That said, the knee-elbow position offers extreme improvement in the baby’s outcomes over the woman being on her back. If the provider has limited skill in upright breech birth, it may be protective and easier to conduct maneuvers if the mother is on her hands and knees or in a knee-elbow position.
- Hands-off the breech
- Hands-and-knees (knee-elbow) position
- Leave the cord intact and unclamped
Hands-off the breech means few or no vaginal exams. No wiping the mother’s bottom or pushing it up away from the mattress or floor to prevent her sitting on the baby. She’ll feel the baby and won’t sit on the baby too much. The mother’s rocking down may help or maintain flexion.
Hands-and-knees (or knee-elbow) lets the woman on a flat surface rock back and forth, rise up, and lower down as her instincts move her. A raised hospital bed, birth ball, or even her loving partner are not in front of her accidentally preventing her intuitive movements during the birth of the baby’s head. Gravity brings the baby to the anterior as the hips or chest come through the pelvic floor.
Leaving the cord intact, even with its white, is an important way to support the baby’s vitality after birth and increase apgar scores. When should you cut the cord? After the birth of the placenta is a good time.
Can vaginal breech happen in a hospital?
Yes! But mothers may have to travel to find a provider, especially an experienced and physiologically-based one. Check out this lovely little blog post on a sweet, hospital birth. (NOTE: I don’t think the episiotomy was necessary, but the doctor was learning to be comfortable with vaginal breech birth.)
Watch this physician training film, which uses a doll and mannequin. The techniques are widely accepted in some areas of the world. Personally, I have some questions:
- For one, the segment showing the spontaneous birth (as the body of the doll is being born) shows the doll’s spine to mother’s hip, which is a sign of an anterior shoulder dystocia. Yet, the baby is born from the mannequin easily. This would not be the case with a real baby, whose arms would be stuck when this position persists!
- In this breech extraction, the doll is rotated by pulling the leg. Doing this will set up a twist in the baby’s pelvis and shoulder musculature and may show up as depressed respiration at birth.
- The baby must be rotated in these emergency situations to fit the next part, lower into and through the pelvis.
The first thing women often hear is that the breech baby’s head can get stuck. This is true, but getting the head unstuck when the baby is full-term is generally not troublesome when the provider knows how to flex the head and bring it into the AP diameter.
Occasionally the stuck head is above the brim and has to be turned to the diagonal to drop into the pelvis and then flexed and turned to face the perineum. You can learn what to do at each level of the pelvis in my Breech Birth Quick Guide.
Shawn Walker, a British midwife and breech researcher, explains it like this:
Some babies who are breech need help, more often than head-down babies. So having experienced support is crucial to the safety of breech birth. The head getting stuck is a terrible image, designed to terrify women, and probably the result of practitioners themselves feeling fearful or inadequate. I prefer to talk about the need for help because it creates an image that help is available, as it should be, but is realistic about the fact that occasionally some manual assistance is required.
Generally, even the RCOG guidelines (you can look up Management of Breech Presentation) recognize that second twin breech is no indication for a CS. The path will be cleared by the first twin, and there are generally few complications due to breech per se with a second twin. There is no evidence that there are more complications for a first breech twin which is fully grown…
Here is an article that looked specifically at results for twin births where the first twin was breech. I think you and the authors are coming at it from the same perspective. In their article they write: “Being a rare clinical situation (less than 0.5% of all deliveries), one might question the need to study safety of vaginal birth in breech first twins. The point is not reduction of the overall cesarean rate, but preventing unnecessary cesareans.
Can vaginal breech birth be supported at home?
Again, I would say yes. In seeking safety parameters for home breech birth, guidelines must be developed from the best practices of breech-experienced midwives and doctors.
Protocols, or guidelines for care, are designed to increase safety by reducing the trial-and-error approach of a lone individual. With protocols, we hope to avoid “wish midwifery” (“I wish the birth was going to pick up and finish soon,” or “I wish the baby was coming down,” etc.).
Sometimes a parent or provider decides to continue with a birth that is outside the protocols. This may be simply because the protocols can’t apply to every single variation of normal birth, but the chance that the risk is rising should be acknowledged with increased communication, coverage, and/or transport.
Protocols, however, are not enough information for a family or provider to make complete decisions about a particular breech birth. Yet, with more parents learning about breech birth online and elsewhere, a practical—and hopefully balanced—approach may be helpful for decision-making.
Practice all skills for both “all-fours” and “on the back” maternal positions. Once you learn a formula and use it a couple times, you’ll be better able to assist in any position.
Knowing the pelvic diameters and what your fingers feel inside will suddenly make sense. Turn the baby to the largest diameter at the level of the pelvis where the baby needs to move through next. Of course, this is only when the baby is in an unfavorable diameter, or else you would be sitting on your hands.
Where is breech birth safest?
The Royal College of Obstetricians and Gynecologists Guideline for Breech Birth (2017) recommends hospital birth as the best location for all breech birth, but they mark their statement as a “D,” based more on opinion rather than strong scientific evidence.
That makes sense when hospitals have skilled breech providers, but it doesn’t make sense when there are next to no hospital providers skilled in breech normal birth and resolving complications by restoring breech rotation and flexion.
Few hospitals in America have a skilled vaginal breech care provider. Since shifting to a high cesarean rate for breeches results in a higher maternal death rate (and subsequent sibling stillbirth rate) and since 3-4% of births are breech presentations, there is a growing vocal subgroup of parents who are choosing home breech birth over cesarean.
With birth being a human right, it is our responsibility as providers and nations to provide legal and educated care for these families.
Breech birth can happen at home, but there are risks
Breech birth is becoming more accepted in American home birth culture. We are seeing more home breech birth videos on the internet.
A good example is Annaka Faith’s birth story and video on Leslie’s Daily Surrender blog. We hear how her midwife brought in a second midwife with breech experience to increase support and skills if Leslie’s baby were to need help during the birth. What happens is classic and is addressed in the following paragraphs. Go read the blog first, though, as it’s a lovely story.
Midwives learning from other midwives have the advantage of learning physiological breech birth. A disadvantage is the gap in 2-3 generations of midwives who’ve missed experience with more than an occasional breech. Home birth doesn’t have the extra support for full resuscitation, though it is advantageous for the baby that many midwives know not to cut the cord during resuscitation and an intact cord helps the slow to start baby while the midwife resuscitates (reanimates).
What skills does a provider need to possess in order to offer breech birth care?
The skills of providers will vary. Even one with many successful breech experiences behind her could suddenly be faced with a situation she can’t solve. This crisis can and does also occur in the hospital as well as a home birth.
Hospitals close doors to breech after a complicated breech upsets the hospital staff and/or physicians. A similar crisis in a home birth puts parents and midwives into a whirlwind of exposure, review, and too often, a retribution by the medical/legal system.
A very experienced midwife may be more likely to notice when a labor leaves the range of normal, and there is often time to transport the mother for an intervention. Once the baby’s hips are born, the birth must be helped to finish correctly.
When a doctor who works where interventions are routine wants to begin to help parents achieve a natural birth, the doctor may not have the experience to notice when a labor actually needs an intervention. I know that sounds crazy, and I don’t mean to be biased, but I’ve brought up a few conversations to get the needed intervention when I’ve seen this happen.
A midwife, doctor, and doula team can offer the best care when everyone is working harmoniously within their strengths and roles. True cooperation means not pushing an agenda or being afraid to offer insights on observations.
What makes for breech competence in a provider?
A home birth midwife decides to support families having a home breech birth. The question then arises: How many breech births are enough to satisfy her ability to handle a complication?
Just because breech is “normal” doesn’t mean all breech births are spontaneous. Sometimes, when a breech birth is difficult, it can get very difficult very fast, with no time to transport.
Few American midwives have complete breech training. There are now several conferences a year coming from the upright breech experts, and these bring life saving information. However, we must also know about breech birth skills to help a woman on her back.
Upright breech labor is often more comfortable for the woman. Most crises are easily handled by the provider trained and practiced with breech birth in a hands-and-knees maternal position. A family member observing experienced breech catchers might miss the fact that there was even a stuck arm or head due to the calm mood and quick (but gentle) response to the crisis.
My responsibility as an educator is to go on about “the tougher variations of stuck,” because they do happen and they do lead to scary close calls and even death. Face that fact, and don’t divert from it! With all potentials listed, paired with your intuition, you can better assess whether your resources are adequate to your needs in providing or receiving breech care.
Midwife Nicole Morales (CPM, USA) has developed a thorough breech birth skills checklist from the work of Shawn Walker’s Dephi Study and other breech skill discussions. Nicole teaches breech birth and more at Nizhoni Institute of Midwifery in San Diego, California. She is a mother of a vaginally born breech baby and also a Spinning Babies® Approved Trainer.
It is vital for safe breech birth to know breech cardinal movements. A provider must recognize when the baby is unable to make the next cardinal movement. See Jane Evans’ article on the Physiological Breech Birth, including the cardinal movements in MIDIRS journal.
Watch difficult breech births. Use a doll and pelvis to illustrate each stall and each step. Do this 100 times. Remember, skills are processed with logic, but practiced with heart and hands.
Here’s a picture of a baby who is coming well in a hands-off, knee-elbow maternal position. The arms are about to come out on their own as indicated by the deep crease in the chest showing the compression of the elbows on the chest.
It is also good to know several ways of helping if the arms and/or head becomes stuck. If you can’t see it coming before it happens, you have more to learn. The first view of the breech will show you if there may be trouble ahead. At the first peek, there may still be time to change plans.
Before a midwife attends a home breech birth, she will be more helpful if she knows how to resolve the stuck shoulders of head-down babies. Rotation and handling the shoulders in a head-down baby aren’t exactly like stuck shoulders with a breech, but are very similar. The principles are the same, just applied upside down!
Having been through several shoulder dystocias gives the midwife practical skills in a crisis. Other necessary skills would include:
- Physiological resuscitation of the newborn
- Creative cord unwrapping
- Recognition of cord compression
- Handling a rapid hemorrhage
- Serenity to keep hands off
- Courage to be hands-on
- And the wisdom to know the difference!
Early placenta detachment can occur. The appearance of the baby may not show evidence, and blood may not pass the breech head yet still be in the pelvis. Keeping the time from hips-out to head-out to approximately three minutes is protective of consequences of unforeseen complications.
Knowing how to apply safe fundal pressure, and never pulling, is a key skill to speeding an otherwise normal breech birth for the reasons of poor tone, poor heart rate, or no further effect from maternal contractions.
Another very nice skill, though not a common one, would be pediatric craniosacral and myofascial release. One may refer to a person who can do “cranials” for the baby, which will improve breastfeeding and other vital functions immediately, as well as in the following hours, days, and weeks after birth.
Even before the birth, communication skills with parents about birthing outside of the typically accepted practices of American birth, and perhaps without family support, is important to nurture the mother’s body and mind connection.
Personal Breech Birth Protocols
Breech birth can be a lovely variation on a natural process. Labor may be less painful and shorter than with a head-down baby. Risk reduction through a holistic approach compares appropriateness of home or hospital, and cesarean or vaginal birth with this mom (emotional preparedness, health, pelvis) and baby (presentation, health). Breech vaginal birth can be a conscious choice for conscientious parents.
Provider protocols protect our decisions when fatigue, emotion, birth plans, or inexperience might confuse issues. These breech protocols reflect, in my opinion, best practices for a home breech birth in my area:
- All mothers are assessed for pelvic alignment and myofascial issues. Repeated bodywork increases safety.
- All midwives discuss and agree to consultant’s parameters and recommendations before, during, and immediately after the birth.
- The baby’s head is of a normal size, and tucked (chin to chest, flexed) or neutral before labor, as noted by palpation (feeling the woman’s abdomen). The mother is informed for assessment by an ultrasound or MRI.
- The baby is frank or complete. Footlings are referred, and suspected footlings are closely examined (externally) to see if the buttocks aren’t also in the pelvis with the feet, which means this is a complete breech and has been misdiagnosed as a footling. With a footling vaginal birth, the baby is of no more than average size and the mother continues bodywork to help her pelvis and womb become optimal for birth.
- The mother’s pelvis size is fine as determined by the previous vaginal birth of an average-sized or larger baby, or by pelvimetry, which includes an internal exam of the pelvis. (An MRI is not universally recommended here.) Ischial tuberosities also measures wider than the mother’s fist.
- Safety increases when mothers are both relaxed and free to move during birth. This way, women can respond instinctively to labor and their baby.
- Labor begins spontaneously, without induction or augmentation, between 36-42 weeks at home (34-43 in a hospital)
- The mother doesn’t have hypertension, diabetes, or diabetic symptoms. If she has metabolic stagnation or imbalance you should be more cautious.
- The baby is full term and there is no restricted fetal growth (IUGR).
- Labor progresses readily without a stall in active labor in the presence of strong contractions. A start-and-stop pattern in active labor without progress is a means for transport (no breaking the water).
- The mother’s birthing position is physiological. Hands-and-knees (or knee-elbow) is protective once the baby is visible. The birthing person is not restricted to any position however, and is free to move.
- The person catching keeps hands-off entirely unless the baby shows the need for help in order to come out. There should be no breech extraction, no perineal massage or support, no wrapping the half-born baby in a cloth, and no pushing on the mother to stop her sitting on her baby (mom will feel the baby and stop herself). Episiotomy is not routine. No one can wipe the mother’s bottom during birth. All this is to keep the mother from clenching. Quiet patience is key.
- Monitor appropriately. A fetascope is the method of choice. Use a doppler only when the fetascope can’t pick up heart tones. Touch the cord if it is not visibly pulsing in assessment for emergency intervention.
- The second stage can last up to 4 hours. After a latent phase early on, the pushing urge takes over and there is descent. If there is no progress after an hour of good pushing, we need to transport for surgery. With slow descent (the baby is coming down), pushing at home should be given 3 hours. If the hips aren’t then being born (or “rumping,” meaning birth time isn’t imminent), we transport. A cesarean is strongly protective of the baby in this case. Consider a Side-lying Release in labor to potentially reduce the duration of descent.
- Fundal pressure (not suprapubic) is okay when immediate birth is necessary with the following conditions. Fundal pressure is only advisable if the baby is not impacted, which means the next large part of the baby matches the pelvic level it’s passing through. Resolve any obstruction first with rotation and flexion.
- The attendant has experience, practices regular simulation of breech birth, knows the necessary maneuvers, newborn resuscitation, delayed cord clamping, and knows techniques and maternal positions to open the pelvic inlet, midpelvis, and outlet. The attendant midwife or doctor also practices breech drills with the mother’s other midwife/doctor/nurse whenever possible.
- The attendant is calm, pleasant, and not hovering. Honesty and communication are vital for safety!
About 20% of planned breech vaginal births finish with cesarean surgery, according to Dr. Frank Louwen and midwife Jane Evans. Often this is because the baby doesn’t descend into the pelvis.
Vaginal breech birth resources
The following are all excellent sources of information on vaginal breech birth:
- Jane Evans’ two articles on breech cardinal movements and spontaneous maternal movement to birth the breech head in the 2012 February and March issues of Essentially MIDIRS. This is essential breech knowledge for all baby catchers.
- Excellent, up-to-date discussions in The Midwife, The Mother, and The Breech by UK midwife Shawn Walker.
- Understanding Birth Better, the website of Betty-Anne Daviss and Ken Johnson of Ottawa, has great breech information and published journal article.
- Dr. Fischbien has a short informative podcast on the status of vaginal breech birth that parents may find to be a useful overview.
- Read the AIMS website for Mary Cronk’s article on physiologic breech birth, Keep Your Hands Off the Breech.
- The Royal College of Obstetricians and Gynecologists’ (UK) guidelines are informative (even though I find this biased but reflective of the larger community of providers who are at least open to breech vaginal birth).
- You can check out emerging online breech info in Australia and New Zealand, and a list of Australian breech baby catchers here.
Here is a powerful story from a mother, a home birth midwife herself, who worked hard for a natural birth at home. Notice the clues of soft tissue traumas from a previous car accident and former cesarean, as well as a previous posterior — not unusual history for a breech in a woman who’s birthed before.
Hands-and-knees birth might occasionally include complications, even after many spontaneous breeches, so it’s important to know the details of bringing out the head and the diameters of the pelvis so you know where the head diameter is in relationship to the pelvic diameters so you can rotate and flex appropriately for each level of the pelvis (station) in which you may find the head.
Hands-and-knees maternal position makes your work to rotate and flex the head much easier compared with a mother lying on her back. The pelvis itself has notably larger diameters when the mother is in this position and the sacrum is more mobile. Providers have more room to reach in to assist the baby should such help be necessary.
Hands-and-knees (or knee-elbow) position allows the baby to rotate in harmony with the birth process. The back will rotate towards the mother’s front and facilitate good flexion and avoid a posterior breech presentation for the birth of the chin.
Even loving help might startle or restrict the rotation of the baby who is otherwise rotating and descending fine. The baby needs to rotate, and touch impedes normal rotation by the resistance. Even though it’s subtle, the hands may rotate the baby’s fascia (that important membrane awash in cerebral spinal fluid which wraps every muscle, organ, and bone of the body).
Touching the mother might also cause her to clench her sphincter muscles in response. Additionally, letting the baby hang in this position later extends the back, likely assisting the Perez reflex for the shoulders to enter the brim and then the stepping reflex to flex the chin when the head is in the midpelvis (coming through the pelvic floor).
A water birth in hands-and-knees position may impede the work of gravity, lengthen second stage, and impede head flexion (based on Evans’ research). Water birth in the standing position with one foot lifted up on a submerged stool may improve outcomes. A rain barrel, not a birthing tub, is required for this arrangement.
Let gravity be the midwife.
Informed Consent and Informed Refusal
Please note: There is not enough information here or anywhere on this website to guide parents or inexperienced baby catchers towards a safe breech birth.
Some midwives propose 15 to 30 breech births as a starting point — an entry level for breech competency, while some doctors say 50 breech births is the number for competency.
Some midwives feel that with their level of experience, whatever it is, they offer a better option than mandatory cesarean surgery. (I’m not sure that is always true.) Most of the time, things work out, but when they don’t, don’t let it be because the first 15 breeches you went through were easy and you didn’t know something like that could happen.
Some very important aspects of breech safety are not in the books!
We need time together to discover just how much we need each other. We need to work together for better, safer breech births whenever we can.
We have a moral responsibility to breech babies and their mothers to learn how to support physiological breech birth. Studies show a nearly equal ratio of risk between vaginal and surgical birth, especially in future births.
Only when we can deftly protect physiological breech birth will we know if breech vaginal birth is safe. And only when the statistics of harm due to cesarean surgery are reported can we truly compare. Dr. Louwen and Dr. Rietter’s data on knee-elbow “hands off” breech births is published, and the argument against vaginal breech birth is now unfounded.
Breech birth can be smooth and sweet or it can be challenging and even tragic, in any setting and by any method. Not only physically, but politically and emotionally. Parents and providers in America who choose vaginal breech birth are outside the norm, but what’s common is not always right, and what’s unusual is not always wrong.
Basically, the issue is that breech babies have a higher rate of death due to complications of their position than head-down babies. With the right help, that difference can be smaller, if not absent. No manner of birth and no amount of experience can deny that difference. Parents and providers can’t rest on the superiority of their favored method and imagine they are safe from complications.
Cesarean surgery involves risks that are well known in medical circles, but often understated to consumers. Cesarean surgical birth may be safer than breech birth, such as when providers are not trained or trained providers cannot be found or traveled to.
To make surgery slightly less invasive to the baby, labor can be allowed to start spontaneously and then a cesarean can be done. Or, a cesarean might be scheduled for after the due date to reduce unintentional late prematurity (35-36 weeks gestation) which has a higher infant mortality rate than waiting for full term (37-42 weeks gestation).
A family-centered cesarean can be arranged ahead of time with the head nurse, anesthesiology staff, and the obstetricians involved in the care of a breech baby and mother.
Hospital vaginal breech birth is not the same in every setting or with every doctor. In the US and Canada, midwives cannot catch breech babies in the hospital, and very few doctors know physiologic breech birth. YouTube is peppered with medical breech deliveries and the style can be seen for yourself.
Often a partial breech extraction, or occasionally a total breech extraction, is practiced in the hospital. However, as Dr. Richard Fischer states in Breech Presentation, “Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%.”
Read a mother’s story of her hospital breech birth when she refused a cesarean. It wasn’t the easiest birth (and wasn’t hands and knees or hands-off), but she would do it again!
Midwives and doctors do vary in what they consider to be physiological breech birth. Dr. Louwen’s team has had tremendous success with knee-elbow (closely resembling hands-and-knees) breech births. I wish I had a link to a “hands off” birth with Dr. Louwen to show you!
Dr. Andrew Bisits of Australia uses a birthing stool and doesn’t refrain from gentle touch. The gentle “support of the bum” is followed by the doctor going for the arm. As of late 2013, he is now exploring completely hands-off, upright (knee-elbow) breech. Experienced and gentle doctors like Dr. Andrew Bisits are world treasures, to be sure!
Parents have to be well informed to choose a safe breech care provider. When parents are informed about the risks and benefits of breech birth in both hospital and home settings, they may refuse to give birth in the hospital. A mother might even refuse a cesarean.
Parents have the constitutional right to pick the care they find best for their baby. If a baby dies, a home birth will be seen as irresponsible, even though the breech death rate at a hospital with poor training may well be higher than with an experienced home birth midwife who knows breech, resolving shoulder dystocia, and physiological infant resuscitation.
Canadian obstetrician and breech expert Andrew Kotaska was a lead writer of the new Canadian breech guidelines for the Society of Obstetricians and Gynecologists of Canada. He wrote an article telling why the Term Breech Trial failed to show an honest assessment of the safety of vaginal breech birth among its 126 hospital settings. He is a wonderful teacher with clear insights.
Poor results from centers with inadequate resources following a liberal protocol do not have external validity in settings with better support and more cautious protocols.
Betty-Anne Daviss, a Canadian CPM studying and teaching breech birth, is doing amazing work to help parents, physicians, and midwives communicate and learn from one another to increase the safety of vaginal breech birth in the hospital. She collects data from around the world on the database that she and her epidemiologist husband Ken use to study natural and midwife-based birthing.
They’ve published a breech article with Dr. Andre Lalonde, head of the Society of Obstetricians and Gynecology of Canada. Their article about hospital policies on vaginal breech birth from the Journal of Obstetrics and Gynecology documents that the evidence does not support a policy of routine cesarean section for breech birth. Here’s a section of the article that supports this:
The authors wished to gain insight into Canadian hospital policy changes between 2000 and 2007 in response to (1) the initial results of the Term Breech Trial suggesting delivery by Caesarean section was preferable for term breech presentation, and (2) the trial’s two-year follow-up and other research and commentary suggesting that risks associated with vaginal breech delivery and delivery by Caesarean section were similar. We also wished to determine the availability of vaginal breech delivery and the feasibility of establishing breech clinics and on-call squads, and whether these could include midwives. 20 maternity centres in six provinces participated.
Hospitals were almost five times more likely to adopt a policy of requiring Caesarean section for breech delivery when current evidence suggested that it decreased risk for the neonate than they were to reintroduce the option of vaginal breech delivery when it did not. They found that practice changes are quickly following the evidence that breech birth shouldn’t be by cesarean only. Obstetric and midwifery bodies will require creative strategies to make clinical practice consistent with current national and international evidence.
The full text is available here.
[Daviss, BA, Johnson, KC, Lalonde A. Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions. J Obstet Gynaecol Can. 2010 Mar; 32(3):217-24.]
When breech home birth is right for a mom, she will be content and possess an inner conviction, not a heady drive to show the world that vaginal breech birth is possible. Rather, she will have an inner certainty that she is following what is right for her baby.
Her provider should have the same guidance, rather than being guided by statistical probability, philosophy, or ideology. It is all of our responsibilities to sense the whole truth and not the part that fits our personal ideology.
It is good to sit beside the birthing woman with the understanding that she is following a wisdom which expresses her own natural physiology.
Birth has a purpose all her own. Don’t pull on the baby!
Other problems in breech birth often are a result of the fact that the person helping the mother doesn’t help in ways that are physiologically suited to breech birth.
When a breech baby gets stuck, the baby catcher needs to know rotation and flexion of the breech baby at the level of the pelvis where the baby is stuck.
Most breech injuries are related to provider error. Training is important. Repeating training regularly is important. Please, if you are catching breech babies, even if you’re experienced, please buy my book to learn more.