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Breech Birth: No Cesarean Needed

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Breech birth is one of the most misunderstood and controversial subjects when it comes to women’s pregnancy and delivery. A breech birth occurs when the baby has its head positioned up instead of down in the uterus. Therefore, coming into the world butt or feet first. Most women will never have the option to decide what they want to do when faced with a breech baby. A planned cesarean section is performed for 94% of all breech babies.

If your provider is an OB, DO, or hospital CNM, you most likely will not be given a choice. Breech births can be successfully carried out without a cesarean. In this blog, we will be discussing the different methods used to deliver these babies without a forced cesarian section. 

How Breech Birth Can Be Fixed Internally 

You may be given the option to try to turn your baby in a procedure called ‘external cephalic version’, or ECV. (This is a procedure where the provider attempts to shift the baby from head up to head down using a deep massage technique.) It can be quite painful, or not, depending on the provider’s technique and how difficult it is.

This procedure is about 74% successful and most people who have a successful ECV will go on to have a vaginal birth. For those whose baby doesn’t turn, the majority (88%) will have a cesarean birth – either by choice or because they are forced as they cannot find a provider willing or able to help them birth their breech baby vaginally.

Most hospital providers have not been trained in physiologic breech birth. Rather, they may have been trained in a procedure called “vaginal breech extraction”. This is where the pregnant person is on their back and the baby is pulled out using various maneuvers and ending with a forceps delivery of the head. This is dangerous and often results in damage to the baby, mother, or both. No wonder most providers are unwilling to provide vaginal birth as an option for clients with a breech baby.

How Breech Birth Can Be Done by Changing Position 

In contrast, there is a technique that uses the gravity of the baby moving naturally through the mother’s pelvis. Called “physiologic upright breech birth”. As the name implies, the client is either standing, kneeling, squatting, or on hands and knees. The baby births itself most of the time. A skilled provider will know if the baby needs any help and when to apply which maneuver.

There have been multiple studies that have found no differences in the long-term outcomes between planned CS or planned VBB. Some studies have found a slightly higher risk for the baby between pVBB and pCS. Although, some studies found no difference. The unknown factor is the skill level of the provider

Why Breech Birth is Usually Solved by a Cesarean 

There is almost no option for having a pVBB in the hospital, in the United States. Many people seek alternative options for the birth of their breech baby. Even though this is not their first choice. Home breech birth has been shown to have poorer short-term neonatal outcomes compared to hospital breech birth. But, we don’t know what really causes these poorer outcomes. Anything from an inexperienced provider, possible congenital anomalies, delays, or miscommunication during transfers are all potentially at fault. It’s very possible that home pVBB outcomes could be significantly improved by improving provider training for breech birth.

By eliminating the option for a hospital birth for pVBB, lawmakers, hospital administrators, and Obstetricians are effectively forcing people to have cesareans. This goes against state and federal rulings that protect a person’s right to refuse surgery, as well as moral and ethical mandates to respect bodily autonomy.

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Breech Without Borders 

At Midwife360, Fadwah has been trained in the art of VBB and has attended a handful of pVBB in and out of the hospital setting, as well as several breech births in the hospital during twin births where the second baby is coming breech. She has attended and is working with Breech Without Borders Breech Pro Workshop to add to her skill level and to bring this valuable training to other providers in our community. All birth providers – CPM, CNM, OB, DO – are welcome to attend.

As a birth worker, there is always a risk of a person showing up in advanced labor with a breech baby. Rather than trying to rush into the OR for a cesarean that carries its own set of risks (not only for this birth but for the next birth and baby) why not learn the art of physiologic vaginal breech birth to assist the process safely? Go to midwife360.com to learn more about the upcoming Breech Without Borders workshop.

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Birth Your Own Way

I saw a Facebook post recently, a fundraiser, for a woman who wrote about her search for a provider who would assist her in having a vaginal birth for her 4th baby after having 3 previous cesareans. For whatever reason (VBAC ban, or just no supportive providers to be found) she moved 3 states over just to give birth with a supportive provider. It seemed from the post that they actually moved their family to that location to be in proximity to this supportive provider. Due to moving during the pregnancy, they did not have the funds to pay for the birth upfront, thus the Facebook fundraiser.

How did we get here?

How is it, in our medically advanced culture, that someone has to actually move to a different state to achieve this kind of support? I know that we don’t have supportive providers in our community here in south Florida that would support a vaginal birth for someone with 3 or more previous cesareans. Though, I know that I would support such a person under the right circumstances. Those circumstances are that the pregnant person has to be in excellent health with a healthy, otherwise low-risk pregnancy. She has to be fully committed to her birth plans, to the point of saying “I am doing this with or without you”. In other words, fully committed to the choice for an out of hospital birth.

While there is no guarantee for the outcome, an otherwise healthy low-risk pregnancy has little added risk for VBAC or other complex physiologic circumstances like twins or breech. With good counseling on risks and benefits and the understanding of the limits of any guarantees, clients should be free to make the decision to birth outside the hospital in these situations. Actually, clients should be free to make the decision to birth vaginally and should be able to access a supportive provider wherever they feel the safest – whether that is in the hospital or outside of it.

I am a provider that supports VBAC, twins, and breech for a vaginal birth.

I have found that my sister midwives are not happy that I do this. They report feeling threatened by my choices to support these births out of the hospital due to the possibility that any bad outcome would reflect negatively on the birth community as a whole. They believe that if I have a bad outcome I am giving home birth a bad name. I believe that I am giving people options they would not otherwise have. There are only about 2% of people that choose to birth out of the hospital. Most of those that choose home birth are die-hard home birthers who would not go to the hospital unless someone’s life was in danger (literally). They understand that there are no guarantees in life (or birth) and they typically have educated themselves on the risks and benefits of out of hospital birth and willingly, gladly, sign the consent waiver for home birth under complex physiological circumstances.

Enter the twins

I recently assisted a couple with twins who wanted very little prenatal surveillance, and home birth with mostly a hands-off approach. She went into labor the day she turned 40 weeks. The first baby came fairly quickly and it was the most serene beautiful water birth! Soon after, we attempted to get FHT (fetal heart tones) for Baby B and were unable to locate them for a few minutes, then when we did finally find them, they were very low – the 60s. Mom was instructed to push to try to encourage baby to come quickly, and within minutes, someone called out, “head’s out!”.

When I reached over to touch, it was obvious that it was not a head, and I tore the sac to find 2 legs unfolding into the water. I instructed Mom to get out of the tub as it was a surprise breech (baby had been head down at the last ultrasound at 28w) and I was concerned because of the low FHT. The baby then came fairly easily, but her placenta was sitting on her head and plopped out right after her – complete placental abruption. This is likely the scariest and most serious complication that can happen at home. Luckily Baby A and mom were doing well, no bleeding noted and Baby A was transitioning beautifully.

We immediately began going through the NRP steps that we learn and practice for just this eventuality. We also called 911 as a baby that requires CPR needs to be closely monitored for 24 hours in case there are further issues with the heart and breathing. The paramedics arrived within 6 minutes and by then she was only requiring breaths with the bag and mask as her heart was beating on its own at the appropriate rate.

It was difficult to watch her go without the ability to witness her recovery, but we had no choice as we still had the first baby and mom to care for. One assistant and the dad accompanied the baby to the hospital, the rest of the team stayed at the house. Ultimately, she made a full recovery. She began breathing on her own before they even arrived at the hospital, and was discharged home the next day due to a lot of questioning by and the determination of her parents. She seems to be completely normal and adjusted to life outside the womb.

This couple had 3 previous birth center births and were only having a home birth because their favorite midwife was unable to support a twin birth at her birth center. They were completely uninterested in a hospital birth. I’m pretty sure they would have chosen to birth at home with or without trained medical assistance. Had there not been someone trained in neonatal resuscitation present, their baby could have died. I wonder how our community would have felt about that?

When I help clients with a breech baby, or twins, or VBA3C or 4,5,6,7C or VBAC twins or breech, or past 42w. They tell me there’s no way they will birth in the hospital or no hospital provider will give them a chance to try for a vaginal birth. I believe it’s better to have a trained provider than for them to try a free birth and have a tragic outcome. If there’s a tragic outcome anyway, they have taken full responsibility for their choices.

Think about the big picture

However, I truly believe that our job as out of hospital birth providers is to monitor and observe the big picture at all times and identify an emergency before it becomes one in order to access the proper medical care. This means that we are alert and focused on one mom and her baby(ies) at all times during the experience. This is why we love to work with doulas. It gives us the luxury to arrive in active labor, which is the ideal time to be sharp and ready as birth becomes more imminent.

While I do not relish the added stress of caring for a more complex physiologic situation. I do believe in women’s bodies and the birth process as an inherently normal, natural process. In situations such as those with previous uterine surgery, twins, breeches, or post dates, it is unlikely that there will be any major complications if the pregnancy is healthy and otherwise low risk.

In every situation, as long as the provider is on her toes, focused and present, a major complication can be handled without turning into a tragedy. This is why I will support these clients. I wish more of my colleagues could do the same. I understand that the CPMs would be risking their licenses to do so, but this is not the case for my CNM and OB counterparts. In their case, the fear of birth and mistrust in women’s bodies limits their understanding of what is possible and safe. I have found that many people are seeking healthier living, especially when they are growing a baby. Many are super open to discussions of the importance of a healthy diet, adequate water consumption, and exercise in pregnancy, which all lead to safer birth for everyone.

Don’t judge anyone for their choices in birth. Not when they choose a repeat cesarean or even primary cesarean, and not when they choose home birth – no matter what their circumstances. Every client has their own reasons to choose what is right for them and their families. And don’t judge the providers that help them when they have a track record of good outcomes. It is better to have a trained provider present and we shouldn’t have to hide or suffer unwarranted criticism for our willingness to help.

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Natural Birth After C-Section

Can I have a vaginal birth if I already had a c section?

The short answer is, “YES! YOU CAN!” While the long answer requires a conversation about various risks – risks of a VBAC, or vaginal birth after cesarean, AND risks of repeat surgery. Unfortunately, it is the second set of risks that are routinely left out of the conversation when you speak with a hospital provider (OB or CNM) about it. And, also, unfortunately, these same providers often offer the VBAC and then find a reason at the end of the pregnancy that either induction of labor is ‘necessary’ (not the best plan for a successful VBAC) or a repeat surgery if the pregnancy goes beyond 39 or 40 weeks. 

Where can I have a successful VBAC?

This drives many women to seek an out-of-hospital birth provider for their planned VBAC, even though everyone agrees that the hospital is the best place due to the easy and quick access to emergency services. Since VBAC is prohibited in Birth Centers, this leaves home birth as the only option. And home birth is not for everyone. It is certainly not the best idea for someone whose main reason for choosing it is to avoid the hospital. It is always better to run towards something rather than running away from something. In other words, the choice to have a home birth should be driven by the desire to have your baby in the comfort and safety of your home, not by the fear of the hospital.

Successful home birth requires dedication and preparation

We have seen a situation like this where the client chose to have her baby with us because of her fear of having another c section and her inability to find a hospital provider who would support her decision to birth vaginally. She did not have a doula or take a birth preparation class. (These are 2 of Midwife360’s 3 keys to successful, efficient birthing. The 3rd is using the birth tub.) Consequently, she was unprepared and unsure when her labor did start, and did not request the midwife presence in a timely manner. She birthed on the toilet and her baby actually went into the toilet! They had the midwife on the phone throughout the process and she was able to guide them verbally (the part about the toilet came out later!) and everything turned out well. 

This is an example of how normal the process is for most people – even those who have had previous c sections – and for most babies. Babies are resilient and born to survive and know how to start breathing with little to no help in most cases.

Most predictions by OB providers are wrong

“Your baby is breech, and even if it turns, your pelvis is too small to push. There’s an 80% chance you’ll have to have a c section if you try, and then it would be an emergency surgery, which is more dangerous. So let’s just schedule the c section as this will be safer.”

I’ve heard this same speech from many clients over the years. This particular client told us this story of her first birth – the baby turned out to be 5#5oz. When she got pregnant the second time, they said she would have to have another surgery – it would be safer, they said. “But my mom had a c section and then pushed my brother out right after – he was over 10# – can’t I at least try?” “No”, they said, “it’s not safe”. There was no discussion of the risks of surgery, all focus is on the risks of trying a vaginal birth.

You can do it!

When this woman got pregnant a third time, she knew that she could birth her baby vaginally. She drove an hour away from her home to find a provider that believed in her and would support her. And although she did not take advantage of the 3 keys to success, (she used the birth tub only), she was so determined and dedicated that she was able to adequately prepare herself mentally for the big day. She was able to birth an 8#3oz baby vaginally in the birth tub with her sisters, husband, mother-in-law, and daughters all present and cheering her on! She pushed for over 2 hours, but barely tore and the baby came out quickly with no problems.

Our bodies and our babies are made for birth

When will OB doctors and other birth providers stop telling women what their bodies cannot do? Women are created with the social imperative to create life and deliver it to the outside world. Among many other things, we are very well designed birthing machines! If you didn’t know this already, then you do now!

Be empowered, be informed, stand up for yourself and your baby!