I went to a talk about breech birth yesterday at the International Childbirth Education Association‘s (ICEA) regional conference, given by Dr. Dennis Hartung. Dr. Hartung practices in Hudson, Wisconsin*, where he has become known for allowing women to make informed choices about their pregnancy and birth care [*Update 2015: Dr. Hartung now practices in St. Paul, MN at Health Foundations and attends births at United Hospital]. He has a tremendous reputation with families in the greater Twin Cities area. He was supported in his talk by Gail Tully, a Certified Professional Midwife, educator, and expert on Spinning Babies, breech birth, and shoulder dystocia.
I learned a lot from this talk.
In 1970 approximately 12% of breeches were born by cesarean. In 2001 that number was 87%. This change came rapidly and dramatically, even before the American College of Obstetricians and Gynecologists (ACOG) issued a statement in 2001 that “planned vaginal delivery of a term singleton breech may no longer be appropriate”. They reversed this with a statement in 2006 saying that “Planned vaginal delivery of a term singleton breech fetus may be reasonable…” under appropriate circumstances, and should “depend on the experience of the health care provider”. They further stated that “Cesarean delivery will be the preferred mode for most physicians because of the diminishing expertise in vaginal breech delivery”.
Needless to say the damage has been done. The diminishing rates of breech births over the last 20 years, along with the rarity of its occurrence, has left a large chasm in the training of most obstetricians and midwives. Community midwives, many of whom have continued to attend breech births along with training each other on the techniques, may be the most experienced providers of breech birth in the US.
The main points made in support of vaginal breech birth were:
- Scheduled cesarean births misses opportunities for babies to spontaneously turn head down before or during labor
- The studies that appeared to show outcomes in favor of planned cesarean over vaginal birth used short-term outcome measures (apgar scores, admission to nursery) that have not been shown to correlate with long-term morbidity, and failed to include the long-term consequences of cesarean birth
- Longer term studies of those same children (breech vaginal vs. cesarean) have not shown any differences
- We can be more tolerant of short-term asphyxia than we are. According to Dr. Hartung, “Apgars 2-6-8 are good Apgars“.
The professional organizations for obstetricians in the United States, Canada, and the United Kingdom all support the option of vaginal birth for breech babies under appropriate circumstances, which includes a well trained care provider.
Recommendations made include:
- Real and open discussion, recognizing biases, should occur between families and providers prior to labor
- Birth attendants and parents should remain open to cesarean section when labor is not progressing normally
- Frank and complete breeches are the safest options, with compound and footling the least safe
- Women should remain as mobile as possible in first and second stage, though for Dr. Hartung the use of pain management is “not a deal-breaker”
- From the moment the perineum begins to bulge, the best position for the women to assume is knees & elbows. This position best facilitates the baby to make the cardinal movements of breech birth needed
- The best approach for the provider is “hands off!”
- Assessment of well-being while the breech is emerging can be done by simply palpating the exposed cord
- Intervention should occur only when there are signs of difficulty (further training that went beyond the scope of this talk is clearly important)
The Society of Obstetricians and Gynaecologists (SOGC) of Canada has made their clinical practice guidelines for vaginal breech birth available and may be a starting point for anyone looking to establish protocols.
The talk was attended by atleast one physician, several hospital-based midwives, community midwives, doulas, and of course many childbirth educators.
What are your thoughts about this resurgence of breech vaginal birth? What have your experiences been with breech birth, and would you consider or like to see this option be offered to the families you attend?