PART 1: A different Perspective
One thing we all have in common is we come into this life through birth. However, the quality of the experience and the different choices parents make regarding the event can vary widely.
These experiences and choices can be limited for those who are in breech position in the womb and for their mothers-to-be.
In breech birth, the baby enters the birth canal with the buttocks or feet first as opposed to the normal headfirst presentation in which the baby is positioned head down, facing back.
Today, about 3 to 4 percent of babies present themselves in a breech position, and the vast majority will be born by cesarian section.
Early in June, I joined leading professionals from the Los Angeles-area birthing community to discuss prevention and management of care for breeches and other malpositioned babies.
Sharing information, experiences, and insights, we addressed real alternatives to C-sections for breech births, which are so common in the United States. Ana-Paula Markel, doula (birth coach) and childbirth educator, hosted the event at BINI Birth in North Hollywood for 100 people.
Many questions were discussed, such as: Why are some babies in a breech position? Can we prevent a breech or posterior presentation? What are the options for a mother with a breech baby in our community?
Markel moderated the panel, which included Naoli Vinaver Lopez, a midwife from Mexico; Davi Kaur Khalsa, an LA-area midwife; Dr. Suzanne Gilberg-Lenz, who specializes in vaginal birth of breech twins in hospitals; Jessica Jennings, a prenatal yoga instructor who works at BINI; Dr. Elliot Berlin, an LA-area chiropractor who specializes in helping with breech babies; and Dr. Stuart Fischbein, an obstetrician-gynecologist who assists women who choose to give birth at home. Under certain conditions, Fischbein will deliver breech births at home.
Breech presentation carries the risk of serious complications...
As per Michel's request, I am here posting his comments (as he is actually in Brazil in a middle of a conference)
Dear Marie Paul,
This is an extract of chapter 13 of my book 'The Caesarian'. Although published in 2004, it is still valid.
Breech presentation offers the most typical example of the impact one published study can have overnight all over the world. Without being simplistic, we can claim that the turning point in the history of
breech birth came on October 21, 2000. On that day, the Lancet – one of the most prestigious medical journals in the world – published a large trial involving 121 hospitals in 26 countries.(4) This study had a high scientific value, because it was randomized, which means that, after drawing lots, the researchers divided a population of pregnant women into two groups. This is how they could compare a policy of planned caesarean section with a policy of planned vaginal birth. They studied only ‘frank’ and ‘complete’ breech presentations at term. Frank breech means buttock first, with hips flexed and knees extended, so that the legs are like splints along the baby’s trunk. Complete breech means that hips and knees are flexed, but feet not below the baby’s buttocks.
‘Footling presentations’, when one or two feet are below the buttocks, were excluded from this trial.
This is how the authors of this study summarized their conclusions: ‘Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications
are similar between the groups’.
Since that day it is difficult to find an obstetrician who would accept to take the responsibility of a breech birth by the vaginal route. The quasi-standard strategy is to try to turn the baby three to four weeks before the due date. If it does not work, a scheduled caesarean is advised.
The issue of breech presentation offers a typical example of how the primal health research perspective can enlarge the framework of criteria commonly used until now to evaluate the practices of obstetrics and midwifery. The keyword ‘breech presentation’ offered by our database is productive. It leads in particular to a huge Norwegian study of breech birth and intellectual performance in late adolescence.5 The authors looked at the scores of intelligence testing at conscription (age 18) of 8,738 males born in breech presentation and
of 384,832 males born in cephalic presentation. It appeared that the mean intelligence scores were slightly higher among breech-presented males than among cephalic-presented males, and that breech-presented
conscripts had higher mean scores if born by the vaginal route. In other words, being breech born by the vaginal route is associated with the highest possible mean intelligence scores.
The keyword ‘breech presentation’ also leads to a study assessing at the age of two the children who had participated in the Lancet multicentre randomized trial.6 At that age the risk of death or neuro-developmental delay was no different for the planned cesarean than for the planned vaginal birth groups. We cannot conclude from such a small number of studies. We can just claim that the primal health research perspective tends to support the intuitive knowledge of women who, in spite of all opposition, want to avoid a cesarean section and try the vaginal route.7
However, If we take into account the widespread misconceptions regarding birth physiology, we must accept that, today, it is usually better to give birth by caesarean to a breech baby rather than to try
the vaginal route in the presence of scared practitioners. This will remain true as long as the basic needs of labouring women, particularly the need for privacy, will not have been rediscovered. There are women
who accept the principle of a caesarean birth, but, intuitively or in a rational way, they feel that it would be more beneficial for the baby to wait for the beginning of labour. This point of view is shared by many pediatricians who emphasize that the risks of respiratory difficulties are undoubtedly lower after ‘in-labour caesarean’. We must keep in mind that the alleged advantage of hospital birth is the possibility to perform an operation at any time, day and night. It is often claimed that an emergency caesarean is associated with more maternal complications than a scheduled caesarean. But ‘in-labour caesarean’ should not be confused with emergency caesarean.
Since, whatever the results of randomized controlled trial, there will always be women who will try the vaginal route, and since there are still undiagnosed breech presentations, I find it useful to transmit
some simple rules that I gradually adopted after having the experience of about 300 breech births by the vaginal route (including two home births):
- The best possible environment is usually a place with nobody else around than an experienced, motherly, silent, and low-profile midwife who is not scared by a breech birth.
- The first stage of labour is a trial. If it is straightforward, easy, and fast, the vaginal route is possible. If the first stage is long and difficult, a caesarean should be decided without any delay, before a point of no return has been reached.
- Because the first stage is a trial, it is important not to make it artificially too easy, either with drugs, or even with water immersion.
- After the point of no return, privacy remains the keyword. The priority is to make the birth as easy and fast as possible. Even listening to the heartbeat is a useless and even counter-productive distraction. Creating the conditions for a powerful ‘fetus ejection reflex’ should be the main objective. 8
- It is permissible to be more audacious with a frank breech than with the other varieties of breech presentation.
The strategies adopted for breech births have significant effects on overall caesarean rates, since breech presentations at term represent about 3% of all births.
4- Hannah ME, Hannah WJ, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000; 356: 1375-83.
5- Eide MG, Oyen N, Skjaerven R, et al. Breech delivery and
intelligence: a population-based study of 8,738 breech infants. Obstet
6- Whyte H, Hannah ME, Saigal S, 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
7- Odent M. Home breech birth. The Practicing Midwife 2003; 6(1): 11.
8- Odent M. The fetus ejection reflex. Birth 1987; 14: 104-5
Vaginal birth is more desirable than Caesarean in virtually all cases.
Breech deliveries require a very specific skill set acquired by fewer and fewer OBs in training.
Dr. Odent's comments are excellent especially in his discussion of labor trial and easy safe labor leading to a vaginal birth. And I like very much his statement about an immediate decision to delivery via Caesarean if that trial is long and hard.
I have been a supporter of home birth and out-of-hospital birth for thirty-five years and refuse to have that support questioned by anyone. Additionally, I strongly request that hospitals and skilled obstetricians give mothers with favorable breech presentations the option of a vaginal birth but I do not support breech delivery at home under any circumstances.
I feel very strongly, as you do, that vaginal birth is most important in any variation of birth (breech being one of them) and should be the choice in hospital's birth, instead of typical caesarian. So parents need to start asking for it to their Ob/Gyn... so that we can create better/safer environment for these babies to come to the world.
Thank you for comment Dr. Jay Gordon.
Ok, there is other great trailer on the subject: A breech in the system: http://tinyurl.com/3vzudwg
READ the comments: very valuable and informative... Let's keep this discussion going Parents to be need to know and have more options to Breech Birth.
As a mother that gave birth at home to a footling breech baby unassisted, I rarely join in discussions as I don't enjoy being criticized (which seems to happen with even the most progressive natural birth advocates). But Marie-Paul asked me to share my thoughts/experience and so I will.
I believe that women can create the best possible births by using both their rational, critical mind and their intuitive mind. I personally did not feel the need to consult a doctor or midwife during my pregnancies, as I believe there is an intelligence within us that knows how to give birth. I tapped into this intelligence during my pregnancies and births and received many valuable insights that I believe allowed me to give birth to my babies unassisted despite the fact that none of the labors were textbook.
With my second pregnancy I had a dream in which I saw a woman in labor standing over a little plastic baby bathtub. Her legs were slightly bent and she was catching her baby herself. I heard a voice gently say to me, "Tell her to remember not to do too much." I watched as the baby peacefully slid into her hands. I understood the message of the dream - giving birth successfully isn't a matter of pushing and panting, or struggling and straining. Nor is it a matter of finding experts who supposedly understand a woman's body better than she does. The best birth can be achieved by truly understanding that the same consciousness that knows how to grow an egg and a sperm into a human being, knows how to get that human being out of the woman's body. She simply needs to relax and allow it to happen. When she is afraid (and triggers the fight/flight response) or is surrounded by fearful people, birth can be and often is problematic.
Several months after having the dream I began feeling contractions. Two hours after my first contraction my water broke and I felt that the birth was near. I took out my little bath tub and stood over it, just as I had seen the woman in the dream do. A foot emerged, and over the course of the next minute or two it descended with no help from me. Something inside me then said to give a little push/pull and he slid into my hands. Twelve years later I read a passage from Michel Odent stating that breech babies can be born vaginally but the woman should be in an upright or standing squat position and the attendant should do everything possible to not interfere.
Regarding the intelligence of breech babies (Odent), my breech baby grew into a wonderful young man. During college he wrote for 5 newspapers and within a year of graduating was hired by both the New York Times and Denver Post. Today (at age 31) he is the west coast director of PR for a major health care company. Interestingly enough, this month he won a PR award for a campaign he has been working on to educate doctors about the dangers caused by unecessary c-sections. :)
Thank you Laura for sharing your insights.
I, like you feel very strongly about a mother's intuitive knowledge, and focus my work on getting
pregnant moms in touch with this part of themselves that has been repressed in modern society as we have replaced our wisdom and inner knowingness with machines and gave our authority away to everyone who says they know better than we do about what goes on in our own body. So thank you for sharing your story and your wisdom as a mother.
Women have a strong intuitive knowledge to guide them while pregnant and definitely while giving birth. Perhaps finding themselves limited by our system which doesn’t seem to give much options that are truly beneficial to them and their baby will spur them to talk to their care providers to create new
options making it safer for everyone involved.
Wonderful post, Laura. Your birth worked beautifully but I don't believe that most footling breech deliveries would proceed as smoothly and as safely as yours.
I would not use your birth as an example for encouraging the delivery of footling breech babies at home unassisted. I also read your comment about not wanting to be criticized. Without criticism of either you or Marie-Paul, while I would certainly include intuitive knowledge in the criteria for birth choice I would also include more obstetrical and midwifery knowledge and data before the final decision is made.
All My Best,