A Breech of Trust - Part 1

If you end up with a baby who is in the breech position in Ottawa, and you want a vaginal birth, you could be in trouble. The practitioners that at one time did vaginal breech births are becoming fewer and fewer as older practitioners retire and the new ones are not learning anymore how to do it. We provide in this article a brief explanation of what a breech is and what you might do about it should your baby end up in this position.

What Is a Breech and Why and How Often Does it Occur?

A "breech presentation" is one in which a baby's bottom, foot/feet or knees are presenting instead of the head. (1:187) Should this be the case, the health care professional, upon the usual palpation, would discover a head up under the mother's rib cage, a bottom in the mother's pelvis, kicks on either side of the lower abdomen and the fetal heart rate would be located anywhere above (sometimes below) the mother's umbilicus. Around 28 weeks of pregnancy, 15% of babies are presenting breech and in most cases, the baby turns to a cephalic (head down) presentation around 34 weeks. (2:222) At term, 3 -4% of babies are still breech. (3:564)

There are 4 types of breech presentation: a frank breech (70%), a complete breech, a footling breech (rare) and a knee presentation (rare). Breech presentation is more common in preterm labours (15%) because most babies are breech or lying sideways when they are younger. (2:222)

There are no known causes for a breech presentation and some believe it may be by chance. (2:222) There are, however, fetal and maternal factors influencing the baby's presentation. Some women have birthed all of their babies as breeches, suggesting the shape of the woman's pelvis may play a role. Constraints within the pelvis could also influence a baby's ability to turn into a cephalic presentation. Other maternal factors include uterine relaxation associated with increased number of babies, too much or too little amount of amniotic fluid and uterine anomalies. The location of the placenta may also play a significant role. For example, a breech presentation is common with placenta previa, where the placenta covers the opening of the cervix, or when the placenta is anchored in the higher pole of the uterus. Fetal factors influencing breech presentations include multiple pregnancies, (twins, triplets, etc.) fetal anomalies (hydrocephaly, anencephaly) or a fetal death. (2:222) Ultrasound can confirm the presentation, discover fetal anomalies, take measurements of the fetal head, abdomen and thorax, localize the placenta, rule out placenta previa and determine the fetal head extension. (2:241)

Risks of Having Breech Baby

It is documented that babies coming bottom first, instead of head first, have increased risk of death. In a review of over 10,000 breech births in 86 hospitals world-wide (4), it was found that the neonatal mortality rate in breech births was about twice the overall neonatal mortality rate. This is the reason why turning the baby to the head down position is usually offered. This is a procedure called External Cephalic Version (see below). But it should be noted that a baby death is a rare event, either breech or vaginal delivery, in high resource countries like Canada.

The major risk to the mother in breech birth is cesarean section and the short and long-term outcomes that entails. Go to: (http://www.childbirthconnection.org/pdf.asp?PDFDownload=cesareanbooklet)

The unfortunate assumption is that because there is more danger to the mother and baby when the baby is breech, a cesarean section should be performed, as though it is safer. Since the year 2000, attempts have increased to clarify this and they have come up with the end result: there is no significant difference between cesarean and vaginal delivery. The medical research found this for both the baby and the mother.

The largest, most well-known, and influential study, the Term Breech Trial (TBT) was conducted in 121 sites in 26 countries around the world by Canadian researchers (5). This was a study highly criticized in Europe, and several centres there did not join it because they did not like the methodology, and felt that it was too simplistic an approach for a complex situation which requires skill and judgment(6). Subsequent to its publication, a two-year follow up to the study was done on a subset of the subjects which concluded that the outcomes between doing cesarean and vaginal delivery were not significantly different. That is, whereas the preliminary data of the Term Breech Trial suggested that it was safer to conduct a cesarean section, they did not take into account the long range problems of the mothers and babies who underwent the operation, and the trial was not large enough to determine whether deaths were due to the type of delivery or due to chance. At the two year follow-up the conclusions read: "Planned cesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age." (http://www.ajog.org/article/PIIS0002937804006568/abstract)

The studies of breeches in Norway (7) and in France/Belgium (8) corroborate the conclusions of the 2-year Term Breech Trial follow-up rather than the prior preliminary data publication of the TBT in 2000. That is, they do not find any significant difference in risk between vaginal and cesarean section for term breech delivery. Because these studies were conducted in large centres, they all qualify that these conclusions are true in places where planned vaginal delivery is common practice, with appropriate skill, equipment, and protocols.

It needs to be noted that a breech is a difficult delivery whether vaginal or cesarean section. In both cases, maneuvers often have to be used in order to make sure the breech comes out through the path of least resistance.

When a baby comes head first in either cesarean section or vaginal delivery, the head is usually followed quickly by the rest of the body (except in shoulder dystocia where the shoulders get stuck). With the breech baby, the identified fear is that the head will be slowed on emersion and the baby will have a harder time catching his or her breath when he/she comes out. Most experienced practitioners will comment that they observe that babies coming breech are more "shocky," but that they "come round quickly" because it appears to be a temporary state. The concern if the baby is born vaginally is that the cervix may allow the bottom to pass but not be open enough yet to allow the head to pass, or the mother's pelvis will be too small. Physicians in both North America and Europe usually use some kind of measurement to judge whether they think the baby will pass or not, often either the bi-parietal diameter of the baby's head by ultrasound, or an MRI to judge the size of the mother's pelvis. They rarely do both. (For example, in Ottawa, they often look at the bi-parietal diameter, while in Norway and Germany they do an MRI on the mother having her first baby, but in none of these places do they seem to put the two together.(6))

The reason it is hard to get a baby out by cesarean section is the practitioner is working against gravity, trying to reach deep inside a small cavity while a mother is on her back, and grab a slippery bottom from an incision that cannot be made too large on the mother's abdomen without complications for the mother.

The same maneuvers to get the bottom, arms, and then head of the baby out have to be performed whether the baby is coming out vaginally or by cesarean. Injury to a baby that is coming down quickly in labour into a mother's pelvis that is adequate can be more severe if a cesarean section is performed. This can be particularly true if the mother is whisked into the operating room and cesareans section is performed when the baby is already in the pelvis, as extracting the baby once it is very low is even more difficult and results in unnecessary manipulation that is often avoided if the baby maneuvers itself out with the mother in an upright position (9).

In North America there is a great deal of fear of the cord falling down between the baby's legs if the legs present first, but in Europe they do not consider that as much of a problem unless the baby is premature. Even before the Term Breech Trial, these "footling breeches" were automatic cesareans in North America, whereas in Europe, in centres in Norway, France, and Germany, a baby coming with both feet or an extended leg were not necessarily delivered by cesarean section. The cord is rigid so the dangers of it falling through are not as common as feared and once the baby is descending in a breech there are maneuvers that can be performed such as replacing the legs in the vagina to allow the buttocks to descend or even holding the breech back by putting pressure on the vagina to give time for the buttocks to catch up with the legs and present with them.

Please refer to this website for updated Peer Reviewed Journal Articles and Reports about risks and benefits of surgical delivery compared with vaginal birth of a breech: http://www.breechbirth.ca/Research.html.

Making An Informed Decision

All women should be informed about the options to encourage a fetus to turn to a cephalic presentation. This list includes various postural techniques, swimming, homeopathy, hypnosis, visualization, music therapy, hot/cold therapy, massage, acupuncture, acupressure, moxibustion, chiropractic (Webster's technique), osteopathic manipulation and External Cephalic Version (ECV). Ultrasound is recommended prior to and ECV to determine if there are any contraindications such as a problem with the baby, the cord or the placenta. ECV has a success rate varying between 35-86% after 37 weeks, depending on a variety of factors, such as parity, amniotic fluid volume, fetal position and engagement, the use of a medication to calm contractions and the skill of the clinician. (10:233)

You can find an educational video on Moxibustion for parents at: http://www.acubalance.ca/moxa-moxibustion-breech-baby

The best place to have a baby that is coming breech is in a centre where there is not a black and white protocol or circumstance. That could be "all breeches by cesarean section" for some hospitals or "all first babies by cesarean" or in rural areas in low resource countries, almost all breeches are born vaginally because there is no cesarean available.

"Today in Canada, more than 95 percent of breech babies are born by Caesarean section." (11:56) Cesarean sections have been the norm over the recent years for breech presentations and many doctors and midwives have lost or never acquired the skills necessary to conduct a breech delivery. Since family doctors and obstetricians work on a call schedule, women who wish to attempt a vaginal breech birth are never guaranteed a trial of labour.

Currently, the midwives scope of practice includes a mandatory consultation with an obstetrician for a presentation other than cephalic, unresponsive to therapy at 38 completed weeks. In labour and birth, a breech presentation is a contra-indication to a homebirth and midwives must consult with an obstetrician in the hospital. After the Term Breech Trial came out in 2000, it closed down much of the practice of breech birth. Some midwives prior to the TBT who worked at the Riverside Hospital who had experience conducting breeches were permitted to do them, usually with an obstetrician on hand should a cesarean section or forceps become necessary. Physicians in North America had already been moving towards conducting more cesareans in hospital even prior to the study.

Now most women in Ottawa are advised to schedule an appointment for a cesarean section when a breech is discovered. Some are offered an ECV. This is particularly true if the mother is having her first child. In Ottawa, there are only a small number of family doctors, obstetricians and midwives who are skilled in vaginal breech birth. The fear among the practitioners is palpable when a woman wants a vaginal birth and tries to plan for it.

One of the most unfortunate problems with informed choice for a woman who presents with a breech baby is the rarity with which practitioners discuss the risk of cesareans. It would be wise to go to the site:

http://www.childbirthconnection.org/pdf.asp?PDFDownload=cesareanbooklet

A woman needs to reflect on her personal values and preferences after receiving unbiased, evidence based information. It is the woman's choice to decide what's right for her body and her baby. However, that is very hard when the practitioner you are facing refuses to do the birth other than by cesarean. In an article published in Today's Parent Pregnancy, there is a story about a woman who wanted a vaginal breech birth and was turned away by a midwife and two obstetricians. She decided to have an unassisted home delivery and the baby died. Andrew Kotaska feels that "doctors have been giving women limited options when it comes to breech birth, overblowing the risks or sometimes even forcing them to choose between a C-section and no care." Andrew Kotaska is the clinical director of obstetrics and gynecology at Stanton Territorial Hospital in Yellowknife. (11:57)

We hope to see some changes in Ottawa over the next few years as the Society of Obstetricians and Gynecologists have changed their protocols to open up the issue again. André Lalonde, executive vice-president of the Society of Obstetricians and Gynecologists of Canada (SOGC) has been quoted to say in a recent article about breech birth; "With our modern hospitals, with the proper precautions taken, I think that breech delivery can be offered as an option to women." (11:59) In the meantime, women who wish to try a vaginal breech birth will have to find a practitioner who is skilled, experienced and willing to do a breech birth.

If you are interested in finding out more, contact the Breech Birth Coalition at This email address is being protected from spambots. You need JavaScript enabled to view it.

Part Two of "A Breech of Trust" will appear in the summer issue of From Belly to Baby.

References:

1. Enkin M. Keirse M. Neilson J. Crowther C. Duley L. Hodnett E. Hofmeyr J. A guide to effective care in pregnancy and childbirth. Third edition. Oxford Univeristy Press, (New York) 2000.
2. Oxorn, H. Oxorn-Foote. Human Labor & Birth. Fifth edition. McGraw-Hill, (USA) 1986
3. Fraser, D. Cooper M. Myles Textbook for Midwives. Fourteenth edition. Churchill Livingstone Publishing, (London) 2003
4. Fortney, JA et al, Delivery type and neonatal mortality among 10,749 breeches, Am J Pub Health, 1986; 76(8): 980-5.
5. Hannah M. et al. The Lancet Vol 356, October 21, 2000, 1375-1383. (http://www.thelancet.com/journals/lancet/article/PIIS0140673600028403/fulltext)
6. Information gathered in Europe from centres in Bergen, Norway, Paris, France, Britian, and Germany by Betty-Anne Daviss from 2006 to the present.
7. Albrechtsen Susanne. 2000. Breech delivery in Norway: Clinical and epidemiological aspects. University of Bergen publication.
8. Goffinet, F. et al., for the PREMODA study. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology (2006) 194. 1002-11
9. This upright or hands knees position is used in Frankfurt, Germany, and a study compiling the data from the last five years is under way. It has also been used by traditional midwives for centuries.
10. Tiran, D. Breech presentation: increasing maternal choice. Complementary Therapies in Nursing and Midwifery. Elsevier Ltd. (2004) 10, 233-238.
11. Peters, Diane. Into the Breech. What are your options when your baby is bottom-down? Today's Parent Pregnancy. Rogers Publishing Limited, Toronto. Fall 2008, Vol.08, No.02, pages 54-59