messages about breech births

 A couple of days ago I wrote about 'informed or mistaken'.

Although there are no guarantees in any life event, the truth is that when we make plans and decisions about giving birth to our children we want to avoid anything that could be harmful or lead to poor outcomes.

And although there are many mistakes occurring every day in health care, the first rule of medical ethics is 'First, do no harm': Primum non nocere.

The other 'rule' that applies in this matter is the basic principle of midwifery: "In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996. Care in Normal Birth: a practical guide)

Today I would like to collect a few messages about breech birth that are available in professional circles, and look at each of the messages from this high standard.  Just to be clear, my starting point for 'do'-ing, in the statement 'First, do no harm' is any form of intrusion, interruption, intervention, or altering of the natural process.  This can be something as obvious as induction of labour for social reasons, to more subtle matters, such as requiring a woman to be prone for the convenience of the accoucheur. 

1 Safety of vaginal breech birth

1.1 "The current practice of caesarean section for all breech presentations is not supported by the medical evidence.  Many breech babies can be born safely vaginally."  [BBANZ]

1.2 "a caesarean section is lower risk than a vaginal breech birth"  Dr  

1.3 "Although it is common for obstetricians to advise that it has been proven that the outcomes of planned caesarean section (PCS) are better than the outcomes of vaginal breech birth (VBB), this is an oversimplification of the evidence and is misleading." [BBANZ] 

1.4 "... with the application of strict criteria before and during labour, planned vaginal delivery of the singleton breech at term remains a reasonable option to offer to selected women" [RANZCOG]

 2 Increased risk of complications for the baby

2.1 "Babies born in the breech position (bottom first) are at increased risk of complications at birth because of a delay in the birth of the head.  "  [Cochrane Summaries]

2.2 "OVERALL breech babies have lower Apgars than cephalic babies-REGARDLESS of how they are born"  [FB]

3 External cephalic version

3.1 "Turning a breech baby to head first in late pregnancy may reduce these complications. A procedure called external cephalic version (ECV) describes when practitioners use their hands on the woman's abdomen to gently try to turn the baby from the breech position to head first." [Cochrane Summaries]

3.2 "My preferred option is to turn the baby to head-first position in order to avoid a caesarean section." Dr

4 Moxibustion

4.1 "... moxibustion can be used for turning babies from breech presentation to cephalic presentation ... There is some evidence to suggest that moxibustion may be useful for turning babies from breech presentation (bottom first) to cephalic presentation (head first) for labour when used with either acupuncture or postural techniques of knee to chest or lifting buttocks while lying on the side.  [Source: Cochrane Summaries]

Comment: "First, do no harm"
These statements, taken from reliable sources, demonstrate a little of the current conflict in messages and advice about breech births.  

The principle of 'first, do no harm' is probably the driving force in the medical quest to follow what is called evidence based practice - all in the interests of safety and wellbeing for the 'patient'.  The rise and rise of the randomised controlled trial in the past couple of decades has reshaped and redefined the boundaries of many professional practices.  Perhaps none more so than breech births.  The Term Breech Trial (Hannah et al 2000) has led to the standardisation of elective caesarean for women with babies presenting breech, and the loss of skill and knowledge in the obstetric and midwifery communities, as to critical thinking about the safety of proceeding within physiological processes in particular situations.

Elective caesarean surgery can never be considered benign.  The potential for harm exists for both mother and baby.  Mothers who undergo major abdominal surgery face the physical risks of infection, haemorrhage, and iatrogenic causes such as retained surgical material.  Subsequent pregnancies face increased risk of placental abnormalities, which may lead to severe haemorrhage. The psychological impact of elective surgery cannot be ignored.  Babies delivered this way do not have the normal hormonal preparation that comes with labour, and may need hours or days of specialised care, which involves separation from their mothers, and frequently interferes with the establishment of bonding and breastfeeding.

First, do no harm?  Unnecessary surgery may result in maternal and newborn morbidity, with the potential for mortality.  Unnecessary surgery for any reason should be avoided.  The emergence of maternal deaths at the time of the primary caesarean, or subsequent births, is an infrequent, but serious aspect of potential harm.


When the need for caesarean surgery arises in pregnancy, or in labour, the potential to 'first, do no harm' is changed.  In the case of failure to progress, the likelihood of harm is greatly increased by not intervening.

In the past couple of decades the practice of external cephalic version (ECV) has been fine-tuned by obstetricians in teaching hospitals.  This has been promoted as a way to avoid elective caesarean - for the successful ones - while the default position for breech presentation is caesarean.  ECV does not, per se, prevent the need for caesarean.  Babies who would experience a failure to progress due to cephalo-pelvic disproportion will make this clear in labour, regardless of the presenting part.

In applying the 'first, do no harm' principle, every midwife and obstetric doctor needs to be ready and able to attend vaginal breech birth without fear.  The midwife or obstetric doctor who hides behind the 'de-skilling' banner of the Term Breech Trial (2000) may be delinquent in clinical situations that can arise without warning, when a mother presents in advanced labour, about to give birth to a breech baby, or when a mother intentionally proceeds with a spontaneous vaginal breech birth.
  
 
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Breech vaginal birth: Turn the picture up the other way

Today I am focusing on the subtle but significant difference between spontaneous breech birth, and managed breech delivery.

Recently I was in a major public hospital with a woman in labour, who was intending to give birth to her breech baby vaginally.  This was her first baby.  The fact that her baby was presenting as a complete breech (tailor sitting - legs crossed) had been discovered by a midwife during a routine antenatal check a couple of days earlier.  She was labouring well, and was probably close to fully dilated at around 06:00 hours, when the medical team entered the room to have a chat with her.

Dr #1 was accompanied by Dr #2.  They were both very new to their respective jobs - teaching hospitals have times, like this, when the new Registrars and Residents take up their positions.  Dr #1 did the talking; the younger #2 watched and listened.  They had been told that this woman wanted to give birth vaginally.  Dr #1 was very friendly, using old-fashioned familiar language such as 'dearie' and 'sweetie' that is not really acceptable in such circumstances, in today's world.

Dr #1 informed the woman that the hospital's advice at this point in time was a caesarean birth; that the hospital considered the risk of vaginal breech birth to the baby to be too great, and quickly listed off a bunch of horrible things that could happen to the baby if she did not have that caesarean.  There was no mention of risk to mother or baby from caesarean.  There was no scope for an informed decision or questions - the decision had been made.

I wish I had made a note of the items on that list.  I was surprised at the speed of delivery, and the inherent threat.  Babies being rushed to the nursery with cerebral palsy from hypoxia; with broken bones; with other brain damage ... and that the mother herself had a greater risk of a fourth degree tear!  That if she refused a caesarean she would be required to have an IV line in situ, and continuous electronic fetal monitoring, and be placed in lithotomy position with her legs in stirrups.  I don't think the mother heard or understood much of what was said to her in that brief exchange.

I stayed at the woman's side, and was not able to question or debate the doctor's pronouncements.  She finished her shift in the morning, before the baby was born.

The point that was clear to me was that this doctor was performing what she considered her 'duty of care', in the interests of wellbeing and safety of mother and baby.   She took the high moral ground, referring to the evidence (the 'Term Breech Trial' - Hannah et al, 2000) which was like the Pied Piper of Hamlin, leading all the breech mothers directly to the operating theatre.


I began this post saying that I wanted to explore the subtle but significant difference between spontaneous breech birth, and managed breech delivery.

The hospital in this little story, and probably all the other hospitals in Melbourne, would not acknowledge spontaneous breech birth as a realistic option; as indeed women who want spontaneous natural cephalic births, and spontaneous natural third stages can find themselves arguing against the experts.  The only way that most obstetricians know for vaginal breech birth is a managed breech delivery.   I have witnessed doctors performing the moves with great skill, and have seen babies come through managed breech deliveries well.

There is an excellent set of drawings, accompanied by brief comment and instruction, available online at the Women's Hospital Policy, Guideline and Procedure Manual: Breech - Management of (Publication date (08/10/2012)

This guideline describes vaginal breech delivery.  The drawings are all done with the woman's sacrum below the action.  Even Picture 1, which describes the position of the fetus at the beginning of labour, shows the woman's pelvis in a recumbent position.

Turn Picture 1 and Picture 2 a quarter turn to the Right, and the mother's spine will be upright, as indeed a woman in active first stage labour would usually be.

Pictures 3-8 need to be turned a full 180degrees.  The woman needs to be on all fours - hands or elbows, and knees, as the breech progresses and the baby's body becomes visible.  The body needs to hang, using gravity and the weight of the baby to bring the head into the pelvis and through the birth canal.  Picture 9a becomes irrelevant, and picture 9b is reversed.  Maneuvers to release the arms, and to flex the head, if needed, can be performed by the accoucheur. 

Here is a YouTube video of spontaneous breech birth demonstrating the 'all fours' position for the birth of the baby. 

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decision-making for breech births

In recent months I have been very impressed by the work of a consumer-led group, Breech Birth Australia and New Zealand (BBANZ).  This site has a great deal of useful information and birth stories.  Readers who are interested in being part of the social media discussion on breech births can apply to join the facebook group.


In this context, I have been drafting an information sheet on the decision-points for a woman who has a baby in a breech presentation:

Decision Point #1:      DIAGNOSIS of breech presentation at or near Term

Your midwife or doctor may diagnose breech presentation by palpation, and recommend further investigations such as ultrasound.  Your decision—yes or no—will lead to the next Decision Point.

 Decision Point #2:      ATTEMPT ECV

IF your baby’s breech presentation is confirmed, then you may consider attempt(s) at external cephalic version (ECV). 

After ECV, your baby may be presenting cephalic (head first), or the breech presentation may persist.  In either case, if there is no valid reason to interfere with the natural process, await spontaneous onset of labour.

 Decision Point #3:      PLAN for VBB

Consider the capacity for vaginal breech birth (VBB) at your intended place of birth; the skill and willingness of your primary maternity care team to proceed with VBB; and access to emergency obstetric and neonatal care if required.  Consider the possibility of changing to another maternity service that is more able to support VBB.

Decision Point #4:    Onset of labour

Your midwife or doctor will advise you of recommended ‘boundaries’, such as gestational age of your baby, spontaneous pre-labour rupture of membranes, and changes in your own and your baby's condition. 

Decision Point #5:    Progress in labour

Your midwife or doctor will monitor your progress, and your baby’s wellbeing, as labour becomes established.

NOTE: The wellbeing and safety of mother and baby guide all maternity care.

This list makes it all sound very straight forward, and it should be. 

UK midwife Mary Cronk MBE wrote in 1998: 

These are the points which midwives should bear in mind when facilitating a vaginal breech birth:

• Don't push a breech through a pelvis with oxytocic drugs
• No inductions, no augmentations
• If the labour does not progress - caesarean operation
• Don't pull a breech down through the pelvis - no breech extractions
• Breech by propulsion, not traction
• If it isn't coming down - caesarean operation
• Keep your hands off - sit on them if necessary
• Be ready to bag and mask. (AIMS Journal)

In that article, Mary Cronk outlined the features of a breech birth (as distinct from a breech delivery):

Breech birth

• Spontaneous onset anytime after about the 37th week.
• No augmentation if labour is slow or there is poor progress - caesarean section.
• Mother encouraged to assume positions of choice during the first stage.
• Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
• Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
• Membranes not ruptured artificially.
• Vaginal examinations restricted to avoid accidental rupturing of the membranes.
• If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
• Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
• Mother encouraged to be in an all-fours position.
• No routine episiotomy.
• Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

It's clear to me, from a midwife's perspective, that in the journey of decision-making for spontaneous breech births, there are several points at which caesarean surgery would be the next step.  Many colleagues would say, what's the point? 

We will never know if a vaginal breech birth (VBB) is possible unless we proceed down this mystery pathway.  We will never know if labour is able to progress normally if an elective caesarean is performed at 39 weeks.  The avoidance of unnecessary caesarean surgery is of great benefit to the mother and baby, and subsequent children.

A breech birth requires skill, patience, and courage on the part of the woman, the midwife, and the support team.  A breech birth also requires the willingness of the woman to engage in decision-making over time, as the process unfolds, rather than being attached to an inflexible plan for vaginal birth.

A breech birth relies heavily on the ability of the woman's body to intuitively progress through spontaneous onset of labour, and progress in the first and second stages of labour.  There is no room for induction or augmentation of labour, which might mask the natural reluctance of the woman's body to proceed with the birth of a disproportionately large or poorly positioned baby.  There is no room for mind-numbing narcotics which distance the woman from her ability to make a natural response to her labour, and which inhibit the baby's ability to breathe in the moments after birth.  The maneuvers that a midwife may undertake in the moments before the birth, such as gentle turning to release a nuchal arm, or support to flex the head, require confidence in the mechanisms of breech birth and the midwife's skill.

DIFFICULTIES in achieving VBB
A dilemma we face today when approached by a woman who plans to give birth vaginally to a breech baby is the lack of understanding and skill in spontaneous breech birth in most hospitals.  It's almost a lost art.  Even hospitals where the obstetrics team have indicated 'support' for VBB (more accurately, breech delivery or extraction), the requirement is usually that the woman is in lithotomy position once the presenting part is on view, and that the obstetrician manages the birth.  The baby's cord is clamped and cut soon after birth, and the baby is passed to the paediatric team for resuscitation. 

This scenario contrasts with spontaneous VBB birth: in second stage the woman adopts an upright position (such as 'all fours', kneeling, or supported squat) and her baby is born with minimal touch and without any pulling by the midwife.  The integrity of the cord is maintained, and if initial resuscitation is needed baby is placed on a flat surface, continuing to receive the oxygen-rich placental transfusion from the mother, while the baby's independent breathing is being established.

A second dilemma that midwives face is the discussion on place of birth.  Midwives who understand the advantages to mother in baby in spontaneous breech births are often strongly in favour of home birth.  Yet the implications for the baby particularly, if urgent caesarean birth becomes the birth of choice, mean that there is a real advantage to being in hospital for the latter part of first stage, and second stage labour.  The other matter for midwives to consider is the 'unprofessional conduct' notification that would almost certainly follow a transfer of a breech baby or mother to hospital.  Never mind the woman's choices: midwives are expected to refer women with breech babies to a higher power (Category C in ACM National Midwifery Guidelines, 2008.

In conclusion:
I believe that the process of decision-making in breech births is all about getting the best possible birth for that mother and that baby.  It's not about vaginal birth or caesarean, no matter how much the spontaneous physiologic birth is the preferred option.  If a caesarean is required, then it would be tragic if a caesarean was not available.  



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