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.