Monday, October 22, 2012

Four Options For a Breech Birth

Feet first!

Every once in a while I have a student whose baby is persistently in a breech position(feet or bottom down rather than the head as is typical).  This inevitably causes tons of stress for the family and the mother.  What is mom to do when her baby is breech and she is planning a natural, vaginal birth?

I have also had a few students who are in my class because they are planning a natural VBAC (vaginal birth after cesarean) because their first birth was breech and so they had a c-section.  They were given ONE option for their breech baby-

That option- a cesarean section at 39 weeks.

And that is the ONLY option they were given for their breech baby.

A lot of articles focus on how to TURN the breech baby.  I even wrote one with tons of advice from different women.  BUT- I don't want to talk about turning the breech baby right now.  I want to talk about your OPTIONS if you have a breech baby.

Guess what- some of them WILL NOT TURN.  Another thing that women are not being told, is that they have options BESIDES a cesarean section at 39 weeks.

There are actually many options for the baby that is breech at term.

1~One option (and the one that seems to be most popular right now) is to schedule a cesarean section for 39 weeks.  Some advantages of this are that you get to pick the birth day of  your baby and schedule help with family and the like.  Avoiding any chance of going into labor also decreases the chance of a cord prolapse.  The chance of cord prolapse is slightly higher in a breech delivery.
"The overall incidence of cord prolapse ranges from 0.1% to 0.6%. In the case of breech presentation, the incidence is slightly higher than 1%." (RCOG, Umbilical Cord Prolapse)
 One of the down sides of a scheduled cesarean is the increased morbidity in the mother (2 to 11 times).  Another downside of a cesarean for a breech baby is the difficulty that many women face when trying to have a VBAC.  This is no laughing matter.  In many communities access to VBAC is very limited.  For some women their options after a cesarean are limited to scheduled c-section or unassisted delivery at home.

2~Another option for the woman whose baby is persistently breech is to wait for labor and only then consent to a cesarean section.   One advantage of this choice is that the baby is born when it triggers labor and not before.  Any error in age or size of the baby need not be worried about as the baby is hopefully ready to be born.

Some studies have found that this is a safe option and lowers rates of infant mortality significantly.  This 2012 study found though that at least for preterm babies,
"There is not enough evidence to evaluate the use of a policy of planned immediate caesarean delivery for preterm babies. Further studies are needed in this area, but recruitment is proving difficult." 
(Preterm babies are more likely to be breech at the time of birth.)

Choosing a cesarean for breech but waiting for labor to start is another option for the mother whose baby is breech at term.  This option also allows for the possibility (though rare) that the baby will turn head down after 39 weeks.

3~A third option for the mother whose baby is breech at term is a planned hospital birth of a breech baby.  While some studies (noted earlier) did find that breech birth was safer if a scheduled c-section was performed, some follow up studies found differently.  In 2010 ACOG (The American Congress of Obstetricians and Gynecologists) re-affirmed a committee opinion in light of newer research on the safety of breech birth within certain parameters and when attended by a skilled physician. 
" these reports detail the outcomes of specific management protocols and document the potential safety of a vaginal delivery in the properly selected patient."
They did these because, when the studies were followed it turned out that the risks of vaginal delivery for breech birth were in fact overstated by the previous study.
"Another explanation is that the use of pooled mortality and morbidity data at the time of birth overstated the true long-term risks of vaginal delivery (7)."
The new ACOG recommendation is this-
" The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery. Obstetricians should offer and perform external cephalic version whenever possible. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented. Before embarking on a plan for a vaginal breech delivery, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned."
In short- vaginal breech birth is a valid option in certain circumstances AND if the practitioner is skilled in breech delivery.  They do note that the skill to deliver breech safely is being quickly lost as the tendency is to deliver every breech baby via surgery.  

4~A fourth option for the mother whose baby is breech at term is a planned home birth with a breech skilled caregiver (usually a midwife).

As far as I know there are no statistics on the safety of this choice.  So, why do I include it you ask?  Because it is still an option.  Women deserve to know all of their options.

One of the first couples I ever taught was a first time mom and dad who frankly seemed pretty freaked out about the whole childbirth thing.  They were what you would consider "mainstream".  Their baby ended up being breech at term and they opted for a home birth with a midwife who was very experienced in breech birth.  They had their 10 and a half pound baby at home, safely.  This is not however the only story of a safe breech delivery at home.  There are many.  Home breech delivery is a valid option for some women with some care providers.  

I realize that this is just a story- and not a study and not proof that breech home birth is safe.  The reason I tell it though is that for this couple, in the area I live, their options were breech home birth or scheduled cesarean.  There is literally not a hospital for over 100 miles that will attempt a breech birth.  I sincerely understand why doctors and hospitals are skiddish about breech vaginal birth.  There are studies that certainly find that it is riskier. 

I also find it disappointing that women in this day and age are literally given SO FEW OPTIONS for their birth.  I find it equally disappointing that obstetrics, which was once an art form that involved learning to safely handle and deliver many different types of births and babies safely is now so narrow and limiting.  Surgery is a necessary skill for an OB, certainly.  I don't think however that it should be their ONLY skill.  It is really disappointing that young doctors are not learning how to safely deliver a breech baby. 

I hope they realize something.  When an OB lacks the skill or the nerve to do anything other than surgery for women whose babies are big, breech, different, overdue, slow to descend, have a wrapped cord, have a compound presentation or ANYTHING outside of what is becoming a very narrow box, they are going to LOSE CLIENTS.

Some women (not many) but some when limited by their birth choices in the hospital will simply walk away from that hospital.  They will find a care provider who can serve them even if they are a VBAC or they go post-dates or they have any one of the increasing number of "risky" checks on their chart.

It seems to me that it is getting harder and harder for a woman to actually be low risk.  In fact, it seems to take a lot of luck.

If your baby is breech you have MORE THAN just the c-section option.

I don't know what option is best for you or your baby.  In fact, the studies don't always even know and sometimes they contradict each other.  Sometimes studies change a few years down the line.  But you deserve to know that you have options.  I hope that we will all be aware of those options and choose carefully what is best for you.  I wish that women had access to ALL of these options and skilled providers for whatever it is they decide on. 

(Photo courtesy of Morguefile.com, artist, eveline, Free Photos.)

12 comments:

Anonymous said...

I delivered my sixth baby who happened to be breech at home with a great midwife just seven months ago. What gratitude I felt for this midwife who had the knowledge and expertise to do this. I was so very grateful to avoid a cesarean section. The birth was quick and easy. Some of the typical things that happen when delivering a breech baby happened, but my midwife knew what to do and I felt that I was in very capable hands. Our area doctors will not even consider delivering a breech baby naturally, so I know what you mean. I had a great experience and wish it was available for others whose babies are presenting breech.

kirstbaby said...

I had my second son last July at home. He was breech form 25 weeks and I planned a home birth all along. I knew that it could be done and I wanted to give experience to the midwives who had done all of the training, but had not actually had the opportunity to be present at a vaginal breech birth. I also wanted to be able to tell other mothers-to-be that it is possible! Breech is just a variation of normal!

Unknown said...

I am so glad you posted this! As a mom to a breech babe (2010), I had to fight to have options in birth. The Heads Up! International Breech Birth Conference is taking place Nov. 9 to 11 in Washington, DC. Are you a Mom, wanting to learn more about breech birth options, and share experiences with other Breech Moms? Do you know a Midwife or OB who might like to gain more skills and confidence in breech-catching? Consider coming, or inviting your care provider: http://conference.breechbirth.ca/

Celine said...

"Unknown" should read: CĂ©line

Kathryn said...

Hi, I posted over on Facebook and you asked me to share my story here.

We were planning a home birth for our third child in 2010. I had an ultrasound and baby was head down the last time I as seen. Labor progressed rather quickly. My water broke and my son's foot presented during the next contraction. 911 was called right away. His cord prolapsed shortly thereafter. He was delivered shortly after arriving at the hospital but unfortunately, it was too late. He suffered from HIE (hypoxic ischemic encephalopathy). He underwent cold cap therapy, but only improved slightly. After much prayer, we decided to remove life support when he was nine days old.

When people talk about breech birth now, I can't help but pay attention. It is just awful that we were one of that unlucky 1% to have a cord prolapse. I bristle at the thought that "breech is a variation of normal", it is a complication that requires special handling. I do believe that doctors and midwives need more training and to become more comfortable handling a vaginal breech delivery.

I would never attempt to knowingly have a breech delivery at home. Too much at stake. I am generally not an alarmist and actually went on to have a successful home birth, but on this point, until breech becomes a more safe option at home, I would never encourage someone to do so.

KJ said...

BRAVO!

Anonymous said...

I recently birthed a footling breech at home without any complications (thank Goddess). I knew something wasn't "right" when my water broke the morning he was born, but I was confident in my birth team and my body to do what was needed to make sure my baby was born safely. There were definitely some very scary moments for me (the midwife was unable to arrive until at the very end of my labor, EMTs were called because I wanted to make sure we had resuscitation equipment on hand because I was educated and informed on the complications of a breech birth, and I had trouble focusing and laboring calmly with it being a precipitous labor), but I ended up with a beautiful baby boy who was born into the skilled hands of a midwife who arrived just in time. I sometimes question whether I would do it all over again like that and the answer always ends up being "YES!" (although if you ask my husband he would say "absolutely not"). I am so grateful I didn't have major surgery and was able to care for my baby without recovering from a C-section. Breech is something I would tell every woman to make sure she is educated on to make the best decision possible for her and her baby. And definitely make sure your birth team knows how to handle that scenario without any doubt.

Anonymous said...

Similar to other commenters, I planned a homebirth and was caught by a surprise foot after my water broke. Luckily I had had a conversation about breech delivery with my midwives early in my pregnancy, and knew that they were not experienced with breech births, and furthermore that no OBs in my area had the experience.

I was lucky to be able to resist the urge to push while riding in the ambulance to a hospital for a c-section delivery. I lament my c-section, but I don't regret anything else. The breech was unforseeable (he turned in labor). The transfer worked like I was designed to. And I was on the lucky side of the statistics...no further complications.

Mama Birth said...

I appreciate all of you sharing your different experiences. It helps so much to put faces and stories to the studies. Thank you-

Lynne said...

I had my first baby at home in the UK in 2001. I was aware that she was breech from 32 weeks. We tried all natural methods to turn her and then when all these failed we focussed on birthing a breech at home. My midwives were experienced in breech and and I had researched everything I could about breech birth. My knowledge, my confidence in my midwives and my trust in the process of natural birth were the most important factors in a successful homebirth breech delivery. At the time I was angry that so many women are only given the option of Caesarean section for a breech and I agree with you Mamabirth that women need to know all their options so that they can make an informed choice. A vaginal breech delivery is not for every woman. If women know all their options they can make the choice that they feel most comfortable with, then natural or C-section will be an empowering experience!

Anonymous said...

If the woman is truely informed of the risks and is a good breech candidate (not a FTM) with trained personal may one even be considered. Too many poor choices end up with bad publicicity and therefore decreases the availability of HCPs to continue to try vaginal breech.

"Manual version is successful but fetus is injured."

After midwifes provided prenatal care for a woman throughout her pregnancy, an obstetrician was called when a fetus, at 38 weeks' gestation, was found to be in breech position. The obstetrician successfully turned the fetus by manual version, but the fetal heart rate decreased immediately following the version and remained low. Twenty minutes later, a cesarean delivery was performed. The child was given a diagnosis of hypoxic-ischemic encephalopathy and cerebral palsy. 
Patient's Claim: the cesarean delivery should have been performed sooner.
Physician's Defense: not reported.
Verdict: $1.625 million Missouri settlement

OBG Management, December 2009, Vol. 21 No. 12 page 52

Then Jessica Weed's unskilled and unprofessional attempt to deliver a baby...

http://www.dailymail.co.uk/news/article-2202117/Midwife-charged-child-abuse-newborn-mother-develop-complications-home-birth.html

Sabrina Craig said...

Glad to see that online! You'd think that a breech baby limits and ties you to hospital operation, but a lot of successful births entail a bit of will and ingenuity on the mothers' part as well. That shouldn't absolve doctors and medical people from any accountability; however, the accountability, if anything, should be further emphasized. Thanks for sharing!

Sabrina Craig @ Medical Attorney NY

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