Breech birth is not inherently dangerous if medical intervention is avoided and if the mother is allowed to instinctively choose her birth position and give birth at her own pace. It really disturbs me to not see this attitude represented at all among most people. Every suggestion made, every time you touch a woman during pregnancy, labor, and birth, every time you hint that something about her baby, her pregnancy, her labor, or her birth is not exactly as it should be, is an intervention that could lead to complications.

Description of breech birth

In most pregnancies, your baby will be head down and face down in your uterus. A small percentage of babies assume different positions, some of which make vaginal birth risky and require medical intervention. Here are some abnormal delivery positions you should be aware of:

Breech: The most common alternate delivery position is breech, in which the baby's rear end comes out before the head. In other words, a baby is breech when her buttocks or legs are lowermost in the uterus--closest to the cervix. In a complete breech position, he is butt-first with knees bent; in a frank breech, the legs are extended up, with feet near the head; if one leg is lowered over the cervix it is a footling breech. Approximately 3 in 100 babies approach their delivery date in a breech position. The incidence of babies in the breech position is higher earlier in pregnancy. For example, between weeks 18 and 22 of pregnancy, 24 percent of babies are breech, and between weeks 28 and 30, the incidence is at eight percent. However, during the third trimester there is only a three percent incidence of breech positioning.
	Occiput posterior: This position is similar to occiput anterior (the normal position), except that the baby faces the mother's front, instead of her back. About 1 in 50 babies are positioned this way.
Transverse: A baby in the transverse position is sideways, usually with his shoulders or back over the cervix. Sometimes referred to as a shoulder or oblique position, a transverse position occurs in 1 in 2,500 births. The risk for having a baby in the transverse position increases if you go into labor prematurely, have given birth four or more times, or have placenta previa. Your doctor will deliver the baby by cesarean section, either right when you start labor, or a little earlier. A vaginal birth would be too risky for you and the baby. If there is a long labor period before the cesarean is performed, there is an increased risk of uterine rupture and umbilical cord damage.

Rare abnormal delivery positions include face-first, brow-first, and compound, in which a hand or foot emerges from the birth canal with the head or buttocks. With all abnormal positions, there is additional risk to the mother and fetus. In many cases a damaged or obstructed umbilical cord threatens the baby's oxygen supply. If the baby goes without oxygen for too long, he can develop brain damage or even die. There is also an increased risk of cervical or vaginal tears with abnormal positions.

Types of breech birth

A) Complete Baby sits cross legged B) Incomplete Frank breech, bottom first, legs up around the ears. Most common type of breech presentation. C) Footling Either foot or feet coming first. This is the most common breech presentation for premature babies.

What are some reasons a baby turns breech?

Breech presentation is common in premature babies. If you are told your baby is in breech presentation before 36 weeks gestation there is no concern. Some of the known reasons for a baby deciding to turn to a breech position include:

1. There has been a recent and rapid increase in the amount of amniotic fluid
2. There is a congenital malformation of the uterus
3. Uncommon pelvis shape
4. The fetus is pre-term or particularly small
5. Uterine mass or fibroids are impinging on the uterine cavity
6. The placenta is presenting in front of the cervix (placenta previa)
7. You are pregnant with more than one child (40% of all twin pregnancies will have one of the twins in a breech presentation)
8. Slack muscle tone of the abdomen or your uterus has "relaxed" from previous pregnancies
9. Emotional factors are also considerations.

If the baby was positioned abnormally because of a maternal physical imperfection, such as an abnormally developed uterus, your chances of having an abnormal position in your next pregnancy are increased. Sometimes the position is associated with a condition such as premature labor or placenta previa, so if your subsequent pregnancy is not affected by the related condition, your chances for a second breech birth are not increased.

“ Isn't it possible the baby wants to be born breech for a good reason? For one example, I give you my father who was born in 1946 at home, unassisted, in a frank breech position. He had an open myelomeningecele. Had he been born in a vertex position he might well have been paralyzed. however, due to lack of intervention, he was born healthy and underwent, at three months old, the first-ever corrective surgery for this condition in that area of the country. Some babies need to be born breech due to congenital anomalies or even a short cord. They can‘t figure out any other way to reach us on the outside” -Maka Laughingwolf maka@maka.net

Do you have to have a C-section?

According to the Centers for Disease Control, about 13 percent of all breech babies are born vaginally and different studies have drawn different conclusions about whether this should be attempted. It depends on the circumstances and your provider's medical approach, so it's best to stay flexible and be as well-informed as possible.

Breech Baby? You May Not Need a C-Section After All
Just because your baby decides he'd rather be born bottom-first doesn't necessarily mean you should get a cesarean section, says a new study in the July issue of the British Journal of Obstetrics and Gynaecology. In fact, routine c-sections for women whose full-term babies are breech may raise the women's risk of complications such as urinary tract infections, endometriosis, hysterectomy, pulmonary embolism, and cardio respiratory arrest. Researchers at University Hospital in Geneva examined 705 consecutive breech deliveries and found that women who delivered vaginally were not only healthier but also were out of the hospital sooner than those who'd scheduled c-sections. More research is necessary to prove which delivery method is best for moms of breech babies, the researchers found, but, happily, neither delivery method affects the babies' risk of complications.

What is normal in a breech birth vs. a breech delivery?

These are the points which midwives should bear in mind when facilitating a vaginal breech birth:

Delayed pushing until full dilation is important as when you do push, you want the baby to be delivered quickly and without resistance.
Having a first baby should not disqualify a woman from a vaginal breech birth.
Don't push a breech through a pelvis with oxytocic drugs
No inductions, no augmentations
If the labor does not progress - caesarean operation
Don't pull a breech down through the pelvis - no breech extractions
Breech by propulsion, not traction
If it isn't coming down - caesarean operation
Keep your hands off - sit on them if necessary
Be ready to bag and mask.

In the hospital setting the following points are of great importance:

• The jury is out on the routine use of epidurals during a vaginal breech birth. Though it prevents the premature urge to push and allows the use of forceps and manipulation of the baby without causing pain, it also hinders pushing, which is essential when a woman must rapidly and effectively push out the baby's head.
• Also the common lithotomy (flat-on-the-back) or semi-sitting positions are contraindicated for a vaginal breech birth (indeed, for almost all births) due to their impacting the sacrum (the back of the pelvis) and decreasing the diameter of the pelvis.

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These lists below dramatically illustrates the difference between breech delivery (sometimes referred to as breech extraction) and normal physiological breech birth.

Breech delivery

• Could be induced.
• If slow or poor progress, may be augmented.
• Epidural commonly strongly advised.
  Food and fluid restricted, therefore IV drip in situ.
• Membranes commonly ruptured artificially to enable an electrode to be applied to the buttocks to enable continuous electronic fetal monitoring. The scrotum is to be avoided...
  ..therefore, first stage immobility.
• When second stage reached, patient put in lithotomy position (on her back).
• Contractions enhanced/controlled by oxytocic drip.
• When buttocks on perineum, routine episiotomy.
• Attending practitioner applies traction to the buttocks gripping the hips.
• Legs, if extended are brought down with pressure from the attendants fingers behind the knee. Further traction is applied to the trunk, the arms are pushed up over the baby's head by this manoeuvre.
• The arms now are required to be delivered by Loveset's manoeuvre. The baby is then lifted up by its feet, by a second attendant and forceps are applied to deliver the head.
• Third stage managed actively by oxytocic injection and controlled cord traction.

  According to the Medical community, a vaginal delivery may be attempted if certain conditions exist:

  • the estimated fetal weight is between four and eight pounds
  • the baby is in a position where the buttocks (as opposed to the feet) are overlying the cervix
  • the baby's head is either looking straight (called the military position) or flexed--your doctor can determine by ultrasound or X-ray
  • the mother's pelvis is considered adequate, which is determined either by a physical examination or by X-ray

Breech birth

• Spontaneous onset anytime after about the 37th week.
• No augmentation if labour is slow or there is poor progress - caesarean section.
• Mother encouraged to assume positions of choice during the first stage.
• Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
• Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
• Membranes not ruptured artificially.
• Vaginal examinations restricted to avoid accidental rupturing of the membranes.
• If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
• Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
• Mother encouraged to be in an all-fours position.
• No routine episiotomy.
• Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

Mary Cronk AIMS Journal Autumn 1998
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Links for more information regarding a normal breech birth

Heads UP! All about Breech site (turning techniques, studies, videos for sale, stories, & Articles)
http://www.breechbabies.com/

ICAN (International Cesarean Awareness Network)
http://www.ican-online.org

Maggie Banks Website about Breech Birth
http://www.birthspirit.co.nz/

Incredible detailed pictures of a great natural breech birth (hospital born)
http://www.birthdiaries.com/diary/47vbirth.htm