There seems to be a positive epidemic of babies wanting to be born bottom first at the moment, and in today’s maternity services that invariably means a caesarean section. There is a procedure which can be offered if the baby is discovered to be breech at 36 weeks, an ECV (external cephalic version). This very much depends upon the hospital she is booked at, her previous obstetric history, medical history and factors affecting this pregnancy and there is quite a variation in success rates, but the average appears to be 50 – 60% if the turning is attempted at 37 weeks.
As the result of an (in)famous study conducted by Hannah the preferred mode of birth for all babes presenting in the breech position is C Section. Prior to, and since the Hannah study several other researchers have concluded that planned caesarean section does not improve outcomes when compared to planned vaginal births for the breech baby when the birth is conducted by a well-trained, EXPERIENCED clinician. This is the crux of the matter, experienced, how does a doctor or midwife gain this experience if all women are being advised, encouraged to opt for a caesarean?
I can empathise with women who decide to take their obstetricians advice as when one of my daughters decided that she wanted a vaginal birth for her baby who as breech I was panic struck, who did I believe could expertly help a bottom-first baby enter the world safely, very few was the answer. I know, and trust, an independent midwife Jane Evans who is experienced in breech births, but when I spoke to the head of midwifery about the possibility of Jane coming into the hospital to deliver baby I was told that the Trust wouldn’t allow it. The consultant that daughter was seeing referred her for an ECV, thank heavens it worked as, although the doctor had offered to be on call for the birth should the ECV fail, I knew that his recent experience of breech births was negligible.
These are babies who are known to be breech before their mothers go into labour, what about undiagnosed breech? I have a confession to make, I failed to realise that one of my women, W, had a baby lying bottom first. I take some comfort from the fact that the G.P and the hospital registrar and the midwife inducing the labour and the midwife who examined her in labour also failed to discover the correct position. It was found, luckily, when the monitor was failing to detect baby’s heartbeat so they decided to use a fetal scalp electrode, at this point W’s cervix was 6cms dilated and W had been in labour for 4 hours. Although W’s labour had been induced using a prostin pessary her waters had broken by themselves and her labour was not being augmented in any way, and she had only just stared using entonox. A portable scanner was rushed in, an extended beech was visualised and W was immediately taken to theatre where baby was born by caesarean section. Mum and baby girl are both well but Mum is questioning the decision to get baby out via the ‘sun-roof’. I wouldn’t say anything to her but I wonder if the decision was taken for the right reason. The labour was progressing normally, it wasn’t slow, the contractions were well-co-ordinated and W was coping well with entonox, all positive signs indicating that there were no problems with baby versus W’s pelvis.
This is not unusual, in fact it is almost the norm however far labour has progressed, I have known several babies whose bottoms were visible but were then born by a caesarean section. A little voice inside suggests to me that this may be happening due to clinicians feeling de-skilled with regard to breech births, and who can blame them, if you’ve never seen one how can you have the confidence to support a woman through a vaginal, breech birth?
What’s the answer? I don’t know. We have all been brain-washed into believing that caesarean section is safest for the breech baby courtesy of the Hannah trial and, even though many professional organisations and researchers are now beginning to argue against her conclusions and recommend a more judicious use of the scalpel, I don’t think we will see a rapid increase in obstetricians supporting or encouraging women in having a vaginal birth for their breech baby.