To help navigate the journey from discovering your baby is breech to making a decision about your birth it may be helpful to consider these steps below. These have been developed from listening to women’s breech experiences and through my own experiences of supporting womens birth choices.
1 – UNDERSTANDING BREECH
2 – UNDERSTANDING YOU
3 – WHAT DO I WANT?
4 – YOUR OPTIONS
5 – YOUR NEXT STEPS
1 – UNDERSTANDING BREECH
Thirty plus years ago having a breech presenting baby in pregnancy would have meant you would have continued to have a normal birth on the whole, but today breech has a different meaning. Over the last twenty years there has been increasing medicalisation of birth (with the majority of birth in hospitals, increased interventions such as induction of labour and screening and increasing caesarean section rates) and a strong risk focus. There is an attempt to minimise risk and uncertainty in birth through increased surveillance and monitoring. However, nothing is completely risk free and people’s ideas of what a risk is for them is very different. Breech has become to be seen as being a risky thing, most likely because there is a higher association with congenital abnormalities with breech babies that babies that are head down a well as the general narrowing of the concept of what normal is in childbirth – breech was firmly kicked out of the ‘normal birth’ club.
In the year 2000 a group of obstetricians published a piece of research comparing planned caesarean section to planned vaginal breech birth. They concluded it was safer for the breech baby to be born by planned caesarean section. Within a very short period of time vaginal breech birth became almost obsolete. In the subsequent years this research has been heavily criticised as being of poor quality, but the damage was done. With less and less vaginal breech births confidence has reduced; many junior staff in maternity services have never seen a breech birth and the unknown is a worry. Caesarean sections for breech make up 11% of all the caesarean sections performed in the UK, but the risks to the mothers and their subsequent pregnancies are only beginning to be considered.
However, the tide is turning. Over the last 15 years other research has been published that suggests that in some circumstances, where mother and baby are healthy and well, full term and spontaneously labour the outcome for the baby from a vaginal breech birth is similar to being born by caesarean section, whilst for mother it is safer than a surgical delivery. So now we have a mix of messages from research; some saying caesarean section is better and some saying vaginal breech birth is an option in some circumstances. What we don’t have is a single answer; this is why you may hear different views and opinions from people.
What we have is a number of things to consider when you are thinking about what is best for you in your situation. Some of this is based on research and some based on experience and opinion, but it may be helpful.
2 – UNDERSTANDING YOU
The research now suggests that for some women vaginal breech birth is a safe option. The studies provide us with some guidance as to which women and situations may be more suitable to vaginal breech birth than others. Midwifery knowledge also bears this out and strongly encourages looking at each case individually rather than treat everyone who carries a breech baby the same.
There is some evidence to suggest that there is an increased likelihood for a good outcome following vaginal breech birth for mum and baby in the following circumstances:
- The pregnancy is full term (37-42 weeks gestation)
- Mother and baby are both well with a healthy pregnancy
- The baby is either a flexed (curled in a ball) or extended (legs stretch out with feet near the baby’s face) breech
- Baby is of average size for you
- You feel supported and confident in your decision to plan for a vaginal breech birth
- You go into labour spontaneously and your labour progresses well
If you or your baby have had complications during your pregnancy it is important to consider how these may affect the birth. Your midwife or obstetrician should discuss the options with you and explain how your individual situation.
Women who have shared their experiences of vaginal breech birth expressed frustration that information is often not provided in a way that is relevant to them; they want to understand how the statistics or information provided applies to their situation so they can consider it better. Women have a legal right to informed choice so providers have to give information based on their individual circumstances as much as it is possible. Do ask for this but remember the information, research and knowledge we have on breech is still very limited so there may not be all the answers you are looking for.
3 – WHAT DO I WANT
None of the information or advice you will hear or read is irrefutable ‘fact’; all of it is based on interpretation of data and opinion that are influenced by that person’s experiences, views and beliefs. In other words we each have to evaluate the information, be aware of the bias of the source and consider what we value to help us make a decision.
Research into women’s breech experiences tell us that women draw on a number of things to help them make a decision about their birth. This includes their personality, life history, culture, social groups, and beliefs. Doctors and midwives also have a considerable influence and this can be felt as pressure by some women. Authors of studies suggest there should be more awareness of these pressures as well as improved communication and a greater respect for women’s ideas and values.
To try and grasp your key beliefs, pressures and influences it is suggested that you consider what you think and feel about a number of central issues. For example:
- What is important to you about your birth
- What do you value most
- What (and who) makes you feel safe
- If there anything you really want to avoid and why
- What further information or considerations do you need to make your decision
- Are there things you will compromise on
- What are your considerations for after the birth, the first few weeks and beyond
When you have considered what is important to you it can help you decide on your birth preferences. You may wish to use this in your discussions with your midwife or doctor.
4 – YOUR OPTIONS
Some of the research and information available suggests that being supported by someone who is experienced in vaginal breech birth is an important factor in the outcome for mother and baby. What is meant by ‘experienced’ is has not been decided and it is likely to be tricky to impose a definition for numerous reasons.
At the moment therefore the people who most matter in deciding if they have ‘enough’ or ‘the right’ experience are the individual health professional and the woman they provide care to. If the mother is aware about the knowledge, skills and experience available then this should suffice for informed choices to be made. All midwives and obstetricians in the UK are trained to support women to give birth to breech presenting babies and are expected to have annual updates. However only some maternity units currently update staff on supporting active breech birth so staff may be less confident if you request to birth on all 4’s or without intervention. Discuss your birth preferences with your midwife and see what support and options they can provide for you.
If you choose to have a caesarean section you may wish to ask about preferences such as delayed cord clamping and skin to skin in theatre.
If you don’t feel listened to when discussing your options with a health professional ask to speak to someone else. You are entitled to a second opinion and you should be supported in your informed choices. A Supervisor of Midwives can also be a source of help and support and there is always one on call 24/7.
5 – YOUR NEXT STEPS
Women who have shared their breech birth stories describe key moments when they come to their decision. This can be though some information they have found that makes sense to them, meeting someone who they feel listens and respects them, finding confidence from past experiences, their own strong beliefs or from people around them, midwives or doctors. Making a decision often brings a sense of relief and a time to re-focus on the pregnancy and baby.
Women also describe this as also quite a lonely time; the decision can only be yours to make but it really helps to be supported by partners, family and midwives. On the other hand, some women also describe this as empowering, reaching a decision for which they take ownership of their birth.
Even when you have reached your decision bear in mind that occasionally circumstances change; some women who choose caesarean section go into labour before their surgery date and then go on to have normal births and about 40% of women who choose vaginal breech births will end up with a caesarean section. And some babies turn themselves right at the end of pregnancy becoming head down, after all! With this in mind you should have a final scan just before your surgery if you are planning a caesarean section, just to check the baby is still breech.