Am I a good candidate for vaginal breech birth?
The only absolute dis-qualifier for vaginal breech birth I’ve come across is having a stargazer. When a baby’s head is hyper-extended, s/he is called a stargazer and a breech birth would be very very dangerous. You want baby’s head to be tucked, chin to chest. This can be checked by ultrasound. Sometimes unknowledgeable or fearful caregivers create a stargazer during labor by pulling on the baby as it is being born. This is terribly dangerous.
The main question on everyone’s exclusion list is what type of breech you have. A footling, kneeling, or other type of flexed breech is the most tricky. When small parts are coming first (like feet) it makes cord prolapse not near as dangerous because there is nothing pressing on the cord, as long as the prolapse happens when birth is imminent. And you must be absolutely sure your cervix is totally open before you do any pushing. This can be hard with baby’s presenting part already descending.
A buttling (complete or frank breech) is easier to manage because the butt acts as a kind of head as far as blockage of the cervix (to prevent cord prolapse) and to exert steady pressure on the cervix for opening.
Some factors that may help your candidacy:
(None of these are true disqualifiers. They are merely things that make the decision easier.)
You have had a vaginal birth before.
You have not had a c-section.
You are generally healthy and not over 35.
Your baby is not measuring very large. *
Your pelvis looks nice and sizeable to anyone who wants to check it
For some caregivers, the following are a consideration:
You are willing to be active in labor.
You are willing to labor without drugs.
You will not be induced.
* Ultrasound is notoriously poor at predicting weight. One study showed that it is even worse at predicting the weight of breech babies.
What are the chances you actually really need a cesarean? Of course it depends on who you ask. Jane Evans and Mary Cronk, two highly respected UK midwives, have found that cesareans are necessary in about 20-25% of breech pregnancies. I wish I had known these Farm Midwifery Center statistics when I was pregnant. Ina May Gaskin and her colleagues have delivered every kind of breech at their center in TN. Of 2,844 Pregnancies between 1970-2010, there were 99 breeches. Most of them were Frank breech (75), with 24 Footling/Kneeling, and their total c-section rate for breech was less than 10%. (This is assuming you have someone as skilled and experienced as Ina May, Jane Evans, or Mary Cronk attending your birth.)
Twins. A recent White Paper (a white paper is an authoritative report or guide) says “there is little evidence to support the claim that twin pregnancies have beneficial outcomes when cesareans are performed. Hogle et al. (2003) performed a literature review and meta-analysis and found no advantage for cesarean delivery unless baby A was breech.41 More recently, a review of over 8,000 breeches in Scotland arrived at the same conclusion.41 The current trend for delivery of all twins via cesarean is likely driven primarily by physician discomfort with the uncertainties that occur during
labor in twin births.”
Prematurity. The paper mentioned above states: “Cesarean deliveries have increased for premature infants, but recent studies examining the relationship of cesarean and risk of neonatal death and intracranial hemorrhage have not shown any benefit from this increase except in the very specific case of premature breech babies.” Recent work in Frankfurt on vaginal breech birth puts the number at 32 weeks. After 32 weeks, they offer vaginal breech birth for early babies.
Perhaps you can know if it will be safe when you are in labor:
A number of caregivers, notably Michael Odent (of mother-baby friendly fame) say that in the vast majority of cases they cannot know if a vaginal delivery will be safe until labor has started. They use the first stage of labor as a test. If it goes quickly and all is well, the mother and baby are both doing fine, it’s a go. But if the first stage is very long, stop and start, mother is in a lot of pain or baby is showing signs of distress, they take is as a sign that the baby needs to come into the world by c-section.
Dr. Mayer Eisenstein, a doctor who has done several decades worth of home births in the Chicago area, has another rule for determining safety in vaginal delivery. It is simply that at 5 cm, if the presenting part of the baby is at a positive station (see video link), it is highly likely the mother will deliver without complication, no matter what part is presenting. Here is a video showing station of baby (illustrated-not graphic): http://www.youtube.com/watch?v=ze53Ep-gwBQ Read the whole bit here (http://rixarixa.blogspot.com/2007/11/simple-breech-birth-criteria.html).
Mary Cronk talks about the difference between breech delivery/extraction and breech birth. She encourages caregivers to keep their hands off the baby’s body, and discusses what makes vaginal breech birth safe. http://www.aims.org.uk/Journal/Vol10No3/handOffbreech.h
Here is an article on an Irish study of 298 women with extended breeches who had trial of labor. They had maximum labor times and avoided induction and pitocin. 146 succeeded and there were ZERO negative outcomes. (reprinted from gentlebirth.org)
(Reuters Health) Feb 10, 2003 - With proper selection based on prelabor criteria and careful management of labor, women with breech presentation can safely deliver vaginally, according to Irish researchers who described a prospective outcome study here at the meeting of the Society for Maternal Fetal Medicine.
The researchers at the National Maternity Hospital in Dublin followed all 641 women with breech presentation after 37 weeks during the four years from 1997 to 2000. Computerized records provided perinatal and labor outcomes.
A trial of vaginal breech delivery was allowed only if the presentation was extended type and if the estimated fetal weight was less than 3.8 kg. When vaginal delivery was attempted, labor induction was avoided as was the use of oxytocin, for either the first or second stages.
Slow labor was not an immediate reason to go to C-section. The threshold to send a woman in slow labor for a Cesarean was 6 hours for the first stage, and 60 minutes for the second stage, for a first birth. A woman who had already given birth before was allowed to labor in first stage for 4.5 hours.
Of 298 women who tried vaginal delivery, 146 succeeded.
"There are well-known criteria to have a safe, vaginal breech birth," said Dr. Karin Blakemore, of Johns Hopkins in Baltimore, Maryland, who commented on the poster presentation. "You don't offer vaginal delivery for big babies."
The Irish study presented here found "no perinatal death and no poor outcomes," as defined by an Apgar score of less than 7 at 5 minutes, or cord venous pH of more than 7.2, or abnormal neonatal neurology, Dr. Blakemore pointed out. "Zero is a powerful number," she said.
Why even try!? If it doesn’t work out you had to go through labor and get an emergency c-section!
True. Only you can can make this decision. It is not easy, especially if you are very worried about labor. If you plan to labor at home, a mid-labor transfer is not fun. If you plan to labor in hospital, you don’t have that to worry about, but you do have surgeons breathing down your neck. You must, like every mother, decide what is best for you and your baby.
A couple of things might help. You should know that, like the vast majority of “normal” out-of-hospital births, most transfers happen because of failure to progress and you talk about it with your midwife and get ready to head to the hospital. Most transfers are not 911 emergency transfers, even in breech.
If you have a trial of (un-induced) labor, you will get the benefits of that labor for yourself and baby. Plus, something I always thought was super cool, your baby--and not the hospital’s schedule--chooses his birthday.
If you end up transferring, you will know you did everything you could to avoid major abdominal surgery and give your baby a natural start to life.
Plus, an ‘emergency’ cesarean is not necessarily more risky than a planned one. In Birth Matters, Ina May Gaskin discusses a Dutch Maternal Mortality Committee that studied just those elective C-sections related to breech that took place between 2000 and 2002 and “found that four women died after elective C-sections performed simply because of breech presentation. During that same period, there was no maternal death after an emergency C-section for a breech. These Dutch data undermine the argument that emergency C-sections are necessarily more dangerous for the mother than those that are scheduled” (p.127).