A breech presentation is normal, it is just not typical. This is really important to remember: breech is not an abnormality. And a normal labour and a spontaneous birth are not excluded just because the presenting part is breech (although not all breeches can or should be born vaginally).
Like with all other births, a vaginal breech delivery involves some risk. There are situations where, for clinical reasons, medical intervention is necessary - for instance, placenta praevia, prematurity or anatomical abnornmalities (such as fibroids) or bi-cornuate (divided) uterus.
Even though many babies presenting by the breech can and should be born normally, caesarean section is currently the most common mode of delivery (irrespective of clinical indicators). However, the fact that caesarian section has become the accepted practice for breech births does not mean that it is the only acceptable option.
Birthing breech babies normally
Even though a normal breech birth can be as straightforward and unproblematic as any other normal birth, it is essential that those who practise normal births are skilled, experienced and confident. The practitioner 'comfort level' is an influential factor on the outcomes of less common procedures. Your attitude will affect her considerably - any uncertainty on your part may cause a collapse of confidence on her part.
You will need to explain what is involved to the woman and her birth supporters and discuss the options with them. It is essential that she feels confident in her own ability to have a normal breech birth.
The elements of good practice in a breech birth include making judicious clinical assessments, a thorough understanding of the physiology of breech labour, prior experience of attending breech births, considerable patience and the acquisition of some skilful techniques. It is also important that you have good support frameworks and effective lines of communication.
The woman's position can significantly affect the physiological labour process. Current practices like administering an epidural or continuous electronic fetal heart monitoring (EFM) restrict mobility. Although you may be able to avoid unnecessary epidurals in the hospital environment, EFM in breech labour remains requisite. Consequently, you will need to ensure that she is still able to move around and adopt different positions.
Experienced midwives say that the main difference between a breech and a cephalic labour is that there should be absolutely no augmentation for breech. If a breech labour does not progress, the woman's body is telling us something. In this case, she will need a caesarean. Prepare her for this possibility beforehand. Then, if it arises, explain what is happening. But unless the baby is showing sings of distress, there is no great hurry or rush: just transfer her to theatre.
The Term Breech Trial
The Term Breech Trial's findings (Hannah et al 2000) have been influential for health professionals' attitudes to breech births. And they have imposed a new standard of care for the management of breech deliveries around the world.
The study concluded that, for breech presentations, "the results were clearly in favour of planned caesarean section" over planned vaginal delivery. But after adjustment to exclude women who had had prolonged labour, induction or augmentation, epidural or no skilled/experienced clinician at the birth, the results were similar. What was not considered was the satisfaction of the women concerned. Remarkably, the follow-up study two years later, did not show any difference in the long-term outcomes. Hopefully, these supportive findings will now challenge the practices put in place after the original study.
Don't let the skills disappear!
Whilst normal breech birth is quite possible, and need not be more difficult than any other birth, midwives (as well as other health professionals) have become very uncertain about it. It is an area of practice where good collaborative working practices can make a huge difference.
The best way to learn the skills - and acquire the confidence - is to 'shadow' an experienced midwife or obstetrician at a normal breech birth. You can also practice for breech birth with your colleagues. Ask for a doll and pelvis and organise an impromptu learning session. Don't just confine this session to other midwives, either – try to involve other colleagues as well.
Tips and tricks
Ask yourself 'why is this presentation breech?' - if the woman has not had a scan in late pregnancy, you may have to initiate this.
'Hands off breech' – the old advice accords with the latest findings. Let a breech baby emerge of its own accord! Don't try and assist it (even if you are itching to do so!) When its buttocks reach the woman's perineum, you will need to decide whether to perform an episiotomy. In some cases you might need to gently flex the baby's head (for further information see Mary Cronk's article 'Midwives and breech birth' listed below).
Use the 'all fours', hands and knees position – it is particularly effective, as it allows gravity to assist the birth without providing too much added impetus (as it would in the standing position). Many women with babies presenting in the breech choose this position spontaneously in labour. During the birth, this position will allow the baby's legs to flop forward, easing the emergence of the rest of her or his body.
Banks M (1998) Breech Birth Woman-Wise
, New Zealand: Birthspirit Books, New Zealand
Cronk M (1998) Midwives and breech birth Practicing Midwife
1 (7/8): 44-45
Hannah ME, Hannah WJ, Hewson SA et al (2000) Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet
Hannah ME, Whyte H, Hannah WJ et al (2004) Maternal outcomes at 2 years after planned caesarean section versus planned vaginal birth for breech prentation at term: the international randomized term breech trial. American Journal of Obstetrics & Gynecology
191 (3): 917-927