Weighing Up The Risks/Benefits
Unfortunately there is no simple answers to the question of what is the safest thing for each woman to do. There is no conclusive facts from the research, just information to consider and apply to each individual situation. Heath professionals will advise you based on their interpretation of the research, their own clinical experiences and their views / opinions. The advice given should be tailored to you and your situation so that you can make an informed decision.
Information to consider:
- The type of breech. Some studies have found higher rates of cord prolapse (when the cord comes down in front of the baby causing it to be compressed – this would be considered an emergency and likely require a caesarean section) when the baby is a footling breech.
- Increased chance of vaginal born breech baby needing support at the time of birth. Several studies have found that vaginal born breech babies have lower APGAR scores (a quick measure of the health of a newborn around the time of birth). However another study found that low APGARS do not reflect longer term developmental issues or deficits.
- Planning a caesarean section does not reduce longer term ill health or death in babies. Breech born babies were found in follow up studies to have similar wellbeing at 2 years of age regardless of how the baby had been born
- When specific criteria are met vaginal breech birth is considered a safe option. Several studies have found that when women and baby are well and full term and progress well during labour in a unit with experienced staff the outcomes for both vaginal born and caesarean section born babies are similar. It is worth noting that these studies had different care approaches (see below) so comparisons are difficult.
- Drug interventions during labour and birth. There is some evidence to suggest those mothers whose breech labours were induced or augmented with drugs and/ or had epidurals resulted in poorer outcomes for the baby
- Surgical birth carried more risk for women and some risks to the baby. The main risks to mother include infection, blood clots, bleeding. These risks increase if you are overweight. If women have 3 or more caesarean sections there further serious risks to consider. The risks to the baby are being cut during the operation, and increase risk of asthma and becoming overweight. NICE guidelines on casarean section maybe helpful to read
- Vaginal birth has some risks and benefits: You are more likely to have perineal damage with a vaginal birth than surgical birth. However, you are more likely to have skin to skin with baby after birth and be able to breastfeed successfully. Your recovery is quicker and your future labours will usually be shorter with very low risks to you and your baby.
We need to be honest about what we don’t know. So here is what we don’t have research evidence on as yet:
- The impact of care approach during labour and birth. The care and interventions around the time of birth will have an effect on birth outcomes but there is continued debate amongst health professionals over the best practice approach. There is no current research to support either a medically-managed, interventional approach (usually including routine epidural, continuous CTG to monitor the baby, lithotomy position leaving women immobile and clinician’s use of manoeuvres or forceps to deliver the baby) or a spontaneous ‘hands off’ approach (the mother actively birthing her baby in a position of her choice, and the health professionals supporting but not touching the baby) or a mixture of both approaches to vaginal breech. Much of the advice and information around care during labour and birth is based on opinion rather than research, and debate continues. A study was published in 2015 that looked at outcomes for breech births with women in different positions. They concluded an upright all 4’s position appeared safe for the baby.
- Vaginal breech birth underwater. Whilst there have been some breech waterbirth there are no research studies to evaluate the outcomes. Maggie Banks, an experienced midwife in New Zealand, talks about waterbirth breech here.
- Vaginal breech in different care settings. There have been no studies yet comparing the outcomes for breech babies born at home, in maternity birth centres and in main obstetric units. What is important, as for all births, is that the birth environment is calm and those around you are supportive of your choices.
- Health professionals. There has been no study comparing the impact of obstetrician-led breech births and midwife led breech births but the skill and experience of the health professional has been considered to be a factor in the outcome for the mother and breech baby. There is no current research to say what this skill or experience should be. All midwives and obstetricians have training in breech, but not necessarily in supporting active breech or upright breech, so do ask if these are your birth preferences.
- Unknown (unplanned) breech. There have been only 2 very small studies on unplanned breech births and their outcomes. These suggest the outcomes for breech babies is the same whether they were born normally or via casarean section. The studies were small, however so we dont know for sure the best way for these unexpected breech babies to be born. Unplanned breech situations should not automatically result in a casarean section. In these situations midwives and obstetricians should consider the individual situation and help women make decisions that are right for them.