Andrea Sarty writes:

Back in the year 2000 my partner and I were struggling with what to do about our breech baby.  She was due in a matter of weeks and was just sitting around with her bottom in my pelvis and her head sliding in around under my ribs.  We had been planning a home birth but had to do a major rethink.  We began researching and preparing ourselves for the negotiations our midwife said we would all need to go through with the obstetricians about what kind of birth we wanted, if indeed we wanted to have a vaginal breech birth.

Thankfully our baby turned head down at 38 weeks, the night before we went for an attempt at an external cephalic version (were the obstetrician manually tries to get the baby to turn around).  Our stressful insight into the rocky journey for women choosing vaginal breech birth ended.

We have since had the insight reopened when my sister-in-law, Clare, discovered her baby was in a breech position.  (Read Clare's natural, vaginal breech birth story here.)  It was clear, when she began her negotiations with the obstetricians at Hutt Hospital, that the environment had changed and grown more fearful even since my partner and I had discovered our breech baby.

During the year 2000 a major clinical trial was underway that was intended to find out once and for all whether breech babies should be born vaginally or by elective caesarean.  The trial was known as the 'Term Breech Trial' and involved over 2000 women in 26 countries.  The trial was halted before its intended sample size was reached because the data monitors found that the evidence in favour of caesarean delivery was clear. It was found that the rates of mortality and morbidity for babies assigned vaginal births was significantly higher than for those assigned elective caesareans.

(Read 'Outcomes at 3 months after planned caesarean vs planned vaginal delivery for breech presentation at term: The International Randomized Term Breech Trial', The Journal of the American Medical Association, Chicago, 10 Apil 2002, Issue 14.)

There has been some criticism of the Term Breech Trial from natural breech birth advocates.  Some of the key criticisms, which I have extracted from Maggie Banks' article ('Breech Birth Beyond the ‘Term Breech Trial'), are:

• Details of the nature of the vaginal breech births were not published. 
  Indications are that the births were highly ‘managed' with frequent use of induction and augmentation of labour (a total of 64.7% of the vaginal birth group were given prostaglandins or syntocinon), use of lithotomy position, and use of forceps.
• The vaginal births were supposed to be attended by experienced practitioners but there is evidence that this was not the case in some births.
• A number of the babies who died were of very low birth weight indicating that they were already compromised and should not have been candidates for vaginal delivery or were not full term.
• 9.6% of the women assigned to elective caesarean had vaginal births, many of these were due to rapid labour and delivery so that there was no time to organise a caesarean.

So although the study was supposed to find the definitive answer as to how breech babies should be birthed there is not as much definition as many would desire in making this decision.  For some women and their families the choice will be clear - they will accept the findings of the study and opt for an elective caesarean and for many this will be the safest option.  For some other women, however, the circumstances of their breech decision may indicate to them that a vaginal birth will be the best option.

Clare felt the latter was the case for her and her baby and has kindly shared the story of her journey through this hostile landscape with us in her birth story, to follow.  Clare's midwife, Suzanne Miller, has generously provided her own perspective on the environment facing women wanting to vaginally birth their breech babies.  Suzanne has presented Birth Wise with a set of articles and resources for women making the decision about vaginal or caesarean breech birth and this will be available through the library for all Birth Wise members. 

Suzanne Miller, Clare's midwife, writes:

Supporting a woman through the process leading up to a vaginal breech birth is very emotionally demanding and stressful.  The woman has a very difficult journey ahead, paved with fear and guilt supplied by many of the medical professionals she will encounter.  Women choosing vaginal breech birth are frequently told that they are irresponsible and are putting their babies at risk for selfish reasons. 

A woman choosing to vaginally birth a breech baby will need to be very strong and assertive and will need to be very clear that:

• she has gathered and read a variety of information about breech birth;
• she understands the risks involved in vaginal breech birth;
• she understands the risks involved in caesarean breech birth; and
• she accepts the risks and is making the decision in awareness.

The fear of the obstetricians, GPs and midwives who will not attend breech births is understandable in the current medico-legal environment.  If a midwife loses her registration she loses it for life.

The fear of the baby's head getting stuck after the baby's body is born is one of the main concerns of those unwilling to attend breech vaginal births.  When a baby is full-term, however, its hips will be roughly the same size as its head.  So if a baby delivers easily to the shoulder, head entrapment is much less likely.

It is up to the woman to decide who will be present at her birth and who will be the LMC at the birth.  She has the choice of a midwife or an obstetrician as her LMC.  She may also choose to have a paediatrician and even an anaesthetist attend the birth in case a quick caesarean is recommended.

Some of the key ingredients in a safe vaginal breech birth are:

• the membranes should not be artificially ruptured to stimulate labour;
• unless there is a need to assist the birth of the baby's legs or arms, the midwife should allow the baby to descend unassisted until the shoulders are born, then gently support the baby's weight to allow the head to emerge slowly over the perineum;
• the birthing woman should keep an upright position;
• the baby should be monitored closely by the midwife; and
• the midwife should have an experienced colleague working with her. 

This approach to the birth fits with the midwifery model of care and is not practicised by an obstetricians in Wellington.  A woman faced with a breech birth needs to do her research, discuss it with her caregivers, and come to a decision that feels right for her and her baby - it is her decision.

Suzanne is a midwife with the Birth Works Midwifery Service and lives in Horokiwi.  Suzanne has been a practicing midwife for twelve years and in that time has been present at several breech births, although she greatly enjoys delivering normally presenting babies too!