Breech Position
Does cesarean section improve breech outcomes? The major reasons why breech babies have more problems than vertex babies have nothing to do with birth route. Breech babies are more likely to be premature or growth retarded. They are more likely to have congenital anomalies, genetic defects, or neuromuscular deficits or problems such as hip dysplasia or cerebral palsy. This is because size, weight, shape, and normal movements guide the baby into the vertex position. In most cases vaginal breech birth did not cause the problem, and cesarean section will not cure it.
In many other cases, as happened with external cephalic version, doctors blame breech injuries on vaginal birth instead of their own mismanagement.... Moreover, universal cesarean section does not eradicate iatrogenic injuries and asphyxia. Breech babies have been injured as doctors maneuver them through the cesarean incision, and with general anesthesia, asphyxia rates are as much as tripled. Babies have also been cut badly enough to need suturing. In fact, with one exception, studies have consistently found that while breech babies do worse than their cephalic counterparts, cesarean section did not help. That study's very uniqueness suggests there may be other explanations for its findings.
Certainly some breech babies should be delivered by cesarean section, but which ones? Cesarean section is usually advised if the fetal neck is hyperextended because of the risk of spinal cord injury during the birth, but there agreement ends. Some experts recommend restricting vaginal birth to frank breech presentations. They reason that umbilical cord prolapse is unlikely and because the buttocks are almost as big as the head, the cervix will dilate far enough to pass the head as well. Other studies that include nonfrank breeches find no excess mortality or morbidity. They argue that although a cesarean may be necessary, with proper monitoring a cord prolapse should not cause asphyxia because unlike prolapse in vertex positions, the prolapsed cord is protected from compression by the soft fetal legs.
A woman with a small pelvis and a big baby risks head entrapment because the largest, most unyielding part of the baby comes last, but where do you draw the line? Pelvimetry has poor predictive value for head-down babies, and there is no reason to think it does any better for breech. Pelvimetry also assumes, incorrectly, that the pregnant woman's pelvis is rigid and that no other factors besides pelvic dimensions affect her ability to push out the baby.
- Henci Goer, "Obstetric Myths Versus Research Realities," Bergin & Garvey 1995
Some risks of breech birth:
Rapid head decompression causing intracranial hemorrhage: Premature babies have softer skull bones than those at term. Breech presentation causes the head to come through the pelvis relatively rapidly and thus produces more rapid compression and decompression of the skull without the benefit of the gradual molding that occurs in a vertex presentation. This can result in anything from no damage whatsoever to minor, undetectable bleeding to massive intracranial hemorrhaging to skull fracture. This risk is lessened in the term baby because its skull bones are firmer.
Extended arms creating the breech version of shoulder dystocia: If the baby's arms become extended over its head or crossed behind its neck, this will delay descent during pushing and make the delivery of the arms and shoulders much more difficult. The necessary maneuvers used to free the baby's arms increase the risk of injury to the neck and the nerves of the arms (although injury is certainly not inevitable).
Impaired placental circulation developing during the birth or cord prolapse: It is possible for the placenta to separate while the head is still in the yoni [vaginal canal].... Cord compression is inevitable during a breech birth as the head passes through the pelvis. If the baby is large, the cord will also be somewhat compressed as the body passes through the cervix.... Cord prolapse may occur, especially if the baby is premature, because the presenting part is less likely to be engaged and will not fill the pelvis as well as a term baby during labor.
- Anne Frye, Holistic Midwifery Vol. I, Labrys Press 1995
Around seven or eight of every ten gently managed breech births will be easy and straightforward and trouble-free, and will give the attendant a false sense of "no problems." But the other two or three will run into deep and frightening problems, and occasionally one will end in disaster, leaving both mother and midwife with lifelong regrets. This minority of serious problems must be acknowledged with a proper sense of proportion, because no one can predict which breeches will be easy and which will be dangerous. Therefore I believe it is proper to classify breech as "high risk,"--not in the hospital-establishment sense that every breech is likely to run into problems, but because an unpredictable minority will encounter problems which might be very serious or even fatal.
The first requirement for assisting with breech births is experience. Also important is shared knowledge, so midwives should exchange stories and discuss problems and read up all they can about breeches. The next requirement is more heads than one, so recruiting other midwives with more experience is a good idea.
Another requirement is to properly advise and counsel the prospective parents.... The parents need to fully acknowledge the risks, trust their helpers, have confidence in the natural process and their own power within, and resolve to accept possible disaster without blame or recrimination. Having accepted all this, they should then not "lose it"-there should never be undue anxiety, panic, or hysteria.
- John Stevenson, M.D., Midwifery Today Issue 26
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Question of the Week
Considering that a primigravida usually has a longer labour than a multip, the reason often being that the muscles are tighter and stronger, does anyone think primips should be encouraged to stop their pubo-coccygeal, pelvic floor exercises [kegels] at about week 34?
- Anon.
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Question of the Week Responses
Q: Does anyone know how often to do moxibustion to turn a breech baby? I have read 10 minutes two times per day. My patient's acupuncturist said 10 times per day! [Please also share other ways you know of to turn a breech.]
- Anon.
A: This is an excerpt from "Obstetrics and Gynecology in Chinese Medicine" by Giovanni Maciocia:
"The technique involves heating UB 67 Zhiyin [located at the lateral side of the base of the toenail on the little toe] on both feet for 15 minutes, once a day for 10 days in all; initially for 5 days only, then waiting a few days and monitoring the position of the fetus, and then, if its position has not been corrected, repeating the treatment another five days. It is important to pause and to monitor the position of the fetus rather than applying the treatment continuously, because the fetus may turn into the correct position and then, if the treatment is continued, may turn into the wrong position."
Treatment can be started as early as 28 weeks. The study reported in JAMA a few years ago started at 32 weeks. Maciocia points out that most research studies find week 34 to be optimum.
In my experience this works well, but will not help if the cord is short or shortened because it is wrapped around the baby's neck. One woman's baby would correct position but then flip back to breech.
If you do not have access to moxibustion, try incense, especially the Japanese kind that breaks easily. There are many techniques for applying moxa. Most of all, you don't want to burn the patient. Move forward and back from the point in a quick motion so that the heat does not get too intense. Be sure to keep a finger on your patient's skin near the point so you can monitor the heat as well. If you use incense, you may have to quickly brush the point with the stick to get her to feel it initially as the incense does not burn as hot as moxa.
- Colleen Morris, L. Ac.
A: I found chiropractic adjustments worked well to turn my baby boy. I also used some inversions techniques. For example, lying backward in a recliner chair with my feet up and head down for 15 minutes at a time. I did this 3 times a day until I felt the baby turn. I finally got him to turn at 32 weeks.
I also got in the water A LOT. Swimming is an excellent way to encourage a baby to turn. The weightlessness can relieve a lot of pressure, open the pelvis and feel better for the mommy too. I swam, or just floated, with my head down and my feet up behind me for an hour or so at a time (being careful not to overexert myself or hold my breath for long stretches). Deep breathing and visualizations are good, too. I also credit the swimming and chiropractic adjustments with preventing another posterior baby!
- L.S.
A: I would love to see some professional assessments of the latest study on mode of breech delivery published in the Lancet (Vol. 356, October 21, 2000, p.1375-1383). The article titled "Planned Cesarean section Versus Planned Vaginal Birth for Breech Presentation at Term: a Randomised Multicenter Trial" by Hannah, Hannah, Hewson, Hodnett, Saigal, & Willan; clearly states that there are better outcomes when breech babies are delivered by c-section. While they address the issue of care provider experience, no midwives were included. I would love to see what Ina May Gaskin or Henci Goer have to say about this study.
I have always wondered about the wisdom of turning babies, feeling that they may be in that position for a reason. Yet if you can't get them to turn, then according to this article women are doomed to birth surgically. Comments?
- Amy V. Haas, BCCE
Fairport, NY
A: I'm a certified clinical hypnotherapist and I turned a breech baby in one hypnosis session! It was easy! You might also look for a hypnotherapist in your area.
- Ingrid
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Switchboard
Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
International Connections
I am from Africa and have a lot of experience with childbirth. If you know of midwives who will like to have some experience in Africa, I will be willing to help. Email me at megtomdio@hotmail.com
- Tomdio Maggie
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Please, are there any women out there who can send me here in India any information, studies, or cases they have experience with regarding breastfeeding after breast reduction surgery? I have a woman here whose milk supply is so low we have had to resort to supplementing her newborn with a bottle, and with inverted nipples on top of it she has had horrible cracks to contend with. Please email me at di_india@yahoo.com
- Diane
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I'm a French-speaking Haitian midwife who works with a French-speaking African population. I'm in search of some handouts/literature in French about STIs, pregnancy, birth control, etc. I have a very small budget. Please contact me at TeeniMJB@aol.com
- Martine
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====
A friend suffered from obstetric cholestasis with her first pregnancy. Itching occurred at 32 weeks and baby was born at 36 weeks by c-section. She is now well into her second pregnancy and at 28 weeks itching is reoccurring (a month earlier as predicted). She is fully aware that baby could be born any time on from 32 weeks this time. This is a very serious condition and has resulted in many fetal deaths because the cause of the itching was not known. Advice is to keep closely monitored. There are many interesting sites on the Internet concerning this condition.
- Anon
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Is it common for women in her late 30s having 2+ children to have stronger cramps, fainting spells, and soaking 4-5 pads in one day when the period returns after birthing?
- Susan
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I just had my third baby at home. I struggled with bleeding on and off for 7 weeks. I then had every other week cycles a couple of times. Is this normal?
- Melissa
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Re my question on ABO incompatibility in Switchboard Vol.3:11, I would like to make a correction: I am O+ and my husband AB+. Therefore, it is possible for my children to be B+?
- Claudine
Reply to: jscl@mindspring.com
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Has anyone heard of any dangers in using colloidal silver (orally or topically) during pregnancy or breastfeeding? Or are any dangers known for using it with infants? Many of my friends use it for their toddlers' ear infections.
- Joy, RN
Pensacola, FL
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I am trained at a hospital in Denmark. We use lidocaine gel with great success for suturing those with 1 degree and small second degree tears which need to be sutured. We also use xylocaine spray which seems to numb the skin better. We soak a piece of cotton with this, apply it and wait 10 full minutes before suturing. Benefits are no obstruction and a good numbing effect. So far there have been no adverse reactions as long as you know the woman does not have an allergy to lidocaine.
- Marlene, LM
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What about the use of nettles to prevent hemorrhage postpartum? I have read that it helps. Anyone have opinions on the use of nettles during pregnancy?
- Amy V. Haas, BCCE
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