In the U.S. today, about 4 percent of babies are breech at full term, which means they’re in position to exit the uterus feet- or butt-first rather than headfirst. Before 1959, virtually all such babies were safely delivered vaginally; today, most are born by Cesarean section.
But as more mothers and babies are experiencing sometimes serious complications associated with surgical deliveries (in 1970, the C-section rate was 5.5 percent; today it’s 34 percent), some experts are re-evaluating their position regarding breech births.
Beginning in the 1960s, obstetricians gradually shifted the way they delivered breech babies because they preferred the predictability and the presumed greater safety of a C-section birth. But not every doctor jumped on the C-section wagon immediately; many continued favoring vaginal breech births. That is, until the Hannah Term Breech Trial (TBT) published in 2000 brought them to a screeching halt. The TBT followed 2,083 breech babies in 26 countries, randomly assigned to either vaginal or planned C-section delivery. Early data suggested fewer newborn deaths and injuries occurred in the C-section group.
“The impact of this study was stunning,” says Heather Weldon, M.D., an OB-GYN at Southwest Medical Group OB/GYN Associates in Vancouver, Wash. “Within months, breech C-sections went from 50 percent to 80 percent and, by 2006, 90 percent. Then, we found out the study was flawed."
In fact, critics began poking holes in the TBT immediately after its publication. For example, some poor outcomes attributed to vaginal delivery occurred in birth centers that used substandard techniques or unskilled birth attendants. Some babies had genetic defects or were premature. In short, most weren’t injured because they were delivered vaginally, but because of other factors. Further study indicated that most of the babies recovered fully from their birth injuries regardless of delivery method, and researchers also hadn’t factored in the increased health risks resulting from C-sections.
“The data actually support vaginal breech birth as safe in certain scenarios and not in others,” says Amy M. Romano, C.N.M., M.S.N., associate director of programs at Childbirth Connection, a nonprofit organization dedicated to promoting evidence-based maternity care. “The results should have supported informed decision-making, but instead, hospitals reacted by taking that choice away from women.”
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Another unfortunate result was that medical schools quit teaching vaginal breech delivery skills to entire generations of new doctors. “Any care provider can get surprised by a breech baby during labor, but many doctors don’t know what to do and that’s dangerous,” says Ina May Gaskin, C.P.M., founder of The Farm Midwifery Center in Tennessee and author of Ina May’s Guide to Childbirth (Random House) and Birth Matters (Seven Stories Press).
A baby can be breech off and on throughout pregnancy without causing concern. But after 32 weeks, it might be a good idea to try to reroute him if you want to avoid a C-section.
If he’s still breech at 35 weeks, care providers tend to worry, and if 37 weeks comes and goes, it’s time to take action: The closer it gets to your due date, the less likely it is for your baby to flip because there’s just not enough wiggle room.
The following two techniques should not be tried before 37 weeks because they may stimulate labor:
If you’re close to your due date, your baby is still breech and you want to avoid a C-section, surgery may be your only option unless you can find a doctor or midwife who is qualified and willing to deliver him vaginally or you don’t meet the criteria for a safe vaginal birth. For details about one hospital’s pioneering program, see below.
Oregon Health & Science University (OHSU) in Portland is among a few hospitals nationwide to support vaginal breech delivery. “Without hospital-based options, some patients attempt high-risk deliveries at home,” says Leonardo Pereira, M.D., OHSU’s chief of maternal-fetal medicine. “OHSU has established safety criteria for patients, and we are training clinicians to deliver breeches vaginally in order to make the service available at more hospitals in the future.”
Among other criteria needed to qualify for an attempted vaginal breech delivery, the woman must have her pelvis measured via an MRI, and the baby must be full term and in frank or complete breech presentation. Very small or very large babies may not qualify.
To find an appropriately trained doctor or midwife, call your closest academic health center and ask whether vaginal breech delivery is offered or whether they can refer you to providers who do offer it. You can also look for providers at midwife.org or birthpartners.org.
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