Friday, August 15, 2008

The dance of breech

In Jennifer Block's Pushed, she discusses the disappearing art of vaginal breech birth, and the small groups of physicians and midwives going to extraordinary lengths to learn those skills--often halfway around the world--and bring them home to the communities they serve. This excerpt describes the characteristic movements women often make when birthing breeches (if, of course, they aren't restricted in their movement or positions.)

Jane Evans is about to catch a breech baby. The woman she's attending is on all fours, and the baby's buttocks are emerging: one cheek, then the crease demarking two; then one chubby leg plops down, then the other. The baby--a girl--is now dangling from her mother. "Most women left to their own devices will get on hands and knees," Evans explains, clicking to bring up the next slide. "The baby needs to turn its pelvis, which is really hard to do if mum is on her back." We next see her gloved hands gently bringing one of the baby's elbows down, then the other. "Remember, you're assisting progress--you're not pulling," she says. More of the baby hands gree--she's jerking her knees up in midair. Evans explains the mechanics at work; the head needs to be flexed chin-to-chest to be born safely. There are maneuvers an attendant can use to facilitate this; one is to reach up with a finger, find the baby's mouth, and draw the chin down. But here, the baby is doing it herself. "What happens when you lift your knees?" Evans asks rhetorically, as members of the audience bob their hands. "You drop your chin to chest." She clicks to the next slide. The mother has now sunk to chest and knees, butt to ceiling, with arms extended as if supplicating before royalty. "When the baby hits the G-spot, mother drops to the floor and goes Muslim," says Evans. Laughter in the audience. She grabs a skeletal pelvis and fetus doll off the podium, modeling how on supplication, the mother's pelvis pivots around the baby's head like a visor, setting it free. "And look," she says, moving to the next slide. "The baby practically slides out."

Evans is a British midwife who has been in practice for 30 years...We are in a low-lit auditorium at the Women's Hospital in Vancouver, British Columbia, and she is teaching vaginal breech 101. Not to the doctors at the hospital, though. Like nearly all obstetricians in North America, they no longer attend vaginal breech birth, instead performing a cesarean section. Evan's audience is mainly midwives from the United States and Canada who have come for a 2-day conference on the subject. Evans has flown in from England; Maggie Banks, midwife and author of Breech Birth Woman-Wise, has come from New Zealand; physicians from Belgium, Germany, Norway, the Netherlands, Australia, and across Canada have come to present research. Evans is introduced by Philip Hall, MD, the Manitoba perinatologist and professor of maternal-fetal medicine, who bemoans the current standard of automatic cesarean. "Can't we offer something better to women? Can we do anything to turn the tide?" he asks.

So aren't you just about dying to see this in action? All this talk of babies flexing their legs, of mothers supplicating earthward...but it's hard to imagine without ever having seen it. Guess what? There's a great photoessay from Evan's midwifery group The London Birth Practice showing a footling breech with Evans herself in attendance. We see the mom going from hands and knees to butt-in-air to release the baby's head. The baby flexes its arms and legs, just as Evans had described. You can read the mom's birth story here.

Anne Frye's Holistic Midwifery Vol II: Care During Labor and Birth explains the process of vaginal breech in meticulous detail on pages 933-971. She includes several illustrations of the dance of breech. Below is one set of illustrations, drawn from photos of the birth.


  1. So cool. I remember that passage from "Pushed".
    Another breech tidbit: The Farm midwives sort of all chant, "hands off the breech" and seem to find, if I recall, that women tend to dangle off the bed & the midwives basically sit on their hands if they must & only jump in to catch.
    Love your blog.

  2. Love this. Thanks for sharing!

    I birthed my frank breech (daughter #2)at home and pushed her to about her torso on a birthing stool. I then stood up and birthed the rest of her standing, with my husband underneath her dangling body only for support when catching.

    Yep, "hands off the breech" is what I had learned and I had read/been told that standing is one of the best positions as well. So, I prepared in advance and her birth (the actual pushing out of her lil' breech body) went just as I'd envisioned.

    Ahem, except for the almost 4the degree tear as one of her hands came down. LOL.

    My birth supporters never touched her body until she was passed from my husband, to them, and then quickly to me.

    Here's the looooooong story on my blog. :)

    Someday, my plan is to capture stills from the video of her birth and post them as pics.


  3. Leigh, thanks so much for your story. I'm sorry about the tear--ouch! I hope it healed quickly. Did you transport for stitches?

  4. That's so amazing! Things like that make me feel goosebumpy, it's so awesome what nature can do if left on it's own.

    I've heard both hands off the breech so as not to startle the baby and cause problems, and I've heard soft constant touching from the first moment of sight can keep a baby calm and allow gentle guidance.

  5. I have Doctors who can do breech delivery. One of them did when the Mom was fully and the thought of a C-section was just silly. However, the Hanna Study says that 6 our of 1000 breech births will not go well. With that literature accepted in the medical community, if a Doctor does a breech and it does not come out well, he/she does not have a leg to stand on. It is just too risky for them. We have just had 5 ob's leave to do other things because Ob is not the same as it used to be. We may soon have a very hard time having OB's deliver babies at all becaue many are not going into obstetrics. They pay 80 grand to malpractice folks just in order to practice. IF they didn't have to do this, they could spend much more time with their patients.

  6. OB malpractice premiums can be much higher than $80K in some areas. One of my students had a cousin practicing in Florida, and his yearly premiums were $250K.

    Although the short-term findings of the Hannah trial did find more injuries in the vaginal breech group, the 2 year follow-up found no difference between the two groups. Block's book has a good overview of the trial and the controversy surrounding it. One thing to remember is that it included a lot of vaginal breech births that were induced, augmented, and/or anesthetized--all criteria that many experienced midwives and doctors repeatedly say will make vaginal breech birth more dangerous.

    Thing is--no matter what the findings of a study are, a woman's right to informed consent and/or refusal trumps it.

    There's a fascinating discussion of obstetric risk distortion in the following articles:

    1) Lyerly AD, Mitchell LM, Armstrong EM, Harris LH, Kukla R, Kupperman M, Little MO. “Risks, values, and decision making surrounding pregnancy.” Obstet Gynecol 2007; 109(4): 979–984.

    2) Michael C. Klein, Murray W. Enkin, Andrew Kotaska, Sara G. Shields. “The Patient-Centered (R)Evolution.” Birth 34:3 September 2007: 264-266. (Written in response to the Lyerly article).

    From Klein et al:
    "The second type of risk distortion relates closely to this first issue, with any conceivable fetal risk superceding consideration of other potential risks. As noted by the authors, this risk distortion affects a woman’s choice of intrapartum care for trial of labor after cesarean. The other similar intrapartum issue is in a woman’s choice to attempt vaginal breech delivery. Here again, the guidelines that have resulted from studies about the safety of vaginal breech delivery promote what the authors call ‘zero tolerance' of fetal risk at the expense of discussion of other potential risks. The authors acknowledge the challenges of dealing with rare risks of bad outcomes and suggest that this is something that happens in other arenas of life and in other aspects of prenatal care. Their reminder to understand that 'eliminating risk comes at a cost'
    applies to intrapartum care for breech infants as well."

  7. Hey Rixa,
    I did not transport for the tearing as had an experienced person on call to suture me. And it actually did heal rather quickly with rest and herbs.

    I am thankful for you sharing this type of information, helping to normalize our options and choices in birthing.


  8. I showed those pictures to my boys, and they thought it was cool. I find pictures of breech births absolutely amazing, though I sometimes think how sore the mother must have felt to have the baby presenting that way. Maybe I think that just because of how sore I get when my babies are presenting.

    Thanks for sharing this link.

  9. I am so grateful for this post. Thank you for such a sensical and straightforward view of breech birth. I have not read your blog before but I will be now!
    Co-Founder, Coalition for Breech Birth

  10. I am so happy that these attendants would travel so far to learn this "art". Bless their hearts, and thank you for the great post. People just have NO idea how awful cesarean recovery is. ((((((shudder))))))

  11. Wonderful post, thank you!

  12. As I prepare to birth at home after a c-section, then a hospital vaginal breech birth (which was full of fear & panic from an overmedicalised hospital team) this story and pics is a beautiful light - thank you so much for sharing.

  13. I don't do many breeches, 'cause usually we get them turned in time, but I do do them, at home rather than transport for surgery, if that is what the parents desire. Never had any problems w the ones I've done, not to say I don't have a healthy respect for them!
    It makes sense to me that it would be safest to have a breech in water, but Michel Odent says no, safer standing. Whatever. I do admire him, and take to heart what he says, but I take all w a grain of salt.
    I have a dd who is an artist by nature. Whenb she wa little she would draw me thousands of intricate pictures. Way too many to save, except for a treasured few. One of which she drew at age 8 after a brother's birth, is a picture of me giving birth to a breech, standing up, surrounded by sibs. I actually gave birth lying on my side, to a head first baby, so I have no idea where she got inspiration for the standing breech picture!

  14. I am an Independent Midwife in the UK and have helped several women give birth to their breech babies. I was lucky enough to work with Mary Cronk the UK breech expert before she retired, and attended 3 breech cases with her. I have also worked with Jane Evans. We are all passionate about supporting women in their choices which include breech birth. Unfortunately midwives and doctors have lost the skills of facilitating spontaneous breech birth. The Good news is Jane Evans is still teaching and Mary and I are also teaching the skills to anyone who'll listen. A colleague called Shawn Walker has set up a website to disseminate information to health care providers and couples expecting a baby in the breech position see Love Joy Horner RGN. RM.


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