The Empowered Breech Birth Series

Part 3: Choosing vaginal breech birth – a safer option for both mother and baby? 

In this three part Empowered Breech Birth series, I dive deeper into the fascinating topic of the breech baby, including why breech positions occur, natural ways to prevent and correct breech positioning and what the evidence really says about the risks of vaginal vs caesarean birth for breech babies.

Most babies will position themselves head down in preparation for birth. But sometimes, a baby will remain in a breech position at full term, presenting bottom or feet first. Most breech babies are now born by caesarean section due to the loss of breech birth skills in the medical community and restrictive hospital policies. Learning your baby is in a breech position can be confusing and stressful, especially if you were planning a vaginal birth and can’t find a provider to support your wishes.

Knowing what the research says about the safety of vaginal breech birth compared to c-section may be helpful in your decision making.

More than 90 per cent of breech babies are born by caesarean section in Australia because it’s deemed the safest option. But is choosing vaginal breech birth really a safer option for both mother and baby?

As a birthworker and bodyworker who has supported mothers to turn breech babies naturally, as well as supported mothers during and after both vaginal breech births and caesareans for breech babies, I believe there is a lack of emphasis on long-term safety and wellbeing of the baby and mother.

We are living in a time where very few obstetric care providers in the western world have the skills, capacity or authority to support vaginal breech birth. So when a baby is found to be in a breech position close to full term, parents may be offered an external cephalic version (ECV) or opt for more natural ways to turn a breech baby. But if the baby remains breech, or the parents choose not to modify the baby’s position, most providers will recommend a planned cesarean.

As a result, the most recent Mothers and Babies report found 93 per cent of first time mothers in Australia with a diagnosed breech baby had a planned c-section in 2021, as did 90 per cent of mothers who had a previous breech baby, even when the current baby was in a head-down position.  

These figures are likely not indicative of choice, but reflective of lack of access to skilled care providers, and hospital policies that recommend c-section above vaginal breech birth.

What does the research say about the safety of vaginal breech birth?

The 2000 Term Breach Trial (TBT) concluded that planned cesarean section (CS) delivery for babies in breech presentation at term was associated with a significantly lower risk of perinatal mortality compared to planned vaginal breech birth (VBB).

The trial’s findings influenced medical practices worldwide, leading to a preference for planned CS over VBB due to its perceived safety advantages.

However, the trial’s results might not accurately reflect the outcomes in settings where VBB is supported by experienced practitioners skilled in best practice breech protocols.

Subsequent research and studies have confirmed safety outcomes of vaginal breech birth are considerably improved when supported by skilled practitioners and protocols, suggesting vaginal breech birth maybe safer than many are led to believe.

• The Uotila 2005 study investigated breech birth and highlighted the importance of external criteria in the Term Breech Trial (TBT). The study suggested that the outcomes of planned vaginal breech birth (VBB) versus planned cesarean section (CS) might be influenced by specific external factors and healthcare practices. It emphasised the significance of considering the skill and expertise of medical professionals and the setting in which VBB is performed. The study’s findings contributed to a deeper understanding of the complexities surrounding breech birth and its management, advocating for individualised decision-making based on a thorough evaluation of each case.
• The PREMODA 2006 study aimed to assess the perinatal outcomes of planned vaginal breech birth (VBB) versus planned cesarean section (CS). The study’s findings suggested that when performed in skilled and experienced centers, VBB had comparable perinatal outcomes to planned CS. This highlighted the importance of expertise and support in the management of breech presentations.
• The Gannard Peehin 2013 study investigated planned vaginal breech birth (VBB) compared to elective cesarean section (CS) for term breech presentation in low-risk pregnancies. The study concluded that when VBB was performed in low-risk pregnancies by skilled professionals, it had comparable perinatal outcomes to elective CS. These findings reinforced the notion that VBB can be a safe and viable option for selected pregnancies, highlighting the importance of careful consideration and individualised decision-making in the management of breech presentations.
• The Vistad 2015 study’s conclusion also indicated that VBB had similar newborn infant outcomes as planned CS. These findings provided valuable insights into the safety and viability of VBB when conducted in skilled healthcare settings, further supporting the notion that VBB can be a reasonable option for carefully selected pregnancies with breech presentation.
• The Berhan 2016 study conducted a meta-analysis comparing the risks of planned vaginal breech birth (VBB) versus planned cesarean section (CS) for term breech presentations. The study’s conclusion indicated that VBB had comparable outcomes to planned CS, without statistically significant differences. This meta-analysis reinforced the growing evidence that in experienced hands and suitable settings, VBB can be a safe option for selected cases of term breech presentation.
• The RCOG 2017 guideline on breech presentation at term highlighted recommendations for managing breech births. The guideline emphasised the importance of skilled practitioners and experienced centres offering planned vaginal breech birth (VBB) as a safe option when certain conditions were met. It aimed to promote individualised decision-making based on thorough assessments of each case, acknowledging that VBB can be a viable choice in specific circumstances with appropriate expertise and support.
• The Louwen 2017 study investigated the outcomes of breech presentation births and the impact of the delivery position. The study concluded that delivering in an upright position, instead of on the back, during planned vaginal breech birth (VBB) could potentially improve outcomes and reduce the need for cesarean section (CS). This finding highlighted the significance of considering delivery positions to enhance safety and facilitate successful VBB.
• The SOGC 2019 guideline on the management of breech presentation at term provided evidence-based recommendations to assist healthcare professionals in offering personalised care and support for pregnant individuals with breech presentations, promoting a balanced approach to decision-making. 

 

What about the risks to baby?

A key concern for parents is perinatal and neonatal mortality, which refers to the risk of the baby dying during labour or in the first few days and weeks after birth.

The TBT found that planned CS had a perinatal mortality rate of 3 per 1000, while planned VBB had a rate of 13 per 1000.

However, the subsequent studies reported a significantly lower perinatal mortality rate for planned VBB with skilled care providers, ranging from 0.8 to 3 per 1000, with the latest SOGC study in 2019 reporting a rate of 0.8 to 1.7 per 1000. These findings suggest that, in skilled hands, VBB is not as dangerous as previously perceived.

Similarly, the comparison of severe neonatal morbidity, which includes injuries, seizures, serious birth trauma, low Apgar scores, and NICU stays, also favours VBB when performed by skilled practitioners. The TBT reported a morbidity rate of 3.8% for planned VBB compared to 1.4% for planned CS. However, subsequent studies have shown planned VBB rates ranging from 0% to 1.52%, which were not statistically significant.

Looking at the estimated risk of perinatal death, the RCOG estimated that planned CS at 39 weeks carries a risk of 1 in 2000 (0.5 per 1000), while planned VBB carries a risk of 1 in 500 (2 per 1000).

The risk of planned VBB is only 1 per 1000 higher than a planned head-down vaginal birth, which is still relatively low. It is essential to consider these risks in perspective and involve the mother and her family in making an informed decision that aligns with their preferences and values.

 

Long-term risks of c-section for mother and baby

While c-section may have a small chance of preventing the death of a breech baby, it is important to acknowledge that cesarean carries its own risks and comes with increased long-term risks for both the baby and the mother.

These risks can include:

• longer recovery times
• challenges with mother-baby bonding
• increased likelihood of postpartum depression
• higher risk of complications in future pregnancies and births
• increased likelihood of repeat cesarean and
• potential implications for the baby’s long-term health including higher risk of asthma, allergies, and obesity

Unfortunately none of these consequences have been taken into consideration when recommending c-section over vaginal breech birth as a blanket solution for all breech babies.

It is important to mention External Cephalic Version (ECV) here as well. ECV is a medical procedure where the healthcare provider tries to turn the baby from a breech position to a head-down position externally. While ECV is considered safe in experienced hands, ECV also carries risks including risks of premature rupture of membranes, changes in baby’s heart rate, blood loss, and cord prolapse. A Cochrane review of 31 randomised controlled trials found that ECV was only successful in turning the foetus in 58% of cases. 

Again, parents should be informed of all available options including natural ways to turn a breech baby, and choose what they believe is the best option for their particular situation.

 

Conclusion

The medical system and western society in general tend to focus more on the short-term safety of the baby during childbirth. However, the long-term safety and wellbeing of both the baby and the mother should also be considered.

With evidence showing that vaginal breech birth is a safe option when supported by skilled practitioners and evidence based best practice, it is essential to consider the long-term implications for the entire family when making a decision.

Every pregnancy is unique, and individual circumstances, medical history, and birth preferences should be taken into account when making the final decision. Skilled care providers who are experienced in vaginal breech birth can provide parents with information to support informed decision making, and although they are in decline, there are still some providers in Australian hospitals who willingly support vaginal birth for diagnosed breech presenting babies.

Occasionally we also see surprise breech birth at home, with or without a midwife, when baby’s breech presentation hasn’t been discovered prior to birth, or baby has flipped into a breech position during labour.

In conclusion, vaginal breech birth, when supported by skilled and experienced practitioners, or best practice breech protocols, can be a safer option for both the baby and the mother compared to cesarean section.

Recent evidence from various studies supports this claim, dispelling the notion that vaginal breech is excessively dangerous.

While there are risks associated with childbirth however it unfolds, decision making should also consider on the long-term safety and wellbeing of both the baby and the mother, and any future pregnancies.

I encourage parents to engage in open discussions with each other, their care providers and birth team to make informed decisions that align with their values and preferences. By doing so, parents can make the best choice for themselves and their families, ensuring a safer, positive and empowered breech birth.

 

In case you missed it, Part 1 of the Empowered Breech Birth series provides guidance on making informed decisions about your breech baby.

 

In Part 2 we look at natural ways to turn a breech baby head down.

References

1. Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356(9239):1375-1383. doi: 10.1016/s0140-6736(00)02840-3

2. Uotila J, Tuimala R, Kirkinen P. Term breech trial in Finland: the importance of the external criteria. Acta Obstet Gynecol Scand. 2005;84(2):159-164. doi: 10.1111/j.0001-6349.2005.00686.x

3. Kotaska A, Menticoglou S, Gagnon R, Farine D, Basso M, Bos H, Delisle M-F, Grabowska K, Hudon L, Mundle W, Murphy-Kaulbeck L. Vaginal delivery of breech presentation. J Obstet Gynaecol Can. 2009;31(6):557-566. doi:10.1016/S1701-2163(16)34246-7

4. Louwen F, Daviss BA, Johnson KC, Reitter A. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans? Int J Gynaecol Obstet. 2017;136(2):151-161. doi: 10.1002/ijgo.12135

5. Society of Obstetricians and Gynaecologists of Canada. Guideline No. 384: Management of Breech Presentation at Term. J Obstet Gynaecol Can. 2019;41(9):1289-1302. doi: 10.1016/j.jogc.2019.03.008

6. RCOG Green-top Guideline No. 20b: Breech Presentation at Term. Royal College of Obstetricians and Gynaecologists. 2017. Available from: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg20b/.

7. Gannard-Pechin E, Seco A, Cossa S, et al. Planned vaginal delivery versus elective caesarean section in term breech presentation: a multicentre, randomised controlled trial in low-risk patients. Eur J Obstet Gynecol Reprod Biol. 2013;168(1):11-16. doi: 10.1016/j.ejogrb.2012.12.014

8. Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies. BJOG. 2016;123(1):49-57. doi: 10.1111/1471-0528.13134

9. Vistad I, Klungsoyr K, Bordahl PE, et al. Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. Am J Obstet Gynecol. 2015;213(2):286.e1-286.e11. doi: 10.1016/j.ajog.2015.04.038

10. Royal College of Obstetricians and Gynaecologists (RCOG). Breech presentation at term. Greentop Guideline No. 20b. Royal College of Obstetricians and Gynaecologists. 2017. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_20b.pdf