Thursday, November 20, 2008

Books on breech birth

I have to return a stack of interlibrary loan books tomorrow, so I wanted to write up a review of two books devoted to breech babies.

The first is Maggie Banks’ Breech Birth Woman-Wise. Banks is a registered midwife in New Zealand and has worked in a home birth practice since 1989. She saw many breech births, vaginal and cesarean, during her student midwife days and while she worked as a hospital-based midwife. The vaginal births she saw, though, left much to be desired. Even if a woman was able to avoid the routine epidural, lithotomy, episiotomy, and forceps usually required for a vaginal breech delivery, the births were usually highly managed and babies were actively pulled, manipulated, and maneuvered out of the mother’s body.

The first breech birth she attended at home was a surprise—and was surprisingly straightforward. This led Banks to reflect on her experience and training with breech births:
However stunned I was at the time with an unexpected breech presentation, a similar thought came to me as it had many years ago with vertex presentation. I wondered how many of the problems associated with breech birth are created rather than inherent to breech birth. The answer has led me to support women, who make an informed decision, to birth at home with their breech babies.
Banks notes that midwives have largely lost their knowledge of physiological breech birth, since they often have only seen highly medicalized vaginal or cesarean deliveries for breech presentation. Her book seeks to categorize that knowledge so that women can continue to choose to give birth to their breech babies, rather than be delivered either vaginally or via cesarean. Her books is aimed towards midwives and expectant mothers, especially those facing a persistent breech presentation.

Many of the chapters cover fairly non-controversial topics: types of and reasons for breech presentations, methods of diagnosing a breech presentation, risks associated with breech presentation, evidence for and against medicalized breech birth, and how to encourage a breech baby to turn. Another chapter discusses factors in planning a breech birth, some of which are specific to New Zealand’s maternity care system. Another chapter discusses how to evaluate the newborn breech baby for hip dislocations, which are more common with babies who have been in a breech position for a prolonged period of time.

The last part of the book is the most fascinating and probably the most controversial. Banks outlines a midwifery-based physiological approach to attending breech births, including ideal positions for labor and birth, giving birth actively using upright and mother-directed positions, and techniques for assisting breech births when certain complications or unusual situations arise. The chapter on giving birth has some astounding series of photographs documenting several spontaneous, hands-off breech births. The women are kneeling or standing, and the baby emerges with no assistance or manipulation by the attendants. Int fact, Anne Frye’s textbook series borrowed these photographs for her illustrations of breech births. This approach to vaginal breech birth is the one I discussed in The Dance of Breech.

The second book, Breech Birth by Benna Waites, is a comprehensive examination of everything and anything surrounding breech babies. Four weeks before her baby was born, Waites discovered her baby was breech and embarked on a desperate search for information. From pregnancy advice books to medical textbooks, she was only able to find scattered, limited information—nothing extensive enough to answer her many questions. She was able to find a consultant (senior) obstetrician to attend her vaginal breech birth. This journey spurred her to write a comprehensive, exhaustive book about breech birth.

Exhaustive is a very fitting term in both of its connotations: this book is thorough and meticulous and examines every aspect of breech presentations and birth. It is also so thorough that it may leave the reader a bit exhausted herself! In fact, a consultant OB commented about her chapter on the evidence for vaginal versus cesarean section for breech: “This section is exhaustive and exhausting.” However, do not be intimidated by the depth of information in this book. Each chapter is organized with a concise summary and slightly longer conclusion summarizing all of the main points of the chapter. Breech Birth also includes some photographs of active breech births, although not as many as Breech Birth Woman-Wise.

Besides researching the medical and midwifery literature on breech birth, Waites interviewed nine midwives and obstetricians who have extensive experience with vaginal breech births. The perspectives of these attendants—sometimes agreeing with each other, at other times diverging on certain points—are fascinating and an invaluable resource as vaginal breech birth is fast becoming an endangered species.

Waites does not argue for one overall solution to breech birth. She has a strong interest in examining all of the evidence for breech birth, from opinion and anecdote to clinical experience and research studies. She notes that with breech birth, opinion is often presented as fact. Her books strives to delineate what, if any, uncontested facts can be asserted about breech birth (the only universal one, she argues, is that cesarean section more dangerous for the mother than vaginal birth). Even today, uncertainty is the rule with breech birth. She writes:
there are few certainties when it comes to weighing up the options for breech birth. Even with the Canadian multicentre international breech trial, published in 2000, paraded by some as delivering “the answer” to the breech conundrum (the answer apparently being to routinely offer caesarean section for breech, there is sufficient criticism of the study (see Chapter 8) to leave many feeling that the answer still eludes us. Overall the body of research we have often produces mutually conflicting data, and conclusions often state that studies of sufficient size and good enough design have not yet been carried out. The active, spontaneous approach to vaginal breech birth, described in more detail in Chapter 10 and espoused by some as the only safe way to conduct a vaginal breech birth is yet to be properly evaluated. Uncertainty should therefore be the uncomfortable though realistic norm in cases of breech.
I will not attempt to summarize each chapter in this review—there is simply far too much information to cover—so instead I will list the chapters. This gives a good overview of the topics covered in Breech Birth.

Part I: The what, why, and how does it feel? of breech
Chapter 1: What is a breech baby?
Chapter 2: Why are babies breech?
Chapter 3: The wrong way up? The emotional impact of breech

Part II: Turning Breech Babies
Chapter 4: An introduction to turning breech babies
Chapter 5: External cephalic version (ECV)
Chapter 6: Factors influencing the success of external cephalic version (ECV)
Chapter 7: Self-help and alternative therapies for turning breech babies

Part III: The evidence on vaginal and caesarean breech birth
Chapter 8: Vaginal versus caesarean breech birth: the evidence
Chapter 9: Selection criteria for vaginal breech birth
Chapter 10: The management of vaginal breech birth
Chapter 11: Emergency caesarean section after a trial of labour: not the worst of both worlds?

Part IV: Making a decision about the birth and negotiating for what you want
Chapter 12: Making your decision about the birth
Chapter 13: Negotiating for the birth you want

Of all the chapters, I found Chapter 10 the most interesting. She covers various approaches to vaginal breech birth, from medically managed breech deliveries to hands-off vaginal breech births. She covers topics such as epidurals, breech extraction and assisted vaginal delivery, forceps, various breech maneuvers, Pitocin induction/augmentation, episiotomy, cord prolapse and/or compression, head entrapment, and fetal monitoring. She describes two different techniques for natural, spontaneous breech birth: “hands-off” (à la Maggie Banks, Mary Cronk, and several of her OB interviewees) and “hands-on” breech birth (à la Ina May Gaskin and the other Farm midwives). She discusses justifications for various positions during labor; her interviewees and many other practitioners have found that upright standing or kneeling positions are so much easier than births where the mothers have their legs up in the air. From the summary of this chapter:
The management of a vaginal breech birth is immensely controversial and particularly striking for the coexistence of starkly opposing views. Some argue that epidurals and forceps are essential to promoting safe vaginal delivery while others argue that this is actively harmful. The little evidence we have seems to suggest that less interventionist approaches permitting more spontaneous breech births are associated with better outcomes.
Although I enjoyed both books, I would definitely recommend Breech Birth as the must-have of the two (in part because Waites thoroughly covers Banks', and many other midwives', perspectives on vaginal breech birth). I suggest that all midwives, physicians, doulas, and childbirth educators have a copy of Breech Birth on hand. Because it is published in the UK, it is not easy to obtain at a last minute notice—which is precisely when a woman, close to her due date, is trying to figure out what to do about a baby suddenly presenting, or refusing to turn from, breech. The book is written for a wide audience, from physicians, midwives, and medical students to childbirth educators and parents of breech babies. It is thorough in its research but still accessible to a lay audience without being overly simplistic.


  1. Wow. That would have been good to read when my baby was breech. Thankfully she turned. Thanks for putting such great information on your blog.

    By the way, have you seen the giveaway over on my blog? You might like it.

  2. Both of my girls were Frank breech (the most favorable to birth vaginally, according to most). I have yet to read these books, but really should.
    My first was discovered breech at 9cm during my planned homebirth. For a variety of factors (none emergent) we transported and I elected (for a variety of very difficult reasons) for a C-section. What I really wanted to do was head back home and birth her vaginally.
    Two years later, I suspected my next daughter (planned homebirth) was breech and it was confirmed via ultrasound. I tried Moxa, Acupuncture, gentle Webster, tilts, etc. Finally, I vowed to myself and my baby that I would stop - and that she would choose to be born exactly as she needed.
    I talked to experts in my birth community and learned some tips and advice on birthing a breech baby vaginally.
    I was not scared. I made an informed decision, what I felt was best for me and my baby.
    I had amazing support and confidence - due to this, I truly had no fear.
    Suffice it to say, her birth (the pushing stage, to be precise) went exactly as I'd learned. Beautifully, painlessly, and rather slowly. I knew what the "critical moments" were and remained focused on those.
    I had come full circle, knowing I likely could have birthed my first daughter vaginally too.
    I now believe (probably due to pelvis shape) that all my babies will be breech. I am prepared to birth them at home, vaginally. It is all I know.
    Thank you for sharing this, Rixa. We have a long way to go in terms of support for birthing breeches.

  3. Thanks for this review! I've never had to opportunity to read Breech Birth, and am only familiar with Maggie Banks' book. It sounds like I have a book to buy for myself come this holiday season!

  4. Thanks for that review. Like Radical Midwife I am only familiar with Maggie's book. My question is: how influential can books like this be considering the global obstetric opinion in developing countries about the delivery of breech babies ie elective CS?

  5. Sarah,

    I think that would be one of the frustrations for a reader of either of the two books. Still, Waites' book is a fantastic resource not only for parents, but especially for physicians and midwives who would like to carefully review all of the evidence. It's a real struggle to find anyone who will do a vaginal breech, but they still exist and I find great hope in people like Andrew Kotaska, a Canadian family physician who went back to get OB training because he lives in a very remote location with no OB backup. He is highly committed to offering vaginal breech birth and traveled to Germany to learn how.

    Also, without these resources, how can expectant parents even educate themselves enough to advocate for vaginal breech birth? That's another reason I love Waites' book; it has just about anything breech-related presented in a clear fashion that stresses that breech birth is a complex, contested area that parents should carefully research.

    But yes, the global climate for breeches is quite disheartening for people who, for a number of reasons, feel strongly that vaginal breech birth is important to preserve.

  6. You're totally right, Rixa, about getting the word out. What saddens me is that so many of us midwives (myself included) have lost our confidence and competence in this area of midwifery practice, so even when a woman comes to us asking for vaginal birth, we do not have the skills to support her, so its a real 'catch 22' situation.

  7. We had the great pleasure of having Maggie Banks in our city, Vancouver, BC during the International Breech Conference.

    What a difference between the approach of Maggie Banks and Mary Cronk's partner, who also presented. Mary Cronk always makes the distinction between breech "birth" and breech "delivery". Two very different things. One of the doctors inferred that they were showing "carefully selected" slides of women birthing upright at home. I don't think that any of the physicians who came could even picture a woman off a bed with no epidural/pit drip.

    After spending a whole weekend with physicians and midwives who attend homebirths, you could really see the chasm between the two approaches.

  8. Rixa, thank you for the excellent reviews. Thanks also for suggesting in your last paragraph that birth workers ought to have Breech Birth on hand for ready reference. I hope many reading here will heed it: I was a last-minute-scramber for breech info; though I had browsed a lot of breech literature in my doula days, one is reading with a different set of expectations while carrying a term breech baby.

    Waites' conclusion that uncertainty is the expected norm for breech is both difficult if you like definitive answers, and at once liberating -- for those of us who advocate informed choice in birth; because since we cannot be certain which type of management (or lack thereof) is safer, mothers and their care providers should be free to carefully choose what they personally feel most comfortable with. In other words, all else being equal, in theory we are not bound by risk assessment.

  9. Rixa,

    Do you know if Benna Waites has contact information in her book?

    I'd love it for the Breech Conference planning. I'm bummed (how's that for a pun) that I have not purchased this book, as I have contact with a woman who has a bicornuate uterus and an OB willing to attend a breech vaginal birth, but fearful.

    I had been meaning to order the book a while ago (sigh).

    It also looks like you had your baby; Congrats!

    Christie (Coalition for Breech Birth)

  10. No need to apologize, Rixa. I knew it was a long shot, but thought I'd ask.

    Thank you very much!


  11. I want to learn all I can about breech birtha and will be purchasing this book in the near future. My first child was taken at 37 weeks because she was breech. I so wish I had known of homebirth midwifery then and all I know now. There is no way I would have let them bully me into the c-section had I been properly informed and know what I know now!

  12. I was living in Oxford, England in 1997 when I arrived at the hospital to deliver my 4th child. We soon discovered that he was inverted, and it was too late for an I advocated for a vaginal delivery. Three days before an ultrasound revealed he was inverted, when I arrived at the office for an inversion? Well, it was revealed via ultrasound that he was now in a head down position. My explanation was that I must have a size XXL uterus after carrying 4 babies. I realize this would have been considered very risky (perhaps unacceptable?) procedure in a USA hospital. He was 8.14 and came out in the "star gazing" position w/ his left arm twisted around his head. He was in a classic Frank breech position. I am very grateful to Sheila Kitsinger and the midwives and doctors at the John Radcliffe hospital for cooperating w/ my request to attempt a vaginal delivery. It was a demanding and exhausting process, however it was drug free and difficult, but never considered an emergency. My son was floppy upon arrival~ w/ very weak apgar scores. He spent his first night in a little ICU unit...but he breast fed immediately, which I took as a very promising sign. I would be willing to comment on the process if anyone is interested to hear from the perspective of a mother delivering vaginally w/o drugs.

  13. ps: I delivered a child in the breech position 15 years ago this month, and I'm delighted to report he is bright and healthy and taking Honors classes in H.S. His delivery was a bit traumatic...yes...but it was not damaging to him, more so than any delivery which is troublesome. He was the one who turned himself around! And if you were to meet him? It makes perfect sense that his arrival would be bottom first! I'm very grateful for his delivery and the care I received from Midwives in the UK and then a sensitive OBGYN doctor...grateful for the natural process. It is possible!!!


Related Posts Plugin for WordPress, Blogger...