Breech

Head’s up! A breech baby has their buttocks coming into mother’s pelvis before the head. Usually, the buttocks will be born first, less often the feet or knees emerge first.

What are the types of breech positions?
Is breech presentation a malposition or a normal variation?
When is vaginal birth safer than surgery and when is a cesarean better?

 

There are three basic breech types, with a fourth often noted but very uncommon:

  1. Frank, or bottom first with legs extended towards baby’s trunk.
  2. Complete, or legs folded so that feet are very close to the buttocks.
  3. Footling, or one or more feet coming into the pelvis first, the bottom is above the brim and the feet are below; at 37 weeks, the knees may be bent so that the baby seems to be sitting on the top of the pelvis dipping his feet into the pelvic tunnel.
  4. Kneeling, or both knees are coming first, the feet are folded up behind the baby’s thighs.

Breech 3 types

Is your baby breech?

Unfortunately, even skilled sonographers, midwives, and physicians may write “breech” in the chart when the baby is in an oblique or transverse lie because the baby isn’t head down. The specific causes and solutions for these positions may differ slightly from a breech baby, so it’s important to know for sure.

If you baby is indeed breech, we offer three ways for parents and providers to learn how to help their baby turn head down:

1 .  We have plenty of articles, tips, and tricks on the Spinning Babies® website, and the best part is they’re FREE! Here are some to get you started:

2 .  Buy our convenient ebook with a structured program called Helping Your Breech Baby Turn. You can start helping your baby turn head down on their own, or reduce muscle tension before an external cephalic version (ECV, the doctor turns the baby).

3 .   Our Spinning Babies® Parent Class video walks you through our basic recommendations for helping all babies be in a more ideal head-down position. There’s even an additional scene showing Gail help a pregnant couple use the Breech Tilt position on an ironing board.

Breech Position Consultation

Reasons for breech

  • Born before full term, baby didn’t have time to turn head down.
  • A mild or major neurological difference reducing their ability to turn head down. For instance, some Down’s Syndrome babies will be breech. About 1 in 10 breech babies have some sort of neurological reason.
  • A more common reason for full-term babies is what bodyworkers might call a “muscle imbalance.”
  • Studies show that there is a higher rate of low thyroid function in mothers of breech babies. This may show a metabolic connection to the fetal position.
  • A low lying placenta may be blocking the room for the head.
  • If the placenta is in the upper right area near the fallopian tube, it reduces the baby’s ability to turn.
  • If the cord is wrapped around the baby.
  • A tight abdomen, a super strong core, and/or less amniotic fluid.
  • Looseness in the muscles and ligaments so they are not able to give support for the baby to move head down.
  • A uterine shape that is more cylinder-like and not so round (bicornuate or didyphys)

In my experience, most babies are breech due to uterine ligaments and muscles being either too tight and asymmetrical (twisted or torqued) or too loose. For example:

  • The sacrum is not straight and a short line at the top of the buttocks veers to one side or the other in a subtle way.
  • The ala of the sacrum may be rotated on a vertical axis.
  • There may be a buckle on the horizontal segments of the sacrum.
  • The SI joints or the symphysis pubis may be out of alignment as well.

Some midwives will say that breech babies may be breech because they want to be. That may be, but I suggest we address a possible imbalance of the uterus. I believe the baby will get in the best position possible given the space in the womb.

It’s not that any woman isn’t perfect inside, but optimal room in the uterus depends on pelvic alignment and ligaments of equal length. An imbalance may be restored if a woman has the right technique and help for her body.

Isn’t breech birth normal? Haven’t breech babies been being born since the beginning?

Model of a breech baby from Italy in the 1700s

The breech position can be a normal response to the shape of the space inside the mother’s womb. Usually, the womb is aligned to encourage the baby to be head down. Whether or not it’s normal that any particular breech baby isn’t head down varies, just like the ease around head down babies varies. Not all head-down babies have easy births, and not all breeches have difficulty.

As long as the baby is able to complete the rotation and movements for breech birth (called the Cardinal Movements), and there are no malformations of the baby or the mother that might interfere, the birth may be natural and normal. Most of the time, a breech baby can be born vaginally and quite safely.

Most breech babies, just like head-down babies, tuck their chins and come out in a tube shape. When the baby’s head is tucked in like this, making the baby rather tube-shaped, then breech is actually a fine position for birthing a full-term baby naturally.

Can’t we use an ultrasound to see the baby’s head position?

An ultrasound in early labor or close to the baby’s due date can verify head position at that time. It is now thought by experts that if the baby’s head has been looking up during pregnancy, a cesarean is the best choice. If the head is looking straight (neutral) or down (flexed), then the chin can tuck and a vaginal birth with experienced, breech-smart help can be a safe option.

The baby’s head and arm position can certainly change in labor. A mother, doctor, or midwife can’t always predict which baby will come easily or get stuck. If the baby gets stuck, it is too late to do a cesarean. But it’s not too late for a breech-smart expert to correct the problem by immediately rotating the arms free and flexing the chin so the head can fit the pelvis.

Online resources for parents and providers considering vaginal breech birth via a physiologically sound approach

  • The late Midwife Mary Cronk, one of the most experienced home breech birth midwives in the world, wrote a very excellent article on breech as an unusual, but not abnormal, position. She also spoke about using the hands-and-knees position to protect the baby’s own spiraling motion through the pelvis for a safe breech birth.
  • Jane Evans, a UK midwife who worked closely with Mary Cronk and who helped develop education efforts with midwives and physicians interested in the Cardinal Movements of breech birth, wrote Breech Birth: What Are My Options?
  • Shawn Walker is a PhD and practicing UK midwife with a revolutionary and educational blog.
  • Rixa Freeze, PhD, blogs about Frank Louwen’s manner of improving the safety of vaginal breech birth to be of superior safety to cesarean.
  • Ina May Gaskin posted an exciting article on the lost art of breech birth.
  • Maggie Bank posts her articles on breech birth at BirthSpirit.com. You can find her breech birth book there as well.
  • A group of parents and professionals in Canada are promoting the normalcy of breech birth and helping connect parents with professionals that support natural breech birth and the research to support breech vaginal birth at Coalition for Breech Birth.
  • Here is a beautiful story of a laboring woman on her hands and knees with her baby mirroring her position as she is halfway born.
  • Here is a video of another mother in a hands and knees position. The complete birth and 30 seconds of the postpartum is intact, so you can see the birth in real time. This birth is entirely hands off, except for the long delay in wiping the baby’s head clean so mama could kiss her.
  • This is a lovely story of a footling breech born at home. There is a lull in labor during which the mother walks the neighborhood. She then comes home and has her boy. There are entrapped arms, which we don’t see, and a trapped head for which we see the midwife deftly correcting the flexion and then baby is out. Good thing the midwife really knew her moves!
  • Here is a mother’s story of her surprise breech and how the midwife’s mentor knew to keep hands off! When there is a surprise breech, it’s best to keep your hands off the baby completely. A surprise breech is often progressing well — and that’s because the midwife or doctor either didn’t check the position in labor or they arrived at the birth as the baby was coming.
  • Here is a lovely birth story from an Arizona mom whose midwife invited a second midwife to share the support and skills of breech at a home birth.

Who can we find with breech vaginal birth experience?

Nearly all American doctors have poor training in breech skills, and many midwives are entirely untrained as well. You might try looking towards the far ends of the birth provider spectrum to find providers with breech skills, such as the chief of staff of Labor and Delivery at a big hospital, a country doctor, or the rare, breech-skilled home birth midwife.

A childbirth educator, birth activist, or doula might have the name of someone with breech skills as well. Some women and couples travel long distances to a doctor or midwife experienced in natural breech birth. These names are not likely to be put on the internet with the current fear about breech vaginal birth and the high risk of potential legal costs. Even when breech birth goes well, midwives and doctors can face serious opposition for supporting a mother’s vaginal breech birth.

 

What makes a person experienced with breech birth?

Is it a certain number of breech babies delivered? Is it a good knowledge of the physics and cardinal movements of breech birth? Is it knowing when to keep your hands off and when/how to help the shoulders and head without pulling? The answer is: all of the above—and these skills are lacking in many countries today.

Here are a few standout candidates from several countries of the world that check off all of the breech birth boxes:

 

Germany
  • Dr. Frank Louwen of Frankfort is leading the world in safe vaginal breech birth in the hospital. His excellent teaching could transform breech birth practices worldwide. His statistics on 750 vaginal breech births are quite positive, showing safety when women lay on their backs.
  • Dr. Anke Rietter, also of Frankfort, is an expert in upright breech position for vaginal breech birth. She is a physician/author included in the upright breech birth outcomes mentioned with Dr. Louwen above.
Canada
  • Andrew Kotaska is a leading voice and teacher of obstetricians.
  • In Ontario, Dr. Peter O’Neill is a breech expert and trainer. He asks women to be on their backs for breech birth, which I don’t feel comfortable with, but he is excellent in how he handles breech and I’m happy to refer to him.
  • Betty-Anne Daviss, a midwife in Ottawa, is a leading trainer of physiological breech with much to say on the culture of providers in the breech world.
The United States
  • In Wisconsin, Dr. Denny Hartung offers breech vaginal birth care to parents and prefers the all-fours position for more alert breech babies at birth.
  • Denver’s Dr. Michael Hall is a natural breech birth advocate and expert. He’s also happy with hands and knees for safety and says, “It makes sense.”
  • In Los Angeles, Dr. Stuart Fischbein is delivering breech babies at home.
  • Emilio Chevez, also in L.A., is providing Maternal Fetal Medicine. “Milo” is a breech provider and advocate for parents and the community.
  • In Atlanta, Dr. Brad Bootstaylor is skilled in breech birth.
  • Spinning Babies® Approved Trainer, Nicole Morales, CPM, teaches about breech through the levels of the pelvis at Nizhoni Institute of Midwifery.

As you search for a provider to help you, whether they have a degree/reputation or not, ask them to show you how they release stuck arms or a trapped head. If they can’t readily do this with a doll and pelvis (or another prop), then keep looking. They may be nice, sincere, and skilled—just not in breech.

I have seen home and hospital providers not know how to free a trapped baby, even with many successful breech births behind them, because it had always been easy up until then. Breech birth can go well, but when it doesn’t, more babies die because the overconfident provider really didn’t know what to do. I don’t mean to be negative here, but saying this straight can save a life.

Fortunately, there’s good news!

We are living in a time when expert breech providers are gathering and sharing ideas and data. Three different studies show the benefits of an all-fours/knee and elbow position for pushing in the last phase of a breech vaginal birth.

The biggest problem with breech position is the lack of experience in the person catching the baby. Pulling on the baby can cause severe injury. A vertical birthing position fits nature’s design for safe birthing. When a mother is standing, sitting up, or in a hands-and-knees (or knee-elbow) position, it will allow the baby to rotate through the open pelvis.

Breech birth on the mother’s back is not very safe, as the baby can’t help with the birth. Gravity pulls the baby into the mother’s back and not out her vagina. The mother’s sacrum is pressed by her weight into the bed and a doctor or midwife is more likely to pull, even gently—which is bad. Breech itself may not be a malposition, but requiring a woman to lay on her back to push is definitely one!

Stuart J. Fischbein, MD, wrote, “…there is enough wisdom and evidence to suggest that when properly chosen, women can have better outcomes with vaginal deliveries and babies are no worse off. Actually, knowing what we do about the microbiome, epigenetics, and bonding, a vaginal birth is really much better, but those things are never considered in the medical model.”

Dr. Fischbein and I joined Dr. Elliot Berlin to watch Heads Up. Dr. Elliot, a generous Chiropractor in Los Angeles, made this film about choices (and the lack of) in breech vaginal birth. This film is mostly about the mother’s emotional responses to providers reacting to her carrying a baby in the breech position.

Breech & cesarean

Most breech babies in America are born by cesarean surgery. Though obstetricians in the U.S. now consider breech to be too dangerous for vaginal birth, at some university hospitals in Norway, France, and Canada, the safety of vaginal breech birth is well proven.

The techniques to help the arms and head of a breech baby are similar, whether in a vaginal or surgical birth. If delivering a breech baby, a doctor has to figure out how to get the chin tucked and past the mother’s bones, or through the tight abdominal incision.

Here is the World Health Organization’s video training for breech birth. It shows women birthing on their back and the baby being partially extracted, which is the obstetrical model being taught to midwives in South Africa. Now, if the mother gives birth physiologically, she and the baby work together with gravity and labor to help the baby rotate through the pelvis spontaneously.

The techniques to help a breech baby flip that are listed on this website will help a woman’s soft tissues be ready for birth, as well as for a better fetal position so that if the baby doesn’t flip, the womb will be more in line with her pelvis and her pelvis with her pelvic floor, and so on.

However wonderfully we’re designed for birth (even breech birth), having a skilled attendant is necessary for the unexpected. You can read more in Mary Cronk’s article, Keep Your Hands off the Breech. Mary isn’t afraid to use a more “hands-on” approach though when the baby hasn’t rotated or flexed the head, and requires gentle, expert help.

Surgery has reached an accepted level of safety because of improvements to surgical techniques, blood replacement procedures, and antibiotics to treat all too common, post-surgical infections. Major surgery has risks for the mother, however, such as blood loss, anesthesia, and infection.

For the baby, being born cesarean doesn’t mean being lifted up from the womb in the same way that they’re lifted up from a crib. Difficulty with the delivery of the arms and/or head can happen in a surgical birth too. The baby can still suffer an injury or death. The number of future siblings dying might even be equal to the number of breech babies saved by doing cesareans for almost all breech babies (Thomas Van Akker, MD).

Important physiological changes in brain development are now thought to occur during natural labor contractions. A scheduled surgery bypasses this physiology. Surgery can be life-saving, but it sure isn’t gentle.

A cesarean might be the best choice for a breech birth, if:
  • The baby is less than 28-30 weeks gestation
  • The baby is over 42 weeks gestation (not an absolute, but should make you alert to other factors)
  • The baby seems large (8 pounds, 13 ounces (4,000 grams) or more, except in a rapid frank breech labor with good progress)
  • The mother has diabetes
  • The baby has Intrauterine Growth Retardation (IUGR). This is a very important factor, and one of the most supported reasons for cesarean
  • The care provider plans to touch the baby and “manage” the birth, yet neither knows the breech baby’s spontaneous cardinal movements how to rescue the baby with breech maneuvers
  • Labor is slow after 5 cm or stops altogether after labor had been going well.
  • You do not have a person (OB, midwife, birth attendant, cab driver, etc.) who knows how to release stuck arms or head
  • Labor isn’t progressing, even with strong contractions and freedom of movement.
  • The baby doesn’t descend during late labor
  • The placenta is covering the cervix
  • The mother or birth attendant is not confident with the natural birth of a breech baby
  • Metabolic sloshiness (low thyroid function, fertility issues, conception through artificial insemination, etc.)
  • There’s pelvic torsion or somewhat small diameters

 

A cesarean birth can be more baby-centered by:
  • Allowing labor to begin on its own, and then having the surgery within an hour or two
  • Delaying clamping of the cord until the cord stops pulsing
  • Putting the baby into the mother’s arms in the operating room
  • Cuddling and breastfeeding in the recovery room

Here is a video of a lovely cesarean breech birth. I cried upon seeing the mother’s face when she saw her baby. It’s incredible how kind everyone is to the mother and child. Love is the most important thing that your baby is yearning for!

 

Should I have labor before my scheduled cesarean?

Consider whether it is reasonable to your health and whether your labor would allow you to reach surgery in time. This will give the baby a catecholomine surge to prepare for air-breathing (See The “Stress” of Being Born in Scientific American). Spontaneous labor might help protect against “late prematurity,” a growing risk due to increasingly scheduled births that turn out to be not as close to nature’s due date as was originally thought.

Some women will appreciate early labor for these advantages, while others will know that it is not feasible for them.

Discuss the possibility of labor with your doctor, and please don’t spring it on them without any warning. Sometimes delaying surgery until spontaneous labor is not wise, such as when the mom has a long distance to drive coupled with a previously fast birth or other health factors discouraging labor.

 

Healthy labor is good for healthy babies.

US and Canada on breech birth methods

The early 2000’s brought with it an amazing examination of how breech babies are born. Early in the decade, the term “Breech Trial” (a nickname for the Mary Hannah study) recommended cesarean surgery for most breech births. But in examining the study, and adding more appropriate data with better interpretation, Hannah’s group found that qualified breech physicians were successfully swinging the vote in favor of vaginal breech birth.

Here’s the general view of the American College of Obstetricians

In light of recent studies that further clarify the long-term risks of vaginal breech delivery, the American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider Cesarean delivery will be the preferred mode for most physicians because of the diminishing expertise in vaginal breech delivery. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. Before a vaginal breech delivery is planned, women should be informed that the risk of peri-natal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient’s informed con-sent should be documented.

Obstet Gynecol. 2006 Jul;108(1):235-7. Comment in: Birth. 2007 Jun;34(2):176-80. ACOG Committee Opinion No. 340. Mode of term singleton breech delivery.

Note: This view does not reflect the view of experienced breech practitioners, such as Dr. Dennis Hartung of Wisconsin, for instance, who continues to attend natural breech births.

Here is the view of the Society of Obstetricians and Gynaecologists of Canada

Dr. Robert Gagnon, a principal author of the new guidelines and Chair of the Society’s Maternal Fetal Medicine Committee, reported:

Breech pregnancies are almost always delivered using a caesarean section, to the point where the practice has become somewhat automatic. What we’ve found is that, in some cases, vaginal breech birth is a safe option, and obstetricians should be able to offer women the choice to attempt a traditional delivery…the society is also cautioning that many breech deliveries will still require a cesarean section, and that a vaginal birth is not recommended for some types of breech positions. In situations where a vaginal delivery is an option, the delivery should take place in a hospital setting. An experienced obstetrician should be present to attend the delivery and to offer a cesarean section if the labour does not progress smoothly or if complications arise.”

Dr. André Lalonde, Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada, said:

The evidence is clear that attempting a vaginal delivery is a legitimate option in some breech pregnancies.

Canada is following evidence-based logic in promoting the safety of many breech births. Still, the emotional setting of a birth also adds to safety. Calm, trusting patience and a vertical (hands-and-knees) position are still critical aspects of safety in breech birthing.

Note: This view doesn’t reflect that Canada is in great need of breech training for physicians and midwives to meet the needs of parents having breech babies. Women may not yet be able to find a qualified practitioner. Contacting the SOGC or Midwife Betty-Anne Daviss atUnderstandingBirthBetter.com may be helpful.

 

Media Centre also shared the following breech links:

It’s good to compare the opinions of US and Canadian physicians on how a breech baby should be born. I was very interested in the experts’ teachings on physiological breech birth skills, so I put them into a brief picture book for providers who have been exposed to their teachings. You can find this Breech Quick Guide in our online shop.

Videos
Daily Essentials
Daily Essentials can be practiced daily throughout pregnancy to help bring balance and comfort — and an easier, shorter birth.
Spinning Babies® Parent Class
Spinning Babies® Parent Class provides clear instructions on how to use Spinning Babies® for a more comfortable and confident pregnancy and labor.