BY Audrey Hoover
Though breech position is unusual (about 4% of term pregnancies), it’s not rare. A lot of women get caught at the end of pregnancy with a surprise breech and don’t have much time to figure out what to do about it. Without information, many women find they don’t have any options. Learning some basics about breech birth ahead of time can save you a lot of anxiety and hassle in case you discover a breech at the end of your pregnancy.
Having a breech baby throws you into a decision-making circus. Do you try to turn the baby? How do you give birth? Should you try ECV? Which of the myriad methods for turning will you pursue? How much time should you spend trying to turn the baby? How much money? When do you stop trying? When should you schedule a planned cesarean? How far are you willing to travel for a vaginal birth attended by a skilled caregiver? If you can’t find someone, how about unattended childbirth for breech? All of this uncertainty is stressful. Here are some of the issues you should be aware of as soon as possible in any pregnancy.
Avoiding a Malpositioned or Breech Baby
You can often encourage optimal fetal positioning by having good posture in pregnancy. Excessive sitting and asymmetric postures and movements are also linked to breech pregnancies. Sofas, recliners, and bucket seats (like in a car) are notoriously bad for baby’s position. Midwives who work among the Amish noted a significant increase in breech babies when their communities switched from using only hard chairs to using couches and recliners. Chiropractic care can help you maintain balance in your pelvis and uterine fascia and ligaments, making breech less likely.
When to Check for a Breech Baby
The majority of babies turn and stay head down between 28–32 weeks. Many will turn after 32 weeks, but many of the options you have for helping your baby turn on its own work better between 32–36 weeks. You should ask your caregiver what position your baby is in at 32 weeks. If you feel a round ball that you can wobble on the top of your belly, it’s likely a head. Most obstetricians don’t check the baby’s position (or don’t tell you about it) until 36 weeks. They don’t express concern over a breech baby until 36 weeks, at which point they tell you if the baby doesn’t turn you will need a cesarean. They may offer external cephalic versioni (ECV), a process where they attempt to manually rotate the baby by pushing on your belly.
Turning Your Baby
You may feel that your baby is breech for a reason, and not want to turn your baby. Babies do know how to be born breech. There are some amazing videos of the instinctual birthing movements of babies born feet or butt first. Breech babies do encounter problems on the way out more often, though, so if you feel inclined, there are many, many ways people have claimed success in turning breech babies. Many can be done by you at no cost and no risk. Doing inversions and the breech tilt, hypnotherapy, homeopathy, and chiropractic care can all turn a breech baby. You can even turn a breech baby with essential oils.
Vaginal Breech Birth
Recent research shows that vaginal breech birth is just as safe or safer than cesarean breech birth for the baby. Vaginal birth is almost always safer for mom. The American and Canadian OB groups (ACOG and SOCG) recommend vaginal breech birth in select cases. Unfortunately, one of the cases is that you have an OB who is experienced and confident in breech delivery. Due in part to a flawed study released in 2000 and a history of insurance companies threatening teaching hospitals who taught breech skills, most caregivers today have had no opportunity to practice vaginal breech birth. The study was debunked around 2006, but so few people now remember how to attend a vaginal breech. Vaginal breech birth is just starting to come back, mostly in the UK and Australia. But it is available here in the US by a few learned midwives and doctors.
The foremost vaginal breech birth practitioners (doctors and midwives) tend to agree that it is a higher-risk birth and that having an experienced, confident caregiver is the best way to assure safety. Michael Odent, one of the foremost mother-baby friendly obstetricians in the world says, “Breech birth by people who are afraid of breech birth is very dangerous.” This is largely because of rough or hasty handling of a partly born baby.
Though there are some well respected caregivers with many safe breech births in their experience who routinely perform specialized breech birth maneuvers, many of those who attend breech births do so hands-free. You may have heard the phrase “Hands off the breech!” Practitioners have found that breech babies know how to be born and that by letting them birth themselves, they come out safer. Touching the legs or body of a partly born breech may cause the baby to exhibit its moro (startle) reflex, throwing up the arms and extending its head. Both of these things would make it more difficult for the head to be born. So unless the head has become entrapped, many breech friendly practitioners will keep their hands off the breech. These experiences have also taught us that women birthing instinctually also know how to birth breech babies, and, if in tune with their body, will move in such a way as to facilitate the easiest birth for their butt-down baby, often pushing on hands and knees. Since much of the danger of breech birth comes from the birth of the after-coming head, often when the cervix isn’t fully dilated, a caregiver with good breech experience will know how to expertly assess dilation and help a woman wait to push.
In a recent study, researchers compared outcomes for planned cesarean and planned vaginal birth for breech babies among 8,105 women in France and Belgium. In the planned vaginal birth group, 71% were successful. No significant differences were noted in outcomes between the vaginal and cesarean groups. An article by C.P. Weiner, published by the journal Clinical Obstetrics and Gynecology states, “Routine cesarean delivery of the near-term or term breech fetus increases maternal morbidity, maternal mortality, and the cost to society, but it does not provide a foreseeable benefit to the near-term and term breech fetus….Although preached with great emotion, the recommendation for routine elective cesarean section to deliver the near-term or term breech fetus cannot be substantiated by studies published over the last decade.”
Cesarean Breech Birth
A little known fact is that a cesarean does not remove all the danger of breech birth. It is safer to come out head-first, no matter whether it is an abdominal or vaginal delivery. Your baby still has to be squeezed and maneuvered out of a small hole; it is just quicker and more manageable with a cesarean. Baby is still at an increased risk for injury by virtue of being breech. For example, a vertex cesarean has a 1.9% chance of being cut during the operation, a breech baby has a 6% chance of this laceration.
Still, most everyone agrees that cesarean is the safest option for some breech babies. A number of caregivers, notably Michael Odent (of mother-baby friendly fame) say that in the vast majority of cases they cannot know if a vaginal delivery will be safe until labor has started. They use the first stage of labor as a test. If it goes quickly and all is well, the mother and baby are both doing fine, it’s a go. But if the first stage is very long, stop and start, mother is in a lot of pain or baby is showing signs of distress, they take it as a sign that the baby needs to come into the world by c-section. Dr. Mayer Eisenstein, a doctor who has done several decades worth of home births in the Chicago area, has a similar rule for determining safety in vaginal delivery. It is simply that at 5 cm, if the presenting part of the baby is at a positive station, it is highly likely the mother will deliver without complication, no matter what part is presenting.
What are the chances you actually really need a cesarean? Of course it depends on who you ask. Jane Evans and Mary Cronk, two highly respected UK midwives with lots of breech experience, have found that cesareans are necessary in about 20–25% of breech pregnancies. Ina May Gaskin and her colleagues have experienced every kind of breech at their center in Tennessee (99 breech deliveries from 1970-2010). In this (admittedly very small) sample, their total cesarean rate for breech was 10%.
Finding a Caregiver
Your ability to find a local caregiver who attends vaginal breech birth is largely a geographic lottery. In some places in the country there are a number of midwives who feel confident about breech, and in some places there is a huge local stigma, fear, or history of litigation concerning breech birth. You can contact people from MyBreechBaby.org or the Coalition for Breech Birth for referrals, or just ask around in your birth community. You may have to travel to have a vaginal breech birth.
You can also ask your OB. ACOG says that if elective cesarean is an option, in spite of its inherent dangers, so must elective vaginal delivery be an option. This doesn’t mean they are going to offer you a vaginal breech birth, but your doctor has fiduciary responsibility which provides that if you want something that is reasonable but she can’t do it, she has the duty to support you, find someone who can do it, or figure out a way to make it work. This includes planning a c-section where your baby never leaves you, moving around during labor, and having a vaginal breech birth. Unless there are extenuating circumstances, none of these things is unreasonable and you can find someone to support you. You also have the right to tell your doctor she is being unethical when she doesn’t show respect for your decisions, uses scare tactics, or pressures you into a birth you do not feel good about.
Changing Birth Through Consumer Demand
Doctors tell me that they don’t offer vaginal breech birth because women don’t demand vaginal breech birth. Hospitals are businesses. Cesareans bring in more money, and vaginal breech births more risk of litigation. Remember that you are the consumer. You (perhaps through your insurance) are paying for a service. This doesn’t mean you always get what you want, but it means you have the right to full information, to ask and to be heard. And you have the right to look elsewhere. If we all take our money and our babies away from hospitals that don’t offer evidence-based care, they will be forced to change.
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Thinking Woman’s Guide to A Better Birth, Henci Goer, chapter on breech
Breech Birth, Benna Waites