Lana Matheson wanted the childbirth experience. Before her first pregnancy, the 29-year-old social scientist had been collecting stories of women’s births across BC as part of her job with the University of British Columbia’s department of family practice. So when she found out, at 38 weeks, her unborn baby was breech — bum down instead of head down — she was devastated. A doctor tried to turn the baby in a procedure called external cephalic version (ECV), but the baby had already dropped into her pelvis and it didn’t work (see Turn, Baby, Turn). Obstetricians at the BC Women’s Hospital in Vancouver told her that she needed a Caesarean section. That just didn't seem right to Matheson. She knew there were benefits associated with labour and vaginal birth for both babies and their mothers. But breech birth carried risks too: The baby could be deprived of oxygen if the cord got compressed; the shoulders or arms could get caught; a trapped head could kill the baby during birth. But based on her own research, Matheson wasn’t convinced the risks of a breech vaginal birth outweighed those of a surgical one. “I hear what you’re saying, but I want to try,” she insisted.
When she went into labour, the obste-trician on call agreed to deliver her baby vaginally, as long as Matheson followed her every instruction. If things looked even a bit awry, it would mean a C-section. Matheson agreed. After 12 hours of labour, her baby, Kathryn, was born vaginally with no complications (though her bottom end was so swollen and bruised, her dad couldn’t tell he had a girl — a normal result of the pressure of delivery).
What’s a breech baby?
Babies flip and turn in the womb throughout pregnancy, but by 36 weeks most are head-down — the ideal position for birth. Three to four percent of full-term babies are in one of three breech positions. The most common is a frank breech, with the baby in pike position with legs pointing straight up, feet at the head. A complete breech, the rarest kind, is when baby is in cannonball position with legs crossed, feet near the bum. In a footling breech — the least favourable for vaginal delivery — one or both feet are sticking straight down, and would come out first during a vaginal birth. Some babies are breech because of congenital problems or because of a mom’s unusually shaped uterus. But most often there’s no obvious reason.
Research and practice
Matheson’s vaginal breech birth story is not one you hear often. Today in Canada, more than 95 percent of breech babies are born by Caesarean section. (The remaining five percent are mostly babies who come out breech by surprise.) That’s because in 2000, a landmark Canadian study was released that found surgical birth safer for bum-down babies.
The Term Breech Trial, a University of Toronto study, recruited 2,000 women in 121 centres around the world. Half the moms with breech babies were delivered by C-section, while the rest tried for a vaginal birth (some of these ended up with a Caesarean too). Three years into the trial, the study was stopped early. An interim analysis found that breech babies born vaginally were three to four times more likely to die at birth, and more likely to have serious health problems in the first six weeks of life, than those born by C-section. “The results of the Term Breech Trial provide us with reasonable evidence that a policy of planned vaginal birth is no longer to be encouraged for singleton fetuses in the breech presentation,” the study authors plainly stated.
At the time, about 40 percent of breech babies were born vaginally in Canada. But the trial’s dramatic results changed, almost overnight, the way doctors in Canada and in many other parts of the world dealt with this type of birth. “We have uniformly adopted the guidelines that came out of the Term Breech Trial so that women with a breech presentation are now routinely booked for a C-section,” says Gareth Seaward, head of obstetrics at Mount Sinai Hospital in Toronto. Most other hospitals did the same. While there was no change in Canadian guidelines allowing vaginal breech delivery in some circumstances, as issued in 1994 by the Society of Obstetricians and Gynaecologists of Canada (SOGC), the society’s American and UK counterparts both issued statements in 2001 stating that vaginal breech birth was unsafe and should not be practised.
This policy suited some women just fine. Debbie Baker gave birth to her breech daughter by C-section six years ago. “It wasn’t upsetting to me at all. The goal is to get the baby out safely and if the C-section is the safest way, that’s fine with me,” says Baker.
But with few doing breech births anymore, long-time doctors found their skills grew rusty. New doctors were taught in school how to deliver vaginal breech babies, but never got practice in real life.
The decline of this skill set is something doctors and hospitals worry about. When a baby arrives bum-down unexpectedly, it’s important to have a knowledgeable attendant who can assess the labour and is skilled at specific techniques to help get a breech baby out. And the women who really want a vaginal birth have a very difficult time finding someone willing to attend them.
That’s what happened to Robin Guy of Ottawa. She’d had a successful and quick home birth with her first child. But her second baby was breech. She tried ECV an exhausting four times, as well as a variety of natural remedies, but baby Miriam would not turn. Guy’s midwife was not comfortable delivering the child. (Midwives in Canada are trained to deal with emergency breech deliveries, but almost always transfer care when a breech is identified in advance.) Guy went on a hunt and found two obstetricians who said they’d deliver her baby vaginally if they were on call when she went into labour. They weren’t. The doctor on duty did not want to deliver her baby vaginally, and she ended up consenting to a C-section. “It fulfilled the worst of my expectations,” says Guy, who tears up every time she talks about her second birth and her lengthy recovery.
More worrisome is another story: A woman from BC’s Fraser Valley, wanting a vaginal breech delivery, was turned away by a midwife and two obstetricians. She decided to deliver the baby at home, without help. And the baby died. “Collectively, the obste-trical community bears some responsibility for this,” says Andrew Kotaska, clinical director of the department of obstetrics and gynaecology at Stanton Territorial Hospital in Yellowknife. He 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.
Now the tide is turning again. Over the past eight years, doubts have been raised as to the reliability of the Term Breech Trial, and newer reports have suggested vaginal breech delivery can be safe. In recent years, both the US and UK have changed their recommendations to state that vaginal breech birth should be offered in some circumstances. And currently the SOGC is reworking its own guidelines to encourage doctors to consider vaginal birth for some moms with a breech baby.
When the Term Breech Trial was published in 2000, breech delivery experts criticized the study’s design. Kotaska, who did some training in Nuremberg, Germany, where they delivered about 60 percent of breech births vaginally, has a lot to say about it. He feels that too many women were considered good candidates for vaginal birth who should not have been accepted because of problems with the baby; that the second stage of labour was allowed to run too long (increasing the risk of cord compression); and that ultrasound evaluation was not part of the trial criteria because some centres had no access to ultrasound technology. “Rather than keeping the standard of care high, they lowered it so they could get more centres included,” he says.
“I don’t share those concerns,” says Mary Hannah, the study’s principal author and a professor of obstetrics and gynaecology at the University of Toronto and Sunnybrook Health Sciences Centre. She says she and her collaborators have scrutinized their data and feel the study’s design and results were valid.
However, Hannah thought her work would result in women hearing more about the risks of vaginal breech birth, not the choice being taken away. “I’ve always thought women should be given the option. They should be able to make up their own minds.”
In 2004, Hannah published a two-year follow-up report on some of the babies in the trial. While the vaginally born babies were more likely to have low Apgar scores, seizures and very poor muscle tone immediately after the birth, as toddlers these kids had no more health or neurological problems than those born by C-section.
This new report got a lot of attention, and made experts wonder if vaginal breech birth might not be so unsafe after all. A 2006 study from France and Belgium supported this possibility: Researchers observed 8,000 breech births and found that babies born vaginally or surgically did equally well.
With all this flip-flopping in research and guidelines, both doctors and moms-to-be struggle to decide what to do when an ultrasound reveals a breech baby.
What this means to you
With new Canadian guidelines on the way, hospitals and doctors are beginning to re-examine their breech birthing policies. “With our modern hospitals, with the proper precautions taken, I think that breech delivery can be offered as an option to women,” says André Lalonde, executive vice-president of the SOGC. It’s an approach long favoured by European hospitals — to offer breech vaginal birth under optimal conditions and be prepared to do an emergency C-section at any time during these births.
The new guidelines from the SOGC are expected to support informed consumer choice for breech delivery, within specific safety criteria. Right now, not every woman with a breech baby in every hospital across the country will be offered both options. Many hospitals have not yet changed their policies. And even if they did, who would attend women attempting vaginal breech births? Few obstetricians in Canadian hospitals have the skills — or the confidence in their skills — to catch a breech. Doctors and hospitals worry about legal issues if a birth goes badly. Lalonde says the SOGC is looking into funding training programs, and may also sponsor initiatives that set up breech birthing teams in major hospitals. Kotaska thinks skilled older doctors need to start mentoring younger ones.
For now, it’s up to the individual mom-to-be with a breech baby to do her own research and ask her caregivers about the risks and the options. Many women will still feel safer with a Caesarean section. Those who wish to try a vaginal breech delivery will need to seek out a caregiver with the experience and willingness to attend the birth. Because whether head first or bum first, you should have a choice about the way your baby comes into the world.
Best bets for breech
If you would like to try a vaginal breech birth, here’s what your doctor will assess:
Your birth history Being a first-timer won’t rule you out, but those who’ve had a vaginal delivery in the past have better odds.
Birth weight A lighter baby may not do as well during a vaginal breech birth.
Baby’s head If the baby’s head is hyper-extended or very large, the baby’s bum might not open things up enough to let the head through the birth canal.
Pushing stage Since there can be problems with a compressed cord, a very long pushing stage can increase risk.
Turn, baby, turn
Pregnant women with a breech baby have one option before debating how they’ll birth their baby: an external cephalic version (ECV). This is done by a midwife or obstetrician, usually in the hospital where there’s equipment to monitor the baby and quick access to a C-section if something goes wrong. The risks (rupturing the membranes or the placenta) are very low, but most health care providers like to be prepared.
The caregiver uses her hands on the mother’s belly to first scoop the baby out of the pelvis and then give him a nudge so the head moves downward. That push can make the baby do a flip to head-down. “If it works, it can be very fast,” says Eileen Hutton, director of the midwifery program at McMaster University. For first-time moms, it works 30 percent of the time, and as often as 60 percent for women who’ve been pregnant before. Ideally, an ECV is done at around 37 weeks. Hutton is currently studying the success rate on trying the procedure earlier in the pregnancy. Smaller babies are easier to turn, but there may be a higher chance they’ll flip to breech again. The ECV’s biggest downside: It’s uncomfortable for mom.