Breech Birth In Canada

by Asheya on July 25, 2011

For as long as women have been having babies, a small percentage of those babies have been born breech. Breech presentation means the baby emerges with the head last, and foot, leg, or bottom first. Twenty five percent of babies are in the breech position at 32 weeks, and only three percent remain in that position at full term. Premature babies are therefore at a greater risk of breech presentation than term babies, since not all of them will have had a chance to flip to the vertex, or head down position.

There are different types of breech presentations, including:

Frank Breech (50 to 70% of breech presentations), with hips flexed and knees extended, like this:

Complete breech (5 to 10%), Hips flexed, knees crossed, like this:

Footling or Incomplete breech (10 to 30%) One or both feet first, like this:

(source)
(images courtesy of webmd)

In past decades breech babies were delivered vaginally. Techniques for dealing with breech birth varied, and it was acknowledged that breech presentation carried more potential for complications than vertex delivery. My grandmother gave birth to five children, two of whom were breech, and her physician cut a large episiotomy and used forceps for both babies.

A research study at the University of Toronto called the Term Breech Trial was begun in 1997 to determine the best approach to breech births. It was intended to span five years but results appeared to be conclusive in favour of planned cesarean section by 2000, so the study was stopped and published before the five years was finished. Over 2000 women were included in this study, from twenty six countries. This study dramatically changed the obstetrical approach to breech births around the world, resulting in thousands of women undergoing scheduled cesarean section to deliver their babies. In Canada alone between 2000 and 2009, it is estimated that between 11, 000 and 14, 000 women per year underwent surgical delivery based on the published results of this study.

Criticism of this study and its results included:

  • the radical change of the international approach to breech births based on a single, randomized controlled trial which was stopped before its completion
  • the reduced skill set of obstetricians in dealing with inevitable precipitous breech births or for women who choose vaginal birth, or for whom cesarean section surgery is contraindicated
  • constraint in women’s choice in mode of delivery
  • reduction of the role of midwives in the care and continuity of care for women with breech babies
  • and the results themselves which carried a large number of variables based on the size and international nature of this trial.

Nevertheless, cesarean section for breech presentation became widespread, and in Canada the vast majority of breech births were delivered surgically starting in 2000.

The breech birth guidelines published by the Society of Obstetricians and Gynecologists of Canada (SOGC) underwent review in 2009 as a result of continued analysis of the Term Breech Trial including the original study follow up results and mounting criticism of its methodology and conclusions. The Globe and Mail published an article in June of 2009, shortly before the SOGC published new breech birth guidelines in August of 2009. The Globe and Mail stated,


Physicians should no longer automatically opt to perform a cesarean section in the case of a breech birth, according to new guidelines by the Society of Obstetricians and Gynecologists of Canada.

Released yesterday, the guidelines are a response to new evidence that shows many women are safely able to vaginally deliver babies who enter the birth canal with the buttocks or feet first (entire article available here).

Since then it has been considered safe to deliver breech babies vaginally in Canada. The new Breech Birth Guidelines released in 2009 state that

In light of recent publications that further clarify the lack of long-term newborn risk of vaginal breech delivery and the many cohort reports noting excellent neonatal outcomes in settings with specific protocols, it is acceptable for hospitals to offer vaginal breech delivery.

Breech births are more physiologically complex than vertex births, and so it is recommended that a practitioner experienced in breech delivery techniques be in attendance, and that physicians across the country recieve training or retraining as Canadian hospitals move back to offering women vaginal delivery of their breech babies as a reasonable and safe option. Breech vaginal birth is proven safe for babies in the frank breech position, whose estimated weight is less than 4000 grams, and not suspected to have Intra-Uterine Growth Restriction (IUGR).

It is now July of 2011, two years after this change in guidelines, yet very little has changed as far as options for women with persistent breech babies. Many women are simply told they must have a cesarean. Others are presented the option of a breech vaginal birth but discouraged from doing so for safety reasons, which is not supported by research. Very occasionally, an obstetrician will be comfortable and experienced with breech vaginal births and present it as an option. If an obstetrician is not comfortable and experienced with breech vaginal births, they should refer women to someone who is, but this rarely happens.

If women request breech vaginal delivery, often they have to travel to another community to find an experienced obstetrician. This needs to change. The fact is, research outcomes have proven that with an experienced attendant, and ultrasound to confirm baby’s position and size, vaginal breech birth is safe for healthy, average sized babies. Particularly in a developed nation such as Canada. Vaginal birth is safer and has fewer long term health risks for women especially as they go on to have future pregnancies.

{ 8 comments… read them below or add one }

Daizy July 25, 2011 at 12:14 pm

Great article! I will share it with ICAN and local MOC!

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Asheya July 25, 2011 at 12:39 pm

I know there are obstetricians, midwives, and family doctors interested in learning skills required if breech birth gets complicated, but one of the difficulties is finding other experienced obstetricians/midwives/family doctors to train them along with finding women who decide to give birth to breech babies to attend. If care providers live in a small community, where there isn't another care provider experienced in breech birth, and on top of that only 3% of all births are breech and they only have 300 births a year (so 9 breech births approximately)and some of those the woman would choose cesarean, it becomes difficult for care providers to obtain the skills required. On top of that, not all breech births are complicated. I don't know the percentage of breech births that require intervention, but many will happen spontaneously without assistance, especially if the woman is in a hands and knees position. These births are of course excellent for the woman and baby, and a testament to the normality of breech birth. But for care providers trying to learn what to do in case of a complication, they do not provide the necessary in-the-moment training and experience. There are robots that can be used for training about birth, and it seems that using this kind of simulation would at least expose more providers to what to do in a breech birth complication. The main concern with breech birth is head entrapment and the cord getting pinched after the body is born–if the head won't be born, I think you have about 8 minutes to resolve the problem. So the skills care providers need are the ones related to what to do if the head isn't coming. Often hands and knees will resolve the problem, and the next thing to try is putting a finger in the baby's mouth and gently pulling, to help them tuck their chin and provide traction. A lot of the maneuvers used by OBs are complicated and involve the woman lying on her back, and essentially trying to do to the baby what gravity will do if you put the woman on her hands and knees. So yet another question: is the training that OBs provide for complicated breech births actually the best training? And finally, most OBs and hospitals won't 'let' a woman with a head down baby deliver her baby in the water in a birthing tub, let alone a breech baby. But delivering in the water is actually the best way to deliver a breech baby, primarily because as soon as the cord hits the air it contracts and begins to restrict the flow of blood from the placenta to the baby. This in turn limits the amount of time available to safely deliver the head. In a head down birth the cord is not delivered until after the head, so this contraction of the cord does not happen until after the baby has access to oxygen. In a breech birth, delivering in the water prevents the cord from being exposed to air, which means the cord is still fully pulsing and the change over of the baby's system of getting oxygen from the lungs instead of the placenta hasn't started yet. May have to post this comment as a follow up post to this one! Asking the question: even if care providers get breech birth training, are they getting the best training?

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Tiffany July 26, 2011 at 8:28 am

At 34 weeks our midwives confirmed our baby had turned breech. We were given a list of things to try including homeopathics, acupuncture, chiropractics, inversion poses, you name it we tried it to get our baby to flip.

At 38 weeks our midwives recommended we attempt an ECV (external cephalic version), which was painful and unsuccessful. After the attempt, the doctors told me there were a few doctors in Calgary that would deliver breech babies vaginally, but no one likely would as this was my first baby, so basically "don't count on it". They immediately asked when I'd like to book my c-section. I was like, "NO!", I wanted to at least go into spontaneous labour and see if the baby would flip in the meantime. If not I wanted to have a trial of labour even if the end result were a c-section, but I was NOT resigning myself to booking a c-section!

2 days before my due date, my water broke without contractions. I agreed to labour in the hospital as soon as my water broke in case of cord prolapse or other complications arose. My midwife called ahead to see who was on staff at the hospitals and where. Foothills didn't have anyone on staff who would do a vaginal breech delivery that day, but coming on shift within hours at Rockyview was a doctor that was an advocate for vaginal breech, so off we went to Rockyview. The doc we wanted was intended to be on shift in my early labour, which wasn't ideal if I had a long labour as someone else would be on shift and probably wouldn't be as willing to do a vaginal breech delivery at the time I would be ready to push. As it turned out, the 2 doctors switched shifts. The doc on when we got there said she had only done 1 vaginal breech in a decade and was not really comfortable with it. We laboured away though, still unsure how quickly I'd progress or if anything complicated was going to come up. But as it turned out, in the nick of time I came 10 cms when the right doctor at the right time was there. Every nurse, intern, everyone asked to watch as these aren't done all that often and I said "Of course!!" If we're going to expect doctors to offer the option to women we need to get everyone trained in the old methods that have seemed to be lost. It was a condition that I had 1 hour in the pushing stage to get our baby out. After that they would perform a c-section. Luckily I had the urge to push way before I was fully dilated, so when it came time I was so relieved to start pushing and got our baby boy out in 22 minutes and I got my vaginal breech delivery. We were fortunate enough that we hadn't gone overdue, so our baby was a small enough size that a vaginal breech wasn't contraindicated.

I had absolutely no complications, moderate 2nd degree tearing, but nothing major. I was so incredibly happy to be able to deliver our son naturally, and had it not been for an old school pioneer doctor, I'd have gone under the knife.

So all I can say, is sometimes the stars align. We didn't commit to anything, so when the time came we got to just wait it out and see how things unfolded. I am so thankful that we did!

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Heidi June 4, 2012 at 8:01 pm

Such a great article & even better to see things changing around vaginal breech births in Canada!

I was due with my first in Feb 2007 & upon arriving at the hospital, it was confirmed I was 6-7 cms and in full labour. As soon as I was checked the nurse announced to the OB that she felt feet and not a head (my daughter was an undiagnosed breech) & in a went for an emergency C-Section. I remember asking through my tears if there was any chance that the baby would turn or if I could still have a natural delivery & the Dr just laughed as she told me there was no choice – a
C-section was the only option. I will never forget the feeling of being strapped down to the operating table & having my baby ripped out of me as the Ob on duty chatted with the nurses drinking her coffee. I still cry when I think about it.

When I was pregnant with my 2nd, I wanted a different outcome and level of care & so sought the care of a midwife. I had a wonderful pregnancy & the best of prenatal care. And I was determined to have a natural VBAC this time around. It came as quite the surprise when around 36-37 weeks, my midwife told me that she thought that the little bum that we thought was under my ribs was actually the baby’s head – this baby was breech (later confirmed frank breech)! I did everything I could to try and get my little one to turn; breech tilts, chiropractic, craniosacral, walking on hands/knees, laying on an ironing board, pulsatilla. All I could think about was the possibility of having another C-section. I felt frustrated, angry and even resentful. There was one piece of advice that my midwife gave me that I will never forget – ” you don’t always get the birth that you want but the birth that you need”. It was at that point that we decided we would plan for the best vaginal breech delivery – – my midwife referred me to an OB that is experienced in breech deliveries and was willing to let me try to have a natural birth. I went into labour much the same as I had with my first although this time 12 days late as opposed to 3 weeks early, and arrived at the hospital at 6-7 cms. I had done so much research before the birth & was comfortable in my decision to have a breech delivery but found it somewhat frustrating how the hospital staff tried to deter me from my decision & I can see how most would be scared into a C-section. After 2 hours of labour & 2 hours of pushing, I am happy to say that I successfully had a natural breech VBAC in Oct 2008 – thanks to my midwife & the OB that allowed me the opportunity to listen to my body. As breech deliveries are somewhat rare, it seemed that everyone in labour & delivery was in the room watching. I had nurses ask me the next day why I would try to deliver naturally when I knew the baby was breech. All I can say is having gone through both a C-section and natural breech delivery – I would take the breech delivery any day!

Fast forward to today – June 2012 & I recently gave birth to my 3rd. After having a successful breech VBAC last time round I hoped I would get my water birth at home with #3. What are the chances that this little one would be breech as well? I saw the same midwife as with my 2nd and as my last 2 were breech, we were a lot more aware of babies position earlier this time round. At around 33-34 weeks everyone told me I still have time for baby to turn….but having gone through this before I knew better. Again, weeks of doing everything as before & adding moxibustion & acupuncture this time round, the weeks went on & baby was still breech. So back to the same OB that delivered my son & again we had to plan for a breech delivery. This time round baby #3 was 5 days late – - & after only 17 min of pushing I gave birth naturally to my 2nd son, a footling breech this time round! The OB that deliver my first son was just getting off & the OB on duty & resident were two younger doctors & they were amazing as well. The tone/mood was also different as the staff were so much more accommodating to the possibility of a breech birth & it was an atmosphere of “way to go, that was amazing” as opposed to “why would you try and do that” as with my 2nd.

Having gone through 2 very different natural breech deliveries – I am hopeful that things are starting to change & I hope that more doctors are becoming educated & open to natural breech deliveries. It can be done & can be a wonderful birth experience!!

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Corrie September 8, 2012 at 8:53 am

Thank you so much for sharing your story!! I am 36 weeks, breech, and have just been told to try to make a decision regarding c-section. Everything in me wants to try for a natural vaginal delivery. I have all the way through my pregnancy but most of what you read advises against it and lists all these risks. I don’t want to harm my baby with my strong (some say stubborn) wishes but am having a hard time going with the decision of c-section without even trying. I have had a great pregnancy all the way. Felt great, no sickness or nausea, still do for the most part!
It’s great to hear of someone else who at the very least wanted to give ‘natural’ a shot…
Thanks again!

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melissa v. September 11, 2012 at 6:29 pm

Thanks for your comment, Corrie! It can be a difficult decision, trying to decide what is right for you and your baby when a breech baby presents itself. None of us wants to harm our babies! Breech vaginal birth is a good and a safe option for many women. Breech cesarean birth is also a good option for some; each situation is individual, and it should be up to the woman to decide what is best for her baby, her body, and her birth. Good luck! And come back and let us know how your birth goes!! =)

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Heather January 26, 2013 at 4:48 pm

I am currently 35 weeks with my sixth baby. This little one is currently breech. My first baby was posterior and I ended up with a c-sec. My next four babies were all born with the help of midwives. And they were all between 10 and 11 lbs each. I am hoping to deliver naturally, and would love the name of the doctor in Calgary that does breech deliveries. I am doing everything in my power to encourage baby to turn, but would like the comfort of a back up plan.

Thanks!! Heather in Okotoks AB

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Claire May 2, 2013 at 1:24 pm

Heather, I am in Calgary and exploring the possibility of a vaginal breech birth in the next couple of weeks. I would love to hear how your birth went, please email me at claire.tchhailo@gmail.com

Cheers,
Claire

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