Monday, February 23, 2009

Musings on breech

I had an enjoyable meeting with my midwife this week. When we were checking fundal height and heart tones, I asked her to palpate and see where/how she thought this baby was lying. Baby was definitely breech: a nice round wobbly head up near my ribcage, a butt/hip above my pubic bone, and lots of arms & legs on my right side. (And today, it's all over the place--I'm feeling movement in my cervix & on my left side, possibly a head or a butt on my right side.) Having a confirmation that the baby was that dreaded "B" word--breech--left me with lots of thoughts. So here goes:

I find myself more prone to anxiety and worrying during pregnancy, and more this time compared to last pregnancy. My logical brain knows that fretting about a baby's positioning at 30 weeks gestation is fairly pointless, and that the vast majority of breech presentations resolve themselves by term. But does that make any difference to my emotional self? Not really! Here I am, knowing all of these things and having reassured many other women about breech presentations, and I still can't stop fretting about the future: what if the baby stays breech? what would happen then? what would I do?...

It's not that I am worried about a vaginal breech birth per se. I feel quite confident that I could give birth to a breech baby, and I have read extensively about the controversies surrounding breech management. But I am quite afraid of birthing a breech baby in the current medical & legal climate. Going into labor with a breech presentation would mean the following for me:
  • No continuity of care, as my midwife cannot attend a breech at this time. She really wants to add breeches and twins to her practice in the next five years, but she does not have enough training yet to attend a breech birth.
  • A last-minute desperate search for someone to attend me, or a last-minute unassisted birth with no midwife backup. I live about an hour away from a very large city with a total metropolitan population of 1.7 million. There may (or may not) be one or two physicians who still attend breeches. There used to be more, but almost all of them have stopped attending vaginal breeches, some of them against their will. My midwife used to work as a L&D nurse in a large tertiary hospital in that city, and she said they used to do vaginal breeches all the time until a change in medical opinion declared a vaginal breech to be malpractice. She remembers one OB letting off the F-bomb because he was so upset he'd have to start doing c-sections for all breeches. She knows of a few physicians who, although they currently don't officially do vaginal breeches, might be able to attend a woman if she into labor on a day they happened to be on call and insisted on a vaginal birth at the hospital. She'd have to know that this option even existed and who to ask for, of course.
  • Or, if I wanted to stay at home, I could try to find a direct-entry midwife who has skills with breech births. There are one or two, but there is a complicated back story that makes me more hesitant about that option. In brief: my midwife's third baby was breech. She was abandoned by those midwives the day before she went into labor because of the breech presentation, leaving her to do it on her own.
  • A massive amount of stress and worry, because I could not simply carry on with my birth plans. Instead, the days or hours leading up to the birth would be characterized by extreme upheaval and uncertainty. And there's still no guarantee I could find someone willing to attend a vaginal birth.
  • And of course, if I did go to a hospital and manage to find a doctor to attend me in this hypothetical situation, I wonder if that would be a very good setting for a vaginal breech: unknown physician, probably a lot of anxiety and fear, unknown amount of manipulations or interventions in the process. Not a very good setting for a smooth vaginal breech birth. The best possible atmosphere for a successful vaginal breech birth is one that is the least disturbed, one with low levels of stress and adrenaline, one with laid-back hands-off providers with lots of skill and experience seeing physiological breech births. Basically the opposite of what I would be able to find if I found myself faced with a breech presentation at term.
The problem with breech in this country isn't the actual presentation and birth--it's the hostile climate that makes a vaginal birth nigh to impossible.


  1. This was one of my biggest worries. I was born via c-section because I presented breech (and was stubborn, having turned back to breech after one or two EVs), so having a breech baby myself has--up until recently (I'm 36 weeks now) been a major source of worry for me. I live in AR, and licensed midwives are not allowed to attend breech deliveries. Having a breech baby here most certainly means a c-section, as I don't believe there is a single OB in town who would allow a vaginal delivery. My baby has been head-down for quite a while, but there was a stretch of time where I was sure it was trying to turn breech every time I would lie on my left side. I would stay awake just making sure it couldn't "make a run for it," spoiling all of my homebirth plans.

    I hope all of this works out well for you. I have a friend whose baby turned breech at 32 weeks, and my friend and her husband were able to turn it back on their own, so it seems like you've still got some time!

  2. I have been reading your blog for almost a year, and have basically decided to do a homebirth this pregnancy because of the information you post. I am 37 weeks pregnant with my third. I am really excited about my homebirth. My first two were hospital births with CNM, and I didn't have bad experiences at the hospital, but after reading so much about birth about a year ago, I realized that birth could be even better than what I have experienced.

    Your musings about breech reminds me of a conversation me and my husband were having a week ago. My baby is head down, and has been so for a while, but it is scary to feel like there isn't a very good support network for breech vaginal births. My homebirth midwife has attended a number of breech births and twins, but they changed the laws in my state and went into effect in May 2008 and she is no longer allowed to attend breech and multiples.

    Anyway I feel like my husband and I were going through a lot of the thinking you were. We knew of one physician that 3 years ago would do breech vaginal births, but I don't know if he still does, and then what happens if he doesn't happen to be on call? I would be so worried about going to the hospital with a breech baby, because I feel like I would pretty much be forced into having a c-section.

    Anyway I wanted to tell you that I have been having a lot of the same thoughts about breech and also wanted to thank you for your very informative blog and that I am so excited about giving birth at home, and your blog is a lot of the reason that I chose to do a homebirth for this pregnancy.

  3. I am so sorry you are going through this. I am 20 weeks pregnant and this was one of the first questions I asked my midwife. I was told that breech was guaranteed c-section. The only thing I can do is stay at home as long as possible before going in (at least enjoy the labor process) and hope that by the time I get there - it will be too late for a c-section. Of course, I probably should make sure we have clean towels in the car (just in case). And then when I arrive I will just say over and over... "I do not consent to surgery."

  4. I understand the breech worries! My #2 was breech until 38 weeks - as in never once flipped until the day he decided maybe head down was the way to go. He was born a week later, weighing in at 1.5 pounds smaller than his big brother. I honestly think his size had a lot to do with him staying breech as long as he did. Don't worry though - babies usually flip! Let me know if you want my list of breech turning tricks!

  5. Well along with everything else you can definitely use your Fear Clearing cd to help ease your worries.

    They also have a Turn your breech baby cd.

  6. You could always truck it on over to The Farm! I think that would be a better option than taking your chances with an unknown hospital/doctor/etc... And having that backup plan in mind, at least for me personally, is very comforting! :)

  7. Isn't it crazy how I can give all this same advice to pregnant women--I can spout off statistics about the likelihood of the baby turning, I can give a huge list of tips for encouraging the baby to turn, etc.--but then when it's *me* somehow none of that knowledge seems to make it any easier! Anyway I wish we could get to the point that a breech baby is no big deal, that it doesn't have to mean this huge upheaval of plans.

    It's good to know The Farm exists, but for a lot of women it's not really practical. Even for me, it's an 8-hour drive and having had a 10 hour labor the first time, I highly doubt I'd make it on time even if I left at the very first twinge of labor!

  8. "The problem with breech in this country isn't the actual presentation and birth--it's the hostile climate that makes a vaginal birth nigh to impossible."

    yes, exactly the problem.

    I'm struggling with a similar issue right now. I'm totally a UC minded person... and yet now I'm fretting over if I should finding a midwife as to avoid a hospital stay. and yet I have to find the right midwife who can handle the situation... etc etc... it's a bit of a mess.

    and frankly, sometimes research and studies are not the answer. sometimes the question is just far deeper and more personal that statistics.

  9. My last baby was in a frank breech position up until about 35 weeks and I faced the same fears you did. I had never had one stay breech that long and was VERY relieved when he flipped and I could feel feet and butt up top.

    I know that I could probably safely have a vaginal breech birth, but none of the midwives around here can legally touch them and no doctors can do them anymore. When I lived in Hawaii there was an older doc who I did co-care with who could still do vaginal breeches but no one here in my area that I know of personally and I did NOT want a C-section. Not because I would have felt like a "failure as a mom" or anything, but because my husband was deployed and I knew next to nobody and I had four small children including a special needs child to take care of after the birth. I remember thinking it would FIGURE that I would end up with a C-section at the WORST possible time to have one. My hubby was present for all our other births.

    Are there chiropractors in your area who can do the Webster Technique? You might want to get some names now in case the baby doesn't flip. I got names of some chiros who know Webster from my midwife and her assistant in case I got to be 38 weeks and he was still butt-first. Fortunately as I said, he flipped and spared me all that worry.

  10. Ugh. Breech birth in this country is a very sore subject with me. Breech is such a NON-issue and I am appalled that women are getting cut open for something as natural and silly as breech presentation. Women all over the world birth breech without so much as batting an eyelash, and this country makes it out to be a death sentence. :end rant:

    In any case, I never even worried about it in my pregnancy. I had my baby UC, and would totally have UCed breech without a second thought. In fact, even if I had had a midwife, I still might UC a breech, as the art of not messing with breech babies is quickly being lost, and I don't know that I could trust anyone to stay hands-off during the second stage.

    In today's medicalized climate, I believe that a breech woman who walks in the doors of a hospital will walk out with a surgery scar. Even if she walks in pushing, I think there's a good chance they will emergency c her. My own SIL went to the hospital with a breech, 8 cm dilated, and they emergency sectioned her.

    I wouldn't step foot near a hospital with a breech, because I refuse to get cut open over something as trivial as a breech presentation. And I am increasingly convinced that UC is pretty much the safest way to birth a breech in the US today.

  11. i cant even begin to imagine what living under such Medico-legal conditions must be like. I really feel for all you US women who want the right to birth how you choose. Vaginal breech birth is not common here but if you want to try you can still find someone to assist. Sending you 'listen to your own advice' vibes from down under. LOL

  12. My only suggestion would be to find a chiropractor who does the Webster Technique. Jen told me about it when Rachel was breech at 30 weeks, and I was freaking out about the very real possibility of a c-section. As it was, she flipped the day after the chiropractor did his thing.

  13. I posted a comment on your post about the book Homebirth in a hospital or something like anyhow, when you posted back you made it sound like you lived near the Baby Friendly hospital that I had my babies at, I was wondering if you had done any research about delivering breach at that hospital??

  14. I'm sure I'll have more coherent thoughts on this later, Rixa, but for now, I'll thank you for being so transparent with your process.

    As a mom affected by the crisis that is breech birth in this country for all three of my pregnancies, I can relate to all that you have said and you have truly outlined what is wrong in very clear terms.

    I was recently dismayed to find out that even my midwives, who knew up front that I carry my babies breech, and supported me beautifully through my pregnancy and labor, rarely do so for women because of the political climate.

    It's a mess, and if I can do anything about it, I'm going to!

    Thanks again!

  15. Hugs to you. It is interesting how it is easy to tell other people information and then it happens to you and it has a totally different feel to it.

    Maybe move down to the farm for a few weeks? Easier said than done, but it might be really interesting.

  16. Christie, it's funny, I had just added the link to the Coalition earlier on today!

    Jamie--I used to live close to that hospital (30 mins) but I have since moved to another state. There is one OB there who does vaginal breeches, with a lot of arm twisting, although I hear his bedside manner is lacking.

  17. Although I've been one of your blog readers for a long time I've never left a comment before.
    But I can't restrain myself today! :)

    The comments referring to breech birth as a "trivial" reason for a c-section seem to be coming from people who have never seen or done a breech birth (other then watching an instructional video, which of course has successful breech births).

    As much as I hope to some day have the skills to attend breech births (I'm currently a midwife student), I would never call breech birth "trivial"... or something that just anyone can always do successfully so long as they keep their hands off.

    Most of the time breech birth goes well when a hands-off approach is taken. BUT it does have a MUCH higher mortality rate when handled by people who do not have a lot of experience with it.

    I'm all about vaginal breech birth. I think it is SO SAD that our doctors and midwives these days aren't even getting trained in them at all. They are terrified of doing a breech because they have no experience with them.

    The politics of breech birth are awful. But I hate to see the baby thrown out with the bathwater by people claiming that breech is without risk and that providers who worry about it are just living in unreasonable fear.

    I've done a breech birth (a surprise) and it wasn't easy or fun. We employed a hand-off approach as much as possible (till it became obvious that the head was entrapped), but the baby's head didn't just slip out like magic. It was eight of the scariest minutes of my life til we had a head.

    I hope more people get trained in vaginal breech. I hope more mothers attempt vaginal breechd births. And I hope that the politics of vaginal breech birth get much, much better for providers and consumers.

    But to call doctors silly or unreasonably fearful because they are scared of breech only discredits our (homebirthers) grasp on reality.

    Breech birth can be a big deal. But with the great advances we've made in obstetrics, it's sad that somehow we didn't think it was important for breech birth to be an important skill for practitioners. Just c-sections and complicated surgeries and drugs...

  18. I'm very sorry you're having to handle all this worry when you've got enough work to do to simply create new life. I wish you lived a lot further south. I know several excellent lay-midwives with lots of experience in breeches-at-home.

    On an up note, my last one was breech pretty much the entire pregnancy but after a series of (quite painful, actually) full-body rolls between 40 and 42 weeks, he settled into head-down the day before labor started.

  19. Rixa,

    I haven't been able to clean it up yet, and my toddler is asking to nurse, but I wanted to share my response blogpost to yours:

    Thanks so much,


  20. hmmmm, please don't tell me that, that would be my midwife's doctor would it?? Cause if it is that kinda shocks me.?.?

  21. It's Dr. Harrington who does breeches; he's an OB. Your midwife's doctor partner is a family practice physician if I'm not mistaken.

  22. I don't know much about this at all. However, I have a friend who was completely committed to natural childbirth. She was breach afraid. She googled info on old wives tales about getting breach babies to flip. She found info about going in a pool and doing an underwater handstand (9 mo pg!) well, she went over to her parents pool. The water was cold. Her father was her "life guard" She sucked up her pride and donned a bathing suite and did the headstand. The baby flipped and she went on with her delivery as planned.

  23. I'm really sad that your midwife can't attend breech births until she has more training. That sounds ridiculous to me. What kind of training could be better than attending breech births (with someone else experienced, of course... if that's possible)?

    Hugs to you as you process this, and prayers for a baby that turns around and relieves your anxieties. :)

  24. Having survived a breech birth and knowing that you uc'd before, my advice to you is to take a deep breath and relax. If your mw does not feel comfortable attending a breech birth (which I don't understand...what kind of experience do you need to KEEP YOUR HANDS TO YOURSELF?!!) talk to her and see if you could fudge an "oopsie" I.e, the baby came before she could get there kind of thing. That way you'd still have your backup care, but the birth itself would be autonomous.

    You have to remember that breech is a variation of normal. That means you don't NEED a backup plan specifically for breech any more than you do any other presentation. You have plenty of knowledge and proven instincts. You will be fine.

  25. I relate to you about increased worrying and anxiety during pregnancies. That was a real battle I had with my daughter's pregnancy. I wanted to trust but it was so hard - and one of my biggest points of worry was breech. I still think about what would happen if I have a breech baby in subsequent pregnancies. I know vaginal delivery is possible and safe but I would want a midwife attending who trusted that and had skills to assist if needed. I'm not always sure what kind of action to take to change the political climate around breech birth. I know legalizing midwives can actually make finding a midwife to attend a breech harder.

    My midwife is, or at least was last year, the president of the state's midwifery association. I wonder if she might have some ideas? Your midwife sounds really well connected and with enough history to know so that might not help - but I'd be willing to ask around down here if you think it might give you more options.

  26. First of all, I do believe that there is a very good chance that your baby will turn in the coming weeks, which will resolve this dilemma for you.

    That being said, I am sympathetic with Mary's comments. I don't think one can dismiss the fact that there are some increased risks associated with breech birth. Dismissing risks as "silly" sounds naive and frankly, ignorant.

    In the end, if baby is breech at the time of impending birth, you will have to make difficult decisions about how and where to deliver, within the practical and political constraints that you describe. No matter what decisions you make, it will not necessarily be your ideal birth scenario. For what it's worth, I personally would not regret erring on the side of baby's safety, whatever that entails, even within the constraints you face.

  27. I have to comment on the thought that because breech is a variation of normal, it's totally safe and nothing to worry about.

    My little sister was born breech, and her head was trapped. If there hadn't been a doctor with forceps there, my awesome 24 year old sister would not be here today.

    Just because something is a variation of normal does not mean it is safe and no big deal. yes, most breeches are born just fine without intervention, but if you can't acknowledge that breech also has a much higher rate of mortality than vertex, you are lying to yourself.

  28. I would like to point out that in my previous comment, I said nothing about breech being without risk. Of course it has risk - but it's still an asinine reason to have a c-section. And I don't think it's as big a deal as people make it out to be. Granted, it's not a favorable delivery position, and it has risks, but it's not the death/disability sentence that everyone seems to think it is.

    And I still stand by my original statement that I believe in today's medicalized climate, in the U.S, a breech is best birthed UC.

  29. Emily--you called it a non-issue, as well as natural and silly. Fortunately or unfortunately for Rixa, she has read and thought about the risks inherent in birth, especially breech births, much more than you have. Therefore, it doesn't seem possible for her to sail through a pregnancy with no worries whatsoever about rare but catastrophic complications...

  30. Okay calm down everyone. We can each speak for ourselves, but try not to put words in other people's mouths (mine or others) or suggest that someone has or hasn't thought about an issue thoroughly. I think the comments have started to focus on the risks (real or perceived) of breech birth, whereas my bigger concern is with the surrounding risks & challenges of the 21st century American birthing climate as it relates to breech babies.

    On top of all this, sometimes I still can't tell at all how this baby is lying. Sometimes it's clear where the head is, but at other times I am lost in the landmarks. With Zari's pregnancy it was always totally clear how she was lying/presenting, whereas this one has me puzzled half of the time. So I don't even know, sometimes, if I should be fretting since I am not entirely sure of where all the baby's parts are in relation to my pelvis!

  31. Yk, I think this discussion really hits on so much of the problem.

    I've done *a lot* of research on breech birth, out of necessity (again, I had 3/3 breech babies), and I totally get why it is scary to people.

    Initially, my reaction to people saying that breech is a non-issue, essentially "so what" that my 3rd baby was also breech felt dismissive. But thankfully, I had developed a relationship with most of them that allowed me to really examine their words. It is very true that if I lived a long time ago, I wouldn't know that I had a septate uterus, and breech would not be as fear-laden as it is today.

    If I may be so bold as to ponder out loud the motivation by the breech is no big deal sentiments, I see it as a counter to all of the fear. Fear in birth is readily available, but when you sit down to examine the facts, and allow yourself to let go of fear, your truth can become more clear.

    In my 3rd pregnancy and, imo, first birth, I gave myself permission to follow my instincts. I scoped out hotels near the best hospital in my area, and would have gone if I ever felt the need. I never did.

    Yes, bad outcomes with breech births happen. They do with vertex births and they do with cesareans. Probably the hardest thing I had to grapple with in my last pregnancy was that there are no guarantees. We all know it on some level, but to really sit with that and know that we could do everything "right", whatever that means, and still have to grieve the outcome.

    Mary said: BUT it does have a MUCH higher mortality rate when handled by people who do not have a lot of experience with it.

    Personally, after reading Breech-Birth Woman-Wise and experiencing a minimally, almost non-interventive pregnancy and birth of my breech baby (who was just trying to put a net around my poor dog's head; he is still an adventurer, lol), I have to seriously wonder if there truly is an increase in risk over non-breech vaginal birth *if* there is a skilled attendant (or possibly a non-interventive UC, I've not researched UC enough to speak competently).

    Henci Goer breaks down the numbers and does the risk comparison much better than I ever could, so I always defer to her expertise when having these discussions,

    "Just because something is a variation of normal does not mean it is safe and no big deal. yes, most breeches are born just fine without intervention, but if you can't acknowledge that breech also has a much higher rate of mortality than vertex, you are lying to yourself."

    What is the definition of "much higher"? And no, I don't necessarily expect people to have numbers readily available, I know I don't always. My point is that those are subjective terms.

    A cesarean also has a "much higher" risk of death for the mother (2-4x depending on the study and whether it is emergent or not), so again I counter that it is not as simple an equation as breech vaginal birth is more risky than a cesarean for breech. They both carry risk, and it is up to the family to decide which set of risks they are willing to take. And this is crucial, they must have breech-competent providers available.

    I am currently trying to assemble people who are willing to work toward that end, so please reply if you are interested in hearing more.

  32. I went through a lot of heartache over simply theorizing a possible breech scenario since I knew full well that my mw was not comfortable attending them (and her CNM status prevented her from knowingly attending, if I understood correctly) yet I felt very comfortable with it myself. Early in my last pregnancy she and I had a long talk about it. I had read a lot on the topic (Breech Birth Woman-Wise is very good) and did not feel that giving birth breech is a big deal and the best course of action was to do nothing at all, preferably giving birth in the water both to keep people's hands off the baby and to keep him/her warm (so the air contact against the torso wouldn't trigger a premature first breath) as well as the lack of gravity assisting in less traction on the baby's neck/head.

    My mw ultimately said that she would still attend me even if my baby was breech (although we'd have to claim it was a surprise) but that it's not something she'd do for everyone and she's certainly not comfortable with it (and gave me horror stories to back that up). I decided to keep her (I liked that she was comfortable literally waiting in the wings just in case I should want or need her) but also decided that if my baby (or babies, as they turned out to be twins) were breech she would not be coming anywhere near me when I actually pushed them out.

    As it turned out my baby A was vertex and baby B was breech-transverse during labor but rotated head down on his own, in his own time. Until he crowned though, we thought he was presenting breech.

    I think breech is dangerous when people meddle. Even if the local hospital had been willing to let me give birth vaginally to a breech I would not have done it. The chance that they're going to mess with nature is too high and this is an instance where the mother really needs to just move how she needs to move and not let anyone touch her or the baby. I just don't see that happening in the hospital (with extremely rare exception). I think we're much safer at home with a u/c at that point.

  33. I, too, am a mama whose two children were breech. That's how I grow them and carry them and birthed #1 at home.
    No, she didn't slip out. It was a long long long pushing stage and took alot of effort and time to inch out every bit of her body. Her head didn't just come out either. That said, all breech births don't go that way.
    It helped that I was prepared in advance to know how the birth would likely go, i.e. breathe through contractions for an hour even after 10cm (to be sure you are really, really open), stand to birth, hands off the breech, and push like heck to get that baby out. Listen for heart tones, of course, too.
    Rixa, one other thought I have: I was concerned about my breech baby's presentation too and decided I'd do everything short of an external version (Moxa, Webster, lights, sounds, acupuncture, hot/cold, etc). Then, I decided to stop it all, surrender to the process, and trust it.
    When she was born, she did have a true knot in her cord. I will always wonder if my turning efforts caused that. I don't ponder it too long because I cannot have regrets. But my point is, for my next baby (if breech) I've decided to let nature take it's course.
    For what it's worth...:)
    Sending you love love love.
    Oh and PS...both of my labors were painless (hard hard, intense work, but no pain) and I've half-jokingly wondered if they've had to do with breech presentation! LOL So, as much as I'd like to birth a vertex baby, I'm kinda scared to give up what I've always known.

  34. Well Good Luck I hope you find the strength and courage to birth a breech UC. Sarah J Buckley birthed her last baby unassisted and it was a breech. You can find the info at her website Women are capable of birthing breech babies unassisted or else mother nature would have prevented it in some way. I think the midwife is causing to much of unneceesary fear and worry. When it comes to birth it's better not to know and control it and just let it happen.
    my blog

  35. Rixa, I'm reading this much later because I am having similar trouble pinpointing my baby's position and wondering if I have a breech or persistently OP kiddo. It's very different from when I was pregnant with Robin. It's still too early for me to worry, but it's what pops into my head when I wake up at night -- what if the baby is breech? what if she stays breech??? These reflections are good to read.


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