If you have recently learned that your baby is presenting breech (when the buttocks or the feet are at the bottom of the uterus rather than the head), you are likely to be feeling upset and confused. Regardless of how straightforward your pregnancy has been to date, your maternity care providers are likely to offer only planned caesarean section (PCS) at 38 or 39 weeks if your baby does not turn.
I have first hand experience of the 'breech situation', having learned in the 32nd week of my first pregnancy that my baby was breech. I was new to Australia and I had already established that my own understanding about the best way to approach childbirth conflicted with the highly medicalised system here. However, I had experienced a 'normal' pregnancy and I was expecting a 'normal' birth and so I assumed that the conflict I sensed would never manifest. I was extremely upset when I realised that if my baby did not turn, I would thereafter be treated as 'high risk' and that a PCS would be recommend.
I attempted all the usual tricks to turn my baby (see www.spinningbabies.com/baby-positions/breech-bottoms-up), unsuccessfully. Then, at 37 weeks, External Cephalic Version (ECV)—a procedure in which a doctor attempts to turn a baby manually from the outside—was attempted and failed. I realised that not only would I be offered PCS but that no provision was in place for my refusal—Australia's largest specialist maternity hospital simply didn't cater for planned vaginal breech birth (VBB). This was particularly frustrating as I learned that there were several obstetricians on the staff who were supportive of and experienced in VBB but that these people could not be on call for me. If they were there on the day, I might be allowed a trial of labour. If not, I would probably be pressured into a caesarean section.
Whilst VBB has traditionally not been seen as problematic , in the latter part of the 20th century, the practice has become rare. This is especially since the Term Breech Trial (TBT), a multi-centre randomised controlled trial, which supported the practice of PCS for breech presentation. The TBT quickly lead to a change in obstetric policy throughout the world (despite the fact that the follow-up study two years later showed no long-term differences between the PCS and planned VBB groups, leading the authors to conclude the PCS does not lead to a reduction in the risk of death or neurodevelopmental delay at the age of two).
However, despite its profound impact, the TBT was not the last say on the management of breech presentation. It has been criticised in terms of its methodology (including VBB in conditions which were too risky) , its conclusions (attributing neo-natal harm to mode of delivery rather than to inappropriate management) , and the way it has been applied to obstetric policy (automatic PCS rather than improving VBB conditions). Furthermore, other studies have shown that for good candidates, the outcomes of carefully managed VBBs are usually as good as those of PCS. One often-cited study, PRE-MODA, which had larger numbers than the TBT and was better controlled, showed no significant difference in neo-natal outcomes between planned VBB and PCS. And, importantly, women still demand the opportunity to give birth to their babies vaginally.
Part of the reason few maternity care providers offer VBB is that they do not possess sufficient skills and experience with VBB and are therefore unable to support it safely. In a large maternity hospital, for VBB to be 'on offer', a significant number of staff need to be trained in it. It is generally accepted that the safety of VBB is affected by the skill of the birth attendant, who should know not to intervene in the birth unless absolutely necessary. If assistance is necessary, the birth attendant needs the judgment and skill to assist in just the right way. VBB has traditionally taken place with the woman in lithotomy position (on her back with legs in stirrups), with an automatic episiotomy and a forceps delivery of the after-coming head. Although it is now thought that this is not the best way to deliver breech babies, unfortunately, very few birth attendants have received training in modern breech birth technique.
It is clear that VBB is a better option for the mother in terms of recovery from the birth, ability to care for her newborn and, most importantly, for her future pregnancies. Caesarean section also carries a small risk of maternal death, which appears to be under-acknowledged. Also 'swept under the carpet' by the focus on short-term risk to the fetus is the impact of PCS on the mother's psychological wellbeing. Some studies also suggest that babies benefit from the experience of labour. Taken together the research supports the view that VBB may be a good option for some women, but only if a supportive and skilled care provider can be found.
The factors which are often cited as making somebody a 'good candidate' for VBB include frank breech (bottom-first, legs extended) or complete breech (bottom-first, legs crossed) presentation, flexed or neutral fetal head, estimated fetal weight of 2500-4000g, normal amniotic fluid volume, normal pelvic proportions and no other contra-indications to vaginal birth. Some care providers will only support VBB for second or subsequent pregnancies. However, assessment should be individualised as birth is a complex phenomenon (which is the basis of one criticism of the TBT) and so these factors should be seen as guidelines and not criteria. Management in labour typically involves continuous electronic monitoring, and requirements that progress is 'normal', and that the active second stage (in which the woman is pushing) takes no more than 60 minutes. Induction or augmentation of labour are inadvisable for breech presentation and so in the absence of spontaneous labour, or if the labour is not progressing well, it is common for a caesarean section to be advised.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists takes a fairly open approach. Its statement on the management of breech presentation maintains that "while it is true that women with breech presentation at term will most often be delivered by caesarean section, management should be individualised. The term breech trial did not have the statistical power to meaningfully analyse subgroups, some of which are likely to be pregnancies that do extremely well with breech vaginal delivery." It is disappointing that this approach is not followed through in practice, as few hospitals or obstetricians offer individualised assessment of suitability for VBB.
When I learned that my baby was breech, I spent a lot of time researching VBB. The idea that I would plan a caesarean birth simply did not gel with me. I do understand that caesarean section is normally a very safe procedure and can save the lives of women and babies in certain circumstances. But in my view, it is a procedure that should be kept for emergencies. I did not consider myself to be facing an emergency—my baby was simply presenting bottom-first. In fact, apart from the fact that it was my first pregnancy, I was an ideal candidate for VBB. I felt let down by the public health system, which I believed (and still believe) should have gone to greater lengths to support me in my choice to birth my baby vaginally. I felt alone—like I had somehow fallen through the support net, having not taken the 'usual' route of PCS. I cannot put into words the level of stress my husband and I felt towards the end of my pregnancy. And it was completely unnecessary. I should have been supported in my (very well informed) choice to labour spontaneously and all going well, to birth vaginally.
In the end, we found a private obstetrician who would support my choice to attempt a VBB. It was a huge relief but I resented the need to transfer to the private system at 38 weeks and the fact that I had to pay to avoid unnecessary surgery (we were uninsured and paid out of pocket for both the obstetrician and the private hospital, with borrowed money). I vividly remember the public hospital calling me up to book my caesarean section (in three days time!) and replying that I was going to give birth vaginally. I wonder how often that happens? Not often enough. If women before me had taken a stronger stand, perhaps I wouldn't have been in the predicament I was in.
I went into labour at 41 weeks plus three days after five days of pre-labour. I was in active labour for just under seven hours and my baby was born safely and in good condition. However, instead of feeling proud or happy, I felt partly defeated, shocked and appalled at the reality of the experience. (in the words of a good friend, I was 'too hard core' to accept any pain relief) and partly relieved the whole unnecessary stress of the 'breech situation' was over. Finally, I thought.
I formed Breech Birth Australia and New Zealand (BBANZ) when my baby was about three months old as, to my surprise, I was still very upset about my experience. It started with a Facebook group (www.facebook.com/groups/breech/), through which I attempted to connect with other women who had been through a similar experience. It did not take long before the group took off and we now have a lively discussion forum related to breech presentation.
It is interesting learning the different choices women make and the different options made available to them in different parts of Australia. Some of our members have transferred to the nearest tertiary hospital for support in their choice to attempt a VBB. Others, like me, have moved from a tertiary hospital to a private obstetrician or to a smaller public hospital. In some parts of Australia, hospital options are too limited and so women have found midwives to support them in breech homebirths. Some women who join BBANZ do still choose a PCS but they do so with the knowledge that their choice was fully informed and the best option for them. Like any labour, not all of the attempted VBBs are seen through to the end. Some of our members have ended up with a caesarean birth after an attempted VBB. However, by and large, these women are positive about the fact that they were supported in their choice, grateful that their babies were not born before they were ready and satisfied that the caesarean section was necessary. We also have members with very sad stories about forced caesareans, something which should never happen. Each story is unique but each contains an immense personal struggle as well as a struggle with 'the system'. We have shared some of our birth stories on our website www.breechbirth.net.
The BBANZ website also includes links to a wide range of internet resources (including personal blogs and birth stories) and books on the topic of breech birth, policies of different obstetric bodies, medical studies and articles analysing the respective options of PCS and VBB, and advice about the steps to take if you find out that your baby is breech. Importantly, the growing network can help connect pregnant women with others who've been in the same situation and to put them in touch with maternity care-providers for second opinions on whether they make a suitable candidate for a VBB.
It is my hope that women in the future, including my own daughter, do not have to go through the same struggle that I did for the opportunity to give birth to their breech babies. I am looking forward to change.
Note: The first Australian breech birth conference will take place in Sydney on 29-30 November 2012. The conference is organised by Women’s Healthcare Australasia and a team led by Dr Andrew Bisits, who is well known for supporting women in their choice to attempt VBB. For more information see www.breechbirth.net.
M Hannah et al, 'Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multi-centre trial' The Lancet (2000) 356
H Whyte et al, 'Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial' Am J Obstet Gynecol (2004) 191(3): 864-71
See M Glezerman, 'Planned Vaginal Breech Delivery: Current Status and the Need to Reconsider' Expert Rev Obstet Gynecol (2012) 7(2), 159–166 and G Lawson, 'The Term Breech Trial Ten Years On: Primum Non Nocere?' Birth (2012) 39(1): 3-9. cf G Burke, 'The end of vaginal breech delivery' BJOG (2006) 113: 969–72
A Kotaska, ' Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery' BMJ (2004) 329: 1039-42
M Glezerman, 'Five years to the term breech trial: The rise and fall of a randomized controlled trial' AJOG (2006) 194: 20-25, 22 and M Turner, 'The Term Breech Trial: Are the clinical guidelines justified by the evidence?' Journal of Obstetrics and Gynaecology (2006) 26(6) 491-94: 492
For example, Glezerman (2006) above and Turner (2006), above
C Deans and Z Penn 'The case for and against vaginal breech delivery' The Obstetrician & Gynaecologist (2008) 10: 139-144, 141
F Goffinet et al, 'Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium' AJOG (2006) 194: 1002-11 (PRE-MODA)
G Lawson, 'Report of a breech cesarean section maternal death' Birth (2011) 38(2): 159-161, A Kotaska 'Routine Cesarean Section for Breech: The Unmeasured Cost' Birth (2011) 38(2): 162-64 and JM Schutte et al, 'Maternal deaths after elective cesarean section for breech presentation in the Netherlands' Acta Obstet Gynecol Scand. (2007) 86(2): 240-3
HC Moore et al, 'Hospitalisation for bronchiolitis in infants is more common after elective caesarean delivery' Arch Dis Child (2012) 97(5): 410-4
Kotaska (2004) above
See M Cronk, 'Keep your Hands off the Breech' AIMS Journal (1998) Vol 10 No 3
RANZCOG, 'Management of the Term Breech Presentation' College Statement C-Obs 11