Vaginal Breech Birth - Informed Consent

Informed Consent and Informed Refusal

Breech birth can be smooth and sweet or it can be challenging, even tragic, in any setting and by any method. Not only physically, but politically or emotionally. Parents and Providers in America who choose vaginal breech birth are outside the norm. What's common is not always right, what's unusual is not always wrong.

But that is a piece of philosophizing. Basically, the issue is that breech babies have a higher rate of death due to complications of their position than head down babies. With the right help, that difference can be smaller, but not absent. No manner of birth and no amount of experience can deny that difference. Parents and providers can't rest on the superiority of their favored method and imagine they are safe from complications.

Cesarean surgery involves risks that are well known in medical circles but often understated to consumers. Cesarean surgical birth may be safer than breech birth, such as when providers are not trained and trained providers can not be found or traveled to. To make surgery slightly less invasive to the baby, labor can be allowed to start spontaneously and then a cesarean can be done. Or a cesarean might be scheduled for after the due date to reduce unintentional late prematurity (35-36 weeks gestation) which has a higher infant mortality rate than waiting for full term (37-42 weeks gestation). A family-centered cesarean can be arranged ahead of time with the head nurse, anesthesiology staff and the obstetricians involved in the care of a breech baby and mother.

Hospital vaginal breech birth is not the same in every setting or with every doctor. In the US and Canada, midwives cannot catch breech babies in the hospital. Few doctors know physiologic breech birth. YouTube is peppered with medical breech deliveries and the style can be seen for yourself.  Often a partial breech extraction, or occasionally, a total breech extraction, is practiced in the hospital.  "Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%," states Dr. Richard Fischer in Breech Presentation. You can read a mother's story of her hospital breech birth when she refused a cesarean here. It wasn't the easiest birth (and wasn't hands and knees or hands-off) but she would do it again.

Midwives and doctors do vary in what they consider to be physiological breech birth. While Dr. Louwen's team has had tremendous success with
knee-elbow (closely resembling hands and knees) breech births. I wish I had a link to a "hands off" birth with Dr. Louwen to show you. Dr. Andrew Bisits, of Australia, uses a birthing stool and doesn't refrain from gentle touch. Notice how empowered and proud this mother is in her birth with Dr Bisits. The gentle "support of the bum" is followed by the doctor going for the arm or arms. 

Is it a routine move or was it necessary because the gentle support of the bum inhibited the cardinal movements for shoulder rotation? This is a question we hope to answer. It is perhaps answered by Louwen's statistics of 200+ knee-elbow breeches with only 2 births requiring help for the arms (and all heads were born easily). Experienced and gentle doctors like Dr. Andrew Bisits are world treasures, to be sure! The difference in approach doesn't deny that, please! I am simply seeking the most physiological approach (while having immediate help available should it be needed). 

Parents have to be well informed to choose a safe breech care provider.

When parents are informed about the risks and benefits of breech birth in both hospital and home settings, they may refuse to give birth in the hospital. A mother might refuse a cesarean. Some home born breeches with experienced midwives present may actually be a safer setting at home than in their local hospitals (or with inexperienced midwives at home).

Parents have the constitutional right to pick the care they find best for their baby. We hope to be right with our choices. If a baby dies, a homebirth will be seen as irresponsible, even though the breech death rate at a hospital with poor training may well be higher than with an experienced home birth midwife who knows breech, resolving shoulder dystocia and physiological infant resuscitation.