So, your baby is breech. You’re sure his position is accurate. You’ve tried everything you can to turn your breech baby but he won’t turn. Or maybe he turns but keeps returning to breech. Do you have to have a cesarean birth? What are your options? We’re going to unpack all of that in this post.
Are C-sections necessary with a breech birth?
Sometimes. And the way things are in the U.S. today, usually. Eighty-six percent of babies that present in the breech position at term will be delivered via cesarean section.
Footlong breech is one type of breech presentation that will almost always result in a cesarean because there are more risks for baby and mama since the diameter of the baby’s feet is much smaller than the diameter of the shoulders, buttocks, and head. Thus it would be possible for a footlong breech baby to slip through the cervix partially before it were fully opened. Keep in mind that this position is extremely rare especially in a full-term baby. Most footlong breech babies are preterm since it would be difficult for a large full term baby to fit in the mother’s uterus this way.
However, there are times when a breech baby may be delivered vaginally.
Some practitioners will deliver Complete and Frank Breech vaginally. The reason these positions are more compatible with vaginal birth is because the presenting part is the baby’s bottom, which is often roughly the same size as the baby’s head. As a result, we are much less concerned that the bottom would protrude through the cervix before it were totally open or that the bottom would fit through the pelvis but the head would get stuck.
It’s important to keep in mind that sometimes babies will flip head down at the last minute or even during birth. Additionally, it’s possible for a cephalic baby to flip to breech during labor which is one reason that vaginal breech birth skills are important for every practitioner to have.
Doctors used to deliver breech babies vaginally as standard practice decades ago. (Papa Natural’s grandma successfully delivered a breech baby!) This skill used to be taught to ob/gyns and midwives regularly. Most ob/gyns will never witness a breech birth during their training since the standard of practice now is to perform a cesarean, so it’s truly becoming a lost art.
With the introduction and rise of cesareans, coupled with malpractice lawsuits, vaginally delivered breech births have been greatly discouraged, and in most instances, eliminated as an option for moms.
Some of this is for good reason. Delivering breech babies vaginally can slightly increase the risk of interventions, complications, and infant mortality. We also know that cesareans have their own set of risks too.
However, vaginal breech birth is becoming more available due to an increase demand from moms. We see this trend in the U.K., Germany, Australia and even in the U.S. The American Pregnancy Association modified their stance on the safety of breech vaginal deliveries in 2006, stating that the risks should be assessed on a case by case basis (they previously claimed that cesarean birth was the best choice for all breech cases).
Of course, each depends on very strict factors such as baby’s exact presentation, size, weight, prior births and gestational timing.
Criteria for Vaginal Breech Birth
According to American Pregnancy Association and the American College of OB-GYNs, the following conditions are considered necessary in order to attempt a vaginal breech birth:
- The baby is full-term (at least 37 weeks gestation), although in practice preterm babies sometimes come very quickly and are born uneventfully in the breech presentation before a cesarean can be done.
- The baby is frank or complete breech presentation.
- The baby does not show signs of distress while its heart rate is closely monitored.
- The process of labor is smooth and steady with the cervix widening as the baby descends.
- The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal. Generally most of these babies will be between 2,500g and 4000g, or approximately 5.5-8.8lbs.
- Anesthesia is available and a cesarean delivery possible on short notice.
- May be more likely to be successful or have less complications in women who have had at least one vaginal birth already
Some studies show that a vaginal frank or complete breech birth is just as safe as a cesarean, although there are some mixed opinions on the results.
What Are The Risks Of Vaginal Breech Birth?
Though one study found that, when strict criteria are met, a cesarean vaginal birth is a safe option, another large study showed that elective cesarean section in breech births has a lower risk to baby (0.6% versus 1.6%) and a slightly increased risk to the mother than planned vaginal delivery. Keep in mind that the overall risk, or absolute risk, to the baby in either scenario is very low.
Trauma to head
The main risk of vaginal breech birth is that the baby’s head, the largest part of its body, helps to stretch the cervix, birth canal and vagina for safe passage. With breech birth, the butt is usually leading the way down the birth canal and may be smaller, which could result in the baby’s head becoming stuck. Additionally, with breech birth, there isn’t the same level of moulding that occurs with a head down birth. This is particularly relevant for a premature baby with a more fragile build. (Keep in mind that cesarean birth does not mold the head either.) Sometimes forceps are used to guide the baby’s head out of the birth canal. Although the idea of forceps sounds scary, skilled providers that have lots of experience with forceps can safely deliver babies this way as an alternative to a cesarean birth.
Cord prolapse is another potential issue with breech birth, particularly in the footling or complete breech. Because the feet are not tightly applied to the cervix and are smaller than the baby’s bottom, which creates more empty space in the pelvis, the umbilical cord may drop in front of the baby’s feet or bottom and become compressed either against the cervix or inside the vagina. It is possible for the cord to actually emerge from the vagina in serious cases. Compression of the umbilical cord can dramatically interfere with baby’s supply of oxygen and blood. Cord prolapse happens in a frank breech presentation at a rate of 0.5% (the same risk as a normal head down presentation). The risk increases to 5% in a complete breech position and 15% for footling breech. Keep in mind that the greatest risk for cord prolapse is when the water breaks, so keeping the bag of water intact as long as possible and allowing it to break on its own, free of medical intervention, is an important step in preventing this emergency from occurring. The only “treatment” for a cord prolapse is to deliver the baby as quickly as possible by cesarean.
Finally, and independent to the way the baby is birthed, breech babies have higher rates of genetic issues or abnormalities. This may be the main reason why they aren’t flipping to the head down position in the first place. As a result, statistically breech babies will show greater risks when born vaginally.
Delivering a Breech Baby
Though in a normal labor with a head-down baby a few interventions (induction, Pitocin, extraction) may be preferable to c-section, the same is not true with a breech birth. Midwives believe this is because if the baby isn’t being born on it’s own, there is a reason and a c-section is safer.
That means that labor needs to begin on its own (no induction) and progress naturally (no Pitocin) in order to have a safe breech birth.
In fact, your midwife will keep hands off as much as possible until baby’s presenting part is born to not complicate your and baby’s progress. In order for appropriate head flexion to occur, which helps the baby’s head to most easily fit through the pelvis, the baby needs to make some spontaneous cardinal movements as the presenting part emerges, and these movements best occur with gravity, not with the provider’s assistance.
Your midwife or practitioner may want to monitor you and baby more closely during labor. That doesn’t mean you have to have continuous monitoring, just more frequent.
Hands and knees is an ideal labor position for vaginal breech birth and is recommended by many midwives but be prepared to try a different position if all fours isn’t working for you.
Respected Midwife Ina May Gaskin recommends that women don’t bear down during a breech birth until they can’t resist any longer. This is supposed to keep the cervix at an optimal dilation for the head to pass through.
Babies born via breech births often require supplemental oxygen but bounce back quickly, so just be aware of this possibility.
The important thing to remember with a breech birth is to allow the baby be born instead of actively trying to deliver it.
What if I’m having twins and one or both are breech?
Some practitioners feel comfortable delivering twins vaginally when the first twin is head down and second twin is breech (this is a common twin presentation). Although it’s not the standard of practice, there are a few providers who will be willing to attempt a vaginal delivery when both twins or the leading twin are breech. After the first baby delivers, providers may perform maneuvers internally to help the second baby to turn head down or may be comfortable allowing a breech baby to descend in the complete breech or frank breech position since the first baby has proven that the size of the pelvis is adequate. Midwives are more likely be comfortable with breech delivery of one or both twins, but some states restrict the midwives’ scope of practice so that they are not allowed to attend planned twin or breech deliveries.
What if my practitioner can’t or won’t allow a planned vaginal birth?
You can either accept the situation. Grieve. And give birth via gentle cesarean. Or, if you live in Tennessee, or are willing to travel, you may want to consider going to Ina May Gaskin’s The Farm Midwifery Center to deliver your baby. The Farm Midwives are some of the few practitioners in the U.S. who still know how to perform vaginal breech deliveries. There are also certified professional midwives (CPMs) in several states who may be experienced with breech delivery both at home and at birth centers. Some OBs, such as the famous Dr. Stuart Fishbein in California, almost exclusively focus their practice on vaginal breech birth. Traveling a distance to birth your breech baby vaginally may be worthwhile!
Is your baby breech?
Keep reading and get the facts!