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.
An interesting one and something I’ve not really thought through yet, despite mentally planning for how I’d ideally like the birth to go. Thanks for so much info.
Vic – Hopefully breech is not a position your baby finds itself in 🙂
I think what is especially difficult is that Hannah compared PLANNED vaginal delivery with PLANNED CS for breech. Even if you accept the findings of that study it doesn’t provide a guide for what to do when the breech is discovered in active labour. Have you seen the new Canadian (SOGC) guidelines for breech? It may be that the tide is turning….
Yehudit – The canadian obstetricians are now questioning the excessive use of CS for breech presentation BUT they recognise that many clinicians are not even being taught at medical school how to ‘manage’ a vaginal breech birth, I hope that it is different in the UK. Litigation is such a spectre on labour wards nowadays that it is a brave obstetrician who recommends vaginal birth for a breech baby, the times we see them are when Mothers have demanded it. Sad and dangerous.
This is quite a shocking piece. I had always assumed that even though a c-section was recommended, there would be plenty of people who nevertheless had successful vaginal breech births. The fact that midwives are lacking experience of breech births is very worrying to anyone like me, who would always want to give vaginal birth a go before resorting to the c-section. And from what you say, it is very difficult to imagine the tide turning. It’s quite sad really.
Cave Mother – It is shocking. Within my Trust all midwives have to attend an update every year on breech births, the docs are invited but rarely attend, hopefully they have their own little sessions.
CS for breech is so much the norm that I congratulate any woman I visit who has had a vaginal breech birth, this year there has been 1!
My baby was found to be in breech position at 30 weeks – we’d had to have a growth scan due to suspected talipes. Baby had been feet down at 20 weeks, moved to a head down position, but then ‘lurched’ round the night before my 30 week appointment!
There was much emphasis on how I’d have to mention it to my community midwife at my next appointment. Caused much amusement when I mentioned it to her (at 32 weeks…) plenty of time to turn she said, and she was right (although I’m aware that babies don’t always do as they’re told!). She recommended an independent midwife just in case baby didn’t turn – although my midwife is very experienced she would have been unable to catch my baby if he had been breech; against local policy. I would have been more than willing to try for a vaginal birth if it were an option.
Oh, and the talipes…just a positional thing. Not enough room for him to stretch out his feet inside my pelvis!
What happens though if the woman refuses a section?
My last baby was breech for a while , he turned around 30 weeks so was not much an issue but as i had planned a homebirth my midwife and i chatted about it for a while and agreed on a comprimise – if he was still breech when i went into labour i would go to hospital but still get a normal birth.
Im in Scotland btw
I’ve always wondered if I didn’t have to have an epidural for my vaginal breech birth if my baby girl wouldn’t have needed to go to the NICU (it is so uncommon to have vag. breech in San Diego, CA, USA that they required the epi. and there were over 16 people in the delivery room observing). I progressed great to 8cm, had the epi, stalled, they broke my water (ugh), then my little girl’s pulse ox was so low while pushing that a medial lateral episiotomy was given and out she popped with some help of forceps. After five hours in the NICU I was finally able to keep her with me. Was this the result of the cord being squeezed or the epidural? I’ll never know if I made the right decision, because my heart says do it natural, but after seeing my little one unresponsive… I just don’t know.