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?
Nursing the Issue 
Thank you for posting this. I was a victim of this trend in 2008.
Sheryl, I’m sorry you feel victimized by the system. There are circumstances in which cesareans are the better choice, but my hope is that one day every woman will feel their voice was heard & every cesarean will be a necessary one.
I attended, as the Doula, a breech birth in a primapara (first time mom) with Dr. Hartung in 2008. This was my first experience with vaginal breech birth (and with Dr. Hartung). It was wonderful for all, especially the mom. The mom was originally under the care of a CNM, but the CNM closed her practice and transferred care to Dr. Hartung, toward’s the mother’s 2nd trimester. Although this was very traumatic for the mom at the time, it turned out to be for the best and looks very much like divine intervention now. The baby turned breech shortly after transfer of care and stayed there. After becoming educated about EV (external version), the mother decided to forgo EV and attempt vaginal breech birth. Dr. Hartung’s only requirement was that she have a CT scan of her pelvis to ensure optimal space for baby to be born vaginally.
Dr. Hartung was fantastic at the birth. He has the presence of a Midwife and truly cares about birthing women and babies. Also, this birth helped me as a doula…it brought faith back in to my Doula work; Faith in Careproviders, faith in hospitals and faith that women can still birth a baby, even if they’re breech. This type of team effort is what birth should be. Women need to be fully informed about their options and if an OB/GYN is not comfortable with performing a vaginal Breech birth, they need to be honest about their experience and refer to another careprovder (even a CNM or LayMidwife, if necessary) if a mom wants a vaginal breech birth. Nothing is guaranteed in birth, but faith in women needs to be the priority of any person who works with birthing women. Vaginal breech birth is not for every mom, nor every baby, but it needs to be an option for women who want it.
This mom hired me for her 2nd birth, which she had with a CNM in another hospital due to insurance changes. She did finally get her waterbirth with a CNM and it was another empowering experience. I thank God for Dr. Hartung and the fact that this young mother doesn’t have to worry about future pregnancies because a c-section scar.
Dr. Hartung delivered my second child in February. We had found out my daughter was breech on a Friday morning (already past our due date) and were immediately told we would be having a c-section. Thankfully, our doula had heard of the wonderful Dr. Hartung and we were able to get an appt that afternoon. He calmed our fears and frustrations about being told to have a c-section and sent us off to let labor happen on its own, after checking things over to ensure the baby was healthy and in a good position. Monday afternoon rolled around and I went into labor. A natural birth was very important to us and we wanted to be in a place where they supported that same philosophy. When we arrived at the hospital in very active labor, the labor nurse greeted us by telling me how much she loved breech deliveries! There was so much support for me to move at will and do what I needed to stay comfortable and our doulas were also welcomed with open arms. When the time came, Dr. Hartung had me get into the elbow-knees position and out popped our little girl with 9-9 apgars (literally, it was that easy!) I can honestly say, the breech delivery was easier than my heads-down first girl. Dr. Hartung is such an honorable, intellegent, good-natured man and I will happily travel the distance to have him deliver my future children, breech or not. The world needs more doctors like him, so women know they have options and can feel confident about their birthing situations. Dr. Hartung was truly a blessing to our family.
Is Dr. Hartung training any other OBs or Family Practice docs on how to do breech deliveries? I’m afraid it’s becoming a lost art. I’m also afraid of the impact on him & his practice if all of us are referring all of our breech mommas to him. Any thoughts?
We moved from Madison to Lake St. Croix Beach, MN in 2011 and I was pregnant by fall with my 2nd. I had been seeing a CNM at Hudson and planned to deliver there in May. I found out our baby was breech at 37.5 weeks. With a natural, head-down birth for our first child, this was quite a shock to us. I wanted to do this one with no drugs too, and I really wanted a vaginal delivery. We tried an external version (EV) first, and the little bugger didn’t want to flip. I tried the chiropractor, acupuncture, hand stands in the water, flash light and bag of peas, you name it. My baby was just meant to be breech.
My cousin who lived in Minneapolis just happened to tell me a story about how her friend drove all the way from Minneapolis to Hudson at 10cm to have a certain doctor deliver her breech baby (which I would never recommend by the way). So after I found out that our baby was breech, my first question was “Isn’t there like a super-doctor here that delivers breech babies?” Yes, that would be Dr. Hartung.
After the EV, I was told my options, a natural delivery by Dr. Hartung being one of them. But the doctor who did my EV did not recommend it due to the risk of….the head getting stuck. What? Uh oh…my first child’s head was in the 90th percentile. So my husband and I made an appt to talk to Dr. Hartung that same day and I’ve never felt more comfortable and relaxed talking to a doctor. When I asked if we should be concerned due to the fact that my first child’s head was enormous, he laughed and said that he had some special forceps for that, but he’s never had to use them. So there are all of these women that are traveling to Hudson doing extended stays at hotels so that Dr. Hartung can give them a vaginal breech delivery and not once has he needed to use these special forceps? Yet the other doctors highly recommend a cesarean due to the risk of the head getting stuck? Okay I understand that a breech vaginal birth is higher risk, but if there are complications during labor then you can still go and get a cesarean just like you would for a head-down delivery in which labor is not progressing.
So anyway, Dr. Hartung delivered our 2nd beautiful baby girl with about 5 minutes of pushing. He is totally hands off and only intervenes when necessary. My midwife was there as well and he was coaching her the whole way through so that she would gain more experience with breech births. By the way, our 2nd girl’s head is 75th percentile, and there were no issues. I know it is different for every woman, but she didn’t have any trouble and no cone head.
I really don’t understand why they don’t bring back the education on breech vaginal births. Everyone thinks cesarean immediately and that I’m crazy for what I did. I will give myself some kudos, but mostly for not taking drugs. Hey it wasn’t exactly fun, but my first wasn’t either. Dr. Hartung gives women an option that should be widely available. We are so happy that we moved to a place that happens to be 10 minutes away from Super Doctor Hartung. He rocks.
Great information. I have a lot more reading and learning to do about breech births! Great to run into you today. I would love to learn how to do breech births in order to better serve our population, as well as women in other countries.
I just changed the title of the article, realizing it could be misinterpreted to think that Dr. Hartung had written it. He did not (see “About Me” above)