A Natural Breech Birth: Under What Conditions?

We hear here and there beutiful stories of succesful natural breech births. But the reality nowadays is that the great majority of babies who are still presenting butt first at the end of pregnancy will be born via caesarean section. Why so much surgery? Is is really that dangerous to be born breech? What are the risks? Why is so difficult to find a provider who will even let you try for a natural breech birth? In the current medical system, under what conditions is it possible to have a vaginal breech birth?

First of all, ''breech'', is the word used to describe when a baby is presenting buttocks first, instead of head first. Sometimes, the baby seems to be ''sitting'', which we call a complete breech, sometimes the baby has his's legs all the way up with it's feet next to his head, which we call a frank breech. Sometimes, the feet are presenting first (footling breech), and sometimes there is a mix between the positions.  About 3 to 4% of full term babies are still breech at the time of birth.

In 2000, a study titled the ''Term Breech Trial'', seemed to be showing that the risks for the babies are greater with a vaginal birth than with a cesarean section. Since that study, we suggest, almost systematically to all women whose babies have not turned to schedule a cesarean section. However, this study has been largely criticised for many reasons, including:
- That a great deal of deaths or problems that occured during this study were not due to the mode of birth, but to malformations of the baby.
- That many of the vaginal births were performed without qualified care providers
- That the study doesn't show a comparison between the children born vaginally and those born via caesarean after two years
- That the conditions to allow for a vaginal birth were not severe enough.
- and much more...
Here is a critical review of the Term Breech Trial:  http://www.ncbi.nlm.nih.gov/pubmed/16389006

Other studies have been carried out since (you can read some here, here, here and here) all showing a much lower complications rate than the Term Breech Trial. This study concludes that when qualified care providers are present and that the criteria for a vaginal breech birth are respected, planned natural birth for singleton pregnancies is a safe option that can be offered to women.

Here you can read the ACOG Mode of term for Singleton Breech Delivery  and the SOGC Guidelines for Vaginal Delivery of Breech Presentation

One of the greater risks with breech birth, is since the baby's body is usually smaller and easier to push out than the head, there is a risk that the head will get stuck there and the baby can suffocate. There is also an increased risk of cord proapse (umbilical cord presenting first). But as the studies have proven, when certain factors are taken into consideration, that the care provider is qualified ant that the appropriate precautions are taken, vaginal breech birth is safe. On top of al this, we musn't forget that caesarean delivery also has many risks and that it is a major abdominal surgery that should only be used when abolutely necessary.

But what are the ''criteria'', or conditions to qualify for a vaginal breech birth?

1- The mother's pelvis must be measured by pelvimetry to determine if tha baby can get through. This is more or less pertinent if the mother has previously given birth vaginally.
2- The baby's head must be flexed down, his chin against his chest and looking down.
3- The baby's weight estimate should be between 2500 and 3800 grams (between 5,5 and 8,3 lbs). Don't forget, however, that weight estimations have a large margin of error ( usually +/- 500grams (1lb), but it can be much more, especially as the end of pregnancy approaches).
4- The baby must be presenting in the frank breech position (legs up), but some care providers will also accept a complete breech presentation (baby sitting legs crossed)
5- The mother must know the protocols for breech with her chosen care provider and accept them
6-  The baby's gestationnal age must be at least 34 completed weeks

There are other conditions for a vaginal breech birth. Some even change from place to place. Here are a few examples:
- Labor must start on it's own, meaning that there is no induction on a breech baby.
- The mother must sign a consent form
- She must ideally be a multipara (have given birth before) but that said, it's still possible even for a first baby.
- She must have a textbook labor, meaning her progression must be continuous, her cervix should dilate  well and relatively quickly.
- The mother will probably have an IV drip installed
- She will have to give birth in the operating theater, in case an emergency cesarean is needed (however this rule may differ from one hospital to another)

The midwives of Quebec no not handle breech births. Not yet at least. In Quebec, it is possible to attempt a vaginal breech birth at the following hospitals, given the doctor present at your birth is trained in breech births (not all of them are): Ste-Justine, Lasalle, CHRDL Joliette, Sometimes et LeGardeur, Sacré-Coeur, L'Hôtel-Dieu d'Arthabaska in Victoriaville, and at the CSSS St-Jerôme. There may be other hospitals doing them, but it's hard to know which. I even called a couple but no one could really tell me anything. Recently, the Society of Obstetricians and Gynaecologists of Canada softened it's positions on vaginal breech birth. Since this change, more and more doctors, in theory, should be able to assist breech births.

If a caesarean is planned, it is always a good idea to reverify the baby's positions before performing the surgery, because babies can sometimes turn at the last minute. It is also a good idea to wait for labor to start on it's own too, to be sure the baby is actually ready to be born. There is a margin of error in the calculation of due dates (not all women have a 28 day cycle), and when we are planning a cesarean section at 38 or 39 weeks, there are risks of prematurity associated with a miscalculation of gestationnal age.

KNOW YOUR RIGHTS! No one can impose anything on you if you do not want too. The following quote is taken from the SOGC guidelines: '' 21. In the abscence of a contraindication to a vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman's choice of delivery mode should be respected. ''

Interesting fact: The three videos listed here are home breech births. It is interesting to observe that in all three cases, the mother is on all fours for the pushing stage, and that the midwives do not touch the baby except for catching it before it falls after the head is out. It seems to me that this looks like the best way to handle a breech birth...
Home breech birth
Frank breech birth
Birth video of a breech baby

As a conclusion, I would like to say that a breech presentation is not a pathology, an anomaly or a medical emergency. It is a variation of normal. It is absolutely possible to give birth to a breech baby when certain things are checked closely, and I think it is sad that midwives of Quebec can't handle this type of birth, and that so little obstetricians-gynaecologists agree (or even know how to) to handle them. Even with the multiple criticisms of the Term Breech Trial, and with everything we know today about the risks of caesarean secrion, surgery is still the most widely used way of handling breech babies. I hope with all my heart that more and more care providers will learn to assist vaginal breech births and that the tendency will come back to vaginal birth being the first choice for breech, for the greater benefit of moms and babies.

A Breech in the System : A film I haven't seen yet (but which looks very interesting) about one woman's fight to have a natural breech birth

This website: http://birthwithoutfearblog.com/category/bwf-topics/breech-birth/ has lots of birth stories of successful natural breech births.

http://www.birthdiaries.com/diary/ext014/ (témoignage accouchement naturel par les pieds très graphique)
http://www.birthdiaries.com/diary/birth037/ (témoignage accouchement par le siège, très graphique)
CHU Ste-Justine  (plus précisément leur conseillère en soins)
CSSS de St-Jérôme
Maison de naissance Côte-des-neiges
GASKIN, Ina May, Spiritual Midwifery, Book Publishing Company, U.S.A., 2002, 480 pages.