Babies have been brought into this world since the beginning of mankind. Even up until the time when my father was born in 1930 a majority of births in the US were still taking place at home. This completely changed in the next ten years and led us to where we are now, with a majority of births taking place in the hospital. The reasons for this shift were numerous. Today many women sight “ what if there is a complication” as reasons to deliver at a hospital. One of these “complications“ can be a baby in breech position.
Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix and occurs in 3-4% of all deliveries. In 2010 ACOG (The American Congress of Obstetricians and Gynecologists) stated” The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery. Obstetricians should offer and perform external cephalic version whenever possible. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented. Before embarking on a plan for a vaginal breech delivery, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity might be higher than if a cesarean delivery is planned.”
According to an historical account of midwife Jane Sharp who wrote the Midwives Books in 1671, “if the head comes first, the birth is natural, but if it come any other way, the Midwife must do what she can to bring it to this posture. Sometimes the infant comes with the legs forwards, and both arms downwards close to the sides, this way the Midwife may endeavor to take it forth if it continue in the same posture by anointing and gently handling the place. But if it is safer, if she can, to turn the legs upwards again by the belly, that the head may first come down by the back of the womb for that is the natural way.” pg 155 The Midwives Book. Jane goes on to out line other ways to assist a breech baby and her writing shows that she was clearly experienced in helping assist at breech births and that it was a part of a midwife’s job to know what to do to help at births were the babies present in breech position. Given the frank discussion on how to handle a baby in breech position and the very specific instructions on how to assist at a birth like this, it is curious why “most countries now recommend planned cesarean sections in breech deliveries, which is considered safer than vaginal delivery.” (BMC Pregnancy Childbirth 2013,13(153)
First, let’s look at the numbers. According to Birth without fear,” Breech presentation occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22% of births prior to 28 weeks’ gestation to 7% of births at 32 weeks’ gestation to 1-3% of births at term. Which means that 96-97% of babies will turn head down prior to their birth (97-99% if born at term).”Remember, that the percentage of breech deliveries decreases with advancing gestational age. This information is very helpful to a mother who has been told at an early ultrasound that her baby is breech. She can know that very often these babies turn on their own by 32 weeks. Other factors that can play into the position of the baby, and are often screened for include, uterine malformations, the presence of fibroids, polyhydramnios, placenta previa, and multiple gestations may cause a baby to stay in the breech presentation. (Medscape.com) This information can be helpful in determining risks associated with vaginal delivery, for example placenta previa does cause major issues for a mother and baby and can play into why a baby continues to lie in breech position.
So the question then becomes, what can we do to assist the baby in breech position?
Gail Tulley of Spinning baby has been working for 10 years on techniques that can be used during pregnancy to help mothers achieve optimal fetal positioning in addition to turning breech babies head down prenatally. She outlines specific exercises for all mothers to perform and specific exercises for a mother with a baby in breech position to perform. If the baby is in a persistent breech position and labor begins, the fear that many mothers hear about is the risk to the baby that the head will get stuck. Shawn Walker, British Midwife explains it this way.” 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. “(3) Ina Mae Gaskin has posted videos and written books on delivering breech babies. Gail and Ina May both outline specific modern techniques that can be used to assist in a breech delivery. Some of these techniques mimic in some form the work of Jane Sharp and others techniques are completely different. Keep in mind that is the work of only two birth attendants in the US.
So if the techniques are there, what about the outcomes for moms and babies?
There have been several studies done comparing the results from breech babies born via c-section to those born vaginally. In 2000, a randomized multicultural trail called the Term Breech Trial (TBT) published its results. The trial followed 1042 women who were assigned to deliver vaginally and or via cesarean for babies in breech presentation. The trial reported some significant differences in outcomes with lower perinatal and neonatal mortality, and lower serious neonatal morbidity in the group of mothers who had planned cesarean section vs those who delivered vaginally. This one study had a major impact on practices and the modern practice of delivering breech babies via cesarean section and even influence the ACOG statement on breech birth.
A Norwegian group looked at information on international breech births and obtained information on perinatal morbidity and mortality in term breech infants in Norway. “Their results showed a lower perinatal morbidity among infants born vaginally in breech presentation compared to both study groups of the TBT. The mortality rate was .31% when corrected for lethal malformations and 0.09% after the additional correction for death before admission to the maternity clinic. This could be explained by close fetal monitoring, national procedures, and sufficient skills of obstetric staff, combined with high quality neonatal service, in contrast to many of the participating clinics in the TBT.” (BMC Pregnancy Childbirth :2013, 13 (153) . Clearly there are many factors that play into the outcomes from breech deliveries.
The French have taken a different approach than doctors in the US. “French gynaecologists continue to perform vaginal breech deliveries. Through various observational studies, they have shown that their management approach, although different from the one used in North America, is safe.” (6). A majority of babies, some studies state as high as 54%, in breech position are still delivered vaginally in France and in Europe, namely the additional countries of Belgium, Ireland, Switzerland, and the Netherlands. This is because “French authors have questioned the selection of patients for vaginal breech delivery in the TBT. The reason for this is that only 9.8% of patients underwent pelvimetry, 68.7% were assessed by ultrasound, 57% were assessed during labor, and 33.4% had continuous fetal heart monitoring during labor. It should also be noted that 5.8% of fetuses were macrosomic. Finally, a slower progression of labor than the French standards was accepted in the TBT: minimum cervical dilatation of 0.5 cm per hour and maximum duration of pushing (active second stage) of 60 minutes.18 The analysis of perinatal deaths in the TBT was also criticized.” Couple this information with the risks to the mother associated with cesarean birth and the Europeans have not been as quick to jump to cesarean birth for all babies in breech position.” (6) The French go into very specific criteria for women that are selected eligible for vaginal delivery as well as specific conditions during labor. The difference boils down to not only the care the women received prenatally, the amount of information gained prenatally, but also the difference in care that women received while in labor with the key being the French standards for labor allowed for labor to progress slower than the standards used in TBT. Perhaps the women whose labors were called for cesareans in the TBT if given more time would have progressed and delivered vaginally.
In going back to what the ACOG said, ”The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery.” The question then becomes, what has happened to the care providers that have the skill and expertise in vaginal delivery of the baby in breech presentation? Is it simply that in the time since 2010 and our comfort for using cesarean sections for any deviation from normal birth that we have lost the skill care providers that have had since at least the time of Jane Sharp in 1671 to delivery breech babies? And is it in for the best of all mothers and all babies to offer women only the choice to birth babies in the breech position via cesarean? Certainly more research can be helpful, but will we loose these skills before that research can be done or are the keys to successful vaginal birth for breech babies out there in historical texts and in the few hands of skilled care providers?
In thinking back to when I was an expectant mother, I clearly remember reading stories of babies born vaginally in breech position, In fact, one of the things that most drew me to midwifery and homebirth then was trusting the understanding midwives have for the different ways a normal deliveries can look. I was drawn to the skills that I had read many midwives possessed in a time when many doctors were relying more on tools and machines which often times denied a mother the ability to labor and birth normally under the guise of safety. I didn’t know the terms then, just what I wanted as a woman and mother for the birth of my child. Now I know about informed consent. I try to instill in my mama friends, the responsibility of every pregnant woman to be informed of her choices. When faced with a variation of normal, a baby in breech position, a mother deserves to have access to information about how breech deliveries are taking place all over the world, information about the risks and benefits to all approaches for delivery, and should dialogue with her caregiver about what the options for her delivery are. Birth is never a one size fits all. It really is about options and what the mother and her care giver decide together what is the best option for this birth.
1. Vaginal Breech Delivery- results of a prospective registration study.
By Ingvid Vistatd, Miladad Cvancarova, Berit L. Hustad, Tore Hernriksen
BMC Pregnancy Childbirth. 2013;13(153)
2. Jane Sharp: A Midwife of Renaissance England by Jane Beal, Midwifery Today Autumn 2013 pg 30-31
3. Spinning Babies: Breech; Bottoms Up, http://spinningbabies.com/baby-positions/breech-bottoms-up
4. Ina May Gaskin- Midwifery Today, http://midwiferytoday.tumblr.com/post/27135829808