How To Deliver a Breech Baby

December 14, 2007

Breech position of an unborn baby is one of the most common reasons for doing a C-section. C-sections are done, of course, for problems, and the problem with breech babies is that the head comes out last. The reason this is a problem is that the head is the biggest part of the baby and that damage to it causes the most harm to a baby from a quality of life standpoint.

When a baby is normally head first, the entire delivery can't happen if there's a significant difference (the wrong way) in the size of the baby's head and the size of the mother's pelvis. This problem is remedied via a C-section. But the terrifying thing about these conditions in a breech baby is that the rest of the baby delivers first but the head becomes trapped inside. The cord is compressed at this point, so heroic measures are employed to get the baby's head delivered as well, no matter what. There's no difference between injury to a baby's head coming out first versus injury to a baby's head coming out last, except that there's ample warning when the baby's head leads the way. The entrapment of the aftercoming head is always a bad surprise. Even when delivery is ultimately successful, there are those who feel the children so delivered may be at risk for what are called soft neurological problems, like Attention Deficit Disorder, dyslexia, hyperactivity, and so on.

C-Sections

So for many reasons, there has been a tendency in obstetrics to make it a policy to deliver all breech babies by C-section.  But then when high C-section rates began coming under fire, there also began research into re-evaluating this policy while being conscious of safety also. Those in private practice read the journals and the studies, but no matter how reassuring, they must use their own judgement on a case by case basis.

What we're talking about here is a difference in thinking between those in private practice and those in academics. Even though all legitimate medicine moves ahead based on studies, still there are intangibles to consider. For instance, if there were only a 1% chance of a terrible complication based on a study, if that 1% were to occur in private practice based on that study, the incidence may as well have been 100% to those particular parents. Also, that one baby will haunt the doctor the rest of his life. (We never forget our troubling cases.)But the authors of studies are somewhat anonymously protected from this guilt. They'll never have to face these people again. And additionally, the complication rate for C-section is stunningly lower in private practice than in the populations used in studies, which include a  lot of indigent people with poor nutrition, bad health, etc. Fear of C-section complications cannot be added into the mix the same way in the two types of populations.

So the safety of the more aggressive approach (C-section) and the private practice mentality that demands a perfect baby (by not taking ANY chances) are what lead to the "cop out" of C-sectioning all breeches in private practice, where we doctors know our patients by name and face and good or bad fortune.

If an expectant couple were to insist on the academic position and want to try for a vaginal breech delivery, however, I feel obligated to consider it, because it is legitimate. But this consideration would be undertaken only if the criteria of the American College of Obstetricians and Gynecologists are met:

  • 1) An ultrasound as labor begins to make sure the baby is "frank" breech--not complete or footling (incomplete). Only a frank breech (the most common type in which the hips are flexed but the knees are straight,jack knifing the baby so that the buttocks deliver first) may deliver from below. In the other types, one or two feet and legs are in the way, which will jam up while trying to negotiate the pelvic pathway out.
  • 2) An estimated fetal weight of no more than 3800 grams(about 8 pounds), which can be determined by the ultrasound.
  • 3) X-ray pelvimetry to get actual bone measurements of the pelvis and compare them to the dimensions of the baby's head. If it's close, this delivery is better handled via a C-section. If there's a generous difference in the pelvis's favor, it's doable.
  • 4) A proven pelvis. That is, this can't be a first delivery.  The expectant mother has to have had a baby before, vaginally, and of term size, indicating that this is a pelvis that can come through (no pun intended).
  • These are the official academic criteria under which it's considered proper to attempt a vaginal delivery of a breech baby. But keep in mind that we private practitioners want no problems with our babies, which means no problems with the parents' babies. It may be a cop-out, but a C-section based on cowardice may be in everyone's best interests, because we're all on the same side.

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