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.