Little did I know, when I witnessed my first vaginal breech delivery at a small county hospital in middle Tennessee in 1972, that I was seeing a physiological process that was being rapidly phased out in the US. The birth was to a mother having her first baby. She had planned a homebirth, with me as her midwife. I discovered in early labor that the baby was a frank breech (buttocks first, legs straight up), and my training had not included how to deal with such a presentation. Off we went to the hospital. When we arrived, no one there even considered cesarean section as an option. At the time, I didn’t know anyone who had had a cesarean. This isn’t surprising—30 years ago, the cesarean rate in the US was a little more than 5 percent, and then as now, women with breech presentations accounted for only 3 to 4 percent of all births.
WHEN VAGINAL BREACH BIRTH WAS THE NORM
Over the next two years, six more breech babies in our practice were vaginally born at that same hospital, and a surprise breech fell into the hands of my midwifery partner, Pamela Hunt, at the mother’s home. There was never a hint from any of the several physicians involved that a cesarean might be better or safer for the baby. At our local hospital, it appeared that all physicians attending births, whether they were family doctors or obstetricians, were expected to be competent in the art of vaginal breech birth. It was the policies of other US hospitals that later made us aware of the trend taking place in the rest of the country vis-à-vis breech birth—the increasing use of cesarean section, without a trial of labor.
During the mid-1970s, one of the doctors in our area—our mentor, John O. Williams Jr.—taught us midwives how to attend vaginal breech births at home. He had had to provide that service for many years to the Old Order Amish community, population 5,000, which meant caring for Amish women, some of whom had 15 babies or more. When he passed part of his practice on to us midwives, he knew that the women in the Amish community would now and then continue to need midwives who were expert in the art of breech delivery. During this same period, women from different parts of the country began applying to come to us for vaginal breech deliveries, making me aware that some doctors were calling for routine cesareans for all breeches, no matter what this meant for the women involved.
MANDATORY CESAREANS FOR BREACH BIRTHS
The first call for mandatory cesarean for breeches in this country actually had come in 1959, in an article written by Dr. Ralph Wright. Wright provided case studies of three stillbirths after vaginal breech deliveries that had recently taken place at his hospital. Each was a forceps delivery, with the mother under general anesthesia. What Wright left out of his argument was any recognition that other services were apparently able to handle breech deliveries without fatal injuries to babies. He never commented on whether there had been any serious or fatal injuries to babies after cesarean sections.1 Wright’s argument boiled down to this: The recent bad outcomes from attempted vaginal breech deliveries at our hospital demonstrate that the process of breech birth is inherently flawed; because of this, all breech babies should be surgically delivered. At no point did Wright entertain the possibility that a conscious mother, better obstetrical technique, and less anesthesia might have produced better results. Never did he examine what the consequences might be if the next generation of obstetricians never had the chance to witness a vaginal breech birth.
Wright’s article came only three years after the publication of two major articles on a large series of breech births at several major hospitals at which the cesarean rates for breech ranged between 6.8 and 18.8 percent.2, 3 One of the authors, Dr. Goethals, pointed out that maternal deaths were more likely to occur after cesarean than after vaginal birth, and he offered evidence of this fact gathered from his hospital.
It is important to recognize that most American women who had breech babies in the 1940s and 1950s gave birth to them while lying on their backs, unconscious from general anesthesia. Others were under the influence of scopolamine, which normally meant that they were tied down. This was a time when it was common for forceps to be applied to the head in a vaginal breech, too often with disastrous results for the baby.4, 5
CESAREAN BECOMES THE NORM
The cesarean delivery rate for breech presentations rose from 11.6 percent in 1970 to 87 percent in 1987, when the cesarean rate for all births was nearly 25 percent.6 By this time, studies began to appear that showed that routine cesarean section did not necessarily protect breech babies from injury during delivery. The injuries were often the same as those cited for vaginal breech birth: intracranial injuries, brachial plexus injuries, fractures of the limbs, and injuries to the facial nerves.7–11 And with cesarean, a new category of injury was added: accidental laceration of the baby’s buttocks.12
When we compare today’s situation to that of 50 years ago, the differences could scarcely be greater. The cesarean rate for diagnosed breech presentation is more than 95 percent, and it’s increasingly unusual to meet women of childbearing age who have given birth to a breech baby vaginally. Vaginal breech birth is now so rare that very few medical or midwifery students have an opportunity to see it even once during clinical training. With little or no chance to be mentored by a clinician with significantly more experience in breech labor and birth, they lack the skills and knowledge that a safe and competent practitioner in this area should have. This lack of skills and confidence continues to drive the cesarean rate for breech presentations even higher and contributes to accidental injury of the baby during cesarean delivery.
UNDIAGNOSED BREACH BIRTHS
This situation leads to a new danger: What happens when a physician encounters an emergency vaginal breech birth when he or she has never before seen such a birth? Some breech babies are born too quickly for a cesarean to be performed. An example of what can happen was related to me by a nurse from an east Tennessee hospital some years ago. A young first-time mother was brought into the maternity ward in very strong labor. Her baby, a footling breech (one or both feet first), was about to be born, and the only doctor in attendance was panicking because there was no anesthesiologist present for a cesarean. The baby’s body was quickly born, and just then, the anesthesiologist entered the room. The doctor had him put the mother under general anesthesia, which made her unable to push the baby’s head out. The baby was stillborn by the time the doctor was finally able to extract the head.
The undiagnosed breech happens more often than most people imagine. In one study, the portion of all breech deliveries that were undiagnosed reached 40 percent.13 In other studies, the rates of undiagnosed breeches ranged from 17 to 33 percent.14–16 The majority of injuries in cases of vaginal breech delivery are those caused by pulling or jerking on the baby’s body in an effort to hasten delivery. A panicked, inexperienced physician might resort to such measures, unaware of how much force he or she is using. It was precisely for this reason that some obstetricians, writing a generation ago, called for taking more time, using mannequin demonstrations of proper breech technique and other ways of training younger obstetricians in breech delivery. Videos of well-conducted breech births might also be a good resource in medical schools, but these are now in short supply because insurance companies have threatened to refuse malpractice insurance to hospitals that permit planned vaginal breech births.
DOCTORS AND MIDWIVES WHO DELIVER VAGINAL BREACH BIRTHS
Physicians who work in maternity units where neonatal outcomes after vaginal breech birth are good are the practitioners most likely to be able to keep open to pregnant women the option of vaginal breech birth. I’ve met several obstetricians from Scandinavian countries who belong to this category. Countries with resources too limited to assure a woman with a breech presentation or multiple gestation access to a cesarean before she goes into labor are also likely to see the wisdom of continuing to prepare their obstetricians and midwives for vaginal breech births.
The daughter-in-law of the late Lawton Chiles, a US senator and later one of Florida’s most popular governors, planned to give birth to her second child at a hospital because the baby was a breech presentation. Her labor began so quickly that she was unable to get to the family car, so she had her husband call 911. The paramedics arrived in time to witness the emergence of the baby’s body but had no idea how to assist the birth of the head. Fortunately, a Florida-licensed midwife, Doreen Virginiak, who was also a paramedic, heard the emergency call and arrived on the scene just after the birth of the baby’s body. Because she was familiar with the maneuvers necessary to deal with safe birth of the head, she was able to complete the delivery in time for a good outcome.
May all midwives and physicians in this country be similarly prepared. I cannot persuade myself that women or their babies are truly well served when physicians are no longer taught the skills to safely assist all of those babies who can be vaginally born. The proper teaching of obstetrics ought to be geared toward adding skills, not limiting them.
1. Ralph C. Wright, “Reduction of Perinatal Mortality and Morbidity in Breech Delivery through Routine Use of Cesarean Section,” Obstetrics & Gynecology 14 (1959): 758.
2. Thomas R. Goethals, “Cesarean Section as the Method of Choice in Management of Breech Delivery,” American Journal of Obstetrics and Gynecology 72 (1956): 977.
3. J. Edward Hall and Schuyler Kohl, “Breech Presentation: A Study of 1,456 Cases,” American Journal of Obstetrics and Gynecology 72 (1956): 977.
5. Alan Rubin and Gifford Grimm, “Results in Breech Presentation: A Seven-Year Study,” American Journal of Obstetrics and Gynecology 86 (1963): 1048–1049.
6. M.S. Croughan-Minihame et al., “Morbidity among Breech Infants Ac- cording to Method of Delivery,” Ob- stetrics & Gynecology 75 (1990): 821.
7. S. M. Taffel et al., “Trends in the United States Cesarean Section Rate and Reasons for the 1980–85 Rise,” American Journal of Public Health 77 (1987): 955–959.
8. Bethesda, Maryland: National Institute of Child Health and Human Development, National Center for Health Care Technology, Cesarean Childbirth: Report of a Consensus Development Conference, NIH publication no. 82-2067 (1982).
9. R. K. Tatum et al., “Vaginal Breech Delivery of Selected Infants Weighing More Than 2000 Grams,” American Journal of Obstetrics and Gynecology 152 (1985): 145.
10. D. B. Petitti and I. M. Golditch, “Mortality in Relation to Method of Delivery in Breech Infants,” International Journal of Gynaecology and Obstetrics 22 (1984): 189.
11. P. E. Fehr, “Management of Breech Presentation at Term,” Min-nesota Medicine (August 1984): 439.
12. J. Smith et al., “Fetal Laceration Injury at C-Section Delivery,” Obstetrics & Gynecology 90 (1997): 344.
13. R. A. Flanagan et al., “Management of Term Breech Presentation,” American Journal of Obstetrics and Gynecology 156 (1987): 1492.
14. J. Cockburn et al., “Undiag-nosed Breeches Presenting in Labour—Should They Be Allowed a Trial of Labour?” Journal of Obstetrics and Gynaecology 14 (1994): 151.
15. W. C. Leung et al., “Undiagnosed Breech Revisited,” British Journal of Obstetrics and Gynaecology 106, no. 7 (1999): 638.
16. E. C. Nwosu et al., “Undiag-nosed Breech,” British Journal of Obstetrics and Gynaecology 100 (1993): 531.
17. M. E. Hannah et al., “Planned Caesarian Section versus Planned Vaginal Birth for Breech Presentation at Term: A Randomised Multicentre Trial,”
The Lancet 356 (2000): 1375.
18. Benna Waites, Breech Birth (London: Free Association Books, 2003).
19. J. Van Roosmalen and F. Rosendaal, “There Is Still Room for Disagreement about Vaginal Delivery of Breech Infants at Term,” British Journal of Obstetrics and Gynecology 109 (2002): 967–969.
20. I. P. Stuart, letter to the editor, Lancet 357, no. 9251 (2001): 225.
21. M. H. Hall, letter to the editor, British Medical Journal 308 (1994): 654.
22. M. Hall and S. Bewley, “Maternal Mortality and Mode of Delivery,” Lancet 354 (1999): 776.
23. R. J. Lilford et al., “The Relative Risks of Caesarean Section (Intrapartum and Elective) and Vaginal Delivery: A Detailed Analysis to Exclude the Effects of Medical Disorders and Other Acute Pre-Existing Physiological Disturbances,” British Journal of Obstetrics and Gynaecology 97 (1990): 883–892.
24. J. Jolly et al., “Subsequent Obstetric Performance Related to Primary Mode of Delivery,” British Journal of Obstetrics and Gynaecology 106 (1999): 227–232.
25. N. Schuitemaker et al., “Maternal Mortality after Caesarean Section in the Netherlands,” Acta Obstetricia et Gynecologica Scandinavica 75 (1997): 332–334.
For more information about breech delivery, see the following articles in past issues of Mothering: “Vaginal Breech Delivery,” no. 40; “A Footling Breech,” no. 21; and “Homebirth in Puerto Rico: Breech Tilt Position,” no. 19.
Ina May Gaskin, MA, CPM, PhD(Hon.) is founder and director of the Farm Midwifery Center. Founded in 1971, the Farm Midwifery Center had handled approximately 3000 births by 2011, with remarkably good outcomes. Ms. Gaskin herself has attended more than 1200 births. She is author of Spiritual Midwifery, Ina May’s Guide to Childbirth, Ina May’s Guide to Breastfeeding and Birth Matters: A Midwife’s Manifesta. Gaskin is the recipient of the 2011 Right Livelihood Award and was inducted into the National Womens’ Hall of Fame in 2013.