. The septum can come down the whole length of the womb, or just be part way down. If in early to mid pregnancy, the breech fetus grows too big to turn in the space they have in "the pocket" or side of the septum they are on, the baby may be breech at the time of birth. More on septums, scroll down, way down.
The womb may be bicornate, or a bit heart shaped.
There are observations that breeches run in families. Whether it is because these shapes of uteri do, too, is unknown to me.
The placenta may block the path of the breech baby's head preventing the breech baby from flipping. The placenta may be up top, in the fundus, but in front of the baby's face. Or, the placenta may be low, in or near the lower uterine segment, preventing the baby from settling his or her head down.
An anterior placenta (placenta is on the front wall of the uterus) may make breech presentation more likely (Jane Evans).
There may be too little amniotic fluid for the baby to flip. (Check and see if the broad ligament can be loosened by a myofascial release and the baby may still be able to flip.)
There may be a short or wrapped cord preventing the baby from flipping. (This is one that people tend to worry about, but it isn't all that common and like a head down baby, its rarely serious.)
The baby may have a birth anomaly that makes breech presentation likely. (These babies may be best served by a cesarean birth, depending on head and abdomen size). This is very unusual. Most breeches are normal babies. No more than 10% of full term breech babies have some physical reason for staying breech.
The earlier in pregnancy that a baby is born, the more likely that the baby could still be in a breech position. More babies are breech at 30 weeks than at 34 weeks, and so on.
About 3-4% of term babies are breech; term is from 37-42 weeks gestation.
Isn't all breech birth normal? Haven't breech babies been being born since the beginning?
The breech position can be a normal response to the shape of the space inside the mother's womb. Usually, the womb is aligned to encourage the baby to be head down. Whether the reason that any particular breech baby doesn't or can't settle head down in the womb is normal or not varies just like the situations about head down babies vary. Not all head down babies have easy births; and not all breeches have difficulty. Far from it. Most breeches have smooth births when birth is spontaneous (scroll down).
As long as the baby is able to complete the rotation and movements for breech birth (called the Cardinal movements), and there are no malformations of the baby or the mother that might interfere, the birth can be natural and normal. Hands and knees (knee-elbow, all fours) birth allows the baby to complete the spontaneous cardinal movements. The famous phrase, Hands Off The Breech is a message to providers, and to all of us, not to interfere by offering help that really is no help at all.
Most of the time, a breech baby can be born vaginally and quite safely. Most breech babies, just like head-down babies, tuck their chins and come out in a tube shape. (Don't worry! As soon as the baby comes through the birth canal, you'll see the more familiar baby shape unfold!) When the baby's head is tucked in like this making the baby rather tube-shaped, then breech is actually in a fine position for birthing naturally.
Online resources for parents and providers considering vaginal breech birth via a physiologically sound approach.
Midwife Mary Cronk (left), one of the most experienced midwives with home breech birth in the world, has written a very excellent article on the breech as an unusual but not abnormal position and the hands and knees position to protect the baby's own spiraling motion through the pelvis for safe breech birth. Read this exquisitely valuable blog entry by Mary Cronk
Jane Evans, a UK midwife who works closely with Mary Cronk, continues their education efforts with midwives and physicians interested in the Cardinal Movements of breech birth. Jane wrote Breech Birth; What are my options?
Ina May Gaskin, America's foremost midwife, posts an exciting article on the lost art of breech birth. Her Spirit and wisdom comes across the page to you.
Maggie Bank posts her articles on breech birth at BirthSpirit.com She also has a Breech Birth book out with excellent photos.
Dr. Stuart Fischbein, a California physician wrote an editorial on the politics of breech birth that is written for parents in the Berlin Wellness Group enewsletter of Los Angeles.
A group of parents and professionals in Canada are promoting the normalcy of breech birth and helping connect parents with professionals that support natural breech birth and the research to support breech vaginal birth. Click to visit Coalition for Breech Birth.
See Breech Birth online
Here is a beautiful picture of a laboring woman on her hands and knees with her baby mirroring her position as she is halfway born! Musings of a Redhead blogspot.
Here is a video of another mother in hands and knees. The complete birth and 30 seconds of the postpartum is intact so you can see the birth in real time. Her baby's Apgars were 10-10. Breech Home Birth at SpinningBabies.blogspot.com This birth is entirely hands off... except for the long delay in wiping the baby's head clean so Mama could kiss her and the midwife not being verbal enough to ask the other midwife to move the wet pads out of the way so the baby could be put through the mother's legs to her arms.
Lisa Barrett, Australian Midwife has a lovely blog with home breech photos to her commentary on the normalcy of breech.
Lisa Barrett also has a video of a Frank Breech (legs extended). You notice the position of the baby whose chest is to the mother's tailbone (head and sacrum anterior at this point). This is the safe breech position assuring the arms are not stuck at the pelvic inlet.
Here is the lovely story of a footling breech, born at home. There is a lull in labor during which the mother walks the neighborhood. She comes home and has her boy. There are entrapped arms, which we don't see, and a trapped head for which we see the midwife deftly correcting the flexion and then baby is out. Good thing the midwife really knew her moves! Pictures are gorgeous, very candid, like you are there and peeking in on this precious event.
There is a lovely breech waterbirth on YouTube (you decide about the music selected). The time seems agonizingly long until you learn the cardinal movements and the signs that the birth is proceeding well. (Thank you, Jane Evans, for teaching me/us this!) See the baby fix her own extended head and come out. The baby's SA position and the pulsing cord assure that there is time for her to do this and that there is no cord compression. Tone is good; but you see the placenta come with the head. That was a long time for the head and the uterus let the placenta go during that time. Hmmm. Fortunately the baby came before running out of oxygen with this early placental release. A beautiful video, powerful, transformative, challenging and entirely Hands Off. I am so grateful for this video! Thank you, breech family for posting it!
When there is a surprise breech its best to keep your hands off the baby completely. A surprise breech is often progressing well- and that's why the midwife or doctor either didn't check position in labor (though they can mistake down for up occasionally, it happens) or they arrive at the birth as the baby is coming. Here is a mother's story of her surprise breech and the midwife's mentor knew to keep hands off!
Here's a blog story about a surprise breech in a hospital. The mood is fairly typical and the breech baby is born with hands-on delivery, a semi-breech extraction, I call it.(Reaching inside for the baby to pull out the breech is a full breech extraction.)
With these lovely images, what's the issue with birthing breech babies, then?
If the baby's chin is tucked and the mother is in a good, vertical position, even a term footling baby may still be born without a problem.
However, when the chin is up, the baby's head seems bigger. A few breech babies will slip out positioned like a lollipop instead of a tube.
Head up or head down, the extended chin makes a problem. The head down baby with the chin up can either take more time, need help to tuck or be born by cesarean, usually in plenty of time. Head entrapment is more possible with a footling breech, but a stuck head can happen with any type of breech baby. Read about avoiding breech complications below.
Many times, a head that is "star-gazing" can be adjusted during the birth – IF the doctor or midwife has taken the time to really learn the physics of birthing the breech head and the techniques necessary. Even with ultrasound, there is no way to be sure the baby won’t become stuck.
The baby's death or severe injuries can result from using inexperience or wrong technique with breech birth. The most danger is when providers want to "help" the spontaneously birthing breech baby out.
When the baby's chin is tucked to the chest, the baby will be more like a tube and fits well. This is true whether the baby is a frank breech or a footling breech.
Can’t we use Ultrasound to see the baby’s head position?
An ultrasound in early labor or close to the baby's due date can verify head position at that time. It is thought by experts now, that only if the baby's head has been looking up during pregnancy a cesarean is the best choice. If the head is looking down, which means the chin is tucked, then a vaginal birth with experienced, breech-smart help may be safe. If the head is looking ahead or is in a neutral position but not tucked, this is considered fine among physicians and midwives experienced with vaginal breech birth.
However! The baby changes head and arm position can certainly change in labor. A mother, doctor or midwife can’t always predict which baby will come well or get stuck. If the baby gets stuck, it is too late to do a cesarean. But its not too late for a breech-smart baby-catcher to correct the problem.
Jane Evans, UK midwife, made a comment about Ultrasound (sonography) causing the baby to lift the arms. Sometimes we see babies in ultrasounds quickly put their hands over their faces, or wave them near their ears in a defensive measure. (Ultrasound vendors call this "the wave.") She could be on to something with her observation.
Thanks, but no thanks
Other problems really are that the person helping the mother doesn't help in ways that are physiologically suited to breech birth. Most breech injuries are related to provider error. One such error is not using gravity for a truly spontaneous breech birth. The other error is touching breech baby at all (unless there is a certain arrest of labor).
Hands and Knees, and No touching the baby
Hands and knees position (or knee elbow) is considered an upright position. With the mother on her hands and knees, the baby can conduct the cardinal movements of breech birth spontaneously in most cases (Unpublished data shows less than 20% intervention may be needed in this maternal position). "Don't touch the breech" is an age-old rule that, when the mother is on hands-and-knees (or knee-elbow) position, allows the baby the safety of spontaneously movement. (With the birthing woman put on her back, or with the midwife or doctor touching the baby to deliver the legs or support the bum, the midwife or doctor may then have to grasp the baby and help overcome the lack of gravity and spontaneous rotation up to 75% of the time.)
Click this link to Mamas and Babies Blogspot to read how an experienced attendant helped the young midwife resist the urge to "help" the surprise breech baby. Its an excellent example with an excellent outcome.
Here is a wonderful series of a hands-off (till the head requires a little flexion) photos from the Association for Independant Midwives in Great Britian. http://londonbirthpractice.co.uk/joomla/educational/breech/home-breech-birth-photo-series_2.html
Fortunately we are living when expert breech providers are gathering and sharing ideas and data. The Coalition for Breech Birth in Canada got together Obstetricians, Midwives and parents together in Ottawa at their 2nd annual CBB conference (October 2009) and in Washington, DC at the 3rd annual CBB conference (November 2012). The midwives came teaching vertical birth and Dr.s Frank Louwen (2009) and Anke Reitter (both years) came sharing the data success of their 300 breech births with mothers using the knees and elbows position. Australia also had a successful national breech conference with international breech birth experts in 2012. Breech skills are making a come back.
Malposition may be the mother's birthing position, not the baby's!
The biggest problem with breech position is the lack of experience in the person catching the baby. Pulling on the baby can cause severe injury.
As you've read in other parts of Spinning Babies, a vertical birthing position fits natures design for safe birthing. When a mother is standing, sitting up or hands and knees (or knee-elbow) positions will allow the baby to rotate through the open pelvis.
Breech birth on the mother's back is not very safe. The baby can't help with the birth. Gravity pulls the baby into the mother's back, not out her vagina. The mother's sacrum is pressed by her weight into the bed and a doctor or midwife is more likely to pull, even gently. This is bad.
Breech, itself, may not be a malposition, but making a woman lay on her back to push is definitely a malposition!
There are four breech types.
1. Frank, or bottom first with legs extended towards baby's trunk
2. Complete, or legs folded so that feet are very close to the buttocks,
3. Footling, One or more feet coming into the pelvis first-the bottom is above the brim and the feet are below, at 37 weeks the knees may be bent so that the baby seems to be sitting on the top of the pelvis dipping his feet into the pelvic tunnel.
4. Kneeling, Both knees are coming first, the feet are folded up behind the baby's thighs.
Unfortunately, even skilled sonographers, midwives and physicians will chart the baby in an oblique or transverse lie with the label "breech". These positions are not breech. Babies who are oblique (in the diagonal) or transverse (lying across, sideways) can not get through the pelvis that way. If the "breech" baby doesn't have his or her buttocks over or in the pelvic brim (whether feet are between the brim and baby's buttocks or not), then the baby may not be truly breech. This can lead to confusion about the safety in laboring.
Note for Unassisted Birthers: The baby in either a transverse lie or an oblique lie can not get into the pelvis. If baby can't get into the pelvis, well then, baby can't get through the pelvis, in which case, the baby is not going to be coming out of the pelvis. If the water breaks there is an increased chance of cord prolapse, which, while less dangerous in a fast breech birth, is very dangerous in an oblique or transverse lie, especially if the mother continues to labor. In labor, the oblique baby might shift to a vertical lie (breech or head down) if the mother lunges with each contraction. If the baby doesn't become vertical and come into the pelvis within 3-6 contractions doing the lunge, the baby may not be able to shift out of that position. (Don't wait doing these if the cord did come down! Get to a hospital fast!) The transverse baby cannot fit the pelvis and has an even harder time being persuaded to move to a vertical position. A forward-leaning inversion for 1-3 contractions may help, but again, if not, go to the hospital, there are too many risks to wait for mother and baby. Continuing to labor with either of these fetal positions will lead to eventual death of the baby AND the mother. Sorry to be so blunt, but I do hear from families who've lost little ones due to fetal position problems who don't have someone skilled to tell when a long labor is helpful and when a long labor will not work to bring the baby. When we labor in trust we must remember that trust works both ways.
Who can we find with breech vaginal birth experience?
Nearly all American doctors have poor training in breech skills, and many midwives are untrained in breech. You might try looking towards the far ends sides of the birth provider spectrum to find providers with breech skills: the chief of staff of Labor and Delivery at a big hospital, a country doctor, or the rare, breech-skilled, home birth midwife.
A childbirth educator, birth activist or doula might have the name of someone with breech skills. Some women and couples travel far to a doctor or midwife experienced in natural breech birth. These names are not likely to be put on the Internet with the current fear about breech vaginal birth and the high cost of potential legal costs. Even when breech birth goes well, midwives and doctors can face serious opposition for supporting a mother’s vaginal breech birth.
What makes a person experienced with breech birth? Is it a certain number of breech babies? Is it a good knowledge of the physics and cardinal movements of breech birth? Is it knowing when to keep your hands off and when and how to help the shoulders and head without pulling? It is all these. And these skills are lacking in many countries today.
Dr. Frank Louwen of Frankfort, Germany is leading the world in safe vaginal breech birth in the hospital.
Dr. Peter O'Niell is a breech expert, trainer, and really sweet man up in Ontario, Canada. He asks women to be on their backs for breech birth, which I don't feel comfortable with, but then he is excellent in how he handles breech and I'm happy to refer to him. I got to take a training from him once.
Dr. Denny Hartung is our local (within 20 min.s of St. Paul, MN) go-to guy in Hudson, WI at Hudson Hospital. He says he loves the ease he sees with hands and knees for breeches.
Dr. Michael Hall is Denver's natural breech birth advocate and expert. He's also happy with hands and knees for safety and says, "It makes sense."
Here is birth advocate Dr. Stuart Fischbein's site. He's attending breech birth at home in Los Angeles. http://www.birthinginstincts.com/
Many midwives don't like to be listed even for their breech skills in today's political scene. I'd refer you to the world experts, Mary Cronk, Jane Evans, Betty-Anne Daviss, Maggie Bennet and Lisa Barrett. Ask the doulas privately.
I can't list all the midwives and doctors who catch breech babies without "chopping," as Jane Evan's terms it. As you search for a provider to help you, even if they have a reputation or a degree, ask her or him to show you how she or he releases stuck arms or a trapped head when the breech birth goes poorly. If they can't readily do this with a doll and pelvis (or teddy bear and crochet hoop or whatever props are around) then keep looking. They may be nice, sincere and skilled otherwise, but not in breech. I have seen home and hospital providers not know how to free a trapped baby, even after many breeches behind them because it had always been easy up till then. Breech birth can go well, but when it doesn't, more babies die because the confident provider really didn't know after all. I don't mean to be negative here, but if saying this straight can save a life, then I'm duty bound to say it.
Here is a lovely birth story from an Arizona mom whose midwife invited a second midwife to share the support and skills of breech birth at a homebirth. http://flymmflamm.blogspot.com/2010/02/how-firm-foundation-birth-of-everett.html
Most breech babies, in the USA, are born by cesarean surgery.
Though obstetricians in the US now consider breech too dangerous for vaginal birth, at some university hospitals in Norway, France and Canada, the safety of vaginal breech birth is well proven.
The techniques to help the arms and head of a breech baby are similar whether in a vaginal birth or a surgical birth. If delivering a breech baby, a doctor has to figure out how to get the chin tucked and past the mother's bones, or through the tight abdominal incision. Here is the World Health Organization's video training for breech birth. It shows women birthing on their back and the baby being partially extracted. This video shows the obstetrical model being taught to midwives in South Africa. http://video.who.int/streaming/rhl/breech_web.wmv
Now, if the mother gives birth physiologically, she and the baby work together, with gravity and labor, to help the baby rotate through the pelvis spontaneously. The techniques to help a breech baby flip that are listed in This website, will help a woman's soft tissues be ready for birth, as well as for a bitter fetal position, so that if the baby doesn't flip, the womb will be more in line with her pelvis and her pelvis with her pelvic floor and so on.However wonderful we are designed for birth, even breech birth, having a skilled attendant is necessary for the unexpected. Here's Mary Cronk's article on Hands off That Breech.
Cesareans are widely considered safer for all breech births by Obstetricians and some midwives. Big city obstetricians are experienced in surgical breech birth. Surgery has reached an accepted level of safety, because of improving surgical technique, blood replacement and antibiotics to treat, the all too common, post surgical infection.
Major surgery has risks for the mother; blood loss, anesthesia, infection, etc. And for the baby; being born by cesarean doesn’t mean being lifted up from the womb like being lifted up from a crib. Difficulty with the delivery of the arms and/or head can happen in a surgical birth, too. Whether by surgery or in a vaginal birth, the baby can suffer an injury or death.
Important physiological changes in brain development are now thought to occur during natural labor contractions. A scheduled surgery will bypass physiology. Surgery can be life saving, but it isn’t gentle.
Canada reverses policy on breech birth
Society of Obstetricians and Gynaecologists of Canada was featured by the Media Centre article:
No more automatic C-section for breech births, says Ob/Gyn Society
(An excerpt) Halifax – June 17, 2009 – Physicians should no longer automatically opt for caesarean sections in the event of breech birth, according to new guidelines for Canadian health professionals . . .
The guidelines are based on a comprehensive review of research and clinical evidence regarding the safety and outcomes of vaginal breech births compared with that of caesarean sections. . .
“Breech pregnancies are almost always delivered using a caesarean section, to the point where the practice has become somewhat automatic,” said Dr. Robert Gagnon, a principal author of the new guidelines and Chair of the Society’s Maternal Fetal Medicine Committee. “What we’ve found is that, in some cases, vaginal breech birth is a safe option, and obstetricians should be able to offer women the choice to attempt a traditional delivery.”
The society is also cautioning that many breech deliveries will still require a cesarean section, and that a vaginal birth is not recommended for some types of breech positions. In situations where a vaginal delivery is an option, the delivery should take place in a hospital setting. An experienced obstetrician should be present to attend the delivery and to offer a cesarean section if the labour does not progress smoothly or if complications arise. [This comment is from the article about the SOGC recommendation and is not a statement from Spinning Babies. Its a fine idea. Though I think home breech birth can be safe with an experienced midwife team with rehearsed resuscitation skills, good labor progress and a good mother baby match.]
Media Centre shares these breech links from Canada:
Read the complete text of the SOGC’s new guideline, Vaginal Delivery of Breech Presentation
Vaginal Breech Delivery Guideline: The Time Has Come
Dr. André Lalonde
Breech Birth can Be Safe, But is it Worth the Effort?
Dr. Andrew Kotaska
About Breech Birth (SOGC)
Public Education Brochure
COMPARE the opinions of US and Canadian physicians on how a breech baby should be born. Scroll down for US and Canada on Breech Birth Methods
A cesarean might be the best choice for a breech birth, if
· Baby is less than 28-30 weeks gestation
· Baby is over 42 weeks gestation (not an absolute but should make you alert to other factors)
· Baby seems large, 4,000 grams or 8 pounds, 13 ounces, (except in a rapid frank breech labor with good progress, so again, not absolute, but should alert you to other factors.)
· Mother has diabetes
· Care provider will touch the baby during the birth interrupting the breech baby's spontaneous cardinal movements and possibly causing the arms or head to extend with resulting need to rescue the baby with breech maneuvers.
· Baby’s back is on the left, labor is slow, and you do not have a person (OB, Midwife, Birth Attendant, cab driver) who knows how to release stuck arms in the somewhat higher chance that they get stuck when the baby starts with the back on mother's left. In some parts of the world providers are well trained in this and so a left-side-starting starting position isn't an issue, but in the US there is a somewhat higher risk of the breech needing a little help here. It doesn't mean the baby will be in bad shape if this should happen and you have a person who knows how to help the baby out. But if they don't have the experience, having been at a few US hospital breech births, I would say a mother would have to consider, using her intuition and self knowledge and honest appraisal, that a vaginal birth holds a little more risk.
I think this would matter more if baby has been fairly immobile (shrink wrapped) in that position for weeks (immobile means the back stays put, kicking and hand movements are not a determinant in this variable). This is an indication of a tight broad ligament, which in and of itself is not a indication for cesarean for breech, but can mean the left-sided baby has to rotate past tight spots in the soft tissues. Its an issue for the OP (head down and posterior) baby so I figure it may be for some breeches, too.
· Labor doesn’t progress with good, strong contractions and freedom of movement
· Baby doesn’t descend during late labor
· There are any other issues that indicate surgical birth, such as a placenta covering over the cervix.
· The mother or birth attendant is not confident with the natural birth of a breech baby
What are the other factors?
· Slow progress
· Metabolicsloshiness - low thyroid function, fertility issues, conception through artificial insemination, hypertensive
· Pelvic torsion or somewhat small diameters
· And again, lack of skill and experience in birth attendant, including OB or Midwife, whether or not they are confident.
A cesarean birth can be more baby-centered by
• Allowing labor to begin on its own, and then having the surgery within an hour or two
• Delaying clamping of the cord for a moment, while baby catches their breath, and
• Putting baby into mother’s arms in the operating room and
• Cuddling and breastfeeding in the recovery room.
Love is the most important thing that your baby is yearning for.
Should I have labor before I have my scheduled cesarean?
Consider whether it is reasonable to your health and whether your labor would allow you to reach surgery in time, to see if you can go into labor before surgery. This will give the baby a catecholamine surge to prepare for air breathing. ("The Stress of Being Born" Scientific American) Spontaneous labor might help protect against "late prematurity," a growing risk due to increasingly scheduled births that turn out to be not as close to nature's due date as was thought. Some women will appreciate early labor for these reasons, others will know that it is not feasible for them. Doctors will not be comfortable with this idea as it causes stress with the Operating Room staff and schedule.
Discuss the possibility of labor with your doctor, anyway, please don't spring it on him/her without forewarning. Sometimes delaying surgery until spontaneous labor is not wise, though, like when the mom has a long distance to drive and a previously fast birth or there are other health factors discouraging labor. Waiting for surgery until labor is inconvenient for everyone except the baby! Yet it is the baby that birth is for, isn’t it? Healthy labor is good for healthy babies.
When, in Pregnancy, is breech an issue and when is it fine?
Before 30 weeks many babies are breech. The breech baby is vertical, so the womb is "stretched" upwards. This makes it easier for the breech baby to flip to head down around 28-32 weeks. Breech is not an issue that early in pregnancy. The medical model of care addresses the breech position between 35-37 weeks, or later, if the breech isn't discovered until later. Many home birth midwives suggest interacting with a baby at 30-34 weeks to encourage a head down position (vertex). Women who have had difficult previous births due to posterior, asynclitism or a labor that didn't progress may want to begin body work and the forward-leaning inversion early in pregnancy (after morning sickness is gone and extra things like fetal positioning activities can be thought about).
When should I start maternal positions or body work to help my breech baby flip head down?
I favor beginning the forward-leaning inversion throughout pregnancy for all women, not waiting until a "problem" in fetal positioning is discovered. By 30-31 weeks, I highly recommend beginning the forward leaning position to encourage a head down position. After 32-34 weeks, chiropractic adjustments are suggested. Moxibustion is a technique of heating acupressure points with the glow of mugwort sticks (compressed mugwort herb in a thick, incense-like stick). Moxibustion has been shown to help breech babies flip. Using it a few times a day in weeks 34-35 show the best rates of flipping breech babies to head down positions in studies.
A detailed time line is given for introducing techniques in pregnancies with breech babies. So you can look up your weeks gestation and do the suggestions listed there if you choose.
External Cephalic Version (ECV)
You may also agree to go through with a cephalic version (the doctor manually turns the baby head down through your abdominal wall). I suggest getting Chiropractic, myofascial and acupuncture, homeopathy or moxibustion (or all) before the version. Financially this may not be possible, I realize. But see what you can do. Inversions on stairs with a friend to guide you are free and effective.
Breech babies may have a number of reasons for being breech.
In my experience, most are breech due to uterine ligaments and muscles being either too tight and asymmetrical (twisted or torqued) or too loose. Often the sacrum is not straight and a short line at the top of the buttocks veers to one side or the other in a subtle way. The ala of the sacrum may be rotated on a vertical axis. There may be a buckle on the horizontal segments of the sacrum. Either of these is easy to fix if you have the right help. The SI joints or the symphysis pubis may be out of alignment, as well. I heard about these causes from Chiropractor friends and observations have bore these ideas out. Success in flipping babies has come out of this metaphor and approach. See a bit about bodywork for breech midway down the article called Professional Help in the Techniques section of this website.
Many chiropractors can loosen the ligaments by doing the Webster Technique. Adjusting the sacrum, for both a vertical twist or a buckled (horizontal wrinkle) sacrum will let the baby put their head down more readily because the bones won't be in the way. It often takes a complete approach, not one without the other, for success.
An unusual exception to the “don’t worry” stance is when a woman has a uterine septum. (Remember, a septum is a vertical wall of tissue separating the womb into two parts. It can make the uterus into more of a heart shape.)
The baby will have to get head down while very small. We don't know what size that is because all each septum is a little different. It may be at 5 or 6 months along. A doctor may not succeed in manipulating the baby in to a head down position at 36 weeks if there is a septum. The baby may not be able to flip down after he/she gets to a certain size. Most women don't know they have a septum until after their first cesarean. It isn't that common, but it isn't really rare either. Alternative practitioners have some non-manipulating ways of helping, view “Professional Helpers" under Techniques and then click, "In Pregnancy."
Generally, a uterine septum does NOT reduce the success of a vaginal birth. Heads or tails, the uterus with a dividing curtain still contracts quite well.
What may be one of the most common causes of breech birth?
Tension or a twist in the lower uterine segment may be a "soft tissue" issue. This is not the woman's fault, we simply live in an era where a slight twist in the pelvis is common. Pressing the gas pedal for hours at a time or just because we drive around almost daily; crossing our legs; sports injuries; abrupt stops as in a "fender bender;" torquing our torso after a fender bender while wearing a seat belt (which is life saving); carrying a toddler on a hip; falls; or even a head injury can twist the pelvis and so twist the uterus when uterine ligaments are pulled in one direction.
Breech position may be caused by unbalance (asymmetry) in the mother's pelvis or soft tissues
When any part of the pelvis is out of symmetry (crooked) then the ligaments supporting the womb are pulled and twisted, too. The shape of the lower womb can be altered by this. The baby then has to find a way to fit that isn’t quite what nature intended. A twisted sacrum is common for breech (and posterior). Aligning the pelvis, and relaxing tight uterine ligaments attached to the fascia near the pelvis, are why Chiropractic adjustments can often help breech babies flip to a head down position.
One thing I've observed is that when the breech baby does flip head down in pregnancy during the last month or two of pregnancy that the baby often moves to the head down, posterior (face forward) position.
When a breech position is suspected using the forward leaning inversion and the breech tilt can help the baby flip head down.
US and Canada on Breech Birth Methods
The first decade of the 21st century has seen an amazing examination of how breech babies are born. Early in the decade the Term Breech Trial, the nickname for the Mary Hannah study, recommended cesarean surgery for most breech births. But in examining the study, and adding more appropriate data and better interpretation of the data that Hannah's group found, suddenly qualified breech physicians were successfully swinging the vote over to vaginal breech birth.
Here's the general view of American College of Obstetricians.
This view does not reflect the view of experienced breech practitioners, such as Dr. Michael Hall of Denver, for instance, who continues to attend natural breech births.
- Comment in:
- Birth. 2007 Jun;34(2):176-80.
ACOG Committee Opinion No. 340. Mode of term singleton breech delivery.
In light of recent studies that further clarify the long-term risks of vaginal breech delivery, the American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider Cesarean delivery will be the preferred mode for most physicians because of the diminish-ing expertise in vaginal breech delivery. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. Before a vaginal breech delivery is planned, women should be informed that the risk of peri-natal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient's informed con-sent should be documented.
Here is the new view of the Society of Obstetricians and Gynaecologists of Canada.
This view doesn't reflect that Canada is in great need of breech training for physicians and midwives to meet the needs of parents having breech babies. Women may not be able to yet find a qualified practitioner. Contacting the SOGC or Midwife Betty-Anne Daviss at UnderstandingBirthBetter.com may be helpful
Dr. Robert Gagnon, a principal author of the new guidelines and Chair of the Society’s Maternal Fetal Medicine Committee reported, “What we’ve found is that, in some cases, vaginal breech birth is a safe option, and obstetricians should be able to offer women the choice to attempt a traditional delivery.”
“The evidence is clear that attempting a vaginal delivery is a legitimate option in some breech pregnancies,” said Dr. André Lalonde, Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada.
Validation for Canada's new breech guideline
"This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery." from the brief for Vaginal Breech Birth, 2009, by A. Kotaska et al.
Canada is following evidence-based logic in promoting the safety of many breech births. Still, the emotional setting of birth also adds to safety. Calm, trusting patience, which means, Hands Off the Breech, and vertical (hands and knees position most excellently) are still critical aspects of safety in breech birthing.