Bottom First: Are Breech Births Possible?

A breech baby doesn’t have to be a reason to panic. As an obstetrician/gynecologist with decades of experience, I have delivered around 10,000 babies. I was extensively trained in the art of vaginal breech delivery 40 years ago and have never quit.

Why Aren't Breech Deliveries Common?

In the last 20 years, many obstetricians stopped performing breech vaginal deliveries due certain research studies. However, some subsequent studies do say vaginal breech delivery is safe -- if a few criteria are followed and an obstetrician with training and experience in breech births is present.

Parents can rest assured that breech babies (bottom first) are just as healthy and tough as head down babies. Protocols help determine whether to proceed with a vaginal or Caesarian delivery. It also requires a calm discussion with prospective parents about risks of both procedures. A key factor, of course, is availability of an experienced obstetrician who has confidence in his or her competence with vaginal breech births.

Misconceptions Abound About Breech Babies

Following are some common questions about this type of birth experience:

Is a breech delivery safe for mom and baby?

Much of the research has shown vaginal breech delivery to be as safe for the mother and baby as a cephalic (head down) birth, without the potential complications of a cesarean delivery.

How common are breech births and what are the options when a baby is breech?

Just 4% of births are breech, and half of those can be turned before labor using a technique called external cephalic version (ECV). This involves the doctor using firm pressure to turn the baby to the head down position. There can be some discomfort or pain with this procedure. The other half of breech births (2%) are candidates for breech delivery.

Who is an appropriate candidate for breech delivery?

• An informed mother who desires a natural birth and avoidance of a cesarean section.
• The babies estimated weight should be between 2000 and 3800 grams.
• The baby should be in the complete breech position. (Feet may be felt if the baby is in the complete breech position and still makes vaginal delivery appropriate.)
• Adequate clinical pelvimetry (normal-sized pelvis).
• Military flexed head (not “star gazing”).
• Normal labor pattern.
• Experienced operator present.

Are breech deliveries more dangerous than Caesarian?

No. Breech deliveries are no different than a head down birth, unless the provider does not know how to use the appropriate criteria or does not know how to properly conduct a breech delivery. The approach is the same as used with a Caesarian section where the breech baby is pulled out using specific breech maneuvers. Keep in mind that Caesarian births also have risks which shouldn’t be overlooked, particularly for mothers who are obese.

Can baby’s head get stuck in the birth canal?

That’s the biggest concern for many prospective parents, but I personally have never seen a trapped head. This can occur, however, with small or preemie babies which is why a vaginal breech delivery is generally not done in those cases.

Do breech deliveries need to happen quickly?

A Caesarean section only takes an hour, but a breech labor can take many hours. In fact, it’s not something that can be rushed. The maternal forces of labor are a natural force that safely delivers babies. If the obstetrician pulls, they actually may cause the problem. The normal maternal forces of labor do not hurt the breech baby.

People often envision forceps being used in breech deliveries but they are actually rarely ever needed. An experienced obstetrician will show patience in letting mother birth the baby.

Make sure to speak to your OB/GYN or Women's Health provider to talk about the best birth option for you and your baby.

Resources:

Michael L Hall MD FACOG

1. Richard Fischer, MD. Co-Division Head, Maternal-Fetal Medicine, Professor, Department of Obstetrics and Gynecology, section of Maternal-Fetal Medicine, Cooper University Hospital. http://emedicine.medscape.com/article/262159-print.
2. Gabbe: Obstetrics: Normal and Problem Pregnancies. Breech Pregnancies pages 436-443.
3. Creasy and Resnik’s Maternal Fetal Medicine. Principles and Practice. Ed. 6. Abnormal Presentations: Breech Presentation.
4. Hannah, ME et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicenter trial. Lancet 2000: 356: 1375-83. [THE TBT]
5. Term Breech Trial: Correspondence: Lancet, January 20, 2001: 357. [Safety depends on selection-Arijit Biswas (Singapore): progress of labor more efficient predictor of successful vaginal delivery-Wing Cheong Leung (Hong-Kong): 2-year data show no residual maternal harm and no effect on neuro outcomes. It is time to make peer review more transparent-Susan Bewley (London)]
6. Jay Iams, MD. The Term Breech Trial. AJOG 2004; 191: 872. [If a study seems to be too good to be true, it probably is.]
7. Andrew Kotaska. Inappropriate use of randomized trials to evaluate complex phenomena: case study of vaginal breech delivery. BMJ 2004; 329: 1039-1042. [Good review of the problems with the TBT].
8. Mary S. Croughan-Minihane, PhD et al. Morbidity among breech infants according to method of delivery. Obstet Gynecol 75:821, 1990. [C/S increase from 12% to 79 % 1970-1985, therefore the trend was already in the works-the TBT put the nail in the coffin]. [Psychomotor retardation, cerebral Palsey, and behavioral abnormalities at 4 years of age occurred roughly the same frequency in vaginally and cesarean-delivered infants].
9. Mary Cheng, MB, BS, and Mary Hannah MDCM, MSc. Breech Delivery at Term: A critical review of the literature. Obstet Gynecol 82:605, 1993. [Planned vaginal delivery associated with higher mortality and morbidity. Need a randomised trial.]
10. Danish Siddiqui, MD et al. Pregnancy outcome after successful external cephalic version. AJOG 1999; 181: 1092-5. [C/S rate not increased over patients in labor with primary cephalic presentation].
11. Harmen H. de Haan, MD, PhD. Vaginal Breech Deliveries. AJOG 2000; 183:516. [The Netherlands had a cesarean delivery rate of 11% for breech deliveries in 1998, (and the infant mortality in the Netherlands is consistently lower than those of the United States)].
12. Should planned cesarean section be standard for all singleton breech babies? Ob.Gyn. News 36:4 2001. [Erica Eason, MD-YES, Louis Sanchez-Ramos, MD-NO.]
13. Albrecht Giuliani, MD et al. Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. AJOG 2002; 187; 1694-8. [Our data suggests that planned vaginal delivery remains an option for selected term breech presentations.]
14. Min Su, BM, et al. factors associated with adverse perinatal outcome in the Term Breech Trial. AJOG 2003; 189:740-5. [Breech infants at term are best delivered by prelabor cesarean section. Another analysis of the data from the TBT]
15. UCSF’s experience with vaginal breech delivery. Ob.Gyn. News 38: 18 2003.
16. John T. Queenan. Deputy Editor. Teaching infrequently used skills: Vaginal Breech Delivery. Obstet Gynecol 2004; 103:405. Editorial.
17. May Alarab, MD et al. Singleton Vaginal Breech Delivery at Term: Still a Safe Option. Obstet Gynecol 2004; 103:407-12. [Safe vaginal breech delivery at term can be achieved with strict selection criteria; adherence to a careful intrapartum protocol, and with an experienced obstetrician in attendance.]
18. Mary Hannah, MDCM et al. maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. AJOG 2004; 191: 917-27.
19. Rielberg, CC, et al. The effects of the Term Breech Trial on medical intervention behavior and neonatal outcome in the Netherlands: an analysis of 35,453 term breech infants. BJOG 2005; 112:205-9. [The Term Breech Trial has resulted in an exceptionally rapid change in medical behavior by Dutch obstetricians. This change was followed by improved neonatal outcome.]
20. Fran?ois Goffinet, MD, PhD, 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. [In places where planned vaginal delivery is a common practice and when strict criteria are met before and during labor, planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women.]
21. 21.Mark Glezerman, MD. Five years to the term breech trial: The rise and fall of a randomised controlled trial.  AJOG 2006; 194:20-5. [The original term breech trial recommendations should be withdrawn].
22. 22.ACOG Committee Opinion. No. 340, July 2006. Mode of Term Singleton Breech Delivery. [Should depend on the experience of the health care provider].
23. 23.JFM Molkenboer, MD et al. Birth weight and neurodevelopmental outcome of children at 2 years of age after planned vaginal delivery for breech presentation at term. AJOG 2006; 194: 624-9. [Increased risk of neuro delays at 2 years if birth weight greater than 3500 grams.]
24. 24.Sue Ross, PhD, Mary Hannah, MDCM, TBT Steering Committee. Interpretation of the Term Breech Trial findings. AJOG 2006; 195: 1873-7.
25. 25.The Management of Breech Presentation. Royal College of Obstetricians and Gynaecologists. Guideline No. 20b. December 2006.
26. 26.F. Vendittelli et al. The term breech presentation: Neonatal results and obstetric practices in France. European J of Obstetrics and Gynecology and Reproductive Biology, 2006; 125: 176-184. [The risk of neonatal morbidity according to planned mode of delivery for term breech babies was lower for those giving birth in units that applied the consensus guidelines than among those in other units.]
27. 27.Vaginal delivery in breech position and breech birth. http://health.yahoo.com/pregnancy-birth/vaginal-delivery-in-breech-position-and-breech-birth.
28. 28.Breech. International Cesarean Awareness Network. http://www.ican-online.org/pregnancy/breech.
29. 29.Home 4 Birth. Description of breech birth.                                                                http://www.Home4birth.com/pregnancy/Breech/index.html.
30. 30.Dhamintra Pasupathy, et al. Longitudinal study of the risk of delivery related perinatal death associated with breech presentation at term. SMFM Abstracts. AJOG 2007; 10:090. [Factors other than mode of delivery appear to have contributed towards reduction in rates of perinatal death in this context over the last 20 years in Scotland.]
31. 31.Rachel Michailson-Cohen, et al. Delivering term breech vaginally by strict protocol: Comparable to cesarean for neonate, superior for mother. AJOG 2007 10:239. SMFM abstracts. [The maternal risks of planned CS for breech presentation at term are unwarranted given comparable neonatal outcome when delivering vaginally by strict protocol.]
32. 32. Roberto Palencia. The cost of planned cesarean versus planned vaginal birth in the term breech trial. [More effective and less costly for planned cesarean.]