This is the final installment of our Breech Birth Series. You can read our other posts on this issue, and links to research and discussions on breech birth at Breech Birth In Canada, Breech Birth: Why Not Cut?, Breech Birth: Emili’s Story, and Breech Birth: Emili’s Story Part II~VBAC.
Breech babies are encouraged to turn to a vertex position via a number of techniques. The most comprehensive online resource for turning breech babies is Spinning Babies. Physicians also have some success with External Cephalic Version (ECV) for turning persistent breech babies, but some babies persist in staying firmly head up as they prepare for delivery.
There are a number of resources available for practitioners on techniques for attending breech vaginal births, the technical aspects of which are beyond the scope of this series, but a brief overview of issues and current obstetrical knowledge is of benefit.
One of the main issues is handling of the infant as it emerges. Infants are stimulated to breathe when room temperature air touches their skin, and the umbilical cord, the baby’s lifeline of oxygen and nutrients, is stimulated to begin contracting and shutting off the supply of umbilical oxygenated blood when it touches room air and is handled by caregivers or parents. Thus it is imperative that attendants at a breech vaginal birth keep their hands off the baby for as long as possible, and handle the infant and the cord at an absolute minimum. This gives the baby the best chance at being born alert and healthy. It has been noted that water birth could help mitigate these risks by maintaining a warm, wet environment for longer than a land birth. Asheya noted in a discussion of this issue,
[M]ost 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 in breech delivery the cord comes out before the head and as soon as the cord hits the air it contracts and begins to restrict the flow of blood from the placenta to the baby, and the blood that was going to the cord is shunted to the lungs which have no way to breathe yet . This 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 into close to 37 degree centigrade water keeps the cord warm and functioning and prevents the cord from being exposed to room temperature air, which means the cord continues pulsing as it does in the womb, blood is not shunted to the lungs and the placenta continues to supply the fetus with oxygen . In addition, the warm water probably contributes to the baby not being startled and putting its arms up which makes delivery harder. (I learned this from a midwife, who learned it from two international midwives who have attended many breech births.)
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, you generally have about 8 minutes to resolve the problem (if the baby’s heart is beating and the baby is born into the air–you might have longer if the baby is born into the water). 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, as this position gives the pelvis more room to open (about 0.5 cm wider at the outlet) and uses gravity to assist the baby into the right position. 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. (I learned this from a German-trained midwife, who showed me her midwifery textbook. This is also supported by research).
Of course, breech birth represents a relatively small percentage of births, and the vast majority of breech births will result in a smooth, uncomplicated delivery, good APGAR scores, and healthy births without the need for techniques or interventions beyond supporting women and monitoring the baby, much as we do for vertex births. Complications present themselves in a small percentage of births, and for these it is excellent to have on hand a well trained, competent, well supported birth attendant. The Society of Obstetricians and Gynecologists of Canada urges obstetricians across Canada to take training and education and gain as much experience as possible to re learn the skills which have lapsed in ten years of a strict cesarean approach to breech birth.
During this vaginal breech birth hiatus, there were still women in Canada who refused cesarean delivery for their breech babies. These women were referred to one of the very few obstetricians who were still confident to attend vaginal breech births, some traveling up to several days to a major urban centre for this opportunity. Also, some births happen quickly or progress faster than anticipated, and the infant happens to be in the breech position, so there were still some ‘precipitous breech births’ during this ten year period in Canada. Paramedics received training in breech vaginal birth during the ten years after the Term Breech Trial because they were the ones most likely to encounter precipitous breech birth.
Of issue now is how to retrain and refresh (or train, if an obstetrician went to school during the ten year cesarean approach to breech birth) obstetricians in breech birth delivery skills. Access to training or experience can be hard to come by, especially with a roster filled with patients and little time for conferences based solely on breech birth techniques, and also especially for obstetricians in smaller urban centres. Much of the emergency breech skills for these physicians would be theoretical, since experience in complicated breech deliveries would be few and far between. Most breech births deliver in an uncomplicated manner, as noted above.
Breech vaginal birth in Canada: we’re moving forward, but slowly. We at Mothers of Change support and hope for a future with access to breech vaginal birth for women across Canada. May the future come soon!
Breech Vaginal Birth at Birthingway.
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