Breech Birth!

I have delivered a couple of breech (butt-down) term singleton babies in my (eight) years out of residency. The deliveries were both mildly stressful, because they are considered "high risk" and also because of how infrequently they happen at a low-volume rural hospital (and because I had had zero similar births in residency training!).  However, many other (vertex and cesarean, including cesarean for breech) births have been far scarier and the longer I am in practice, the more normal and completely physiological births (including my own two) I have seen. As a result, I (with my M.D. "midwife in disguise" mind) have really been questioning why we (doctors) pathologize breech presentation so much (among other things!) and, over the last 6-12 months or so, started trying to figure out how I could get some more breech delivery experience.

I started residency in 2007, which was not long after the famed "Term Breech Trial" (TBT), was published in 2000, which concluded that cesarean birth was about four times safer for singleton, term breech babies in the short term, with composite rates of neonatal harm (low Apgars scores, need for resuscitation/NICU stay, or death) being lower (1.6%) for babies born via cesarean section, compared to babies born vaginally (5%; death being only 1.3%) [1].

 
Unfortunately, that study led to a dramatic practice shift for term, singleton breech babies to be delivered almost universally by cesarean section in both the United States (and worldwide), despite there being several limitations in the study, including a lack of standardization of provider expertise, lack of consistently applied exclusion criteria, and a lack of consideration for future maternal or future fetal morbidity or mortality that accompany an increase in surgical births (for every baby saved by doing tens or hundreds of c-sections, future babies and moms are harmed due to perinatal risks of VBAC (which is also very much restricted in many areas of the country) or maternal complications of a previous cesarean scar or directly from surgical birth.  There are also perinatal risks (including death in as high as 6/1000) of laboring with a head-down baby, especially in community hospitals like mine without access to 24/7 in-house anesthesia, which were not compared (with the conclusion that laboring, and not just having a baby in breech presentation, obviously has risks for babies!). 

In any case, newer evidence has found that the long-term outcomes (developmental delay or death at two years) for breech babies born vaginally (even those that were compromised after vaginal birth) are not any different from those of babies born by cesarean [2]. Additionally, larger and more recent research studies have also found that the difference in short-term outcomes, including the rare but devastating outcome of neonatal death, are not significantly different between breech babies born via vaginal birth (1.6%) or cesarean (1.4%), in direct contrast to the findings of the 2000 trial [3], and these absolute risks are exceedingly low.

Taking in this information really made me cringe at how many C-sections I have performed on women "just because the baby was breech" (because I did not have adequate training to present non-cesarean birth as a safe and reasonable option. YET).

Well, all that has changed! I just attended an intensive three-day conference in Madison, WI taught by breech experts from all over North America, including researcher (and founder of Breech Without Borders) Rixa Freeze, the Spinning Babies lady Gail Tully, legendary and prolific Canadian Midwife Betty-Anne Daviss, and some very experienced physicians including FPOB Dr. Leeman and OBGYNS Dr. Chavira, Dr. Hartung, and Dr. Hayes who are all trying to "reteach breech" as it has become somewhat of a lost art and truly in danger of extinction in this country. The conference was AWESOME.

 

There were extremely informative lectures about the studies regarding the safety of breech and historical maneuvers, a legal talk by a well-spoken attorney emphasizing that birth choices for women are human rights issues (YES!), demonstration of newer techniques to support physiologic (spontaneous) breech birth, including using upright positioning and rotational, rather than traction, maneuvers on the baby, and ample hands-on simulation time. While most of the conference attendees were practicing midwives (and midwifery students) located in the midwest in the true inter-professional sense, the ever-studious doctorly and birth nerd in me took copious notes, soaking in every piece of information, hungrily.  I can confidently say that, after this conference I am at the peak of my breech birth knowledge and now feel like I have adequate training and skill (just without a lot of live-baby experience) to include it in the counseling of women about their birth options when I go back to my home community, in which I feel vaginal breech birth would be a highly desirable option for many of our crunchy, natural-minded women.

While there are well-established inclusion criteria for characteristics that make successful breech birth more likely and safer (gestational age at term, average fetal weight, flexion of the head, upright positioning of the mother [4], etc.), there definitely are risks of vaginal breech birth to communicate to patients, including umbilical cord prolapse/compression, delay in in-labor cesarean, need for neonatal resuscitation, and possible need for maneuvers to free a stuck baby, including elevation and rotation by provider hands.  Because many hospital provider, nursing, and administrators' anxiety may be so high at a breech birth because it just hasn't been done consistently for nearly twenty years (and it can be nerve-wracking to watch an upside-down baby be born over several minutes/contractions rather than all in one push), it will take a lot of education and reassurance to present it as a valid option in the practice of true informed consent. Changes in practice are hard, but when rooted in human rights and backed by evidence, they are essential.

Planned cesarean deliveries have many surgical and post-operative risks, as well as implications for future pregnancies and babies which need to be weighed against a patient's tolerance for (small absolute but perceptibly increased relative) risks, as well as their cultural values and desires. Many (maybe even the majority of) patients will still prefer the predictability of a planned surgical cesarean birth for breech over the unknowns of a breech labor (which could still end up in an emergency cesarean); however, I strongly believe that evidence, not fear, should drive patients' shared decision-making after consulting with their provider and skill level, which is consistent with ACOG's 2018 Committee Opinion [5].  Birth, especially in a small community hospital, is inherently unpredictable (don't even get me started on how I feel about birth "plans"!) and never without risk (even in head-down babies). Choosing how to birth a (breech or other) baby may be the first of many decisions parents have to make for their child (and future children), and every parent should get to make (without coercion or shame) and own that choice in the true spirit of bodily autonomy.

I am a woman. I treat women. I trust women. I support women to make choices about their bodies and their babies. Birth work (especially feminist birth work) is more than a job-- I've found it to be what energizes me and somewhat of a life's calling.   Bring on the breeches!
 

REFERENCES

1. Hannah ME, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000;356:1375–83. 

 

2. Hannah ME, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Term Breech Trial Collaborative Group. Am J Obstet Gynecol 2004;191:917–27.

3. Goffinet F, et al.  Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium.PREMODA Study Group. Am J Obstet Gynecol. 2006 Apr;194(4):1002-11.

 

4. Louwen, F, et al. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans? Int J Gynaecol Obstet. 2017 Feb;136(2):151-161. 

 

5.  Mode of term singleton breech delivery. ACOG Committee Opinion No. 745. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e60–3.