Sunday, May 30, 2010

Confidence, competence, and preserving breech birth at home

Just a few days after my review of Karin Ecker's documentary "A Breech in the System," Australian midwife Lisa Barrett posted the story of a breech home birth she attended (watch the birth video here). Both women's stories are remarkably similar. Originally planning to use in-hospital birthing centers, they are told their only option is a planned, pre-labor cesarean when their babies turn breech. Both women go through great lengths to encourage the baby to turn, including an attempt at ECV. Both find encouragement and support from home birth midwives, even though neither one plans a home birth. Both plan a natural breech birth "in the system."

The woman whom Lisa attended had settled on a hospital birth with Lisa attending and supporting her. However, once she went into labor, her plans changed. (Read the story, linked above, for the surprising conclusion.)

I admire Lisa for her generosity in helping this woman at the last minute. In fact, when Dio was breech and I was wondering what I would do, Lisa invited me to come stay and birth with her. I was floored by her offer. At that point, we had not yet met in person, so she only knew me from my online presence. Lisa's the invitation meant so much to me during that time of upheaval and uncertainty. Fortunately, Dio turned vertex and I did not need to consider traveling halfway around the world.

One problem with preserving the art of breech is that of numbers. Very few obstetricians, let alone midwives, have attended a significant number of vaginal breech births. However, a birth attendant needs to be both confident and competent in attending breeches. Confident enough to stay calm, to keep their hands off the breech,  and to know their limits. Competent enough to have seen and dealt with the rare but serious complications of breech birth, in addition to a sufficient volume of "uneventful" physiological breech births.

I feel strongly that we need to preserve not only vaginal breech birth, but also vaginal breech birth at home. In today's obstetric climate, it is often the only place where a woman can avoid a cesarean for breech. And even if she can find an OB willing to attend a breech birth in a hospital, a woman often faces an uphill battle for an undisturbed, peaceful birth. Lisa's client commented on the advantage of giving birth to a breech at home: "Being at home meant we didn’t have to negotiate for a normal physiological birth without intervention – it was assumed because there were no problems." Not all women wanting a vaginal breech birth will chose to do so at home, but losing or outlawing that option would mean a great loss for women's autonomy and their ability to choose what is best for their babies and their bodies.

Lisa's client ended her story with these remarks:
I’m so grateful that I was able to have a natural breech birth without panic or fear. The birth of our daughter was such a fantastic, positive experience and it saddens me to think that women are led to believe that breech birth is always dangerous or even impossible. As a woman in the public hospital system, I became a black sheep because I questioned their policies and their underlying evidence and refused to accept their way as the only way. I was too much trouble and was effectively turned away. The only reason I was able to birth naturally was because I was lucky enough to find a midwife who believed in birth and believed in me and because I have a like-minded husband who supports me. These things don’t necessarily guarantee anyone a birth free from intervention, but they certainly give the birthing woman a say as to what happens to her baby and her body, placing her at the centre of the decision making process – which is exactly where she should be.


  1. I've had the privilege and honor to assist in the home delivery of three breech births. One on land and two water births. All three were calm, matter of fact births with no drama or ill effects for mother or child. A fourth, unsuspected, breech that same year (I know, our statistics were NUTS that year!) came so quickly and easily, s/he was caught by the father before the midwife and I could arrive!

    It is sad, indeed, to think that the art of natural breech birth is being lost.

  2. I am grateful to have had a midwife who could handle our unexpected breech baby born at home. I agree with what Lisa's client sums up.

  3. I have one relative who lost a baby due to breech birth---the reason behind the interventions is the risk of a bad outcome---and in this case, a bad outcome means a dead or brain-injured baby! Why would you risk that? Please remember that what you advocate is very dangerous.

  4. I, too, know of a family here in the South who lost a baby due to an attempted home breech birth. I know that there are a lot of unnecessary c-sections that take place, but I can't help to feel that a breech positioned baby is a situation where a c-section is the safest thing. Isn't the goal to have a healthy baby and not to be able to brag, "I had a breech home birth!" My husband and I lost a newborn premature baby ten years ago, and it is not something that I would wish on anyone. Certainly we are to be responsible for our bodies during birth...but that's just the point-we need to act RESPONSIBLY...and that may mean to thank God that the medical knowledge and intervention of a NECESSARY c-section is available. Are the risks really worth avoiding a cesarean for a breech baby?

  5. My grandmother lost a baby in the 1940's when giving birth to a breech baby at home. She lived in a tiny Midwestern town so there really was no choice but to give birth at home. When I was 36 weeks with my son and planning a home birth, we discovered that he was breech. When I told my grandma I could see the terror and pain in her face. She pleaded with me to go to the hospital. I did and luckily he turned and I had a successful vaginal delivery at the hospital. But that look on my grandma's face will forever haunt me and be a reminder of the terrible outcome that is possible in these situations. I hope anyone considering home birthing a breech baby will do so with much thought and prayer.

  6. There are numerous situations in which it has been argued that a C-Section is required. Any variation of norm now seems to fit that bill.

    Angela, I'm very sorry to hear of such a sad outcome in the case of your relative, but that is still not sufficient justification to say that all breech babies should be sectioned. It is a major surgery that puts both the mother and baby at risk, and can have long lasting consequeces for both of them.

    No-one goes into a homebirth without much thought and research. I'm extpecting a VBAC baby any day now, and a lot of heartfelt thought went into deciding to birth at home.

    This baby is not breech, but I would still choose to birth at home if he suddenly turned that way, because in any given situation, someone always knows of a story about when things went wrong. I know of plenty of stories where a C-Section has ended badly for both mother and baby as well.

  7. I understand that the risks of breech birth are slightly higher than a normal birth. But I believe that saying all breech birth should be c-sections because some babies have died is a logical fallacy.
    I could make the same argument for a baby who is head up. Some babies die from complications of just being born. That does not mean they should be surgically removed. the best approach would be to have a Trained professional who knows the dangers signs and what to do if a problem arises.

  8. Jane1973 and Mrs. Schaible,
    You've given me some more info to think about! Thanks!

  9. There are many unsafe ways to birth a breech baby, that doesn't make breech birth in its own right unsafe.

  10. A cesarean or forceps pullout of a breech baby can lead to cerebral palsy or death. There is no 100% safe way to birth any baby. Most physicians who do vaginal breech births in hospital want pitocin running so there are no "halts" in the birthing process (especially with the body out and the head in). This is logical, but that pitocin can cause the placenta to separate prematurely and then you have a baby with no oxygen supply.
    Most hospital breech extractions are also with epidural which affects the baby negatively.

    We tend to buy into the belief that the most aggressive approach will result in the healthiest outcome but it's just that a "belief". Any obstetric nurse will tell you that the outcome of breech birth can be less than optimal no matter what method is used. There is a certain woman who wants to have Mother Nature firmly on her side with a breech birth and that is a sane choice. A natural breech birth at home is a very different phenomenum than a medicated breech extraction in the hospital.
    Gloria lemay, Vancouver BC

  11. As I told Rixa, I am unable to comment on her site… a glitch in BlogSpot sometimes.

    I envy the midwives who are learning or know how to deliver breech babies vaginally. It is a skill I cannot ever imagine learning… unless I, too, travel very far to do so.

    For me, it isn’t enough to book learn or even practice it with dolls. I would need to see several breech births and how does one plan for that? I can see me traveling around the country as midwives call me to the women’s births. Not very practical or likely.

    I had a surprise breech (I was the overseeing midwife for a new, waiting-for-her license midwife) in a primip and have replayed it in my head a thousand times. She was in the pool when we realized the presenting part, visualized, and so began the automatic motions to get her to the hospital for a cesarean. We called 911, she got onto the bed in a knee-chest position and the butt never presented more than it did. Not there on the bed. Not in the ambulance. Not when she was on the delivery table. She was given general anesthesia and had her breeching baby taken out of her uterus “from the top.”

    Even reading this, I am so embarrassed by my actions. This was more than 2 years ago and the sting is greater than it was immediately postpartum. I still don’t know if I was wrong; I have no training and what if what if what if? Why didn’t I have her keep pushing even after we called 911? Was the baby not coming down because she wasn’t fully dilated? Getting her on the bed was stupid; we should have left her in the pool… she was doing so well.

    I’m not writing this for any absolution or hateful comments. Believe me, I have given enough of both to myself. I’m writing to say that the decision can be excruciating for a midwife, even one who works so much with VBACs. I’m sad for her that I wasn’t trained enough to help her, to “save her” from a cesarean… a general anesthesia one to boot.

    I do know, if it happens again, I will do things very, very differently. And maybe that is my lesson. I still wonder what that mama’s was.

  12. NavelgazingMidwife, may I offer a different perspective? I believe that everything happens for a purpose and it is altogether possible that God allowed your actions to be the very thing that saved her and/or her baby from death or a life-long injury. Certainly, there is no way to know for sure but rather than go over it and over it, rest in the assurance that whatever God's purpose was in that event, He wastes nothing. I don't believe you made a mistake - I believe you did the very best you could and someday, you might even find out that it was just the thing that needed to be done. :)


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