Vaginal Breech Birth Training, Hospital Credentialing, and Informed Consent
Vaginal Breech Birth Training, Credentialing, and Informed Consent
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Experienced support and availability for competent breech birth providers is a sticking point in many hospital review processes. Clearly, those who support breech delivery must convene a dedicated team who are willing to be available at all times. For medical-legal purposes, availability means that there are experienced OB’s, midwives, neonatal nurse-practitioners, neonatologists, and labor and delivery RN’s who are trained and experienced in vaginal breech delivery. This may be a difficult undertaking. It will require the cooperation of hospital risk management, obstetrical physicians on staff, staff nurse-midwives, and neonatology. Everyone involved must be sufficiently trained, educated, complicit, and comfortable with the process for safe breech deliveries.
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A stubborn disrespect toward midwifery by physicians can be a huge roadblock. The thinking that a certified nurse-midwife, with extensive training and experience in breech delivery, is somehow “dangerous” and “unqualified” because he or she lacks a medical school education is illogical and elitist. Of course, an obstetrician must be available to perform a cesarean, if this is appropriate, but a midwife with background and expertise is going to be more proficient at vaginal breech delivery than the OB who has never done one or even seen one.
Ideally, an experienced team of obs, midwives, and neonatal professionals can accomplish competent breech deliveries, reducing the incidence of cesarean sections which have significant present and future maternal mortality risks. But it isn’t just reluctance from the obstetrical providers, neonatologists and NNPs can inappropriately interfere. The issue: bedside neonatal resuscitation and delayed cord clamping. Breech babies have unique needs at delivery that babies born vertex do not have. They may take longer to take a first breath; anywhere from one to three minutes. This is due to a delayed physiologic equilibration between oxygen and carbon dioxide in the infant’s blood. When a breech baby travels the birth canal butt first, contractions will push blood from the umbilical cord upward into the placenta.
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Cutting the cord before this neonatal blood returns to the baby following a contraction can have dire consequences. Only breech-familiar neonatologists and NNPs have the patience to refrain from premature and panicked resuscitation efforts that may prove quite harmful to the baby. (See A Guide To Physiological Breech Birth. 2nd Edition, 2024)
In addition to logistical knowledge and cooperation, the other crucial individual in this process is the mother. Many who choose vaginal breech delivery have already done extensive research on vaginal breech and may possess superior knowledge of the process compared with her physician or even her midwife. Obviously, hospital credentialing must be written and approved by the delivering hospital. In addition, providers must be able to share a detailed informed consent with the prospective patient regarding all aspects of vaginal breech delivery and its potential risks.
Texas Midwifery Board Breech Birth Guidelines
Introduction: “Breech babies can be bornsafely without surgery. And with the help of an experienced practitioner, they can be safely born at home.” 1 However, it does come with some higher risk factors. Sometimes these klproblems are created rather than inherent in the birth. It is best that the midwife be as well trained as lpossible in the delivery of a breech baby, have clear guidelines in her lpracctice, is selective in which breech births she attends, and listens closely to her intuitiooooon in each circumstance. In writing the contraindications, it is assumed that the midwife will already be following the Rules of Midwifery (Statute) and therefore common contraindications such as preterm baby, etc. will already be risked out of care.
Recommended Education and Resources:
Any classes offered at a midwife conference, including ATM, MANA, ACNM, The Gathering, Midwifery Today, etc.
Spinning Babies Breech Workshop
Advanced Life Support in Obstetrics (ALSO) - American College of Family Medicine
Birth Emergency Skills Training (BEST)
Frye, Anne. Holistic Midwifery Vol II
Banks, Maggie. Breech Birth Woman WIse
Oxorn and Foote. Human Labor and Birth
Prenatal Recommended Guidelines:
1. Assessment of fetal position during each prenatal visit
2. Offer cephalic version at 36 weeks
3. Continue efforts to turn the baby including inversions, webster technique with a chiropractor, acupuncture, homeopathy etc.
4. Perform a breech risk assessment at 38 weeks to determine mode of delivery
5. Discuss risks and benefits of vaginal breech delivery in or out of hospital and cesrean delivery
6. Address any fears or concerns before labor
Criteria for Breech Birth Out of Hospital
1. Willingness of client and midwife
2. Evidence of a supportive relationship with the mother, partner, and midwife
3. Client’s comfort level with out of hospital birth
4. The client is fully informed of the risks of vaginal breech birth out of the hospital and a signed informed consent is obtained and included in the client’s records
5. The baby should be between 6-8 pounds
6. The ideal fetal position is Frank or Complete Breech in an anterior or transverse position
7. If a midwife is unsure about her skill level, a more experienced midwife should attend the birth
Contradictions for a Breech Birth out of Hospital
Client:
1. Unwillingness to follow the midwife’s instructions
2. History of complicated births
3. Other conditions or issues that would put mom or baby at risk
Midwife:
1. Lack of competence in breech delivery skills
2. Lack of trust or confidence in client or the client’s coping skills
3. Midwife unsure of her own skills 2
Baby:
1. Footling Breech
2. Baby in posterior posistion
3. Baby with known anomaly
4. Baby predicted to be larger than 9 pounds or under 6 pounds
Management of First Stage
1. Ongoing Risk Assessment
2. Obtain all vitals according to standard of care
3. Check Fetal Heart Rate every 30 minutes aith active labor and/or ROM
4. Clear client/midwife communication witih informed choice exercised
5. Refrain from artificial rupture of membranes or stimulating the labor beyond its natural course 3
Contradictions for First Stage
1. Fetal weight less than 6 pounds. Optimal weigiht is 6-8 pounds
2. Developing risks found during ongoing assessment
3. Cord prolapse
4. Malpresentation such as footling, posterior etc.
5. Failure to Progress4
6. Failed descent of the presenting part
Management of the Second Stage
1. Assess Fetal Heart Rate every 5 miniutes
2. Ensure client is fully dilated before she begins active pushing5
3. Hands off delivery of normal breech unless intervention is needed
4. Clear client/midwife communication with informed choice exercised
5. Be prepared with a transport plan if necessary
Contradictions for Second Stage
1. Client not completely dilated
2. Baby not moving down in steady increments
3. Fetal Distress
4. Cord Prolapse unless birth is immediately imminent
Gaskin, Ina May. On Breeches and Twins at Home. Mothering Magazine Pg 59
Frye. Pg 935
Frye. Pg 937
Frye, Ann. Holistic Midwifery Vol II, Pg 937
Frye. Pg 939
Many hospitals have already established organized risk prevention protocols and consents. One hospital system, Georgetown University Medical Center, has established extensive protocols for breech deliveries.
For more than 20 different versions of credentialing/informed consent protocols on vaginal breech delivery, please refer to the website https://www.midwivesontrial.com
Access the information tab. I am happy to provide links at your request. mmh
© 2025 Martha Merrill-Hall