One of the most common worries of an expectant mum when it comes to childbirth is the breech position. This is particularly concerning if one wants a vaginal birth because the default medical advice for a breech baby is almost always C-section as it is considered the less risky option.
In this Australia’s Mothers & Babies 2015 report, on p.30, stats show that 9 in 10 breech babies were born via C-section.
But here’s the truth of the matter: The risks of C-section as compared to a vaginal birth for breech babies are not significantly lower.
In a Finnish cohort study of over 1,000 women (Toivonen 2012), it was found that there is 0% increase in the risk of injury or death of the baby in planned vaginal breech birth compared with caesarean section. The same results were already established a few years earlier by the PREMODA study (Goffinet et al., 2006).
In this article we will look at the following key points (click on the headings to skip ahead to the section):
- Why is C-section recommended for breech babies?
- What are the maternal risks associated with C-section?
- What are the real risks of Vaginal Breech Birth (VBB)?
- The current health recommendations & guidelines for VBB
Is C-section really the safer option? The misconception surrounding this matter goes back to the year 2000, almost two decades ago, when a study called the Term Breech Trial (TBT) (Hannah et al., 2000) indicated that there was an increase of injuries to breech babies when born vaginally.
All of a sudden, the recommendation for breech babies became C-section and women lost their option for a vaginal birth. In Denmark, following the TBT, C-section rates rose from 79% to 94% for breech babies.
However, if C-section really was the safer option, one would assume rates of injury or death of babies to decrease following this new movement. Yet, according to another study that examined the changes which occurred after the TBT, there was, in fact, no expected improvement in the rates of injury or death in babies (Hartnack et al. 2011).
The re-examination of the TBT demonstrates that caesarean section is no longer the only birth option for women with breech presentation.
This excerpt is sourced from Pregnancy to Parenting Australia:
The TBT has since been widely criticised for the way in which women were selected for the study and how their births were managed. There were also weaknesses around the skill levels of midwives and doctors involved as well as a focus upon short-term injury rather than upon the long-term impacts on babies’ brains (SDGC, 2009).
According to Birth Well Birth Right, up until about thirty years ago, Australian obstetricians treated breech birth as normal and they were expertly trained in the management of vaginal breech birth. Today, vaginal breech delivery is rarely taught to obstetric residents, hence it has become a dying obstetric skill.
There are many rumours surrounding why obstetricians, especially in private hospitals, tend to recommend C-section for breech babies, such as fear of liability or a lack of real experience and skills.
The stats indicate that C-section rates are 40~50% higher in private hospitals (this includes both breech and cephalic babies), according to this table obtained from the Australian Government Department of Health:
Births by C-Section
Source: AIHW Australia’s mothers and babies 1998 to 2007 (multiple)10-19
Evidently, the notion that C-section is the default for breech babies is an old, mistaken belief stemming from a highly debatable study done twenty years ago. Today, the general global consensus that C-section is not a one-size-fits-all solution for all breech presentation and definitely not the default solution for both mum and baby.
While assessing risks, it is critical to also take into account the risks associated with maternal long-term wellbeing. Several other studies have demonstrated that C-section is accompanied by increased maternal morbidity, i.e. any health condition attributed to and/or aggravated by pregnancy and childbirth that has a negative impact on the woman’s well-being, including physical, mental and sexual condition.
Regardless of breech or cephalic (head-down) presentation in babies, C-section poses a much greater health risk for mums as compared to vaginal birth. According to this Canadian study done in 2007, the severe possible implications of C-section include but are not limited to:
- Cardiac arrest
- Wound hematoma (swelling of clotted blood within tissues)
- Hemorrhage requiring surgical removal of the uterus
- Anesthetic complications
- Major postpartum infections of the reproductive tract
- A scarred uterus – Increased risk of certain placental complications in future pregnancies
- Venous thromboembolism (VTE) – A disease process that includes deep vein thrombosis (DVT) and pulmonary embolism (PE), and accounts for 7% of all deaths in Australian hospitals
Based on a diagram produced by NSW Government Health Department for their handbook (“Maternity – Towards Normal Birth in NSW“), this reflects the scale of risk associated with childbirth while taking into account the wellbeing of BOTH mum and baby:
When comparing C-section against vaginal birth for breech babies, the risks of injury or death in babies are comparable. According to Birth Well Birth Right, breech babies born by Caesarean are also at risk for the same complications as a breech vaginal birth (birth injuries such as a broken collarbone, nerve damage etc) and in addition, they are at risk of being cut during the surgery itself.
There are typically two common risks associated with VBB:
The case of the baby’s head getting stuck after the body has descended happens for a few reasons:
- Cervix is not fully dilated prior to pushing – It is vital for VBB that it is fully dilated before pushing
- The baby has a hyper extended head – This can be caused by the practitioner pulling on the baby, which is why a “hands-off” approach is highly recommended for VBB
- Baby’s head and body are disproportionate – This is more common with premature babies
Regardless of the reason, an experienced and skilled obstetrician or midwife will know a range of maneuvers to free the baby’s head.
This is not to be confused with cord wrapping, which is very common amongst all babies, regardless of position, and is rarely a cause for concern unless it prevents the baby from descending into the vagina.
Cord prolapse, on the other hand, occurs when the umbilical cord descends into the vagina before the baby and usually happens when the waters break and the cord is pushed out with the gush. This is dangerous as it could cause the cord to be compressed too much before the baby is born.
The risk of cord prolapse in a frank breech baby is 0.4%, the same as a cephalic baby. The risk rises to 5-10% in a complete breech and is the highest at 10-25% in a footling breech, which in itself is a rare occurrence.
Image source: PregMed
It has been suggested that the risk of breech birth is more attributable to the fact that most obstetricians are inexperienced in breech birth management because of the high use of cesarean delivery than to inherent risks in the breech birth process.
In its 2010 policy “Maternity – Towards Normal Birth“, NSW Health Department endeavours to increase the vaginal birth rate in NSW, including breech babies. On p.12, the policy states that “Area Health Services will provide women desiring a vaginal breech birth access to clinicians that will support this choice“.
In other words, if you are aiming for a vaginal birth for your breech baby, the local health districts are there to support your decision and provide you with the professional help you need. Depending on which hospital you are enrolled in, they may refer you to one of their midwives or obstetricians who is experienced in VBB.
The scenario is different in a private hospital setting.
If you have private healthcare and your chosen obstetrician does not have experience in VBB (which is very likely as outlined earlier in the article due to high rates of C-sections in private hospitals), your best bet is to ask for a referral to someone else who does.
As a general rule, VBB is a safe option for candidates who meet most, if not all, of the below guidelines:
- Full-term baby, or at least 39 weeks
- Frank or complete breech
- You have had a vaginal birth before (or at least never had a C-section)
- You have no health issues or pregnancy complications such as gestational diabetes, pre-eclampsia, low-lying placenta etc
- Your labour starts and progresses naturally with no drug or instrumental intervention
It should also be highlighted that in Australia, contrary to popular belief, public hospitals are actually better equipped than private ones to deal with complex labour and emergencies. Not only do the midwives in public hospitals have more hands-on experience with vaginal delivery, including breech births, they also have vital medical facilities like NICU and medical staff on standby for emergency C-sections if required.
You can read more on the comparison of private and public hospitals in this article.
Till today, the topic of VBB is still highly controversial and study findings vary. However, it is generally accepted that although C-sections may slightly reduce the risk to breech babies, the overall risks in either scenario are comparable.
C-section carries an increased risk of maternal health issues (and even death, which remains largely under-acknowledged), which is important because the effects of the surgery may affect a mother’s recovery from the birth, ability to care for her newborn and, most importantly, for her future pregnancies.
The key takeaway from all these is nicely summarised by The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and its statement on the management of breech presentation:
“While it is true that women with breech presentation at term will most often be delivered by caesarean section, management should be individualised. The term breech trial (TBT) did not have the statistical power to meaningfully analyse subgroups, some of which are likely to be pregnancies that do extremely well with breech vaginal delivery.”
(Source: Pregnancy, Birth & Beyond)