The Breech Debate

Breech presentation is often considered to be a difficult issue regarding delivery options and outcome, and complicates 3-4% of pregnancies at term (1). It is associated with higher rates of perinatal mortality and morbidity than cephalic presentation (2). The Term Breech Trial has been particularly influential in sparking debate and further research within the fields of obstetrics and midwifery (3). Since publication of this landmark paper, there has been a marked trend towards caesarean section (CS) rather than vaginal birth. Current medical management involves an ‘external cervical version’ followed by CS if unsuccessful (4). The external cervical version is a manual procedure performed by the obstetrician which aims to turn the baby. Its success is largely determined by the skill of the practitioner and maternal factors (2). Some babies are breech because of structural reasons such as issues with the uterus wall or low levels of amniotic fluid. However there is usually no known reason for a breech presentation. As anxious and fearful women are linked to a higher incidence of breech presentation, any techniques that relax the mother can be helpful. Fear has the effect of tightening the lower uterine segment.

Caesarean section has been considered to be the safest option for term breech babies. (5) However operative delivery may have a detrimental impact on the immediate and long-term health of both mother and baby. (4). It has been suggested that it is preferable to wait until the onset of labour before the CS, to prevent prematurity and give the baby the benefits of contractions. Risks associated with vaginal breech delivery include intra and extra uterine anoxia, intracranial haemorrhage, as well as damage to neurological, musculoskeletal and genital systems (4). There are reports of good results with vaginal births for breech presentation, particularly home births which avoid the pressures of the hospital setting. Few midwives will now undertake a breech birth, possibly leading to a loss of skills for these challenging deliveries (Tiran, 2004). There is a difference between an obstetric delivery and a breech birth. In an obstetric delivery the woman tends to be on her back. She will often have an epidural, and most will have electronic foetal monitoring. Forceps may be used to encourage a quicker delivery, and the labour may be induced. Mary Cronk and Jane Evans, the renowned midwives, were influential in presenting their experience with breech deliveries at a meeting at the Royal College of Obstetricians and Gynaecologists (RCOG) in 19 January 2004. (6) The Cronk/Evans approach has a number of principles as outlined below; • Don't push a breech through a pelvis with Oxytocic drugs: no inductions; no augmentations. • If labour isn't progressing, suggest a CS. • Don't pull a breech down through the pelvis, no breech extractions. Breech by propulsion not traction. • If it isn't coming down, move to a CS. • Keep your hands off, sit on them if necessary. • Trust the woman's body. • Be ready to bag and mask.

Guidelines towards CS might mean that women are offered little room to decline operative procedures. Increasingly women with a diagnosed breech are opting to other methods to turn the baby, perhaps in an effort to gain control and empower themselves (Tiran, 2004). Methods that have been linked to helping turn a breech baby are listed below;

• Moxibustion • Hypnotherapy, visualisation and relaxation techniques • Music or sounds low on the mother’s belly to encourage the foetus to respond, by moving towards the stimulus. • Yoga • Homeopathic remedies that have been suggested include Pulsatilla, Natrum muriaticum or Medorrhinum. • Elkin’s manoeuvre; spending 15 minutes every 2 hours of the waking day in the knee-chest position • Heat around the belly or cold on the fundus, where the back of the baby’s head is. • Massage strokes downwards over the bump i.e. in the direction you want the baby to turn • Bach Bougainvillea flower essence • Pelvic tilts over a bean bag, or an ironing board at a 45 degree angle on a sofa; 10-15 minutes several times a day. • Webster’s technique- a chiropractic adjustment which involves sustained pressure on a specific point on the abdomen, followed by a sacral adjustment if warranted. • Osteopathy

(1) Turner M, 2006, The Term Breech Trial: Are the clinical guidelines justified by the evidence? Journal of Obstetrics and Gynaecology, 26 (6); 491-494.

(2) Krebs L, 2005, Breech at term; early and late consequences of mode of delivery, Dan Med Bull, 52:234-52.

(3) Hannah M, 2000, Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial, The Lancet, 356:1375-1383.

(4) Tiran D, 2004, Breech presentation; increasing maternal choice, Complementary Therapies in Nursing and Midwifery, 10, 233-238.

(5) Porter R, 2006, Breech delivery; the dilemma, BJOG, 113:973-974.

(6) Cronk M, 2005, Hands off that breech, AIMS Journal, 2005, Vol 17 No 1

For further information;

http://www.aims.org.uk/Journal/Vol15No4/BreechBirthMidwiferyApproach.htm

http://www.breechbabiesclub.org. Support from mothers who have experienced breech babies at term, and attempts to turn them

http://www.birth.com.au/Breech-baby/Vaginal-breech-birth.aspx