- 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?
GAIL AND DR. STUART FISCHBEIN joined Dr. Elliot Berlin to watch Heads Up. Dr. Elliot, a generous Chiropractor in Los Angeles, made this film about choices and lack of choices in Breech Vaginal Birth. This film is mostly about the mother’s emotional responses to provider reactions to her carrying a baby in the breech position.
You may rent or buy Dr. Elliot Berlin’s video for download or streaming on any device.
There are four basic breech types:
- Frank, or bottom first with legs extended towards baby’s trunk;
- Complete, or legs folded so that feet are very close to the buttocks;
- Footling, or 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;
- Kneeling, or both knees are coming first, the feet are folded up behind the baby’s thighs.
Unfortunately, even skilled sonographers, midwives and physicians, may chart the baby in an oblique or transverse lie with the label “breech”. Follow the links to see more about those babies that have neither head nor bottom over the pelvic inlet.
When, in pregnancy, is breech an issue and when is it fine?
In time, the breech Baby’s head becomes heavy enough, between 5-7 months, for gravity to bring the head down in a symmetrical womb. The baby will move head down if there is room or if there is tone in the support to the uterus to direct baby head down.
- Before 24-26 weeks most babies lie diagonal or sideways in the Transverse Lie position.
- Between 24-29 weeks most babies turn vertical and some will be breech.
- By 30-32 weeks most babies flip head down and bottom up.
- By 34 weeks pregnant, the provider expects baby to be head down.
- Between 36-37 weeks, a provider may suggest a external cephalic version.
- About 3-4% of full term babies are breech; term is from 37-42 weeks gestation.
During the month 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 until 32-34 weeks unless the womb has an unusual limitation in shape or size such as a bicornate uterus, in which case baby needs to be head down much earlier than when the uterus has more room.
The medical model of care addresses the breech position between 35-37 weeks, when baby survival outside the womb won’t include special nursery care to breathe or suck. Physicians Oxorn and Foote, however, recommend helping babies turn head down at 34 weeks. 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 bodywork and the forward-leaning inversion early in pregnancy (after morning sickness is gone and extra things like fetal positioning activities can be thought about).
Read the details about what to do at what time in pregnancy in the membership level of SpinningBabies.com (coming).
Common issues with breech are:
- Health of the baby overall
- Safety of the birth
- Safety for the mother facing surgical birth
- Emotions of the mother and partner
Reasons for breech
Breech babies may have a number of reasons for being breech.
- Born earlier in pregnancy than full term and hadn’t had time to turn head down.
- About 1 in ten breech babies has a mild or major physical difference reducing their ability to turn head down. For instance, some Down’s Syndrome babies will be breech.
- Two studies show that more mothers of breech babies have low thyroid function compared to all women who don’t have a breech baby at time of birth. This may show a metabolic connection to fetal position.
- A low lying placenta blocks the room for the head
- The cord is wrapped around the baby
- The first time mom has a tight abdomen, super strong core, less water
- The mom whose birthed about 5 or more times, has a loose womb and baby isn’t prompted to turn head down by muscle tone
In my experience, most babies are breech due to uterine ligaments and muscles being either too tight and asymmetrical (twisted or torqued) or too loose.
- 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.
An imbalance may be restored to balance if a woman has the right technique or help for her body. 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 is high with this approach.
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.
Breech position may be caused by imbalance (asymmetry) in the mother’s pelvis or soft tissues. In other words, a 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. For example,
- Pressing the gas pedal while driving;
- Crossing our legs;
- Sports injuries;
- Abrupt stops as in a “fender bender” torquing our torso;
- Carrying a toddler on a hip; falls; or even
- A head or ankle injury
All of these can twist the pelvis and, in turn, twist the uterus, resulting in asymmetry.
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 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.
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 imbalance of the uterus. I believe the baby will get in the best position possible given the space in the womb. It’s not that any woman isn’t perfect inside, but optimal room in the uterus depends on pelvic alignment and ligaments of equal length.
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.
See “when to do what” on Flip a Breech
Isn’t 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 or not the reason that any particular breech baby doesn’t or can’t settle head down in the womb is normal 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.
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, 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 article 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.
- 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 at Coalition for Breech Birth.
- 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. She 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 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. 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!
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. Knowing the three levels of the pelvis and where the widest space is at each level helps the provider know where to rotate the portion of the baby that is stuck on the narrow part of the pelvis.
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” and hold the baby incorrectly, squeezing vital organs, or pulling on the baby.
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 is cesarean is the best choice. If the head is looking straight (neutral) or down (flexed) then the chin can tuck and a vaginal birth with experienced, breech-smart help may be as safe as a cesarean for the baby.
The baby’s 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 it’s not too late for a breech-smart baby-catcher to correct the problem by rotating the arms free and flexing the chin so the head can fit the pelvis.
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.
Don’t Pull On The Baby
Other problems in breech birth often are a result of the fact that the person helping the mother doesn’t help in ways that are physiologically suited to breech birth.
When a breech baby gets stuck, the baby catcher needs to know rotation and flexion of the breech baby at the level of the pelvis where the baby is stuck.
Most breech injuries are related to provider error. Training is important. Repeating training regularly is important.
Hands and knees, and not 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 from 63%, up to 75%, of the time.)
Read this post at Mamas and Babies Blog about how an experienced attendant helped a young midwife resist the urge to “help” the surprise breech baby. It’s 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 Independent Midwives in Great Britain.
Fortunately, we are living when expert breech providers are gathering and sharing ideas and data. The Coalition for Breech Birth in Canada got 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. Frank Louwen (2009) and Dr. 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 nature’s design for safe birthing. When a mother is standing, sitting up or in a hands-and-knees (or knee-elbow) position, it 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!
Stuart J. Fischbein, MD typed in the chat box on the Heads Up live streaming and chat I attended March 6, 2016, “Well, Elliot, there is enough wisdom and evidence to suggest that when properly chosen, women can have better outcomes with vaginal deliveries and babies are no worse off. Actually, knowing what we do about the microbiome, epigenetics and bonding, a vaginal birth is really much better but those things are never considered in the medical model.”
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 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 risk 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. His excellent teaching could transform breech birth practices world wide. His statistics on 750 vaginal breech births are quite positive, showing safety above any found when women lay on their backs. Getting published in this anti-breech climate is a challenge.
- Dr. Anke Rietter of Frankfort, Germany is an expert in upright breech position for vaginal breech birth. She is a physician author included in the upright breech birth outcomes mentioned just above.
- In Ontario, Canada, Dr. Peter O’Neill is a breech expert, trainer, and really sweet man. 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.
- Denver’s Dr. Michael Hall is a natural breech birth advocate and expert. He’s also happy with hands and knees for safety and says, “It makes sense.”
- In Los Angeles, California, Dr. Stuart Fischbein’s site: http://www.birthinginstincts.com/. He’s delivering breech babies at home in Los Angeles. In the hospital in Los Angeles, Dr. Wu is giving breech care.
- Many midwives don’t like to be listed even for their breech skills in today’s political climate. I’d refer you to the world experts: Mary Cronk, Jane Evans, Betty-Anne Daviss, Maggie Bennet and Lisa Barrett. Ask the doulas privately.
- As you search for a provider to help you, whether they have a degree or a reputation, ask her or him to show you how she or he releases stuck arms or a trapped head specifically. 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 until 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.
Breech & Cesarean
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.
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 better 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. Read more in Mary Cronk’s article on Hands Off That Breech.
Cesareans are widely considered safer for all breech births by obstetricians, as well as 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.
In 2009, Media Centre of Canada published an article reporting that Canada had reversed its policy on breech birth, featuring The Society of Obstetricians and Gynaecologists of Canada.
In the article, Dr. Robert Gagnon, a principal author of the new guidelines and Chair of the Society’s Maternal Fetal Medicine Committee, said, “Breech pregnancies are almost always delivered using a caesarean section, to the point where the practice has become somewhat automatic. 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 article continues, “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.” [To clarify, this comment is from the article, and 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 (encouraged with body balancing activities such as the ones on this website and others), and a good mother-baby size match.]
Media Centre shared these breech links from Canada:
- Read the complete text of the SOGC’s new guideline, Vaginal Delivery of Breech Presentation
- Editorial: Vaginal Breech Delivery Guideline: The Time Has Come by Dr. André Lalonde
- Commentary: Breech Birth can Be Safe, But is it Worth the Effort? by Dr. Andrew Kotaska
- Public Education Brochure: Breech Childbirth
COMPARE the opinions of US and Canadian physicians on how a breech baby should be born. I discuss more about US and Canada breech birth methods later in this article.
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.) This is a conservative screening limit.
- Mother has diabetes.
- Baby has InteraUterine Growth Retardation (IUGR).
- 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.
- Labor is slow after 5 cm or stops all together after labor had been going well.
- You do not have a person (OB, Midwife, Birth Attendant, cab driver) who knows how to release stuck arms.
- 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
- Metabolic sloshiness – 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 until the cord stops pulsing, and
- Putting baby into mother’s arms in the operating room and
- Cuddling and breastfeeding in the recovery room.
Here is a lovely cesarean breech birth. I cried upon seeing the mother’s face when she saw her baby. How kind everyone is to the mother and child.
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 (See “The Stress of Being Born” in 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.
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, Hannah’s group found that, rather suddenly, qualified breech physicians were successfully swinging the vote over to vaginal breech birth.
Here’s the general view of American College of Obstetricians:
NOTE: 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.
Obstet Gynecol. 2006 Jul;108(1):235-7. 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 diminishing 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.
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.
Dr. André Lalonde, Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada, said:
The evidence is clear that attempting a vaginal delivery is a legitimate option in some breech pregnancies.
From the brief for Vaginal Breech Birth, 2009, by A. Kotaska et al.
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.
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.
NOTE: 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
Are you a provider? Read more on breech here.