Environments of Care and Risk of Litigation

For about 1 in 30 women with term pregnancies, a baby will present as breech. Although varying degrees of panic have been associated with the discovery of breech babies, those preferring to enter the world bottom first are absolutely normal. This is not a pathological situation in later term pregnancy for physicians and midwives who have been trained to safely assist these types of birth. One fourth of all babies are noted in a breech position before 30 weeks of pregnancy. Ultimately, only 3-4% present as breech at term.1

Variations in Breech Position:

Frank, or Extended breech, aka incomplete breech: In this position the baby is bottom down and legs are extended with both feet positioned by the baby’s ears. About 65% of breech presentations are extended.

Complete Breech: In this position, the baby’s legs are flexed, similar to a vertex presentation. During delivery, the baby’s bottom will enter the vagina first. The legs will follow and may remain flexed. The incidence of complete breech is about 32.1%.

Footling Breech: One or both legs are partially, or completely, extended. The presenting part, obviously, is either one foot or both feet. This type of breech has been found to occur in about 1.4% of breech presentations.2

Ninety-three percent of babies that present breech are totally normal, without any sign of congenital abnormality.

Diagnosis: Women will describe a feeling of hardness or soreness pushing upward from under the ribs. Identifying location of kicking is unreliable. Examiner palpation is fairly reliable for experienced midwives. Ballotment of the head just below the mother’s sternum is often diagnostic as a fetal head can be moved side to side, ear-to-shoulder, independently from the baby’s body.3 This sounds strange to the inexperienced but it can be reliable. And ultrasound will confirm. Approximately one third of breech babies are not diagnosed at the time of delivery. There is no evidence to suggest that surprise breech babies have more difficulties than the ones diagnosed prenatally.4

Twins and Multiples: The likelihood of breech presentation of at least one baby is higher in multiples, up to 34-40% incidence.

Vaginal Breech Delivery: Maternal/Fetal Outcomes

In 2000, the term breech randomized controlled trial was published in the Lancet.5 This study, known as the term breech trial, provided the best information, at the time, about the risks of vaginal breech delivery compared with elective cesarean section. The study suggested that all women with breech presentations should be offered elective sections.

However, those who were skilled in vaginal breech deliveries regarded this study with some skepticism, noting that their rates of cesarean section were less than 50%, and their data had never been entered in the trial, as that would have been an ethical issue. Only those women, with breech presentations, who were genuinely unsure of their decision for vaginal delivery could have, per the TBT, been subjected to elective cesarean, based on random allocation to one study group versus the other.6

The Term Breech Trial Collaborative Group (TBT) concluded that elective cesarean sections offered better results than vaginal deliveries in full-term babies with breech presentations, while maternal complications were similar between these two groups. Following this study, the TBT recommendation was adopted by high profile organizations in many different countries, opting for scheduled cesarean sections prior to maternal due dates. Their thinking culminated in a conclusion that automatic C/S would prevent spontaneous breech delivery and its “associated risks”.7

In 2006, the PREMODA multi-center study was published. 8 Based on the results of this study, ACOG changed their breech protocols that same year, concluding that vaginal breech deliveries in single term gestations were a reasonable option for “properly selected” women and the experienced providers attending them.9

Ultimately, the TBT study was called into question and certain associations began to support the option of having a vaginal breech delivery in their protocols for full-term breech presentations. The caveat: only specifically trained staff should attend these deliveries. In these circumstances, the procedure is accepted.10

Eventually, a close look at the original TBT data, raised concerns regarding the original design of the study, its methods and conclusions. In many cases, mistakes were made in regard to inclusion criteria, and institutions varied widely regarding standard of practice. It was also determined that a large proportion of women were recruited during active delivery, without assistance from a provider with adequate experience. 11

Primary cesarean section in a first pregnancy has been associated with neonatal and maternal adverse outcomes in subsequent deliveries (e.g. ruptured uterus). As a result, abandoning vaginal breech delivery and indiscriminately opting for a cesarean would deny women access to health care options.12

A Cochrane review conducted by Hofmeyr et al, focused on planned C/S for term breech delivery, and concluded that it reduced perinatal and neonatal death as well as serious neonatal morbidity, at the expense of somewhat increased maternal morbidity compared with planned vaginal delivery.13

1. Savage, Wendy. BREECH BIRTH, By Benna Waits. Forward pg ix. www.fabooks.com FREE ASSOCIATION BOOKS, 57 Warren Street, London W1T 5NR

2. Ibid. pg 10-11.

3. Ibid. pg 12

4. Ibid. pg 12

5. Savage, Wendy. Forward: BREECH BIRTH, by Benna Waits. Pg ix

6. Hannah, M.E., et al. (2000) Planned cesarean versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Lancet 356:1375-83.

7. j Glob Health. 2022 Jul 16;04055. doi: 10.7189/jogh.12.04055. Pg 3.

8. Goffinet F, Carayol M, Foidart J, Alexander S, Uzan S, Subtil D, PREMODA Study Group. Is Planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol. 2006; 194:1002-11.

9. Rambow A, Brugge M, Maas N.A.F. Beckenendlage – Ist vaginalegeburt out? Gynakologe. 2019;52:692-6.

10. Glezerman M. Five years to the term breech trial; the rise and fall of a randomized controlled trial. Am J Obstet Gynecol. 2006;194:20.

11. Ibid.

12. Partridge B. Conceptual and Ethical Problems Underpinning Calls to Abandon Vaginal Breech Birth. Women Birth. 2020;S1871-5192(19)30954-0

13. Hofmeyr GJ, Hannah M, Laerie TA. Planned cesarean section for term breech delivery. Cochrane Database Syst Rev. 2015;7CD000166. 10.1002

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To Follow: Midwifery and Vaginal Breech Deliveries: “Hands Off the Breech!”

Midwifery and Vaginal Breech Deliveries - Part I

Midwifery and Vaginal Breech Delivery - Part II

Intra-specialty Cooperation: Cultures of Care Revisited