Having a baby in the breech position presents its own set of challenges. A baby from 20 – 30 weeks moves around tonnes and that is expected and wanted, a healthy baby moves. If the baby is still ‘head up’ at 35 weeks we will need a plan for your baby’s birth.
Weirdly, this was one of my (Brigid's) fear in my first pregnancy, that my baby was going to be breech and I would end up having a Caesarean Section.
It is amazing where our fears take us. I now know that only 4% of babies are breech at term. I think had I known that way back when, it would have allayed my fear as those odds are pretty good!
In this podcast we talk about:
How common breech positioning is
The different types of breech presentations
What are the key criteria to having a vaginal breech birth
Vaginal breech birth with twins
What most obstetricians recommend if your baby is breech at term
Brigid [00:00:36] Well, welcome, everyone. This is episode 15 and we're pretty proud of ourselves because we think we've come up with a good title for this one, haven't we, Paddy? It's brilliant. It's brilliant. This is a heads up about breech birth. Get it, a heads up! So this week's been funny for us because we were one child down this week as one was off on camp. It's been quiet, hasn't it. Isn't it weird how just losing one for the week. Yeah. Just the dynamics. Yeah. Yeah. We've even managed to get to school on time nearly anyway so it's given us a little bit time to think about. Grow My Baby program which is coming along really well and hopefully we're going to be launching that towards the end of the year. So just for those who are listening, this is a five module online program which is led by Pat as the obstetrician and me as the mum. We've got other experts, such as physiotherapists. We've got an anaesthetist. We've got a sonographer. So it really is sort of following someone from pre pregnancy right up to when they have the baby bring the baby home. So we look forward to talking to you about that as we get closer to the launch. And if you want to be in front of that, perhaps just jump on our website, growmybaby.com.au because you can just sign up for our newsletter and you'll know when we're about to launch, because I think we'll probably have some nice little specials as we launch just for all you listeners that I've kept with us for this long.
Brigid [00:02:05] So, yeah, we're excited by that. So breech birth. Pat, I'd have to say that this was the my biggest fear in my first pregnancy that my baby would be breech and I'd have to end up with a caesarean. Yeah right. Weirdly, my baby wasn't breech, but I still ended up with a caesarean. It's funny how the fears that you sort of develop in your labour. But this as our pregnancy progresses, our visits to the Obstetrician become more frequent. Sure. Yeah. And what I used to find incredibly uncomfortable, weirdly, is when the Obstetrician or your health care provider feels right down on you pelvic bone to sort of see where the baby's head is. Yeah.
Patrick [00:02:49] So that little manoeuvre that's called a Pollock's manoeuvre, it's just a little manoevre we do to try and feel what the presenting part is, is it the bum, or is at the head? And it's a squeeze just above the pubic bone where people feel uncomfortable. Yeah, but there's a method in it and it's just to try and pick up, in a standard antenatal consultation, without ultrasound to make sure that everyone's baby's coming head first.
Brigid [00:03:12] And can we actually as as a pregnant woman, can we feel our tummies and sort of work out where the baby is at that particular time? Yeah.
Patrick [00:03:20] Motivated patients to do that. If people sort of care enough to really have a feel and get to know the fetal position. So when I'm doing that little pinch manoeuvre, I'll often take the my patients hands and put them on the head and say, look, that's the head there. And people will usually go, oh really? I didn't really know that you could feel that clearly.
Brigid [00:03:38] Because a bum can sort of feel smooth and hard like a head, can't it?
Patrick [00:03:42] Yeah, it doesn't feel as round as ahead. It can feel hard like a head. And the idea is that we don't like surprises, so if a baby is breech we'd like to know about.
Brigid [00:03:52] Yeah. Yeah. So we also know that there are different types of presentation of breech don't we.
Patrick [00:03:58] I think it's worth people knowing a little about a little bit about that so that there's different types of breech presentation and the management of them is a little bit different in how serious it is is a little bit different, but it's worth knowing. And the rough system of naming them, there's a thing called a footling breach, which is where the baby's got one or both feet extended right out so that the body if the baby came out that way, that the the foot would dangle down first. There's a thing called a frank breach, which is basically the baby's bottom is trying to come out first with the knees up against the chest, but the knees bent. So the feet are down next to the bottom.
Brigid [00:04:34] Was that named after Doctor Frank or something like why? Why Frank?
Patrick [00:04:38] Somebody called Frank. And then and then there's a complete breach where it's just the bottom. And and then the knees are up against the chest, but the knees are extended. So the feet are up to the face. Right.
Brigid [00:04:51] And so when is it that you feel like a baby's in the breech position? And then that's their sort of set position because can they move around when when are they head down?
Patrick [00:05:00] Yeah, well, everyone who's been pregnant knows that they move tons. And right throughout the pregnancy, it's pretty common for the baby to be in breech presentation. And in the 20 weeks, it's of no particular importance at all, whether, you know, in the 20s, from week 20 to week 30, whether the baby's breech or not. In fact, I like to see baby in different position from time to time. It tells me that baby's moving and healthy babies move. After 30 weeks, we start to sit up and take notice because we want to make sure that that baby is doing the right thing, will eventually get back around the other way. And certainly, if a baby remains in the breech position up past about 35 weeks, then we start to try to make a plan for that.
Brigid [00:05:44] Yeah, and it's 35 weeks. Is that because there's just less room for them to flip back around? Yeah, that's right.
Patrick [00:05:49] The later the baby's in the breech position, the less likely it is to kick itself back around. I guess there's less room to do a complete 180. And the other thing that's important. That is whether it's your first baby or not. With your first baby your tummy is pretty tight, the muscles are pretty tight and the uterine wall is tight. And the baby, you know, it's a struggle to get around in a tight space like that. If it's your fourth baby and and the muscles of the abdominal wall are not that tight and the muscles of the uterus is not that tight, then the baby's able to move around more easily.
Brigid [00:06:32] I've just got a vision of my big flabby fourth, baby tummy. that's not what you mean though is it. No, I do not. I do not mean that. Oh, good. So how many women generally have a breech position?
Patrick [00:06:47] Like, how common is it? Well, we're talking about breech at term. Yeah. So. So it's about 4 percent. Only 4 percent.
Patrick [00:06:57] To be honest, it's a fair bit of fuss made for, for only about 4 percent. When I say fuss, it's not that it's not important, it is important, but it probably won't happen to you.
Brigid [00:07:05] Yeah. Wow. I wish I had known that back then, I think I would have been a lot less fearful of the baby's position if, you know, 96 percent of the times it's head down and now head down medically is called? Cephalic. Okay. All right. So in your career so far, how many vaginal breech births have you delivered?
Patrick [00:07:27] Not many, to tell you the truth. And the reason for that is that vaginal breech birth has been out of fashion for most of my career. And there are there are some plenty of reasons for that.
Patrick [00:07:39] And some of those some of those are complicated. But certainly I've delivered some vaginal breech births, but they've typically been second twins. Right. So have we done twins in our podcast yet? No, we haven't. Yeah, we need to do twins. Had another good idea today. A really good idea. I'm gonna tell you now. At our hospital they're doing a grandparent's hour in the pregnancy classes. Well, to sort of help grandparents to know what they can do that is really helpful and how to live with the fact that some of that stuff about pregnancy and childbirth has changed since you had your baby? Yeah. Which I think is a really great idea. And I think we better do a grandparents podcast.
Brigid [00:08:16] Yes. I think a lot of my fear I know this is off topic, but a lot of my fear based worries were based on my mother's worries, you know, and that her worries were of her time. Whereas by the time I was having my babies, things had changed a little bit. And, you know, I was a little bit more. Yeah.
Patrick [00:08:35] So wasn't unreasonable for her to be concerned about whatever. But that might that might be less common now. Something that we've sorted out.
Brigid [00:08:42] Yes. So you're twins. Yes. So the second twin. Yeah. So what? Why? Why is it common for the second twin to be in breech? Are they like yin and yang in the belly are they?
Patrick [00:08:52] Yeah. That. Yeah. So they can be they can be breech or we'll talk about this when we talk about twins. But you know, historically with twin births the problems were the second baby. It took too long for the second baby to come out or the placenta started to bleed on the second baby or whatever.
Patrick [00:09:09] So we knew eventually that one of the ways to to make the second babies come out in better nick was to make them come out quicker after the first one and not wait much longer than about half an hour between the two babies. And the way to do that is to do something called a breech extraction, which is if you've had the first baby comes out head first and then obstetrician puts their hand in and grabs the second baby by the feet. Oh, my God. And this brings that baby out as a breech. And the reason we do that and not and not many singleton breech births is that, you know, that second baby is gonna fit out because the first one just did. Yes, I see yeah. Yeah. But the problem with Singleton breaches, especially if it's a woman's first baby, you don't know it's going to fit. And you don't know until the whole thing is done. Because the heads the biggest part of the baby. Yes, exactly. OK. So you can have you know, you can have all the baby out except the head.
Patrick [00:10:01] And and that's where problems are. They get stuck.
Brigid [00:10:04] Now we're going to get onto the birth. But before we do, can I just talk about like so 35 weeks, perhaps if your baby's breech before then, is there anything that a woman can do to flip her baby upside down?
Patrick [00:10:17] Yes. I don't think so. Some people think so. I don't think that there's anything that we can do ourselves to to change those odds, because I think it's mostly about fetal behaviour.
Brigid [00:10:29] What do you mean by fetal behaviour?
Patrick [00:10:31] Well, babies come out head first. It's not because the heads are heavy or anything like that. It's because babies like to kick and there's more room at the top of the uterus for the baby to kick than at the bottom. So that's why the baby likes to be head down and feet up because there's plenty of room to kick up there. And if you look at babies that have got some something wrong with them, like a spina bifida, for example, and the feet and legs don't work well and the baby can't kick, they are breech much more often. Okay. So that's the evidence that we've got, that it's that it's actually the baby kicking that makes the head down and the bum up. Right. So I think that if your baby's in breech presentation, it's up to the baby. Right. And I don't think there's much else that the woman can do. I know there's things that are that suggested that you can do, but I don't believe they they have evidence that they work above and beyond the ones that are going to turn around all by themselves.
Brigid [00:11:35] Right. So you're saying it's kind of like a randomness bias or.
Patrick [00:11:39] Yeah, well, that's right. When we're trying to see whether a treatment works, we have to prove that it works more than chance alone would have explained. So if we if we're going to put our treatment in and suggests that we can turn a breech with whatever acupuncture, then it has to be proven to work more often than the ones that just turn around all by themselves consistently, consistently in a way that's reproducible. So that you could do the same experiment here, America, UK, and it would always work.
Brigid [00:12:12] And that's hard, isn't it? Because I think as a woman who has a breech baby but wants to have a natural or a vaginal birth, you want to be feel empowered and you want to do as much as you can do to help that baby flip into the right position.
Patrick [00:12:25] Yeah, I get it. So what I say to my patients is I'm not aware of evidence that treatment X, Y, Z makes a difference, but it will not harm cannot harm you. Yeah. So go, give it a try.
Brigid [00:12:38] Yeah. So there's there's people that have built their whole careers on this. They like the spinning babies and. Yeah.
Patrick [00:12:43] Well that's right. And you know, I think that what often happens is that if it works, the treatment will be given credit for it working. And if it doesn't work, then it'll be put down to ah well it wasn't going to it wasn't gonna happen. Yeah. Yeah. And but believe me the medical profession is not not exempt from that. You know the old expression nature heals and the doctor sends a bill. We do that. If someone gets better all by themselves we will still say, of course it is because you came to see me. So we're not we're not immune to that phenomenon. But I think with with breech, ultimately, it's up to the baby. There is one exception to that, of course. And that's an ECV.
Brigid [00:13:23] Yeah. So what does they say they stand for?
Patrick [00:13:25] That's external cephalic version. That's that's an actual medical procedure to turn the baby around.
Brigid [00:13:32] Right. And maybe for our listeners, let's just describe that. What what does that entail?
Patrick [00:13:38] Yeah, well, it's it's something they used to do a lot back in earlier in the 20th century. They would do it a lot. And I think they used to do it a lot because caesars in the early days were dangerous. It was dangerous to have a Caesar. The anaesthetic was dangerous. They hadn't invented spinal anaesthesia. So you had to go to sleep. And they kept caesars for severe, severe cases. So a bit because having a caesar could harm you. And one of the things that's happened, of course, over the last 70 years is that having a caesar has become increasingly safe. So we use them for more things. And so so the caesar rate is going up. So back in the day, every obstetrician would have been a superstar at ECVs because it was standard obstetric management.
Patrick [00:14:28] And you would go along to the doc and they would put their hands on your tummy and push upwards on the head to get the head out of the pelvis and up into the upper part of the uterus. And then with one hand on the on the baby's backside, with the other hand on the head, externally, just ease the baby around the other way. And that's sort of the old way of doing it. And there's a there's a modern equivalent where you have it done in the hospital and sometimes you have some drugs given to relax the uterine wall while you do it. And these days, it tends to be done close to an operating theatre in case there's a problem. So you can be whisked around for a quick section if if it somehow causes the baby to go into significant distress. So that's one of the potential complications of doing it, is that you can really upset the baby. It can cause, as the baby turns around, it can cause trauma to the placenta. And of course, it doesn't always work.
Brigid [00:15:30] So the woman, what does it feel like for her?
Patrick [00:15:34] It's reported to feel pretty uncomfortable. And I I think of it as something that is for highly motivated people. You know, if someone really, really wants to give it a try. In my practice, my standard advice for someone's baby's in breech at term is to leave it there. Have that baby by caesarean section and have a VBAC next time. But if they are motivated then I will book them with someone to have an ECV.
Brigid [00:16:03] Yes. And for everyone who hasn't listened to our other podcast, a VBAC is, well, that's vaginal birth after caesar.
Patrick [00:16:09] Yeah. So women quite rightly want to have their babies vaginally. And of course, that's the normal natural state. And that's what we should be aiming for. But I I find that if you say to someone, look, on this occasion, it's actually the safest and potentially the smartest thing to do to have this baby by caesarean section, for whatever reason, this does mean you can't have vaginal birth next time. And the longer I've been in obstetrics, the more I get the feeling that whilst a woman will have a strong desire to have a baby vaginally, that they don't feel they have to have every baby vaginally. And so it's not just a vaginal breech birth or a Caesar. And if I have that caesar, there goes ever having a natural birth. No, you have this baby by Caesar, because that's probably the safest way to go. And if you really want that, vaginal birth you would do it next time.
Brigid [00:17:01] Yeah, that's right. All right. I don't think we've actually done VBAC? We might do that, too. Making lists here, because it's actually you know, those stats are pretty high. It's not rare to have a caesar. Yeah, it's not rare to have a caesar and it's not rare to have a VBAC either. So it shouldn't be. It shouldn't be. That's right. Everyone should be given a chance if that's what they're wanting.
Brigid [00:17:24] All right. So does that mean every single woman that you that comes to you basically with breech, your recommendation is cesarean?
Patrick [00:17:34] No, not all. Not always. I think that that an ECV can be a reasonable thing to do in some circumstances. Motivated patient, but perhaps not first baby. I sometimes recommend that. But basically, I do recommend caesarean section for breech of term, and I don't shy away from that. The trend towards caesarean section for breech at term came out of a very big study called the term breech trial, which was an international multi centre trial where they miraculously managed to randomise, a lot of women to have either a vaginal breech birth or a caesarean section if they had a breech at term. And randomize means just that, like, you know, your treatment is not up to you or the or the obstetrician, the treatment in one group or the other. It's drawn out of an envelope. You open the envelope and it says you are having a vaginal birth. And one of the reasons they were able to do it is that before that, there was no evidence, either way, which one was the safest. So in the absence of that information, it was ethically reasonable to do a randomized trial. And ultimately the term breech trial concluded that that that there were some significant statistically significant benefits to delivering women at term with a breech baby by caesarean section.
Brigid [00:19:04] So there's actually some criticism of that study. Yeah. And some of that criticism is that the people who were doing the breech vaginal breech births actually didn't have experience in vaginal breech birth.
Patrick [00:19:16] Yes. So it was possible to be a centre in that trial and not really have a lot of experience in Virginal breech births. And you could also be a centre in a trial, in the same trial where you had tons of experience. Well, it stands to reason that the women in the experienced centre would go better. And ultimately, it might have partially skewed the results. One of the ways you get around that is doing a trial that's very big so that the results are more trustworthy and less likely to be due to chance alone. And it was a big study. So despite the criticisms, that still has a significant influence on obstetric practice.
Brigid [00:19:55] And tell me, what were the results? Why did it all say that cesarean section was safer?
Patrick [00:20:01] Well, it comes down to the perinatal outcomes. So just that the babies were in better shape and that, you know, as I said, despite the criticisms, the study was reasonably convincing of that. And, you know, some people might say that it was a it was a result that people wanted to hear. Managing a vaginal breech birth, is not easy, it is stressful. And the obstetricians at the time the study was published, well probably went phew. Yeah. Good, there's an there's an excuse not to do it, but the data is what the data is.
Brigid [00:20:37] And so there are women that do go on and have a vaginal breech birth. Sure. Yes. Perhaps it might be worthwhile to go through that also.
Patrick [00:20:45] Absolutely. I also think that's a perfectly reasonable thing to do. But then it comes down to it, it is the experience of the people where you deliver. Yes. So you have to look into that. Yeah. I don't recommend that people just assume that the obstetricians and midwives at the place where they're delivering are necessarily experienced with that.
Brigid [00:21:06] And so what sort of questions would a woman ask her care provider about that, about their experience?
Patrick [00:21:11] Well, firstly, I think that if a vaginal breech birth is what's planned, then seniority and experience are important. And secondly, that there is a certain number of cases that I would want my obstetrician to have done before.
Brigid [00:21:30] Go on, put a number on it, do you reckon?
Patrick [00:21:33] I wouldn't like to say it honestly. They're the sort of numbers that are very hard to get in training these days. Because vaginal breech birth is out of fashion. So the fewer people that have them, the fewer Junior. You know, I call our traineees the junior burgers, the fewer junior burgers are trying to do it. Yeah. And and the less potentially skilled people are. So this is a problem because sometimes at a vaginal birth, the breech is just the thing that you see poking out when the woman's pushing. Yeah, right. If she turns up on the labour ward at 9 centimetres, huffing and puffing, transferred from the wheelchair from the emergency department straight into the labour ward bed pushes and it's a bottom. So obstetricians and midwives need to know about breech births because some will happen by chance. Yeah. And some will have not been detected. Or the baby thinks it's fun to turn on the last day. Yeah. Yeah, exactly. Yeah. So there's been a cephalic scan at 39 weeks headfirst and then the baby comes up backwards. Yeah. So we all need to know something about it. But it's hard for people to get enough experience to say "I'm an expert on vaginal breech birth. Come along to me with your breech baby at term". And the other thing is that knowing how to do a vaginal breech birth is an important part of the delivery of vaginal delivery of twins. Yes. So. So, again, we need to do some to really know what we're doing. One of the useful things to know is that delivering a breech baby at cesarean section isn't a walk in the park either, and some of the techniques that we use to help of a breech baby get out are also used at caesarean section. Like what? Just the way we manipulate the arms and so forth. How we get out the arms and the way we manoeuvre to help keep the head flex.
Brigid [00:23:30] Yes, as yet. Yeah. I wish this was video because Pat's sort of moving his head around and his shoulders and waving his arms.
Patrick [00:23:38] So you still have to do those caesarean section, but it's not the same. Yeah. Okay. You know, you can get out of trouble with this caesarean section by making the cut bigger. Yeah, right.
Brigid [00:23:45] So. Well, I didn't even think that a even a breech baby would be a more difficult caesarean. That's what you saying. Definitely. Yeah. Well, all right. So say we mentioned just briefly before about the different positions. So we had a footling, frank and a complete breech. So say in that situation that you just brought up before where somebody is come into the ED and they're already pushing and you say you're presented with something, a bottom, a foot. Is there a breech that's easier to deliver vaginally?
Patrick [00:24:16] Well, the complete and the frank are potentially easier than the footling because the foot will come down through a partially dilated cervix. But but you can also just do a section and bring the baby back up the other way. Right. So what to do comes with experience. I think that the practitioners who regularly conduct vaginal breech births probably have their own set of criteria that they like a patient to meet before they agree to manage that birth vaginally.
Patrick [00:24:48] Yeah. And I would imagine that they're pretty happy if someone's had a vaginal delivery before. Yes. So, you know, there's room in the pelvis and that around the vaginal opening there'll be some give because she's had a vaginal birth before. Yeah. Which will mean the head which is the trickiest part to get out coming out last will come out more easily. Yes. And and I think that the size of the baby on clinical examination and ultrasound assessment and other is very relevant.
Patrick [00:25:19] You know, I think we'd be more concerned about a big baby.
Brigid [00:25:21] And say in that ED sort of situation or someone's pushed or whatever. And they've got a vaginal breech birth happening. Is there a better position for the woman to be in or to be lying in yet?
Patrick [00:25:36] Well, potentially, but I guess that would be up to the expertise of the of the team there on the day.
Brigid [00:25:46] Right. Okay. So I'm just getting from you that that firstly that your recommendation is for a breached position, baby it's caesarean. In your practice. Yes. And that from there that woman can try again for a VBAC for her subsequent pregnancies. And then we've talked about three main keys of vaginal breech birth. One is the type of breech that the baby is in.
Patrick [00:26:10] Yeah. And I would add to that the size of this. The size of the baby as well.
Brigid [00:26:15] Yes. Size of the baby. Whether it's that woman's first or subsequent baby. That's critical. Yeah. And whether the person who is part of a team, her health care provider is experienced at breech birth.
Patrick [00:26:28] Absolutely. Yes. That's so important. Right. And I really think that's something that people who are planning a vaginal breech birth need to be proactive in in asking those questions. Yeah. Okay. Am I the first person this year to request a vaginal breech birth in your unit or do you do it all the time?
Patrick [00:26:44] Yeah. Okay. And for people to take home from this that it's 4 percent of people.
Patrick [00:26:50] That's right. So. So it's a bridge you probably won't have to cross.
Brigid [00:26:53] Yes. Yeah. But thanks for listening anyway. No really I think that there's so much in, well even just my own internet Instagram feed about women having vaginal breech breech births that it seems like A). It's more common to actually have a breach position in the first place and B). That it's an easy thing to do to, to have a breech vaginal birth.
Patrick [00:27:17] Well, you know, a lot of the time it is. This is an observation error. That means that the more you read about, the more common you think it is. Yeah. So that's a form of bias. We just think something's more common if we read about it all the time. Yes. Also if something's on our mind, we're more drawn towards that. If you're thinking of buying a blue car, you'll see a lot of blue cars. And then whether it's easy. Well, it is easy until it's not. So lots of them do go extremely well. And the problem, of course, the challenge is how do we advise women about outcomes that are rare but serious.
Brigid [00:27:52] Yes. Yes. Exactly. And people aren't going to post when it goes badly.
Patrick [00:27:58] No, that's that's. Yes. Well, they might. But what we read online is complicated by the motivations of the people who put it there.
Brigid [00:28:06] Yes, exactly. All right, everyone. Well, that is the end of this episode I'm gonna say the topic heading again "a heads up about breech birth". Nice one. Nice one. And we're here next week. I think we're going to be talking about whether a woman can actually refuse tests or say no to a particular treatment during pregnancy.
Patrick [00:28:25] Yes looking forward to that one. Oh good. Well, we'll see you next week. Thanks for listening, everybody. Bye.