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 observed 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 the kicking location 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 an 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 at least one baby presenting in the breech is higher in multiples, with an incidence of 34-40%.
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 on the risks of vaginal breech delivery compared with elective cesarean section. The study suggested that all women with breech presentations should be offered elective cesarean 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 been, per the Term Breech Trial (TBT), 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 before maternal due dates. Their thinking culminated in a conclusion that automatic cesarean section 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 specific associations began to support the option of having a vaginal breech delivery in their protocols for full-term breech presentations. The caveat: only staff specifically trained for these deliveries should attend. In these circumstances, the procedure was accepted .10
Eventually, a close look at the original TBT data raised concerns about the study's design, methods, and conclusions. In many cases, mistakes were made regarding inclusion criteria, and institutions varied widely in their standards 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 vaginale Geburt 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!”