The Case For Physiological Breech Birth

Breech birth, a variation of normal human birth that occurs in 3-4% of births, is something that has become a bit of a lost “art”, if you can call it that. There was a period of time where, based on a study that has long since been debated (the Term Breech Trial), it was thought that all breech babies should be born by cesarean. After that, many practitioners stopped practicing and learning how to to attend breech births and it has become less and less common. Despite the fact that the Society of Obstetricians and Gynecologists of Canada has since said that vaginal breech birth may be the best option for some breech babies, the support for vaginal breech birth in Canada from care providers is scarce.

“Today, health-care professionals recommend that in some circumstances, breech babies may be delivered the traditional way, through the vagina. Vaginal childbirth has health benefits for the mother such as a faster recovery and less pain, as well as a better chance of having a vaginal childbirth in the future.” (SOGC, June 2009).

Choosing between vaginal breech birth and cesarean birth:

Planned cesarean birth is always offered to clients with a breech baby. However, depending on the type of breech position your baby is in vaginal birth may be an equally “safe” option when compared with an elective cesarean birth. No matter the position, the way you birth your baby is always your choice.  Generally the frank breech position is considered the most ideal position for a breech baby. This is partially because the risk of cord prolapse, one of the considerations in breech birth, is about the same in frank breech babies as it is for head down babies.

Here are some quotes from a few studies done comparing the outcomes of vaginal births to cesarean births when it comes to breeches:

Vaginal breech delivery or caesarean section in labour was associated with a small but unequivocal increase in the short term mortality and morbidity. However, the long term outcome was not influenced by the mode of delivery.  (Source)

A quote from another study:

We observed that maternal morbidity was lowest for vaginal births; maternal morbidity was not any higher for emergency compared to elective caesareans (Table 1); and short term neonatal outcome (Apgar scores at 5 minutes) was the same regardless of the mode of delivery. (Source)

The Society of Obstetricians and Gynecologists of Canada says:

Vaginal breech birth is a complex phenomenon. Selection criteria, intrapartum management parameters, and delivery techniques are difficult to isolate and study, and there is little rigorous evidence to support or refute them individually. (Source)

If you do choose a cesarean for the birth of your breech baby, you may enjoy this story of a past client. Please stay tuned to the blog for a few vaginal breech birth stories from clients of mine that will be coming soon! In the meantime, you can read this surprise breech birth story of a client of mine, and this surprise breech home birth story of a colleague’s client.

Physiological Breech BIRTH or Breech DELIVERY?

Vaginal breech birth can be approached in two different ways. A breech delivery is the model that most OBs and hospitals in my area are familiar with and recommend. This model involves a highly managed approach and includes many routine procedures and interventions to control and monitor the process. It typically involves a very hands-on and controlled birth of the baby.

A physiological breech birth is an approach that relies more on supporting the natural physiology of breech birth and minimizes the use of interventions unless complications arise.hands off the breech

A common recommendation from the experienced midwives across the globe who have attended physiological breech births is “Hands-Off-The-Breech”: avoiding intervention and not touching the baby at all for the birth of the bum and legs. They usually say that once the birth is in the advanced stages, they will want it to appear to be steadily moving forward. If the late stages of birth aren’t showing signs of steady progress, these midwives typically would recommend more medical intervention.

I highly recommend this $30 webinar on vaginal breech birth, taught by a home-breech-birth midwife. It is an excellent overview of what the true risks are for breech births and insight into the physiologic approach to breech birth.

For a great article on the physiological approach to breech birth, check out “Hands off the Breech” by experienced breech midwife and teacher Mary Cronk.

One of the things that is key about breech birth is that it is prone to stop-and-start labours. Because the baby’s bum isn’t putting the same pressure on the cervix as a hard head does, occasionally you will get dramatic stopping and starting of the process. Because of this, you really want to emphasize all of the things that promote a smooth physiologic birth in any fetal position: keeping the client well nourished and supported and REALLY minimizing disruptions that may cause the birth to slow or “stall”.

 

Preparing for a Physiological Breech Birth:

There are many things to consider when you’ve decided you would like to have a physiological breech birth. Primarily, you need to understand the culture around breech birth in your community, and how supported you will be in making your own choices throughout the process. Hiring a doula experienced in breech birth and advocacy may be beneficial if physiological breech birth is not common in your area.

Here in Vancouver, while there are some hospitals and obstetricians that are supportive of vaginal breech birth, there is a very specific approach to breech birth that they recommend and are comfortable with. This tends to be the breech “delivery” method mentioned above, and involves a lot of medical management and intervention, including more constant fetal monitoring, epidurals, birthing on your back, episiotomies, the common use of forceps, and often birthing in the operating room. You can read our local hospital’s info-sheet on their approach to vaginal breech birth here.

Even at our local hospital that has the most doctors who practice attending breech births, not all of the OBs who work there are supportive and on the day of birth it is luck-of-the-draw as to who happens to be on call and whether or not they will be actively supportive of vaginal breech birth. Some may even attempt to refuse to provide any care other than a cesarean. Of course, everything is always YOUR choice, and your choice in how to birth your baby is more a matter of YOUR comfort level and philosophy around birth than it is about the hospital or medical staff who happen to be on shift. Luckily, in Canada we have laws about access to health care, and regardless of your hospital or OBs preferences in terms of breech birth, they can’t refuse to provide you with care regardless of your choices.

Unfortunately, it seems that the way the options presented for vaginal breech birth locally are presented often leave clients feeling like they will have no input on how they birth their babies. When they were originally hoping for a low-intervention, physiological birth, they can feel lost as to where to look for information and support, and some may even feel like a planned cesarean is the only way to go simply because it seems they will not be supported in making their own choices in a vaginal breech birth.

I can’t reiterate enough that while things are often presented as if options for breech are limited, everything you choose for your birth is absolutely up to you, and the way your local obstetrician or hospital my think about breech birth is certainly not the only approach or perspective out there.

Here is an overview of a lot of the common procedures and interventions that are often recommended for vaginal breech births, and some alternative perspectives to consider:

Birthing in the Operating Room:

The rationale behind giving birth in the OR is so that if a cesarean is needed urgently, you are already in the operating room. It’s important to also think of the potential disadvantages of birthing in the OR, however. Most importantly, moving environments to a bright, busy operating room right at the end of dilation is huge disruption that has the potential to disrupt or “stall” your birth. This is not a small intervention or risk! The hormones of birth are in a delicate and intricate dance, best described in Dr. Sarah Buckley’s article “Your Hormones Are Your Helpers“. Breech birth is considered to be particularly sensitive, and it is essential in a physiological birth that we minimize distractions and interruptions in order to encourage safe progress of the birth.

“Mandatory” Epidurals:

While nothing in birth is “mandatory”, for breech births epidurals are often presented as something that you cannot decline. In my experience, different obstetricians will give different reasons for why they prefer their breech clients to have epidurals placed. Some will say it is a safety measure, again in case you end up requiring a cesarean birth. Some will say it is to help prevent a premature urge to push that sometimes happens with breech babies. Others will say it is to help you conserve your energy so you have the energy to push your baby out later. None of these reasons are evidence based. Epidurals are known to slow birth down, make pushing more difficult, and increase the risk of malposition and forceps. An alternative view point to recommending routine epidurals for every breech baby is that, as with any other vaginal birth, avoiding epidurals may actually be what helps things progress smoothly and physiologically.

Epidurals as a safety measure:

While some OBs will say having an epidural increases the safety of a breech birth, other OBs will say this is mostly a perception of increased safety as opposed to a real, tangible one. These OBs will explain that because it is currently common for labour epidurals to be “light” epidurals to allow the birthing person some continued ability to move in order to support better progress in birth and would need to be “topped-up” in an urgent scenario. This procedure itself takes time and I’ve seen an OB explain that ultimately this may not be much different than if the person was unmedicated in the first place in the case of a (rare) imminent emergency.

It is sometimes presented as an option to have an epidural “sited” without continuing to run the medication unless it becomes necessary. Again, some obstetricians have explained that, since it takes an epidural about 20minutes to start working, in a true emergency this isn’t the route of pain relief that would be useful for a person that only had the epidural placed. If having an epidural placed is something you are considering, make sure to ask the anesthesiologis is also important to ask your anesthesiologists if they will be administering epidural medication during placement, as this is done commonly but often without the client understanding they will be receiving some of the medication.

Epidurals to prevent early urge to push:

It is important with a breech baby to give your cervix lots of time to truly dilate completely, so that when your body begins to bear down and push the baby out there is nothing holding back the birth of your baby’s head when it gets to that point. It’s not uncommon to get a bit of an early urge to bear down before your cervix is completely out of the way. Some obstetricians will say having an epidural can prevent this early urge, but there are other ways to work with your body and avoid actively bearing down before it’s the right time. The traditional midwifery style of gently allowing the end of the cervix to dilate without medication is to suggest the client get into a forearms-and-knees position and coach her to breathe gently and sign away any urge to push until the urge is absolutely irresistible (which usually means dilation is complete). Using a deep bathtub or birth pool can also help reduce this early urge to push significantly if needed. If a very strong early urge to push was present and these non-medical approaches are not helpful, an epidural is always something that you could decide to add to your birth in the moment as opposed to preemptively getting one.

Epidurals to save energy:

The thing about an unmedicated birth is that your physiology is designed to GIVE you energy during pushing. This is one of the most important benefits of an unmedicated birth, and one that is often not understood by providers who primarily work with clients who have epidurals. Clients who are medicated often get tired and lose energy during pushing because they do not have the same physiology as someone who is unmedicated.

Birthing on your back:

Despite the fact that both research and the experience of physiological birth experts (experienced midwives who attend physiological breech births) show that hands and knees or other upright positions are likely the best birthing position for breech babies, many OBs and hospitals recommend birthing on your back. Here is a quote from a 2017 study called, “Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?”

“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.” (Source).

For some amazing images of what a vaginal breech birth in the hands and knees position looks like, check out this incredible post by photographer Karyn Loftesness. You may also want to watch this video on the cardinal movements of breech birth on how a breech baby moves through the pelvis to understand why upright positions can be helpful for the safe birth of your baby’s head. This article is also helpful for explaining the sbenefit of an upright position for breech birth.

“Most women left to their own devices will get on hands and knees… The baby needs to turn its pelvis, which is really hard to do if mum is on her back.” ~ Jane Evans, breech birth midwife.

Routine Episiotomy:

Locally, it is common that breech providers in hospital will recommend a routine episiotomy for every breech birth to speed up the birth of your baby with the idea of increasing safety. However, according to the RCOG, this is not supported by evidence. Routine episiotomies also were common for head down babies for a period, until research showed that this was actually not helpful and in fact was causing more severe tissue damage to birthers.  A routine episiotomy is much different than one rarely used in a situation-dependent emergency situation.

For cephalic presentation, there is clear evidence that selective episiotomy is preferable to routine episiotomy. There is no evidence as to whether advice for breech delivery should differ from that for cephalic delivery. (RCOG, 2006)

Choice of Care Provider:

While technically in BC a breech presentation is an indication for consult with an obstetrician, not a transfer of care, in practice OBs tend to become the primary attendant supervising breech births, sometimes in a shared-care situation with the client’s midwife. Even ECVs, an external method of turning a breech baby to a head down position prenatally (not gauranteed to work but can be a good option to try!), are a procedure that is almost exclusively performed by OBs here. I personally find this quite odd as ECVs were originally a midwifery skill – the OBs historically learned how to turn babies FROM midwives! In Ontario, the Registered Midwives routinely perform ECVs, and I believe this should be the case here in BC as well.

While many [breech and twin] deliveries may become transfers of care, breech presentation and twins are listed as indications for consultation [not transfers of care]. Where a spontaneous birth is anticipated, a midwife may conduct the delivery under the direct supervision of an obstetrician. In a remote area, the availability of an experienced midwife who has the confidence of obstetrical colleagues can prevent a client from having to leave family and community. Midwives may also gain important hands-on experience under obstetrical supervision. Responsibility can be transferred temporarily from one health professional to another, or be shared between health professionals, according to the client’s preferences and needs for care or expertise. (College of Midwives of BC).

If you choose to birth in the hospital here in Vancouver, it is likely that the OB will be very involved and the one to to “catch” your baby and perform hands-on maneuvers for the birth of your baby. However, if you would like your midwife to take more of a primary role, this is definitely something you can request and advocate for. Some clients will choose to have the OB stand in the background or even outside the room unless help is requested by the midwife.

Vaginal breech birth is really something that, in my opinion, all midwives should be trained in and comfortable supporting. The midwifery model of care is so much different than the obstetrical model, and should be a more easily accessible option for breech births. If you would like to see the local practice change to making breech birth with midwives as your confident primary care providers more common please write to the College of Midwives of BC and your local hospital (locally, BC Women’s Hospital would be a good start) to encourage change on this front! I personally am dying to start a Midwives For Breech Birth campaign in my city. This article is my first step!

Choice in Birth Place:

While it may seem like hospital birth is your only option for breech birth, some people will choose to stay home for most of the birth process before moving to the hospital, and some will choose birth their breech babies at home. If you are considering avoiding a lot of the routine procedures the hospital recommends for breech births, it may make sense to consider home birth as an option with the hospital as a back-up plan if needed. It can be a good idea to leave all of your options open when it comes to breech babies! Home birth for breech babies is not something that is very common or likely to be recommended here in Vancouver, but it is certainly an option that you can advocate for with the right support. While the midwives here are required to recommend hospital birth for breech babies, again, everything in birth is your choice, including place of birth. Because you want to do everything possible to minimize disruption in a physiologic breech birth, staying home on familiar territory for at least most of the process may be best for supporting progress.

Advanced Care Plans

In hospital, what some people do is make up an “Advanced Care Plan” in advance with your providers that reviews what choices you are making for your birth. This is an official document (much more powerful than a self-made “birth-plan”)  that is agreed to by the hospital in advance and which carries much more weight than a regular “birth plan.”  This can be helpful when you are birthing in hospital and declining routine methods of care. For interest, here is a sample care plan that clients of mine made up a few years ago when planning a twin birth where the first baby was breech. They ultimately decided to choose to birth at home, but had the directive made up in collaboration with the hospital in case the chose to birth there. If you are choosing to prepare for a vaginal breech birth in the routine methods recommended and preferred by your local hospital, this will not be necessary, but if you are planning a more physiological style of birth and plan to decline some routine procedures for breech births, a complex care plan may be helpful for you. The best way to do this would be to make a list of the things that are important to you about your birth and request assistance coming up with a unique advanced care plan with your medical team.

Your Birth, Your Way

I have had clients make all kinds of choices, from declining the “mandatory” epidural for breech births, to choosing to have the OB wait outside the room in hospital unless called by the midwife for help, to choosing to birth their breech baby at home. So while OBs tend to promote highly managed approaches to breech birth, you can certainly decide for yourself what approach you want, be it at home or in hospital. For some people, this will be planning a cesarean, for others it will be planning a vaginal breech birth in the local obstetrical model, and for others it will mean following more of a physiological approach.

If you decide you are hoping for a physiological breech birth, being well informed and supported is paramount. You will want someone with you who is comfortable supporting you patiently while your birth processes physiologically, especially if this will be your first baby and who is comfortable advocating for you if you plan to challenge or decline some of the community standards around breech in your area. Please feel free to contact me about support for your upcoming physiological breech birth.

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