Vaginal Breech Birth Revolution
There is a revolution coming to America in vaginal breech birth. American doctors and midwives had all but lost the skills to help a breech baby out and instead developed a style that actually increased the risk of harm. The lack of skills, or dare I say, the wrong skills, are spreading in other countries, too. Lately, international parent-to-parent and provider-to-provider sharing is also connecting midwives and doctors promoting physiological breech skills. Increasingly, parents are able to choose vaginal breech birth.
Vaginal Breech Birth Awareness
There are excellent sources of information on breech vaginal birth. There are unfortunate examples, too, like hands on, or training videos where improper understanding of the breech cardinal movements leave the video mismatched to physiology (more on that later). Louwen and Rietter’s study (soon to be published) on upright and hands-off gives statistics far improved over those resulting from lithotomy position and partial breech extraction, the western norm. Sadly, getting those stats published doesn’t seem to fit with American goals in obstetrics. So meanwhile, here’s where to go to find best practice information:
- Visit Understanding Birth Better, the website of Betty-Anne Daviss and Ken Johnson of Ottawa for their up-to-date breech information and published journal article.
- Dr. Fischbien has a short informative podcast on the status of vaginal breech birth that parents may find to be a useful overview.
- Read the AIMS website for Mary Cronk’s article on physiologic breech birth, Keep Your Hands Off the Breech, and MIDIRS for Jane Evans’ two articles on breech cardinal movements and spontaneous maternal movement to birth the breech head in the 2012 February and March issues of Essentially MIDIRS. This is essential breech knowledge for all baby catchers.
- Another great breech awareness site is The Midwife, The Mother and The Breech by UK midwife Shawn Walker.
- You can check out emerging online breech info in Australian and New Zealand here.
- Australian breech baby catchers are listed here.
Breech birth can be a lovely experience for mother and baby. Most breech births go well.
The important factors in safe vaginal breech birth include:
- Labor begins on its own
- Labor gets stronger, progressing on its own in good time
- Once a woman is in active labor, there are no notable stalls in labor (over an hour)
- The urge to push establishes on its own without direction from provider/nurse
- The mother moves freely
- When the baby’s presenting part appears, the mother is in an upright position of her choice, not a learned position.
That said, the knee-elbow position is being thoroughly studied and though not published yet, has extreme improvement in baby’s outcomes over the woman being on the back or even standing up for birth.
- Hands-off the breech
- Hands-and-knees (knee-elbow)
- Leave the cord intact and unclamped
“Hands-off the breech” means few or no vaginal exams. No wiping mother’s bottom or pushing her bottom up away from the mattress or floor to prevent her sitting on the baby. She’ll feel baby and won’t sit on the baby too much. Mother’s rocking down may help or maintain flexion (Evans).
Hands-and-knees or knee-elbow lets the woman on a flat surface rock back and forth, rise up, and lower down as her instincts move her. A raised hospital bed or birth ball, or even her loving partner, are not in front of her accidentally preventing her sudden movements. Gravity brings baby to the anterior as the hips or chest come through the pelvic floor.
Leaving the cord intact, even with its white, is an important way to support baby’s vitality after birth. What do I mean? Better Apgars! When to cut the cord? After the birth of the placenta.
Can vaginal breech happen in a hospital? Yes! But mothers may have to travel to find a provider, especially an experienced and physiologically-based provider. Check out this lovely little blog post on a sweet, hospital birth. (NOTE: I don’t think the episiotomy was necessary, but the doctor was learning to be comfortable with vaginal breech birth.)
Next, a physician training film uses a doll and manikin (womb-ikin?). The techniques are widely accepted in some areas of the world. Personally, I have some questions. For one, the segment showing the spontaneous birth (of the doll) as the body of the baby is being born shows the baby’s spine to mother’s hip, which is a sign of an anterior shoulder dystocia. Yet, the baby is born from the manikin easily. This is not generally the case with the baby in this orientation! Two, in the breech extraction, the baby is rotated by rotating and pulling the leg. This will set up a twist in the pelvis and shoulder musculature. If the provider could stop with the legs as soon as the hips were reachable and continue with only holding the baby’s pelvis (and not kidneys, of course) there would be less torsion in the body of the baby. Torsion sets up, I believe, a chance of obstruction that may not have occurred with less twisting. The baby must be rotated in these emergency situations when nature hasn’t brought the baby or the baby can’t wait for nature’s timing (as when the placenta separates early).
The first thing women hear is that the breech baby’s head can get stuck. True. But getting the head unstuck when baby is full-term is generally not troublesome, when the provider has a clear idea of how to flex the head and bring it into the AP diameter.
Shawn Walker, British Midwife, explains it like this:
Some babies who are breech need help, more often than head-down babies. So having experienced support is crucial to the safety of breech birth. The head getting stuck is a terrible image, designed to terrify women, and probably the result of practitioners themselves feeling fearful or inadequate. I prefer to talk about the need for help because it creates an image that help is available, as it should be, but is realistic about the fact that occasionally some manual assistance is required.
Generally, even the RCOG guidelines (you can look up Management of Breech Presentation) recognize that second twin breech is no indication for a CS. The path will be cleared by the first twin, and there are generally few complications due to breech per se with a second twin. There is no evidence that there are more complications for a first breech twin which is fully grown, especially as you say for a woman who has birthed good-sized babies before. But the more unusual a situation, the more fear it is likely to generate.
http://www.ncbi.nlm.nih.gov/pubmed/10636499 (abstract below)
Above is a link to an abstract of an article that looked specifically at results for twin births where the first twin was breech. I think you and the authors are coming at it from the same perspective. In their article (I can send you a copy if you want, to share with your providers), they write: “Being a rare clinical situation (less than 0.5% of all deliveries), one might question the need to study safety of vaginal birth in breech first twins. The point is not reduction of the overall cesarean rate, but preventing unnecessary cesareans.
In seeking safety parameters for home breech birth, guidelines must be developed from the best practices of breech-experienced midwives and doctors.
Protocols, or guidelines for care, are designed to increase safety by reducing the trial-and-error approach by a lone individual. With protocols, we hope to avoid “wish midwifery” (“I wish the birth was going to pick up and finish soon,” “I wish the baby was coming down,” etc.) Sometimes a parent or provider decides to continue with a birth that is “outside” the protocols. This may be simply because the protocols can’t apply to every single variation of normal birth. But the chance that risk is rising should be acknowledged with increased communication, coverage and/or transport.
Protocols, however, are not enough information for a family or provider to make complete decisions about a particular breech birth. Yet, with more parents learning about breech birth online and elsewhere, a practical, and hopefully balanced, approach may be helpful for decision-making.
Personal Breech Birth Protocols
Breech birth can be a lovely variation on a natural process. Labor may be less painful and shorter than with a head-down baby. Risk reduction through a holistic approach looks at individual comparison between home or hospital, and cesarean or vaginal birth with this mom (emotional preparedness, health, pelvis) and baby (presentation, health). Breech vaginal birth can be a conscious choice for parents.
Protocols protect our decisions when fatigue, emotion, birth plans, or inexperience might confuse issues. These breech protocols reflect, in my opinion, best practices for a home breech birth in my area:
- All mothers are assessed for pelvic alignment and myofascial issues. Repeated bodywork increases safety.
- All midwives agree to consultant’s parameters and recommendations before, during and immediately after the birth.
- The baby’s head is normal size, and tucked (chin to chest, flexed) or neutral before labor, as noted by palpation (feeling the woman’s abdomen). The mother is informed for assessment by ultrasound or MRI.
- The baby is frank or complete. Footlings are referred. Footling vaginal birth; baby is of no more than average size and the mother continues bodywork to help her pelvis and womb be optimal for birth.
- Mother’s pelvis size is fine as determined by the previous vaginal birth of an average-sized or larger baby, or, by pelvimetry which includes an internal exam of the pelvis. (An MRI is not universally recommended.)
- Safety increases when mothers are both relaxed and free to move during birth. This way, women can respond instinctively to labor and their baby. Helpers and providers behave and speak to nurture the calm.
- Labor begins spontaneously, without induction or augmentation, between 36-42 weeks at home, 34 and 43 in hospital with good fetal activity and growth. Mother doesn’t have hypertension; diabetes or diabetic symptoms. Metabolic stagnation or imbalance? Be more cautious.
- Labor progresses readily without a stall in active labor in the presence of strong contractions. A start-and-stop pattern in active labor without progress is means for transport. No breaking the water (AROM).
- The mother’s birthing position is physiological. Hands-and-knees (knee-elbow) is protective.
- The person catching keeps hands-off entirely unless the baby shows the need for help to come out. No perineal massage or support, no wrapping the half-born baby in a cloth, no pushing on the mother to stop her sitting on her baby (mom will feel baby and stop herself). Episiotomy is not routine. No one can wipe the mother’s bottom during birth. All this to avoid the mother clenching. No towel on the baby. Quiet patience is key.
- Monitor appropriately. Fetascope is the method of choice; use doppler only when fetascope can’t pick up heart tones. Touch the cord only if it is not visibly pulsing in assessment for emergency intervention.
- Second stage can last 4 hours. After a latent phase early on, the pushing urge takes over and there is descent. If there is no progress after an hour of good pushing we transport for surgery. With slow descent (the baby is coming down), pushing at home is given 3 hours. If the hips aren’t then being born (or “rumping,”, meaning birth time isn’t imminent), we transport. No discussion. No debate. A cesarean is strongly protective of the baby in this case. [Very experienced midwives and physicians sometimes disagree with these time limits. Other experts follow them precisely. It’s one thing to disagree, it’s another to know the parameters and signs of trouble when the time limits are exceeded.]
- Fundal pressure (not suprapubic) is preferable to pulling on the baby when immediate birth is necessary. No breech extraction. Fundal pressure is only advisable if the baby is not impacted. Resolve any obstruction first.
- The attendant has experience and practices regular simulation of breech birth; knows the maneuvers, newborn resuscitation, and delayed cord clamping; and knows techniques and maternal positions to open the pelvic inlet, midpelvis, and outlet. The attendant midwife or doctor practices breech drills with the mother’s other midwife/doctor/nurse/midwife apprentice whenever possible.
About 20% of Jane Evans’ planned home breech births finish with cesarean surgery. This is the same percentage for Dr. Frank Louwen’s spontaneous breech births in his Frankfort hospital.
Here is a powerful story from a mother, a homebirth midwife herself, who worked hard for a natural birth at home. Notice the clues of soft tissue traumas from a previous car accident and previous cesarean, as well as a previous posterior — not unusual history for a breech in a woman who’s birthed before.
Hands-and-knees birth might occasionally include complications, even after many spontaneous breeches, know the details of bringing out the head and the details of the diameters of the pelvis so you know where the head diameter is in relationship to the pelvic diameters so you can rotate and flex appropriately for each level of the pelvis (station) in which you may find the head.
Hands-and-knees maternal position makes your work to rotate and flex the head much easier compared with a mother lying on her back. The pelvis itself has notably larger diameters when the mother is in this position and the sacrum is more mobile. Providers have more room to reach in to assist the baby should such help be necessary.
Hands-and-knees, or knee-elbow, position allows baby to rotate in harmony with the birth process. The back will rotate towards the mother’s front and facilitate good flexion and avoid a posterior breech presentation for the birth of the chin. Even loving “help” might startle or restrict the rotation of the baby who is otherwise rotating and descending fine. The baby needs to rotate. Touch impedes normal rotation by the resistance, even though subtle, the hands make on the baby’s rotating fascia (that important membrane awash in cerebral spinal fluid which wraps every muscles and organ and bone of the body) (Phillips). Touching the mother might also cause her to clench her sphincter muscles in response (Evans). Additionally, letting the baby hang in this position later extends the back, likely assisting the Perez’ reflex (Tully) for the shoulders to enter the brim and then the stepping reflex to flex the chin when the head is in the midpelvis (coming through the pelvic floor).
Waterbirth in hands-and-knees position may impede the work of gravity, lengthen second stage, and impede head flexion (based on Evans). Waterbirth in the standing position with one foot lifted to a submerged stool may improve outcomes. A rain barrel, not a birthing tub, is required for this arrangement (Enning).
So we let gravity be the midwife.
Informed Consent and Informed Refusal
Reality check: There is not enough information here or anywhere on this website to extract enough information to guide parents or inexperienced baby catchers towards a safe breech birth. Nor does others’ experience justify inexperience.
A little knowledge is a dangerous thing. Some midwives propose 15 to 30 breech births as a starting point — an entry level for breech competency. Some doctors say 50 breech births is the number for competency. Some midwives feel that with their level of experience, whatever it is, they offer a better option than mandatory cesarean surgery. (I’m not sure that is always true.) Most of the time, things work out, but when they don’t, don’t let it be because the first 15 breeches you went to were easy and you didn’t know something like that (whatever it was) could happen. Travel to get training. Work with local obstetricians so they can get training.
Some very important aspects of breech safety are not in the books!
We need time together to discover just how much we do need each other. Work together for better, safer breech births whenever you can.
We have a moral responsibility to breech babies and their mothers to consider and support physiological breech birth when there seems to be an equal or nearly equal ratio of risk. We have to learn what the actual risk to birth from the breech position is, and also what the risk to our chosen method of care is, because those are often two different answers.
Only when we understand physiological birth, and when our skills can deftly protect physiological breech birth, will we know if breech vaginal birth is safe. Only when the statistics of harm due to cesarean surgery are commonly reported can we truly compare. Only knowing what is possible with physiological breech birth can we rank any favored breech method on the spectrum of safety with confidence and accuracy. Until the stats on knee-elbow and “hands off” breech protocols are published, the argument against vaginal breech birth continues. And once the stats of providers such as Dr. Louwen’s and Dr. Rietter’s in Frankfort (knee-elbow “Hands Off” breech births) are published, the argument against vaginal breech birth will be unfounded.
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.
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 or 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. However, as Dr. Richard Fischer states in Breech Presentation, “total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%.”
Read a mother’s story of her hospital breech birth when she refused a cesarean. 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. 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. The gentle “support of the bum” is followed by the doctor going for the arm or arms. As of late 2013, he is now exploring completely hands-off, upright (knee-elbow) breech. 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.
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.
Canadian obstetrician and breech expert Andrew Kotaska was a lead writer of the new Canadian breech guidelines for the Society of Obstetricians and Gynecologists of Canada. He wrote an article telling why the Term Breech Trial failed to show an honest assessment of the safety of vaginal breech birth among its 126 hospital settings. He is a wonderful teacher with clear insights:
Poor results from centers with inadequate resources following a liberal protocol do not have external validity in settings with better support and more cautious protocols.
Betty-Anne Daviss is a Canadian CPM studying breech birth in Canada, Germany and Israel. Betty-Anne is doing amazing work to help parents, physicians and midwives communicate and learn from one another to increase the safety of vaginal breech birth in the hospital. She collects data from around the world on the database that she and her epidemiologist husband Ken use to study natural and midwifery-based birthing. They’ve also recently published a breech article with Dr. Andre Lalonde, head of the Society Obstetrics Gynaecology Canada. Their article about hospital policies on vaginal breech birth from the Journal of Obstetrics and Gynaecology of Canada documents that the evidence does not support a policy of routine cesarean section for breech birth. Here’s the article abstract:
The authors wished to gain insight into Canadian hospital policy changes between 2000 and 2007 in response to (1) the initial results of the Term Breech Trial suggesting delivery by Caesarean section was preferable for term breech presentation, and (2) the trial’s two-year follow-up and other research and commentary suggesting that risks associated with vaginal breech delivery and delivery by Caesarean section were similar. We also wished to determine the availability of vaginal breech delivery and the feasibility of establishing breech clinics and on-call squads, and whether these could include midwives. 20 maternity centres in six provinces participated. Hospitals were almost five times more likely to adopt a policy of requiring Caesarean section for breech delivery when current evidence suggested that it decreased risk for the neonate than they were to reintroduce the option of vaginal breech delivery when it did not. They found that practice changes are quickly following the evidence that breech birth shouldn’t be by cesarean only. Obstetric and midwifery bodies will require creative strategies to make clinical practice consistent with current national and international evidence.
Full text available here.
[Daviss, BA, Johnson, KC, Lalonde A. Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions. J Obstet Gynaecol Can. 2010 Mar; 32(3):217-24.]
Breech birth can happen at home. But don’t be ideological.
Breech birth is becoming more accepted in American homebirth culture. We are seeing more home breech birth videos on the internet. A good example is Annaka Faith’s birth story and video on Leslie’s Daily Surrender Blog. We hear how her midwife brought in a second midwife with breech experience to increase support and skills if Leslie’s baby were to need help during the birth. What happens is classic and is addressed in the following paragraphs. Go read the blog first, though, its a lovely story.
Midwives learning from other midwives have the advantage of learning physiological breech birth, but the disadvantage is the gap in 2-3 generations of midwives who’ve missed experience with more than an occasional breech. Home birth doesn’t have the extra support for full resuscitation, though it is advantageous for the baby that many midwives know not to cut the cord during resuscitation.
As I’ve pointed out before, there are strengths and weaknesses to both home or hospital breech birthing. Homebirth can be argued to have “inadequate resources” from the point of view of a hospital. The skills of the midwives and the complexities of a breech birth will vary, and occasionally, the worst of both will collide. Even a midwife with many successful breech experiences behind her could suddenly be faced with a situation she can’t solve. This crisis can and does also occur in the hospital. Hospitals open to breech and close again when a complicated breech, or a breechling who has congenital problems, upsets the hospital staff and physicians. A similar crisis in a home birth puts parents and midwives into a whirlwind of exposure, review and, too often, retribution by the system seemingly slighted by their choice to give birth another way.
I believe it may be more likely that a very experienced midwife is more likely to notice when a labor leaves the range of normal, and be able to transport to get an intervention, than (sometimes) an obstetrician who hasn’t seen many natural births, nor recognizes the need for an intervention when they have set their heart on helping a woman have a natural birth. Few obstetricians have sat with women through natural labors observing the variations of normal. When a doctor who works where interventions are routine suddenly wants to help a woman achieve a natural birth, the doctor may not have the experience to notice when a labor actually needs an intervention. I know that sounds crazy, and I don’t mean to be biased, but I’ve seen this dynamic in breech, VBAC, and head-down births. It’s one more reason that a midwife, doctor and doula team can offer the best care (that is, if everyone is working harmoniously and within their strengths and/or roles and not pushing an agenda or afraid to offer their strengths).
If that wasn’t enough preaching, here’s another observation:
Occasionally, I hear women say they are planning to stay home with a breech because their midwife has been at breech births. A question arises, however: How many breech births are enough to satisfy her ability to handle the complications? (My experience is limited, too.) My hopes are that women who do stay home with a breech are following their inner voice and listening to their babies. We don’t give birth from the left side of the brain. Facts and protocols are good, but they are not what we must rely on once a complication arises. Just because Breech Is Normal doesn’t mean all breech births are spontaneous. Sometimes, when a breech birth is difficult, it can get very difficult, very fast, with no time to transport. Few American midwives have complete breech training and fewer have the skills of experience for breech emergencies, to go into the unassisted breech home birth.
Normal breech labor is really lovely, often more comfortable for the woman, dynamic and exciting for all. Most crises are easily handled by the well-trained provider. Often the observer might miss the fact that there was even a stuck arm or head when everyone is calm. My responsibility as an educator is to go on a bit about “the tougher variations of stuck,” because they do happen and they do lead to scary close calls and even death. Face that fact, don’t divert from it. With all potentials listed, paired with your intuition, you can better assess whether your resources are adequate to your needs in providing or receiving breech care.
Mothers should listen to what God, Nature, the baby and their inner sense is communicating to them. When breech home birth is right for a mom, she will have a contentment and an inner conviction, not a heady drive to show the world that vaginal breech birth is possible. Rather, she will have an inner certainty that she is following what is right for her baby. Her midwife should have the same guidance, rather than being guided by philosophy or ideology. It is all of our responsibility to know the difference.
It is good to sit beside the birthing woman with the understanding that she is following a wisdom which expresses her own natural physiology.
It is also good to know breech cardinal movements and recognize when the baby is unable to make the next cardinal movement. See Jane Evans’ article on the Physiological Breech Birth, including the cardinal movements in MIDIRS journal. Then, study Anne Frye’s Holistic Midwifery, Vol. II, on the breech cardinal movements. Use a doll and pelvis to illustrate each step. Do this 100 times.
Skills are processed with logic, but practiced with heart and hands.
Here’s a picture of a baby who is coming well in a hands-off, knee-elbow maternal position. The arms are about to come out on their own as indicated by the deep crease in the chest showing the compression of the elbows on the chest.
It is also good to know several ways of helping if the arms and/or head becomes stuck. If you can’t see it coming before it happens, you have more to learn. The first view of the breech will show you if there may be trouble ahead. At the first peek, there may still be time to change plans.
Before a midwife attends a home breech birth, she will be more helpful if she knows well how to resolve the stuck shoulders of head-down babies. Rotation and handling the shoulders in a head-down baby aren’t exactly like stuck shoulders with a breech, but are very similar. The principles are the same, just applied upside down! Having been through several shoulder dystocias gives the midwife practical skills in a crisis.
Other necessary skills would include:
- Physiological resuscitation of the newborn
- Creative cord unwrapping
- Recognition of cord compression
- Handling a rapid hemorrhage
- Patience to keep hands off
- Courage to be hands-on
- And the wisdom to know the difference!
Early placenta detachment can occur and gives the midwife some extra juggling tasks as the baby is emerging or has just emerged.
Another very nice skill, though not a common one, would be pediatric craniosacral and myofascial release. One may refer to a person who can do “cranials” for the baby, which will improve breastfeeding and other vital functions immediately, as well as in the following hours, days, and weeks after birth.
Even before the birth, communication skills with parents about birthing outside of the typically accepted practices of American birth, and perhaps without family support, is important to nurture the mother’s body-mind connection.
Communication flows more smoothly when we let go of our desires, agendas and even assumptions. Birth has a purpose all her own.