Ep 153: Breech Birth – Updated!

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Today you’ll learn about what happens if your baby is breech. I originally talked about this three years ago and it came to mind because recently I did a surprise vaginal breech birth and after that I had folks saying they wanted to come to me with their breech babies so they could have a vaginal birth. I’d love to be able to see everyone who asked but breech birth is not that simple.

Now what does breech mean? Breech is when a baby’s butt is closer to the vagina than the head. It’s quite common in early pregnancy, however it’s actually a very small percentage of babies that are breech at term. Most breech babies are normal, however there are some malformations and mild deformations that can result. There are signs you and your doctor can look out for so you can choose the right management options. From turning the baby to cesarean, one way or another your birth team can help you have a happy and healthy baby.

In this Episode, You’ll Learn About:

  • What is breech presentation
  • How common is it
  • What risk factors can increase the chances of having a breech baby
  • What are the different types of breech presentation and why do they matter
  • How to tell if your baby is breech
  • What are the treatment options for managing a breech pregnancy
  • What are some alternative methods you could try in order to turn your baby
  • What happens after a breech birth

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Ep 153: Breech Birth – Updated!

Nicole: Today you are going to learn about what happens if a baby is breech. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Well, hello. Hello. Welcome to another episode of the podcast. This is episode number 153. Thank you for being here with me today. So in today's episode, you're going to learn about what happens if you're baby is breech. And I originally talked about this like three years ago and it came to mind recently for me to revisit it because one, I personally did a surprise vaginal breech birth not that long ago, I talked about it on Instagram. And after that I had folks saying, Hey, I'm coming to see you with my breach baby, so I can have a vaginal birth. And I was like, I would love to see you, but hold up. Vaginal breech birth is not that simple. And then the second thing that made me want to talk about this topic is one of the students of, one of my students in the Birth Preparation Course was kind of struggling with her baby being breech.

Nicole: And she was asking some questions that had me thinking and had me going to look up some stuff. So if you don't know, the Birth Preparation Course is my online childbirth education class that gets you calm, confident, and empowered to have that most beautiful birth. And one of the benefits of the course is a private Facebook group where folks can ask questions. And I am all up in that group every day, responding to folks questions and, and, and comments about things. Um, giving a little bit of a deeper insight into things beyond what you can get here on the podcast. Often beyond what folks doctors are telling them. So that's one of the many benefits of the Birth Preparation Course. You can check it out at drnicolerankins.com/enroll. Now, in this episode, you are going to learn about breech and what you're gonna learn is what exactly is breech presentation?

Nicole: How common is it? Spoiler alert. It's actually not very common. Some risk factors for a baby being breeched to the different types of breech presentation. How we suspect that a baby is breech. What are some of the options for management, how that's changed over time, some of the controversy surrounding management of breech birth, and then what happens after a breech birth? So we're gonna get into all of that in the episode today. Now a couple things before we get into the episode one, let me do a listener shout out. This is from Caitlin C. Caitlin C left me this review in Apple Podcast. And it says incredibly informative and enjoyable. I cannot say enough good things about out this podcast. If you haven't already checked it out, go listen. Now whether you are pregnant, a support person, or generally curious about aspects of pregnancy or birth, this podcast is for you.

Nicole: Dr. Rankins is extremely knowledgeable and presents the information in an empowering way. As a first time mom, I was nervous and unaware about so much that happens during pregnancy. Luckily, a friend recommended this podcast to me when I was in my first trimester. I'm so thankful she did well. Thank you, Caitlin, for that kind review and for taking the time to leave that for me in Apple Podcast in particular, and thank you to your friend for recommending the podcast. As y'all know, I love this podcast. This is my heart, soul and passion, and I am so grateful and just love bringing information that helps folks be empowered during their birth. All right, let's get into this conversation about breech babies. Okay. So first thing we wanna start off with is what is a breech baby? So quite simply breech just means that the baby's butt or bottom is closer to the vagina than the head. That's it. So the butt, legs, the bottom part of the baby is the presenting part. So that is what's coming first, the, through the cervix or to the vagina and not the head

Nicole: And breeches are relatively common occurrence in early pregnancy. When babies are really mobile, they have a relatively larger volume of amniotic fluid and they can move around and flip around a lot. So we will find when we look that roughly 20 to 25% of babies under 28 weeks are breech. That number decreases to between seven to 16% at 32 weeks as the baby gets bigger, they just run out of room to, to keep turning. And then only three to 4% of babies are breech at term. So 37 weeks and beyond only three to 4% of babies are breech. So it's actually not very common. Now, most babies that our breech are normal. However, breech presentation is associated with an increased risk of some congenital malformations, as well as some mild, um, abnormalities, particularly to torticollis which is where the neck is kind of twisted and turned.

Nicole: And also some developmental dysplasia issues of the hip, where the hip doesn't develop quite the right way, and that needs to be monitored after birth. Again, those things are rare though. Now most of the time breech is random, but there are some things that are associated with it or that are some risk factors for it. And I'm just gonna run through the list. So being preterm, uh, is a risk factor for being breech. And what I talked about earlier, because there's more space to move around. Interestingly, if you or your partner was born breech, then that increases the chances of you having a breech baby. So parents who themselves were delivered at term and breech are actually twice as likely to have a firstborn baby who is breech. Isn't that interesting? So we don't know that that, um, so we don't know a specific like gene or anything that's associated with it, but there's certainly some potential genetic component.

Nicole: That's there. Some other things that increase the chances of breech are having a uterine abnormality. So the shape of the uterus is different. So for example, if you have fibroids that change the shape of the uterus and then the baby settles in a breech position, then it's hard for them to get out of that position. If you have, what's called a bicornuate uterus, uh, where the uterus kinda looks like a heart shape, then that can increase the chances of breech. If you have a septated uterus, meaning there's a tissue in the middle of the uterus, a septum that can increase the chances of breech of as well. Uh, the, the location of the placenta can increase the chances of breech presentation, particularly placenta previa. When the placenta overlies the cervix. If you've had a lot of babies before and your abdominal wall muscles are really loose and lax, then that can naturally increase the chances of having a breech baby. Extremes of amniotic fluids.

Nicole: So if you have a lot of fluid, that's polyhydramnios, then there's a lot of room for the baby to move around and the baby can get to be in a breech presentation. On the other side, if you have low fluid oligohydramnios and the baby settles into a breech, it's hard for them to get out of that position because there's not a room, not a lot of room for them to move around. Um, let's see what else actually, maternal hypothyroidism. So if you have low thyroid that can increase your chances of having a breech baby, if there is a short umbilical cord that increases the chances of having a breech baby, if there are concerns about the baby's growth. So fetal growth restriction that can increase your chances. Uh, if you take antiseizure medicine that can increase your chances, older maternal age, and also first baby increase your chances of having a breech baby as well.

Nicole: Also as with many things, if you had it once before you do have an increased chance of having a, a breech baby, again, that doesn't happen practically very often, but there is an increased risk. One study showed that after one pregnancy that was breech, then the next pregnancy you had about a 9% chance of having a breech baby. If after two pregnancies, both babies were breeched, then that goes up to 25%. And if you had three consecutive babies that were breeched, then it's about 40%. So your babies are probably just gonna likely be breech. All right? So let's get into the different types of breech presentation and there are three different types. And I'm also gonna explain to you why the types of breech presentation matter. So one is complete breech, and that is when both the hips are flexed and the knees are flexed.

Nicole: And that just means bent. So the hips are bent and the knee is bent. It looks like cannonball. So like cannonball shape, if you were like jumping into the pool, you know, you grab your knees and jump in. That is a complete breech presentation that happens in about five to 10% of pregnancies, not very common. The next most common is incomplete breech when one or both of the hips are not completely flexed. Okay? So that means that it may be a footing breech where one foot is going through. So one foot is straight. It may be both feet going through where both feet are straight. So that is an incomplete breech. Rarely it could be both knees, actually. I've never seen that happen, but that's the possibility as well. So incomplete breech happens roughly 10 to 40% of the time. And then the most common breech presentation is Frank breach.

Nicole: And that is when both hips are flexed. So the hips are flexed, but the knees are extended. So the feet are up by the baby's head. And that is when you see there are tons of videos, you see babies online and their little feet are flopped up, like smack up by their head straight up. And that is, that is Frank breech. When they are like that in utero, they come out and they stay like that. So that's Frank breech when the hip is flexed and the knees and the knee is extended and the feet are up by the head. And the reason that the type of breech presentation matters is because depending on the presentation, it increases the chances for problems. So particularly with the incomplete breech presentation. So if you have feet presenting and not like the, the, the butt really presenting, what can happen is that the feet can come out.

Nicole: The trunk can come out of the baby, but the shoulders and the head can get stuck. So the feet, the trunk could fit through a cervix that's not completely dilated. And then the shoulders and the head can potentially get stuck. That increase the risk of the umbilical cord being cut off and something called, um, head entrapment. That is every obstetrician's, one of our worst nightmares to have that happen. So with incomplete breech, that is a risk also with incomplete breech. There's a higher risk of what's called umbilical cord prolapse, where if a foot is coming through and there's space on the side for the umbilical cord to drop through, that is also a true, true obstetric emergency, because it can cut off blood supply to the cord, through the cord and, and hints to the baby and lead to fetal death. So that requires a stat like run to the room c-section. So that's why we get concerned particularly about incomplete breech, that head entrapment scenario, which is a disaster, and then umbilical cord prolapse, which is also an emergency and requires emergency cesarean birth. That doesn't happen quite as much with Frank breech or complete breech because the, the butt is like sitting down nice and solid on the cervix. So those things are less likely to happen. And also, um, if the, if the butt is coming through with the legs, kind of next to it, that's a nice wide surface, wide surface. And it's about the same size as the head. So it's not like a whole lot smaller. So we know that if that butt and the legs fit through like that, where the legs are bent up, then we almost always, the head is going to come through as well. It's not gonna get stuck.

Nicole: All right. So how do you know if your baby is breech? One thing is that you may feel discomfort underneath your ribs from the head. You feel something solid up there. Just feel like, oh my goodness, what is that? Something is up there. Something's up there. So just discomfort under the ribs from the head. If the baby is incomplete breech, then you may feel kicking in the lower part of your belly. So you feel the kicks lower and not higher. Okay. We may pick up the baby's heart rate higher. The heart is closer to the head. So if we're picking up the heart rate higher in the belly, then it may be, the head is up there too. On vaginal exam. We can have a suspicion of it. If your baby, if your cervix rather is dilated, because it just feels different. Like it's, the head feels firm, a butt or something other than the head feels squishy.

Nicole: And it's like, that does not. That does not feel right. So, um, you can tell if this cervix is dilated at least a couple centimeters, and you can feel the head, you have a suspicion on, on vaginal exam. If the cervix is completely closed, it's actually pretty hard to tell if a baby is breech, you may have a suspicion because you don't feel anything like you don't feel a head down there like, like you're expecting to feel. So then you may check. But if the cervix is closed, it can be challenging to tell. We definitively diagnose breech presentation by ultrasound. It's very easy to diagnose you. Pop the ultrasound on a baby's head, looks like the bones of the skull, light up a certain way in a circle. It's very easy to tell by ultrasound whether or not a baby is breech.

Nicole: So what do we do? What are the options for what can happen when a baby is breech? Now I'm gonna talk about options for term babies. So full term babies, 37 weeks or more. For preterm babies, we almost always do cesarean unless they are really really preterm because the head is the largest part in preterm babies. And that has a higher risk of getting stuck. So unless the baby's really, really tiny, like around 23, 24 weeks, typically for preterm babies, we're gonna do cesarean for breech. So I'm talking about the options for term babies. So the first one is something called external cephalic version. An external cephalic version is basically just turning the baby. So we, from the outside, we try to turn the baby to head down position it's typically done around 37 weeks. There is some data that shows that doing it a bit earlier, like between 34 to 36 weeks does have a higher success rate, but we do have to weigh it against the possibility that if there's a complication, if something happens during the procedure and we have to do an emergency cesarean, then we're bringing a preterm baby into the world.

Nicole: So typically we do it around 37 weeks full term. As far as a success rate, I wish I could tell you better numbers about the success rate. It's not terrible, but it's not like fantastic either. So in 2018, one study looked at, uh, a review of about 13,000 attempts. And the overall success rate from that systematic review was 58%. So better than a 50 50 shot, which I think is good. You know, you'd like it to be higher, but definitely better than a 50 50 shot. And then another series of about 2,600 attempts, um, showed a success rate of 49%. And in that study, the success was 40% for patients who were having their first baby. It was 64% for patients who were having, you know, who had had a baby before. So not great numbers, but again, like at least about a 50 50 shot of it working. A higher chance if you've had a baby before. Now, note, if the version was successful, 97% of babies in that second study stayed head down.

Nicole: Okay. And then of those 86% of those delivered vaginally. So if it works and there's a good chance that it is going to, baby's gonna stay in the right position, then you'll go on to have a vaginal birth. So it's certainly worth a shot. Now, some things that make it less likely to be successful are if it's your first baby, if the placenta is anterior, anterior placenta means the placenta has just settled on the front wall of the uterus. You don't have any control over the where the placenta settles in your uterus it settles where it settles. So if it settles on the front portion of your uterus, then it's just a little bit harder to feel the baby to get the right, um, to get our hands on the right spot, to turn the baby. Um, low amniotic fluid is gonna decrease the chances of success.

Nicole: And as I said before, that's because there's just less room for the baby to turn. If the baby has already descended into your pelvis, if the baby is really low, that's harder because with aversion, we literally have to push up the bottom part of the, the baby and then rotate it. If the baby is down in the pelvis, it's, it's a little bit harder to do that. If you carry extra weight, so obesity will decrease the chances. And really that's just because it's just more difficult to feel where the baby is to know where to turn. If you have super firm, um, abdominal muscles that is going to, to make it more difficult for the baby to turn a Frank breech presentation, makes it more difficult to turn. As you might imagine, it's kind of hard to turn a baby whose legs are kind of straight out like that.

Nicole: So that is going to make it more difficult to turn. If the baby is persistently breech, like every time we look that baby is breech, it has never been head down. Then that is going to decrease the chances of success. Actually, that's a pretty good prediction. If they're, they're breech, every single time we look, the baby is probably going to stay breech. Um, if the water's broken, then that will decrease the chances of success. Because again, not as much space to move the baby around. Now on the flip side, things that enhance the chances of success, and really a lot of it is just the opposite of some of the things that I talked about. So if you have a posterior placenta, meaning the placenta is on the back wall of your uterus, that will increase your chances of success. If your amniotic fluid level is higher, that will increase the chances of success as will a fetal part.

Nicole: So the butt that is not engaged in the pelvis. So an unengaged fetal part will help because we don't have to like push up so high and try to move the baby to turn. Interestingly, Black race increases your chances of having a successful, uh, external cephalic version as does, what's called an oblique or transverse lie. So what that means is the baby is not quite where the head is underneath your ribs. It's just not straight down. So either the baby is going across your belly. So you just don't have as much of, um, space that you need to turn the baby in that case, or oblique where it's like between 45 and 90 degrees off one side to the other. So instead of straight down, and I wish y'all could see me. I'm like doing motions, sitting at my desk of the baby, but instead of the head being straight down, it's like off to the side a bit, one way or the other. So there's more a higher chance of a success with those positions, because it's just less that we have to turn. Now, some other things that can increase success are something called lysis, which is basically just relaxing the uterus.

Nicole: And typically we give a medicine it's called a beta stimulant in the US. We use something called Terbutaline and literally it just helps to relax the uterus. So when you relax those muscles, then it can help with having the ability to turn the baby.

Nicole: The other thing that can help is what's called neuro anesthesia. So that's an epidural or a spinal medication. Studies show that that will increase the risk typic, oh, I'm sorry. Increase the chances of success. Um, typically, or a lot of times people don't use any sort of anesthesia for, um, external cephalic version. And I think that's kind of, I was trained to do it, but studies show that it can help. In one study in 2016, having a spinal and typically we're gonna do a spinal because it can do a one shot deal of medication. You don't need a epidural to give continuous medication. So it'll be a one shot deal of medication. And having that spinal increases the increases, the chance of success in this 2016 study, um, from 43%, for those who didn't have it to 58%. So that's a pretty big increase and also increase the rate of baby being head down in labor from 40% to 55%. Vaginal birth increased from 44% to 54%.

Nicole: And the cesarean birth rate was lower. So it was 46% versus 55. When folks had that, that spinal, that is one of those things. I think if your doctor is talking about doing a version that you ask for it, because it can help. Not everybody's gonna do it. So you can ask for, um, having a spinal, you can ask for what's called lysis or medicine to help relax your uterus because those two things will actually increase your chances for success. And then as you might expect, also experience will enhance success. And one study in the Netherlands, having a dedicated team who only did external cephalic version or ECV that increases success rate from 40 to 70%. So just having practice and doing it more frequently, increase the chances of success. Now, one thing I didn't realize before I went back to update this episode is that vibroacoustic stimulation can actually help improve the chances of a successful version.

Nicole: Um, and it's a one small study. It was only like 20 something patients, but it's, it's a little handheld device that we use sometimes to help stimulate a baby. Like if we want to see the heart rate jump up or the heart rate is not looking great. So it's a little handheld device and it sort of sends a stimulant of sound and motion to the baby. And that's a pretty inexpensive, like well tolerated harmless approach to try. And it definitely did reduce the, the failure rate. So that is something that I'm gonna actually try to, um, incorporate, cuz I've never done it before. The next time I do a version to see if that helps

Nicole: Now, the procedure is not without risk. Everything has risk, but the overall risk are low. So in one study in 2008 in a systematic review, when they looked at ECV's done after 34 weeks, this was a lot of patients included in the data. Almost 30,000 serious events were very rare. So the overall complication rate was 6.1% that included stillbirth, placenta abruption, emergency cesarean birth, cord prolapse, some transient changes in the heart rate, vaginal bleeding, water break, all of those together 6.1% happen. Serious complications, which were like stillbirth or abruption that only happened in 0.24%. So 23 cases out of nearly 13,000, the risk for, um, the baby dying after it was born, fetal death was 0.19%. And actually only two of the 12 deaths were attributed to the procedure itself And the risk of placenta abruption, where there are issues with the placenta was 0.18%. So one out of every 1200 ECV's AER, uh, a Marion emergency cesarean birth was performed in, um, only 49 cases. So 0.35%. So all of those complications are low. All right. The risk are very, very low.

Nicole: So as for the procedure itself, what happens is you come into labor and delivery. You're put in a room, uh, you don't eat beforehand just because of the potential for emergency cesarean birth. If need be, it can be one or two doctors who are doing it. Typically it's two. I think it's easier with two but one or two doctors. We watch closely with ultrasound during the procedure, uh, make sure the baby's heart rate stays okay. Usually we tend to like slather your belly with jelly or gel, not jelly, gel so that we can move the baby around and it can be painful. I'm not gonna lie. It can be very uncomfortable, um, for, for many people, which is also another reason to do that, that spinal anesthetic anesthetic to help reduce the pain as well. So it can be uncomfortable. And really it doesn't take long.

Nicole: We typically try like two or three times the whole thing may take 10 minutes to try all of all of the time. So it really doesn't take long. And we literally are physically just trying to turn that baby around. Now, there are a couple of sort of special situations or circumstances with external cephalic version. Typically, we schedule it, uh, at 37 weeks, but it can also be done once you go into labor. So if you come in in labor and your baby is breech, if the baby is not down in your pelvis, if your water hasn't broken, if you have normal amniotic fluid, then it is certainly reasonable to try during that early part of labor to turn the baby right then. Okay. And the advantages of delaying it until labor begins is that you do give that maximum amount of time for spontaneous version to happen.

Nicole: I'll talk about how frequently that happens in just a minute. And then also if the baby turns and you're already in labor, then you know, you just go ahead and have the baby, right. Then now the disadvantages of doing it that way, the disadvantage of, of doing it in an unplanned way. And just waiting until you go into labor is that if you go into labor and the baby is already in the pelvis, that's gonna make it harder. If your water breaks, it's gonna make it harder. So those are the disadvantages, but it can be done if you present in labor and you're in the early part of labor, an attempt to turn the baby can happen then. The other special circumstance is the situation where the baby isn't like all the way breech, meaning that the head isn't up under the ribs, the baby is in, what's called a non longitudinal lie.

Nicole: So transverse meaning across or oblique, just slightly off center, either side. Sometimes we delay those until closer to 39 weeks because those babies have a high chance of flipping back to transverse. So what we'll do is do the version at 39 weeks, put like an abdominal binder on and then go ahead and induce labor, right then just because they have a high chance of going back to that, that transverse oblique position. Now, if the initial attempt at ECV is unsuccessful, we can certainly try again in a couple of days. All right. So it is certainly reasonable if you want to, to try again, but typically we don't try more than twice. And then the other option, if it is unsuccessful is just to wait. Okay. Um, roughly anywhere between four and six percent of babies will spontaneously go to a head down position after a failed external cephalic version.

Nicole: So it's not terribly high chances, but it ain't zero. So if you want to wait until you go into labor before you have a cesarean, then that is certainly reasonable as well. Okay. So what does ACOG say about external cephalic version and ACOG is the American College of Obstetricians and Gynecologists. It is our governing body who sort of makes recommendations about treatment management decisions and their stance is because the risk of an adverse event occurring as a result of ECV is small. And the cesarean birth rate is significantly lower among women who have undergone successful ECV. All women who are near term with breech presentations should be offered an ECV attempt. If there are no contraindications. Now I will say that in practice, not all people are offered this option. So if your baby is breeched, then definitely bring up the possibility of ECV.

Nicole: If this is something that you want to do now. So that is one option, external cephalic version, the other option, which quite frankly happens most of the time for cesarean birth. And I'll talk about why its planned cesarean delivery. And that can either be done without an attempt at a version or after a failed version attempt. Now we don't schedule the C-section any earlier than 39 weeks. And that's because 39 weeks is kind of the golden number that we know from our data where babies are ready to be born. The risk of complications is low every day up until 39 weeks count. So we don't intervene before 39 weeks, unless there's a reason to, and then why scheduling it versus waiting until you go into labor in order to have a cesarean. So there are some slight risk associated with delaying cesarean. Um, if the baby is in an incomplete breech presentation, then that's gonna increase the risk of cord prolapse.

Nicole: Like I talked about like the umbilical cord coming through. If the labor goes really fast and the baby's in that incomplete breech presentation, it can increase the risk of head entrapment. If that happens, that's not likely to happen. There's also an increased risk of infection. If cesarean is done after you're in labor versus like a scheduled cesarean. But again, that risk is not high. And as I said, spontaneous version, meaning baby just turns on, on their own can occur at any time before delivery, even after 40 weeks, actually in one study where they did ultrasound exams, uh, spontaneous version, baby turned on its own, after 36 weeks actually happened in 25% of cases. So that is a pretty decent chance that a baby could turn on its own. Now, some characteristics that lowered the likelihood of spontaneous version were extended fetal legs. So if the baby's in that Frank breech position, it's gonna be harder for them to turn if there's low fluid or short umbilical cord, if you have uterine abnormalities like fibroids, that's gonna make the baby less likely to turn, or if it's your first baby.

Nicole: So I say all that to say that it doesn't have to be a scheduled cesarean at 39 weeks, if you want to, based on your own unique circumstances, if you want to wait until you go into labor and then even try the version then, or, um, you know, check right before you have a cesarean to make sure that the baby hasn't turned and then have the cesarean if the baby hasn't turned, then that is perfectly reasonable. I definitely recommend because the, the chances of babies turning is, you know, like I said, spontaneously is, is 25%. And even after a failed version, they can still turn definitely have the doctor put an ultrasound on and look where the baby's head is before the cesarean so, you know, 100% that the baby is breeched before you have a cesarean for breech, okay. There having stories of overdoing a C-section for breech and baby is not breech. So definitely check just before you go back.

Nicole: So how do we get to this point where most babies are breech babies rather are born by cesarean. Really? That came from something called the term breech trial. This was a study done in 2000. This was right before I did my residency. I did my residency in 2002 and the term breech trial is a randomized trial. So that's the strongest level of evidence that we have available. Meaning people were randomly assigned to having a planned cesarean birth or a planned vaginal birth. It happened in 26 countries, 2000 women with one baby in a Frank breech or complete breech presentation. And what the results of that study show are that perinatal mortality, neonatal mortality, or serious neonatal morbidity were lower in the planned cesarean group compared to the planned vaginal birth group. So in the planned cesarean birth group, the risk of all those things was 1.6%.

Nicole: Whereas it was 5% in the planned vaginal birth group. There were no differences for mom in terms of maternal mortality or serious maternal morbidity. So really all of the benefits were for babies for planned cesarean birth when they're in the breech position. And over time, this study was reanalyzed again, and they, they, um, followed people out longer. And although there were those short differences, there were no long term effects noted for children or moms. At two years, this study completely changed the way that obstetrics was practiced. And it has led to the fact that well, over 90% of breech babies are born via cesarean section today. Well over 90%, I'd say closer to 95, even 99% of singleton breech babies are, are delivered by C-section. And the data from this study has been supported by additional studies. There was a Cochran review. Cochran does, um, big reviews of studies in a really systematic way.

Nicole: So in 2015, there was a Cochran review that looked at planned cesarean for term breech delivery. And compared with planned vaginal birth, planned cesarean did reduce perinatal and neonatal death. Um, and it, it wasn't by, uh, a ton, but it did reduce it. And particularly short, short term were reduced for babies per perinatal, neonatal death and serious neonatal morbidity. So in the, um, in the vaginal birth group, the risk of those things happening was 57 in a thousand. When you look at that, that's still a low number, but it was four versus a thousand in the planned cesarean birth group. So in general, the conclusion is that planned cesarean compared with planned vaginal birth reduces perinatal and neonatal death and reduces, um, any serious neonatal problems. In that Cochran review, they did find a tiny increase in maternal morbidity, but that was mostly in low resource setting countries.

Nicole: Okay. So that is why most breech babies are born via cesarean because of the data that has showed that it reduces poor outcomes for babies. All right. Overall risk of bad things happening in either situation is low, but it's lower with planned cesarean birth. And I have to be honest, I think we are at a point of no return where cesarean is going to be how most term breech babies are born is by cesarean. And that it's because there's just not a lot of options for the third option. So the first option when baby is breech is external cephalic version. The second option is planned cesarean birth. And then the third option is vaginal breech birth. All right? And I just don't think that this option is gonna happen much. It doesn't happen much. And I'm gonna explain why. Now the reality is if for appropriate patients who have characteristics that place them at low risk for any complications, vaginal breech birth is a perfectly viable option.

Nicole: And the study that is most often used to support vaginal breech birth is something called the promoter study. It was done in France and Belgium, and it's an observational study. So not a randomized trial. So the results are less robust than the term breech trial. There were also some concerns about who was included in this study, but this particular study, the composite outcome and composite outcome means they just combine a lot of rare outcomes together. The composite outcomes of mortality or morbidity for babies was not significantly different for planned vaginal versus planned cesarean birth. Okay. So in this particular study of the, uh, 2005, her 2,500 patients, roughly who were in the planned vaginal birth group, most of them 70% did deliver vaginally. And 6.6% of them had an adverse outcome. And those included brachial plexus injury, skull, FLA, skull fracture, genital injury, um, seizure, death in two infants.

Nicole: Some things that were associated with those poor outcomes were preterm delivery, a small baby or a hospital where they didn't have a lot of births. Okay. And then there have been some subsequent smaller studies that have shown a low rate of bad outcomes for planned vaginal breech birth. But the key in the promoter study in all of these studies is that it really has to be strict criteria for who has a vaginal breech birth. Okay? So who is considered to be low risk and those criteria are no hyper extension of the fetal head. When we look on ultrasound and hyper extension just means that the neck is bent back, like it's extended back. And here I am, again, like doing the motion sitting at my desk while I'm recording. But hyper extension means just like the chin is tilted up. Head is tilted back.

Nicole: That is going to increase the chances of head entrapment. Also, we don't wanna do it if the estimated weight is between 2,500 to 3,800 grams, or I'm sorry, we want to do it only if the estimated weight is between 2,500 to 3,800 grams. So that is between five pounds, eight ounces to eight pounds, six ounces, Frank breech presentation. So where those legs are straight up, that is gonna create a nice big wide surface at the bottom. At that bottom part goes through that the head should come through just fine. Babies need to be continuously monitored during labor with electronic fetal heart rate monitoring. And then of course, significant informed consent about vaginal birth during the labor. We avoid induction actually. So only folks who go into labor spontaneously some say no prior cesarean, although that's controversial, some also say had a prior vaginal birth.

Nicole: Although actually the data does not show that there's a difference. As long as you meet those other criteria that I talked about. And then during labor, we don't break the water because breaking the water is gonna increase the chances of cord prolapse, and then also not using any Pitocin. So essentially, if it happens, it happens. If it doesn't, it doesn't, we don't push it in order to happen. Interestingly, there were two small studies that showed that there were better outcomes, fewer interventions, a shorter pushing phase, fewer injuries to baby when mom was in an upright position or on all fours rather than on her back. So that's also an interesting observation as well. Now, the biggest thing that is required for a vaginal breech birth is someone who is comfortable doing it. It requires patience. First of all, like you can't touch the baby as the baby's being born.

Nicole: It's so counterintuitive to what we do. So you'll see legs coming out and literally the legs are just kind of hanging out and then you wait for mom to push more. The baby comes out, you really don't do anything. Don't touch the baby. You just support the baby until at least you see the belly button, all right. At least you see the belly, ideally until you get to the shoulders, you, you don't do anything. You just let the baby come out. And again, that's counterintuitive to what we do. You see half this baby kind of hanging out. And the reason that you do that is because if you pull on the baby, you increase the chances of that neck hyper extending and the head getting stuck. So you really just have to wait. And then also so many people are just not trained on it.

Nicole: Y'all there are a not insignificant number. I don't know an exact number off my head, but just sort of anecdotally in groups that I'm in and things like that. There are plenty of OB GYNs who have never seen a vaginal breech birth who have never done a vaginal breech birth. Okay. So that is not, um, infrequent that you, you have a doctor who has no experience with it at all. Me personally, I will do a vaginal breech birth. I mean, I've been doing this a long time. Most of the time I do it with second twins, I've done it in surprise circumstances. When mom comes in and baby is just comin breech, you know, we just make it happen. I would certainly be willing to do it in someone who was appropriately counseled and met all the criteria and wanted to try for a vaginal breech birth.

Nicole: I personally think it's an important skill to keep up. I don't want the only tool in my toolbox to be a knife. So that's why I offer it, but there's really just not a lot of opportunity to do it. Remember I said that only three to 4% of babies are breech at term. And then you further whittle that down to folks who wanna try versus who don't try, don't wanna try. And the baby has to be in a certain position and have, have all of those things. There's really just not a lot of opportunity to learn how to do breech birth. Now, some of the things that we've talked about as upon possibility to, to make up for that, because there will inevitably be the surprise breech birth who shows up at your hospital is simulations. And that is certainly a way that a lot of residents in training as you're going through your training folks, doing simulations on breech birth in order to, to have that skill.

Nicole: But it really is difficult to have folks who are trained on it and feel comfortable on it. And I say all that to say is that you can see people or you'll see people online who talk about breech birth. And they're like, well, you have a right to have a breech birth. And you do, you absolutely have a right to have a breech birth, but it's a very reasonable chance in the US. You're gonna be doing it with somebody who don't know what they're doing, who maybe has not ever seen it. Okay. So most people, I believe that's not a chance that they wanna take, but just know that yes, you can have your breech birth, but you could be doing it with someone who has very little to no experience doing the procedure. And I think it's just difficult situation to go down now that we've gone down this road where so many babies who are breech are born by cesarean because there's just not much of an opportunity to learn.

Nicole: All right. So as far as what the, um, American College of Obstetricians and Gynecologists says about breech birth, just to wrap that up, and then I'm gonna talk about some quote unquote alternative options for turning a breech baby. Um, what the American College of Obstetricians and Gynecologists says is that the decision regarding the mode of delivery should consider patient wishes the experience of the healthcare provider, obstetrician, gynecologist, and other obstetric care providers should offer external cephalic version as an alternative to planned cesarean for, for a woman who has a term singleton breech, fetus desires, a planned vaginal delivery of a vertex presenting fetus and has no contraindications. It should be attempted only in settings in which cesarean delivery services are readily available, planned vaginal and delivery of a term singleton breech fetus may be reasonable under hospital specific protocol guidelines for eligibility and labor management.

Nicole: If a vaginal breech delivery is planned, a detailed, informed consent should be documented, including risk that perinatal or neonatal mortality or short, short term serious neonatal morbidity may be higher than if a cesarean delivery is planned. Okay, so that's ACOG's stance. So again, takeaway is that really, you should be offered version if not ask for it. And then most doctors are gonna be way more comfortable doing cesarean and not many know how to do a vaginal breech birth. Okay. Now the last thing I wanna end with is some alternative options and things that you may wanna try in order to turn your breech baby. And some of those include position changes and techniques. Spinning babies has a website that has some techniques and things that you can do to try to turn your beach, your breech baby. So I definitely suggest you, um, look at spinning babies for those, um, um, maneuvers and things.

Nicole: They have been quite helpful for some folks, the Webster technique, we, which is something that is done by a chiropractor is also a possibility you wanna make sure it's by someone who is an experienced chiropractor and knows what they are doing and has, you know, comfort and, um, skill and training in doing so. So the Webster technique by a chiropractor is worth a shot. Another weird one or unusual one that I've heard is putting ice on the baby's head for 20 minutes a day for a few days can help as a stimulant, just so to get the baby to move away from the risk of all of the, there's certainly no studies on that. Um, there's no evidence that, that, that, that, uh, will help, but they are certainly not, it's certainly not harmful. There's also not great evidence on the Webster technique or the spinning babies technique that I'm aware of.

Nicole: And in terms of like randomized trials or things like that. But again, those things are not likely to be harmful and they definitely help. Also Moxi I don't, I don't know if I'm saying this right. Mo Moxi busin Moxi boo skin Moxy bustin. It is a type of Chinese medicine where an herb is burnt close to the skin of the acupuncture point, bladder 67, BL 67, located at the tip of the fifth toe. All right. A, it has been used either alone or in combination with acupuncture in order to help turn a baby. And it's typically performed 20 to 60 minutes once or twice per day, two to seven times per week from one to two weeks. Okay. And it's pretty safe and it actually does increase the chances of turning a breech, baby. It's not terribly high, but again, that's certainly something worth trying.

Nicole: Don't do it at home. Don't try to do it yourself. I've seen stories of people like nearly burning their toe. So go to someone, an acupuncturist who is comfortable and experienced with doing this. Okay. Last thing I want to say is that after birth, if you end up having a cesarean for breech, baby, you are a great candidate for a VBAC. Okay. So if you have a cesarean, don't think that you are committed to cesarean. You are definitely a great candidate for having a VBAC or a vaginal birth after cesarean the next time around. Also, regardless of how babies are born, whether they're born vaginal or cesarean babies who are born and they breech in utero and utero are more likely to have that, those hip issues. Like I talked about that torticollis so they need to be examined closely after birth. Okay.

Nicole: Some doctors will recommend an ultrasound just to look at the baby's, um, hips, just to make sure everything is okay. All okay. So just to wrap up about 3% of babies are breech at term, some risk factors for breech. And this is just a few extremes of fluid, uterine abnormalities, like fibroids or unicornorate uterus. If either parent was born breech, the types of breech presentation, Frank breech, where the legs are up by the head, that's the most common, complete breech, which is like Cannonball. And then incomplete is the rest. You may suspect that your baby is breech based on feeling ahead, up in the ribs where you feel kicks ultrasound is the way we definitively diagnose it. As far as the options for management, they have changed over time. We very rarely do vaginal breech birth anymore. Most often, we either do cesarean birth, or you should be offered the option of external cephalic version.

Nicole: Definitely bring that up to your doctor if they don't suggest it. Some things that may make external cephalic version more successful are, uh, having the lysis medicine in order to relax your uterus, having anesthesia the spinal anesthetic in order to, well, actually, we're not sure exactly how it, how it works. I don't know if it just relaxes your, your uterus or just makes it easier to move the baby, but having that spinal anesthesia and then the vibroacoustic stimulator, I am looking forward to trying that as well as for vaginal breech birth, it is an option and appropriate candidates, but know that there are not a lot of doctors who do it or have skill in it. And then the final thing that I will say is that some babies are just gonna come in this world a breech, okay, it's not your fault. You didn't do anything wrong.

Nicole: So maybe just decide that they're gonna be breech. And that's just how things are. So don't blame yourself, do what you can control, the things you can control and, um, know that ultimately of course you want your baby to get here as safe as possible and healthy as, as possible. And it's perfectly natural and normal to be upset if your baby is breech for sure, 100% and be disappointed. But know that some babies are just gonna come into this world breech. And there was nothing necessarily that you could do to change that. Okay. So there you have it. Do me a favor, share this podcast with a friend. If you like it also subscribe to the podcast in Apple Podcast, wherever you're listening to me right now, I am actually gonna start releasing some bonus episodes of the podcast. And the only way that you're gonna know about them is, is if you subscribe.

Nicole: So definitely subscribe to the podcast and leave a review, in Apple podcast in particular that helps the show to grow, and it helps other women find the show. And I love to hear what you think about it. Also, don't forget to check out the Birth Preparation Course, my signature online childbirth education class. That gets you calm, confident, and empowered to have the most beautiful birth. We have an amazing community there, and you can get extra help from me beyond what you can get here in this podcast. That's drnicolerankins.com/enroll. So that is it for this episode, do come on back next week and remember that you deserve a beautiful pregnancy and birth.