Vaginal Breech Birth

BREECH BIRTH

A Breech birth is one in which the baby’s buttocks, foot, or feet come out of the mother’s body first, rather that the head. Most babies are born head first, or vertex, as it’s known. It is most common in the United States today for a doctor to perform a cesarean section, rather that allow a woman with a breech baby to birth vaginally. This occurs for various reasons, including the medical establishment’s belief that there are more risks to vaginal breech births, and for legal liability reasons on the part of the doctors. The problem is that this leads them to ignore the additional risks of major surgery, and it has not been proven that a cesarean surgery actually improves the outcome of babies who are breech. While a few babies are in the breech position because of neurological defects, most are in this position for either unknown reasons, or because that is simply the best way for them to fit through their mothers pelvises. 3 – 4 % of all babies are breech, and many will turn head down before birth.

Vaginal breech birth is a controversial issue, as recent information has emerged that it is not always advisable for a woman to have a cesarean if her baby is breech. It is possible for a woman to have a safe, healthy breech birth, but there are a number of factors that need to be addressed in order for this to happen. A review of a study that evaluated the protocols for selecting fetuses in breech presentation for vaginal delivery or cesarean section can be found in volume 14, #2 of the Birth Gazette.

Why try for a vaginal breech birth? Why not just have a cesarean section, and avoid any of those potential risks? It is important to know that all major surgery presents risks and possible harmful effects to the mother and baby. Risks of cesarean section surgery include: a higher rate of maternal & infant morbidity, hemorrhage, infection, increased recovery time, risk of fetal respiratory distress, negative maternal reactions to anesthesia (aspiration), and Erb palsy and bone fracture in infants. According to an article in volume 14 (#17) of Obstetrics and Gynecology News, cesarean sections should not be done without a clear indication that there is a true medical problem, and recommends that a woman be allowed a “trial of labor”, even if a cesarean is indicated. This increases the chances that the baby and mother will truly be ready for birth, and life outside the womb; thus preventing prematurity, a common side effect of scheduled cesareans. Volume 18 of Obstetrics and Gynecology News (#‘s 15, 16, 24) contain 3 articles that clearly state cesareans should not be routinely performed for babies in the breech position, and that a trial of labor improves the outcome of their birth.

On the other hand, a study published in 2000 of the Lancet states that cesarean sections are a better choice for breech babies, contrary to previous research, as stated above.  While they supposedly looked at careproviders skill and knowledge of breech deliveries they did not take into account that few doctors are trained to deliver breechs vaginally, and that those who do have a very manipulative, hands-on approach.  Also, no midwives were included in the study, which would skew the results, as midwives frequently have more practical (hands-off) experience with catching breech babies vaginally.  Recent analysis of this study that was published in the American Journal of Obstetrics and Gynecology in 2006, and concluded that “most cases of neonatal death and morbidity in the term breech trial CANNOT BE ATTRIBUTED TO THE MODE OF DELIVERY. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies” They declared that The Breech Term Trial has been determined to be flawed, the recommendations be should be withdrawn, and protocols changed. As a result, in 2009 The Society of Obstetricians and Gynecologists of Canada issued new practice guidelines for the management of vaginal breech birth. Click on the internet link posted below to obtain a copy.*

A study from Tel Aviv Iseral conducted in 2010 found that vaginal breech birth was safer for both babies and mothers. Professor Glezerman presented his findings at the Canadian Congress on Breech Delivery, which “indicates that breech babies are no more at risk during vaginal delivery than C-section, and there is reduced morbidity and mortality for the mothers. Based on his findings, Prof. Glezerman is campaigning worldwide for a return to skilled vaginal delivery of breech babies.” (http://www.sciencedaily.com­ /releases/2010/10/101026141510.html)  Of course this would require retraining of Obstetricians worldwide.  A tall order when you consider that the medical schools in the United States are not very receptive to change.

As of 2016,  “ A new and groundbreaking research study has found that, “Upright vaginal breech delivery was associated with reductions in duration of the second stage of labor, maneuvers required, maternal/neonatal injuries, and cesarean rate when compared with vaginal delivery in the dorsal position.” (Louwen et al 2016)”

Not to address this issue lightly, it is important to know that there are risks to vaginal breech births as well. According to Williams Obstetrics these risks include: prolapse of the umbilical cord, trauma to both baby and mother, bone fractures, bruising, hip dislocations, as well as other damage to the baby due to extreme manipulation during delivery. Williams also notes that the use of anesthesia and analgesia can contribute to a negative outcome, and should be used with caution. Another factor taken into consideration is the higher rate of maternal morbidity with cesarean section as opposed to vaginal breech birth. The techniques used in a vaginal breech birth are important, as they can be a significant contributing factor in negative outcomes and damage to both baby and mother. Midwife and Author Ina May Gaskin recommends a “hands off’ approach to vaginal breech births, as opposed to the highly “hands on” manipulative techniques employed by most Physicians and recommended by Williams Obstetrics. Contrary to popular belief, incidences of cerebral palsy are now known to occur in-utero, rather than as a result of the mode of birth.

It is important to keep in mind that the drugs used during, and prior to, surgeries have long been known to negatively affect babies and their mothers. The contractions of labor benefit babies by stimulating their nervous systems, helping to clear their lungs in preparation for breathing, and generally prepare both the mother and baby for their new roles in life. Another factor rarely considered by the medical community is that of the psychological effects of cesarean birth. Many women suffer greatly, and require support group counseling, after having had a surgical birth for their babies.

According to Henci Goer in her book, Obstetric Myths vs. Research Realities, external version, or turning the baby from the outside, is a viable option before resorting to cesarean or vaginal breech birth.  This involves turning the baby by manipulating the woman’s belly, and monitoring with Ultrasound. While there is an average success rate of 63% it is important to note that the risks to External Version include: a prolapse of the umbilical cord, uterine rupture, premature rupture of membranes, cord entanglement, placental abruption, hemorrhage, and preterm labor. Each woman and pregnancy should be evaluated on an individual basis. The chapter on breech presentation is an excellent synopsis of the clinical literature on this topic, and well worth reading.

Another alternative to investigate is the Webster chiropractic technique that is used to encourage the baby to turn. As with External version, it is important to find a care provider with training and experience in applying this technique. A list of chiropractors in the Rochester area who are trained and certified in Websters technique can be obtained upon request by contact Rochester Area Birth Network directly.

In The Birth Partner  Author Penny Simpkin describes a posture or exercise that can be utilized by the pregnant woman called a breech tilt. Apparently this posture encourages some babies to turn head down when done in the last six weeks of pregnancy. She also mentions the use of music to encourage a baby to turn head down. Supposedly placing earphones low on the mothers abdomen and playing rhythmic music may encourage the baby to turn to better hear the music. Another excellent source of suggestions for turning a breech, or making the choice between vaginal or surgical birth, is Anne Frye’s book Holistic Midwifery.

If attempts to turn the baby do not succeed, and the mother wishes to avoid a cesarean, one of the most important factors in attempting a vaginal breech birth is to find a care provider who has experience and training in delivering babies this way. A whole generation of physicians has not learned to deliver breech babies vaginally. If the only training they have is in how to do a cesarean, then this may not be the best person to attend your vaginal breech birth. Especially since it has been noted that extreme manipulative methods commonly employed by physicians frequently contribute to damage to the baby. Finding a care provider with this experience and training can be difficult. The same applies to experience with doing external versions. It is important to interview all care providers first as to their willingness and experience. Do not be surprised if most care providers can not help you. Ask your local natural childbirth educator if they know of any care providers in the community who may be willing to attend a vaginal breech birth, or contact Rochester Birth Network for assistance in obtaining more information. It is important to note, however, that practices and protocols change on a regular basis, so it is recommended to do a recent interview, rather than assume.

Dr. Stuart Fishbein has found that if a woman is otherwise healthy and low risk, has access to a skilled provider,  then a homebirth is a reasonable option. His research shows high rates of vaginal births, and good maternal outcomes.

All pregnant women should pay strict attention to the quality the their diet. It is imperative that they eat a well balanced diet of whole foods. Please refer to our paper on Nutrition During Pregnancy for more information. It is even more important for women who are planning a vaginal breech birth to pay special attention to their diet, as sufficient nutrition help can prevent additional problems and complications that would prevent a woman from having the opportunity to birth naturally. It also helps to ensure a healthy mom with a strong, well nourished, efficient uterus and body; and a healthy, well-formed baby who can tolerate the stress of labor well. In addition to eating a well balanced diet, avoiding harmful substances (such as drugs – including over the counter ones) can also help protect your health, the baby’s health, improve your chances of staying low risk, and having a safe, healthy birth. Attending childbirth classes that increase your knowledge of birth as a natural process, reading books and other information on the subject of vaginal breech birth, and exercising moderately can also improve your chances of a healthy birth. Make sure you have a birth plan that includes all factors that are important to you and your family, and go over it ahead of time with your care provider.

According to world-renowned Midwife and Author, Ina May Gaskin, breech is simply another way to be born. As a result, her birth center rarely transports women with breech babies for cesareans.  Since she believes that fear is an impeding factor in breech births, each woman and baby are evaluated individually, and only natural labor techniques are utilized. She uses a hands off approach, and warns women to prepare to “get really big”. Her statistics show much better outcomes than mainstream communities, which highlights the negative impact that highly interventional medical techniques can have. In the Netherlands, a country where home births are the norm, vaginal breech births occur approximately 57 – 65% of the time, depending on the area.  Another practical source of information on this subject is Henci Goer’s book The Thinking Woman’s Guide to a Better Birth.  In it she reviews the medical studies and suggests many practical suggestions.

It is important to do your research, and keep in mind that this is your baby, and your responsibility. No matter what happens, it is you as a parent who will raise your child and live with your decisions.

Other Resources:

A film of a Frank Breech Homebirth: https://www.birthinginstincts.com/auroras-frank-breech-home-birth

Breech births at home: https://www.birthinginstincts.com/

References:

Fishbein & Freez, BMC Pregnancy and Childbirth (2018) 18:397; https://bmcpregnancychildbirth.biomedcentral.com/track/pdf/10.1186/s12884-018-2033-5

Louwen F, Daviss B-A, Johnson KC and Reitter A (2016). Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans? Int J Gynecol Obstet. Accepted Author Manuscript. doi:10.1002/ijgo.12033  http://onlinelibrary.wiley.com/doi/10.1002/ijgo.12033/epdf

Glezerman M, “Five years to the term breech trial: The rise and fall of a randomized controlled trial.” Amer J Ob & Gyn (2006) 194, 20-5

Brown, Karrison, Cibils; “Mode of Delivery and Perinatal Results in Breech Presentation”; American Journal of Obstetrics and Gynecology; 171:28 – 34; 1994.

Gaskin, Ina May; “Breech Births”; Audio Cassette, 1994 Midwifery Today Conference; available through Midwifery Today professional Journal.

Brak, Margre; “Normal Breech Delivery, a Matter of Experience: A Midwife’s Point of View”;

Technology: A Threat to the Normal Birth Process; Catharina Schrader Foundation; Bilthoven, Holland; 1992; p. 29 – 35.

Van Der Lugt, Bart; “Normal Breech Delivery, A Matter of Experience: From the Gynecologist’s Point of View”; Technology: A Threat to the Normal Birth Process; Catharina Schrader Foundation; Bilthoven, Holland; 1992; p.36 – 38.

Miller /Callander, Obstetrics Illustrated, 4^th Edition, Churchill Livingstone, N.Y., N.Y., 1989; p.304 – 314.

Cunningham, MacDonald, Gant, Leveno, Gilstrap, Hankins, & Clark; Williams Obstetrics, 20th Edition; Appleton & Lang, NY, NY, 1997; p. 435 – 443, 495 – 508.

Kunau, Pene L.; “Application of the Webster In-Utero Constraint Technique: A Case Series”; Journal of Clinical Chiropractic Pediatrics; Volume 3, #1, pages 211 -216, 1998.

Obstetrics and Gynecology News, vol. 18, #15, “Questions Benefits of Performing Cesarean Delivery for all Premature Breech Infants”. Iowa City, International Medical News Service.

Ibid; vol. 18, #16, “ Cesarean need not be Routine in Breech”, Iowa City, International Medical News Service.

Ibid; vol. 18, #24, “Routine Cesarean for Breech Challenged”, Quebec, International Medical News Service.

Ibid; vol. 14, #17, “Labor Trial Improves Outcome for Breech Fetus”, Halifax, Nova Scotia; International Medical News Service.

Ibid; vol. 12, #1, “Postural Exercise Turns Fetus in Breech Position”, Mexico City; International Medical News Service.

Alnbrechtsen, Susanne; Rasmusen, Sevin; Reigstad, Hallvard; Markestad, Trond; Irgens, Lorentz M.; and Dalaker, Knut; “Evaluation of a Protocol for Selecting Fetuses in Breech Presentation for Vaginal Delivery or Cesarean Section”; American Journal of Obstetrics and Gynecology, volume 177, # 3, September, 1997; as reported in: Birth Gazette, vol. 14, #2; Spring 1998, pages 45 – 46.

Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, et al.; PREMODA Study Group.

Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194:1002–11.

Whyte H, Hannah ME, Saigal S, Hannah W, Hewson S, Amankwah K, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol 2004;191:864–71.

Kotaska A, Menticoglou S, Gagnon R. Vaginal delivery of breech presentation. SOGC Clinical Practice Guideline No. 226, June 2009. J Obstet Gynaecol Can 2009;31(6):557–66;

* http://www.sogc.org/media/pdf/advisories/CpgBreechJune09_e.pdf  (accessed 6/23/09)

Kotaska, A.; “Breech Birth Can be Safe, but is it Worth the Effort?” J Obstet Gynaecol Can 2009;31(6):553–554; http://www.sogc.org/media/pdf/advisories/KotaskaCommentBreechJune09_e.pdf (accessed 6/23/09)

American Friends of Tel Aviv University (2010, December 7). Breaching the breech protocol: Researcher advocates returning to old-school methods for delivering breech babies. ScienceDaily. Retrieved February 15, 2013, from http://www.sciencedaily.com­ /releases/2010/10/101026141510.htm

 Balaskas, Janet; Active Birth; Harvard Common Press, Boston, Massachusetts; 1992, P. 187 – 188.

Cohen, Nancy Wainer; and Estner, Lois J.; Silent Knife: Cesarean Prevention & Vaginal Birth After Cesarean;  Bergin and Garvey, New York; 1983, p. 4, 13, 21 -22, 101, 310 – 311.

Frye, Anne; Holistic Midwifery; Labrys Press, Portland, Oregon; 1995; p. 801 – 818.

Goer, Henci, Obstetric Myths vs. Research Realities: A Guide to the Medical Literature; Bergin & Garvey; Westport, Conn.;  1995; P.107 – 130.

Goer, Henci; The Thinking Woman’s Guide to a Better Birth; Penguin Putman Inc., NY, NY, 1999; p. 49 – 74.

Gaskin, Ina May; Spiritual Midwifery – 3rd Edition, The Book Publishing Co., Summerville, Tenn.; 1990, p. 390-402.

Kitzinger, Shelia; The Complete Book of Pregnancy and Childbirth, Alfred A. Knopf Inc., New York; 1993, p. 213 -215.

McCutcheon, Susan; Natural Childbirth the Bradley Way, Penguin Books, New York; 1996, p. 163 – 164, p. 219.

Simpkin, Penny; The Birth Partner; Harvard Common Press, Boston Massachusetts; 1989; p. 113 – 115.

Frye, Anne; “Bottoms Up: Dealing with Other-Than-Vertex Presentation In Pregnancy”; Midwifery Today; #18, Summer 1991; p.33 – 37.

Rogers, Cindy; “Breech Home Birth”; Midwifery Today, #22, Summer 1992, p. 20 & 45.

Cryns, Yvonne lapp; “What am I Doing Here?”; Midwifery Today, # 22, Summer 1992, p.19.

McLean, Marion Toepke; “Stuck in a Controversy”; Midwifery Today, #23, Autumn 1992, p.11.

Stevenson, John; “More Thoughts on Breech”, Midwifery Today, #26, Summer 1993, p. 24.

Kurokawa, Jude; “Courageous or Foolhardy?”; Midwifery Today, #36, Winter 1995, p. 53.

For more information online access www.birthspirit.co.nz , the ACNM website at www.acnm.org,  or www.parentsplace.com/bbies/mom/gen/0,8728194632,00.html; http://www.breechbabies.com/index.html

Birth Without Fear Accessed: September 6, 2011, http://birthwithoutfearblog.com/

Fisher, R.; Ramus, R., “Breech Presentation”; Medscape Jul 9, 2012; http://emedicine.medscape.com/article/262159-overview

Amy V. Haas, BCCE©2002- 2023