The art of vaginal breech birth on all fours

I recently discovered a new article about upright breech birth: a clinical case report titled The art of vaginal breech birth at term on all fours by Wildschut, Belzen-Slappendel, & Jans. (PDF here).

This article describes a case where a woman planning a hospital birth called her midwife to her home when labor began. Soon after, the midwife discovered an undiagnosed frank breech and the mother had a strong urge to push. Sensing there was not time to transport, the mother decided to remain at home. (This birth took place in the Netherlands, where home birth is still quite common.)

The case report includes a detailed report of the birth. Gorgeous, well-lit photographs document the spontaneous birth of a breech baby with the mother on hands & knees. The birth was completely hands-off except for gentle assistance at the very end. Here are a few sample pictures from the article:

The authors (one of whom was the attending midwife) discuss the challenges of undiagnosed breech presentations, the evidence for all-fours positioning in breech births, and the ongoing debate about whether cesarean or vaginal birth is best for breech presentations. When the authors submitted their manuscript, the Frankfurt study on upright breeches by Louwen et al (full text) had not yet been published; the authors cite a smaller study on upright breech birth by Bogner et al (full text).

At the end of the article, the authors comment:

It remains important that clinicians and midwives are prepared for vaginal breech births. Prerequisites for the effective management of vaginal breech birth include the clinical finding of an average-sized baby (defined as a fetal weight estimate between 2500 and 4000 g), maternal cooperation, and the right mindset of the attending clinician or midwife. In fact, management of a vaginal breech birth is a skill; its safety relies on the competence of the attending health professional. The intrapartum attendant should also be composed and have sufficient confidence and courage to manage vaginal breech birth. For this reason, regular hands-on training sessions with scenario teaching, videos and/or image-based lectures, such as presented in this article, are advocated for health professionals to be acquainted with the various maneuvers for vaginal breech birth.

Undiagnosed breeches still occur regularly. When the attending physician or midwife is not skilled and comfortable with vaginal breech--as is too often the case today--this can pose a risk to both mother and baby. All the more reason for midwifery & obstetrics training programs to continue teaching vaginal breech skills.

For another example of an undiagnosed breech late in labor, read Naomi Carslile's experience while working in a UK hospital. Carlisle, a student midwife, narrates a successful (although much more stressful and anxious) vaginal breech birth. Wildschut and his co-authors show how a well-prepared, calm, and confident birth attendant can make the best of the unexpected.

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Ken Johnsson & Betty-Anne Daviss: The Frankfurt Study

First Amsterdam Breech Conference, Day 2

Ken Johnson & Betty-Anne Daviss

Rethinking the Physiology of Breech Birth: 

A Cohort Study in Frankfurt, Germany, 2004-2011

Betty-Anne Daviss opened the session by remarking that this study has been a long time coming; she’s been working on it since 2008. It is a collaboration between Frankfurt and Ottawa involving Frank Louwen, Anke Reitter, herself, and her epidemiologist husband Ken Johnson.

from Spinning Babies

When Betty-Anne and Ken spoke in July 2016, the manuscript had not yet been published. It is now available (without cost) in the International Journal of Gynecology & Obstetrics: Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?. If you scroll down to "Supporting Information," you will find additional tables and a video showing a hands and knees breech birth at the Frankfurt clinic.

B-AD: Research over the last several decades has focused largely on comparison between vaginal birth and elective cesarean section (ECS), and almost no focus on how to improve vaginal breech birth (VBB). She finds that sad. Most of the large registry studies (such as the ones done in the Netherlands, Canada, or the U.S.) appear to have a higher neonatal mortality and/or morbidity with VBB than with ECS. But the registry studies do not capture the details that the cohort studies do.

There are other problems. In Canada, when Lyons et al published their registry study, the conclusions read that the neonatal mortality and morbidity rates were higher with vaginal breech birth. What the abstract did not make clear was that because the outcome measure was reported as a composite variable. Although the two outcomes were reported together as "higher," it was only the morbidity, not the mortality, that was higher. In fact, when she and Ken went to the actual table, the neonatal mortality (NNM) was clearly reported as "0" and the morbidity was, no doubt, not long-term (as in the Term Breech Trial). But if you only look at the abstract and can't wade through the real meaning of the study, you get terribly fearful of vaginal breech birth. And that fear is difficult to undo.

Betty-Anne suggested that we look at cohort studies done in units, like in France, Belgium, Dublin, Newcastle, Norway, and Frankfurt. In all of these places--with skilled attendants, good screening, and protocols--almost invariably the difference in NNM is very negligible.

Today she and Ken are presenting what it looks like to compare two kinds of vaginal birth. It wasn’t an intention-to-treat study; rather, it compares what actually happened. For more understanding of concerns about relying only on RCTs such as the Term Breech Trial and the history of some of the breech research, refer to Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions.

KJ: (Next, Ken presented some information on the premature breeches, which they excluded from the study, but were interesting nevertheless.)

The Frankfurt study included 750 term breeches. 42% were scheduled cesareans; half of those cesareans were by the mother’s choice. The Frankfurt cohort had a high number of primips. Most of the vaginal breech births ended with the mothers upright. They also looked just at the last 2.5 years at the clinic, since they were almost exclusively doing upright births at that point. With mothers exclusively upright, they saw slightly higher success rates.

B-AD: This is an observational cohort study, not a randomized controlled trial. We are looking at what is, not at what’s planned. That is, the cohort study describes what has happened at each birth in the natural process of a particular delivery unit, without instigating or removing parameters, as with the randomized controlled trial. Observational data in a unit can thus be very useful and has some merit of itself that can be more useful than randomization.

But it does raise the question: how do people decide what position they end up in? We explain that in the study.

KJ: Having a woman upright resulted in fewer maneuvers. Forceps and episiotomies were never needed in any of the vaginal breech births.

B-AD: We didn’t collect information about fundal pressure in the database, which is actually used frequently, so that would be useful to do in the future.

KJ: Upright maternal positioning resulted in fewer neonatal injuries and a shorter 2nd stage of labor. How do they define 2nd stage in Germany? It starts at full dilation--not at the onset of spontaneous maternal pushing--so it includes a latent stage. This explains some of the longer 2nd stages recorded in the Frankfurt study.

The Frankfurt study used the definitions of fetal and neonatal mortality & morbidity in the PREMODA study. This allows us to compare the Frankfurt data to the PREMODA study and to the TBT (upon which PREMODA was based).

B-AD: This database is incredibly useful. We need to have more of these databases to amplify this area of knowledge. Observational data in cohort studies is really valuable to individual hospitals so they know what is going on and to compare notes with other units. Collect your data in your unit!

(I had to leave right as they started the Q&A)

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Articles about vaginal breech birth since the Term Breech Trial

Below is a curated list of articles about vaginal breech birth since the 2000 Hannah Term Breech Trial. This is not a comprehensive list, but rather a starting place with some of the more influential articles and studies that have shaped the conversation about vaginal breech birth.

I have not included articles about External Cephalic Version in this list, although ECV remains an important part of managing term breech presentations.

I put this list in chronological order, beginning with the Term Breech Trial. You will also benefit by concurrently reading my breech conference summaries from Ottawa (2009), D.C. (2012), and Amsterdam (2016).

Many thanks to Dutch midwife Miriam Benschop, who is writing a thesis on breech and designing a decision aid for women with breech babies. She contributed many of these references, and I added others that I thought were important.

If you have other studies to suggest, please comment below or email me. I'd be happy to add to this list.

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Hannah MME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR (2000).
Planned caesarean section versus planned vaginal birth for breech presentation at term: a
randomised multicentre trial. Turn Breech Trial Collaborative Group, Lancet 356: 1375-83.

ACOG committee opinion: number 265, December 2001. Mode of term single breech delivery. Obstet Gynecol. 98(6): 1189-90.

The Society of Obstetricians and Gynaecologists of Canada. SOGC Statement on Vaginal Breech [press release]. SOGC News 2001 March.

van Roosmalen J, Rosendaal F (2002). There is still room for disagreement about vaginal delivery of breech infants at term. BJOG 109:967–9.

Krebs L, Langhoff-Roos J, Bødker B (2002). Are intrapartum and neonatal deaths in breech delivery at term potentially avoidable? A blinded controlled audit. J Perinat Med. 30:220–224.

Keirse MJ (2002). Evidence-based childbirth only for breech babies? Birth 29:55–9.

Giuliani A, Scholl WM, Basver A, Tamussino KF (2002). Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol. 187:1694–1698.

Hogle KL, Kilburn L, Hewson S, Gafni A, Wall R, Hannah ME (2003). Impact of the international term breech trial on clinical practice and concerns: a survey of centre collaborators. J Obstet Gynaecol Can 25:14–6.

Rietberg CC, Elferink-Stinkens PM, Brand R, Loon A, Hemel O, Visser GH (2003). Term breech presentation in the Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33824 infants. BJOG 110:604–9.

Gilbert WM, Hicks SM, Boe NM, Danielsen B (2003). Vaginal versus cesarean delivery for breech presentation in California: A population-based study. Obstet Gynecol. 102:911–917.

Hellsten C, Lindqvist PG, Olofsson P (2003). Vaginal breech delivery: is it still an option? Eur J Obstet Gynecol Reprod Biol 111:122–8.

Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, Cheng M, Gafni A et al. (2004). Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech trial. American Journal of Obstetrics and Gynecology 191: 864-71.

Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M et al. (2004). Maternal outcomes 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. American Journal of Obsterics and Gynecology 191: 917-27.

Su M, Hannah WJ, Willan A, Ross S, Hannah ME (2004). Planned caesarean section decreases the risk of adverse perinatal outcome due to both labour and delivery complications in the Term Breech Trial. British Journal of Obstertics & Gyaecology 111: 1065-74.

Kotsaka A. (2004). Inappropriate use of randomised controlled trials to evaluate complex phenomena: a case study of vaginal breech delivery. British Medical Journal 329: 1039-42.

Alarab M, Regan C, O’Connell MP, Keane DP, O’Herlihy C, Foley ME (2004). Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 103:407–12.

Kumari AS, Grundsell H (2004). Mode of delivery for breech presentation in grandmultiparous women. Int J Gynaecol Obstet 85:234–9.

Håheim LL, Albrechtsen S, Berge LN, Bordahl PE, Egeland T, Henriksen T, et al. (2004) Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team. Acta Obstet Gynecol Scand 83:126–30.

Hodnett ED, Hannah ME, Hewson S, Whyte H, Amankwah K, Cheng M, et al. (2005). Mothers’ views of their childbirth experiences 2 years after planned cesarean versus planned vaginal birth for breech presentation at term, in the international randomized Term Breech Trial (PDF). Journal of Gynecology Canada March: 224-31.

Rietberg CCT, Elferink-Stinkens PM, Visser GHA (2005). The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in the Netherlands: an analysis of 35,453 term breech infants (PDF). British Journal of Obstetrics and Gynaecology 112: 205-9.

Verhoeven AT, de Leeuw JP, Bruinse HW (2005). Breech presentation at term: elective caesarean section is the wrong choice as a standard treatment because of too high risks for the mother and her future children [article in Dutch]. Ned Tijdschr Geneeskd 149:2207–10.

Uotila J, Tuimala R, Kirkinen P (2005). Good perinatal outcome in selective vaginal breech delivery at term. Acta Obstet Gynecol Scand 84:578–83

Pradhan P, Mohajer M, Deshpande S (2005). Outcome of term breech births: 10-year experience at a district general hospital. BJOG. 112:218–222.

Glezerman M (2006). Five years to the Term Breech Trial: The rise and fall of a randomized controlled trial. American Journal of Obstetrics and Gynecology 194: 20-25.

Klein M (2006). Not safer and not cheaper? CMAJ 175(10):1243–6 [Comment re CMAJ 2006;174(8):1109–13].

Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtild D, et al. (2006). Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology 194: 1002-11. (This is often referred to as the PREMODA study)

Vidaeff AC (2006). Breech delivery before and after the Term Breech Trial. Clinical Obstetrics and Gynecology 49: 198-210.

ACOG. Mode of term singleton breech delivery (2006). ACOG Committee Opinion 340, July 2006. Reaffirmed 2016.

RCOG (2006). The management of breech presentation (PDF). Guideline No. 20b.

Menticoglou SM (2006). Why vaginal breech birth should still be offered (PDF). J Obstet Gynaecol Can 28:380–5.

Sobande A et al (2007). Breech delivery before and after the Term Breech Trial Recommendation (PDF). Saudi Med J 28(8): 1213-1217.

Yamamura Y, Ramin KD, Ramin S (2007). Trial of vaginal breech delivery: Current role. Clinical Obstetrics and Gynecology 50: 526-36.

Schutte JM, Steegers EAP, Santema JG, Schuitemaker NWE, Roosmalen J van (2007). Maternal deaths after elective cesarean section for breech presentation in the Netherlands. Acta Obstetricia et Gynecologica Scandinavia 86: 240-243.

Kotaska A (2007) In the literature: combating coercion: breech birth, parturient choice, and the evolution of evidence-based maternity care. Birth 34:176–80.

Kok M, Gravedeel L, Opmeer BC, Post JAM van der, Mol BWJ (2008). Expectant parents’ preferences for mode of delivery and trade-offs of outcomes for breech presentation. Patient Education and Counseling 72: 305-10.

NVOG (2008). Richtlijn Stuitligging. (2008 guidelines on breech presentation by the Netherlands Association of Obstetrics and Gynaecology)

Deans C, Penn Z (2008). The case for and against vaginal breech delivery (PDF). The Obstetrician & Gynaecologist 10: 139–144. See also this letter to the editor (PDF) by Lucy Bowyer.

Kotaska A, Menticoglou S, Gagnon R, Farine D, Basso M, Bos H, et al.; SOGC Maternal Fetal Medicine Committee. Vaginal delivery of breech presentation (PDF). Society of Obstetricians and Gynaecologists of Canada Clincal Practice Guideline No. 226, June 2009. J Obstet Gynaecol Can 2009;31:557–66. See also a letter to the editor by Hey (PDF).

Lalonde AB (2009). Vaginal Breech Delivery Guideline: The Time Has Come (PDF). Obstet Gynaecol Can 31(6): 483–484

Daviss BA, Johnson KC, Lalonde AB (2010). Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions (PDF). J Obstet Gynaecol Can March: 217-224.

Taillefer C, Dube J (2010) Singleton Breech at Term: Two Continents, Two Approaches (PDF). J Obstet Gynaecol Can 32(3): 238–243. See also these letters to the editor (conversations between the study's authors and Andrew Kotaska & Savas Menticoglou)

Guittier M, Bonnet J, Jarabo G, Boulvain M, Irion O, Hudelson P (2011). Breech presentation and choice of childbirth: A qualitative study of women’s experiences. Midwifery 27: 208-13.

Lawson GW (2011). Report of a breech cesarean section maternal death. Birth 38: 159-61.

Fahy K (2011). Do the findings of the Term Breech trial apply to spontaneous breech birth? (PDF) Women and Birth 24(1): 1-2.

Fahy K (2011). Is breech birth really unsafe? Treatment validity in the Term Breech Trial. Essentially MIDIRS, 2(10): 17-21.

Glasø AH, Sandstad IM, Vanky E (2012). Breech delivery: What influences on the mother’s choice? Acta Obstetricia et Gynecologica Scandinavia 92: 1057-62

Keirse MJNC (2012). Evidence based medicine and perinatal care: From dusk to dawn. Birth 39: 296-300.

Louwen F, Leuchter LM, Reitter A (2012). Beckenendlagengeburt: Mehr als Sectio vs. spontangeburt (Breech Presentation – More than just Caesarean vs. Spontaneous Birth). (2012). Zeitung für Geburtshilfe & Neonaologie 216: 191-4.

Toivonen E, Palomäki O, Huhtala H, Uotila J (2012). Selective vaginal breech delivery at term-still an option. Acta Obstetricia et Gynecologica Scandinavia: 91: 1177-83.

Evans J (2012). Understanding physiological breech birth (PDF). Essentially MIDIRS 3(2):17-21.

Vistad I, Cvancarova M, Hustad BL, Henriksen T (2013). Vaginal breech delivery: results of a prospective registration study. BioMed Central Pregnancy & Childbirth 13: 153-60.

Van Roosmalen J, Meguid T (2014). The dilemma of vaginal breech delivery worldwide (PDF access). The Lancet. 383:183–1864. See also correspondence between Hehir and van Roosmalen.

Vlemmix F, Bergenhenegouwen L, Schaaf JM, Ensing S, Rosman AH, Ravelli ACJ, et al. (2014). Term breech deliveries in the Netherlands: did the increased caesaren rate affect neonatal outcome? A population based cohort study. Acta Obstetricia et Gynecologica Scandinavia 93: 888-896

Borbolla Foster A, Bagust A, Bisits A, Holland M, Welsh A (2014). Lessons to be learnt in managing breech presentation at term: An 11-year single-centre retrospective study. The Australian and New Zealand Journal of Obstetrics and Gynaecology 54: 333-9.

Hunter LA (2014). Vaginal breech birth: Can we move beyond the Term Breech trial? Journal of Midwifery & Women’s Health 59: 320-7.

Zsirai L, Csákány GM, Vargha P, Fülöp V (2015). Breech presentation: its predictors and consequences. An analysis of the Hungarian Tauffer Obstetric database (1996-2011). Acta Obstetricia et Gynecologica Scandinavia 95: 347-354.

Lyons J, Pressey T, Bartholomew S, Liu S, Liston R, Joseph KS (2015); for the Canadian Perinatal Surveillance System (Public Health Agency of Canada). Delivery of breech presentation at term gestation in Canada, 2003–2011. Obstet Gynecol. 125:1153–1161.

Vistad I, Klungsøyr K, Albrechtsen S, Skjeldestad FE (2015). Neonatal outcome for singleton term breech deliveries in Norway from 1991-2011. Acta Obstetricia et Gynecologica Scandinavia 94: 997-1004.

Berhan Y, Hailemiak A (2015). The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies, British Journal of Obsterics and Gynaecology 123: 49-57

Bogner G, Strobl M, Schausberger C, Fischer T, Reisenberger K, Jacobs VR (2015). Breech delivery in the all fours position: A prospective observational comparative study with classical assistance. Journal of Perinatal Medicine 43: 707-13.

Burgos J, Rodriguez L, Cobos P, Osuna C, Mar Centeno M del, Larrieta R, et al. (2015). Management of breech presentation at term: A retrospective cohort study of 10 years of experience. Journal of Perinatology 35: 803-8.

Davidson J. (2015). The experience of vaginal breech birth. A social, cultural and gendered context (PDF). PhD Thesis, University of Brighton.

Hofmeyr GJ, Hannah M, Lawrie TA (2015). Planned caesarean section for term breech delivery. Cochrane Database Systematic Review. CD000166.

Homer CSE, Watts NP, Petrovska K, Sjostedt CM, Bisits A (2015). Women’s experiences of planning a vaginal breech birth in Australia. BioMed Central Pregnancy & Childbirth 15: 89-96.

Joseph KS, Pressey T, Lyons J, Bartholomew S, Liu S, Muraca G, et al (2015). Once more unto the breech. Obstetrics & Gynecology 125: 1162-7.

Powell R, Walker S, Barrett A (2015). Informed consent to breech birth in New Zealand (full text). The New Zealand Medical Journal 24 July 2015; 128(1418): 85-92. PDF link here.

RANZCOG (2016). Management of breech presentation at term (PDF). Royal Australian and New Zealand College of Obstetricians and Gynecologists.

Petrovska K, Watts NP, Catling C, Bisits A, Homer CSE (2016). Supporting women planning a vaginal breech birth: An international survey. Birth 43: 352-357

Petrovska K, Watts NP, Catling C, Bisits A, Homer CSE (2016). “Stress, anger, fear and injustice”: An international qualitative survey of women’s experiences planning a vaginal breech birth. Midwifery 0: 464–469.

Walker S, Scamell M, Parker P (2016). Standards for maternity care attending planned upright breech births: A Delphi Study. Midwifery 34: 7-14.

Walker S, Scamell M, Parker P (2016). Principles of physiological breech birth practice: A Delphi study. Midwifery. Dec;43:1-6.

Bin YS, Ford JB, Nicholl MC, Roberts CL (2016). Long-term childhood outcomes of breech presentation by intended mode of delivery: a population record linkage study. Australian and New Zealand Journal of Obstetrics and Gynaecology 56: 453-59.

Louwen F, Daviss BA, Johnson KC, Reitter A (2017). Does breech delivery in an upright position instead of on the back improve outcoms and avoid cesareans? (full text) International Journal of Gynecology & Obstetrics 136: 151-161.
* Note: Clicking on "supporting information" on the right side bar will allow you to view an upright breech birth at Dr. Louwen's clinic.

Forthcoming article by Vlemmix F et al about long-term effects of mode of birth for breech, specifically what happens to the mother's next baby after her breech baby (mentioned in Dr. Thomas van den Akker's presentation Who Pays the Price? at the 2016 Amsterdam Breech Conference).

I also recommend Shawn Walker's website; she updates about her breech workshops, demonstrates techniques and maneuvers, and explains the principles of physiological breech birth.

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