No, breech is NOT a variation of normal

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Natural childbirth and homebirth advocates have a distressing habit of seizing on lies and repeating them over and over again to convince themselves and others that they are true. One currently popular lie is that “breech is a variation of normal.”

Here’s a little hint: If it dramatically increases the risk of death, then it is NOT a variation of normal. And breech presentation dramatically increases the risk of death. Contrast that with true variations of normal like left-handedness vs. right-handedness, which have no bearing on health or life expectancy.

To understand why breech presentation dramatically increases the risk of death, it is helpful to review some basic principles of childbirth. At term, the baby’s head is usually the largest part of the baby. That means that if the head fits, the rest of the baby should follow without difficult (shoulder dystocia is an exception). Moreover, the bones of the fetal skull are not fused and can slide past each other, allowing “molding” of the fetal head letting it squeeze through the pelvis. In the breech presentation, the head is still the biggest part of the baby, but now it is coming last and there is no chance for it to mold to squeeze through the pelvis. There is a high risk that the head will be trapped, often resulting in the death of the baby.

Breech babies and their mothers differ in substantial ways from the rest of the population. Breech babies are far more likely to have congenital anomalies, particularly anomalies like hydrocephalus that increase the size of the fetal head. In other words, the baby ends up breech because the head is too large to properly fit in the pelvis. Mothers who carry breech babies often have uterine anomalies that distort the shape of the uterus. In other words, the baby ends up breech because the bottom of the uterus cannot accommodate the fetal head.

The risks of labor differ substantially for breech babies. Typically, the head fills the cervix as it is dilating, making it impossible for the cord to prolapse (fall out), a condition that routinely ends in death. In contrast, the breech, being smaller, does not fill the cervix, making cord prolapse far more likely. In addition, in contrast to vaginal delivery where the baby’s arms are pressed to its sides, the arms of a breech baby may end up over its head. One or both can end up behind the head crossing the neck. This is known as nuchal arms. A baby with nuchal arms cannot be delivered because the diameter of the head plus the arm(s) is too big to fit through the pelvis. Unless the provider can move the arm(s) from behind the head, the baby will die.

In addition, there’s more than one kind of breech. To say that the baby is in the breech presentation means only that the bottom of the baby is coming first. The bottom may refer to the buttocks or the feet (more dangerous). The breech baby may have its chin to its chest or it may be facing upward (more dangerous).

Indeed, in studies that purported to show the safety of vaginal breech delivery, all the babies in the complete or footling breech presentations are excluded. All babies with extended heads (looking up) are excluded. All large babies are excluded. All women with a small pelvis are excluded. So much for “breech” being a variation of normal.

How dramatically does breech presentation increase the risk of perinatal death? The experience in Norway, before and after the C-section rate for breech had risen precipitously, is representative of the risks. According to Secular trends in peri- and neonatal mortality in breech presentation; Norway 1967–1994 by Albrechtsen et al.:

… The extended peri- and neonatal mortality rate in breech presentation births declined during the study period from 9.2% in 1967–76 to 5.5% in 1977–86 and to 3.0% in 1987–94. The highest relative risk of mortality in breech presentation versus the total birth population was observed in intrapartum death and in mortality less than 24 hours after delivery…

During the study period, the overall rate of perinatal mortality declined due to advances in obstetrics and neonatology. In addition, the C-section rate rose dramatically. Both contributed to the overall decline in mortality from breech delivery. But as the following graph shows. C-section for breech uniformly led to better outcomes.

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The bottom line is that, any way you look at it, breech is NOT a variation of normal. Breech babies have a higher incidence of congenital anomalies and their mothers have a higher incidence of uterine anomalies. Breech babies are at much higher risk for cord prolapse and encounter complications like nuchal arms and trapped heads that simply do not occur in head first deliveries. Most importantly, any baby in the breech position has a dramatically higher risk of death.

A variation that kills babies is not a variation of normal.

  • Debbie Cohen

    Premature and breech in 1969.The doctors told my mother not to announce the birth of the child because they anticipated death.I’m almost 47, despite the traumatic birth,it is safe to say,I am alive!

    • Debbie Cohen

      ..I’m alive ,but my punctuation and grammatical usage is pretty bad!

      • The Computer Ate My Nym

        Just make sure to use the serial comma when discussing your interest in cooking, your family, and your pets and everything will be fine.

      • demodocus

        Thanks for the giggle 🙂
        (ppd sucks, we take our giggles where we can!)

  • Ali Azhar

    recently my wife delivered a baby by C/S as my baby girl’s position was extended breech so as a responsible father i decided to agree with Doctor opinion which is the best i can say after reading your sad story.. May your family have best alternate of the loss..

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  • Jodi moore

    Sadly, we won’t be bringing our sweet baby boy home tomorrow. Instead, we will be burying him. Our sweet, much loved and much desired little grandson perished last Friday as he was struggling to be born. His cause of death was head entrapment. He never had a chance.

    He was a footling breech, but the positioning of the placenta made it impossible for his mom to deliver him via C/S. Extraordinary measures on the part of medical staff could not deliver his head . He died with half of his body protruding from his mothers birth canal, and half still in her pelvis. She, our little Eli who was no longer alive, and his Daddy had to remain in this position for over an hour waiting for his mother’s cervix to release it’s grip on his head so he could finally deliver.

    He was never able to take a single breath, never able to open his eyes, never able to grasp our fingers with his little hands. Not even once.

    His birth was a hugely traumatic event for the 20+ medical personnel who tried so very hard to save him. These are super experts with every advanced technique, true expertise and experience, and all possible equipment available to them. These are super specialists who are known for their ability to beat poor odds. But they could do nothing to change the outcome of Eli’s birth despite their heroic efforts.

    In the end, our little Eli’s strong steady heartbeat fell from strong and vigorous, to thready, to nothing. His poor bruised little head finally delivered on its own, long after his heart had beat it’s last.

    His mother and father are devastated and traumatized. His mother suffered physically traumatic procedures to try to help him and suffered internal injuries as a result. She hemorraged after his birth and was at high risk of bleeding out. She underwent emergency surgery to save her life.

    Eli’s OB is traumatized and wept openly. His neonatalogist and perinatalogist is are both deeply shaken. Everyone in the room was crying.

    This all happened at one of the four best institutions in the USA for handling obstetrical and perinatal emergencies. The best of the best.

    Head entrapment does happen. The results are tragic. The interventions are few and brutal. The outcomes are poor. This condition isn’t a joke or a myth. It is all too real.

    If your OB tells you that you are at risk for this complication, please don’t blow him or her off. Please don’t “doctor shop” or worse- seek out a midwife who will reassure you that the vaginal birth you desire will turn out well. Please don’t seek to find someone who will agree with your desire to have a vaginal birth. Don’t let well meaning advice from others sway you. It isn’t worth the risk. It isn’t worth a life, or maybe two.

    We will never forget the things we saw that day. We will never forget holding our precious little Eli, so still in death, and caressing his poor bruised head. We will never forget the heroism we saw that day, or the heart. We will never forget the agony of every moment and the zeroing of hope with each second of entrapment.

    Will this happen to you? Maybe not. But, is it worth the risk to find out?

    If you are the mother whose child dies in this horrific way, then the mortality statistics are 100 percent for you. And they are very high for any child who becomes entrapped.

    I’ve learned that this kind of event is considered to be one of the the worst nightmares for OBs. Ask questions, get a second opinion from a high risk OB. Listen. Please don’t take chances.

    Yes, vaginal birth is beautiful. It is preferred. But, please don’t risk your baby’s life to experience it.

    If even one of you makes a choice that avoids the loss we have experienced, then Eli’s death will have served some purpose.

    Please love your baby more than you want to experience vaginal birth. Don’t take the chance of walking the hard road we have found ourselves on. Please. It is a road of lost hopes and shattered dreams. Please do not join us on this empty road.

    • The Bofa on the Sofa

      Jodi, I am so sorry. I cannot imagine your pain. Thank you for your comments and telling this story. I wish there were something I could to do help you, but all I can say is that please know that you have my sincerest sympathies.

    • moto_librarian

      My heart breaks for you, Jodi, and for Eli’s parents. I will not pretend to know the anguish that you are feeling, but will simply offer my condolences.

    • toni

      I am so so sorry for your loss. I had no idea that they sometimes can’t deliver a breech baby by caesarean. What a nightmare. It’s unbelieveable that some people insist on labouring a breech when they have the choice of a c-section. God rest your soul sweet Eli.

    • Roadstergal

      Thank you for sharing such an eloquent and heart-wrenching story. I am so sorry for you and Eli’s parents for such a horrible experience. I wish there were more that could be offered beyond sympathy and condolences.

    • Box of Salt

      I am sorry for your family’s loss.

      Thank you for sharing the story.

    • Young CC Prof

      I am so sorry for your family’s loss. Thank you for having the courage to share your story.

  • I too read fear, fear and fear all over the place. I sympathize with you, is a dreaded place to be with all that fear in your soul.

    Although the article has strong point it does not talk about the impact of atmosphere and doctors interventions as the reason for the increase risk, for instance with the example of nuchal arms that are result when doctors touch the feet of the baby, activating moro reflex… to have such a one point of view article seems radical to me.

    to contribute to debate: sad truth is that older books had better descriptions of these types of birth and that doctrs used to teach doctors how to handle them other than just c section. That knowledge is being lost. Plus my criteria to define the variations of normal is the scope of what actualy happens, not the teory we built around it.

    • The Computer Ate My Nym

      If the increase in deaths in breech is all the fault of the doctors and everything’s great in a home breech birth, how come the MANA data showed increased risk of dying during a breech home birth? Even the MANA data which was biased in every possible way in favor of home birth could make home breech look good. Yes, I would fear trying to deliver a breech baby vaginally. I’d fear it because it is dangerous.

      • No such asociation was made rather an example was set on how the article only presents one side of the information rather than a more balance info as to let the reader form his own mind rather that induce thought based on fear aka your baby is going to die.

        sorry this is probably gonna be very difficult for you to grasp but breach delivery is more dangerous because of your fear, not the other way around. Trust me I wouldn’t want you trying a breech baby either. Unsolicited reading recomendation: Grantly Dick’s Childbirth Without Fear.

        • fiftyfifty1

          You don’t mean Grantly Dick-Read do you? The man who thought that white women of “good breeding” were having too few children due to “fear” and thus wrote propaganda trying to convince them that the risks of childbirth were all in their pretty little heads and that they should “trust birth” and have a load of children? That guy?! LOL!

          • Irène Delse

            The pregnancy book my mother used during the 1960s was full of this ‘childbirth without fear’ stuff and promised that no, you wouldn’t suffer if you just,did your breathing exercises and kept an optimistic outlook. Yeah, right. Her first pregnancy, she thought she would die so much she suffered. The old-school hospital midwife who attended her was unsympathetic though, and scolded her for screaming. My mom told me she was so surprised that she gulped back her cried and just did what she was told: breath, push, etc. But from then on, she took the promises of the book with a big grain of salt.

          • The Bofa on the Sofa

            The pregnancy book my mother used during the 1960s was full of this ‘childbirth without fear’ stuff and promised that no, you wouldn’t suffer if you just,did your breathing exercises and kept an optimistic outlook.

            Of course, the converse being, if you do suffer, it’s because you didn’t fulfill those requirements. IOW, those who suffer? It’s their own fault.

            I have said it many times before, it doesn’t take much to realize this must be bullshit. I don’t need to experience childbirth personally to know that it is pretty much on the whole not a nice thing. As I’ve said, childbirth was recognized as being so painful 3000 years ago that it was considered a punishment from God. It doesn’t matter whether or not any accepts that narrative, it shows pretty clearly that even back then, childbirth hurt like nothing else.

            But I’m sure it was just because they didn’t have an “optimistic outlook.”

          • Irène Delse

            Interestingly, from what I heard in my family circle, people who were the less religious embraced all the more the Dick-Read credo that women could overcome the age-old pain and fear with the shiny modern science of breathing, fitness and positive thought. In that case, of course, pseudoscience… But the religious old guard were suspicious of even trying to attenuate childbirth pain, because how dare you try evade God’s plan for the daughters of Eve.

        • The Computer Ate My Nym

          If fear is what causes death in breech delivery then I guess midwives and home birth must be pretty scary since the MANA data, which is almost certainly an undercount of deaths, showed 5/222 (2.5%) of breech babies died in home birth attempts attended by a MANA midwife. That’s considerably more than would have been expected to die in a similar cohort of breech infants delivered in the hospital. It’s even higher than the mortality in vaginal delivery in term breech in the Term Breech Trial. So the very scariest thing out there must be a CPM. Best avoid them for a safe and relaxing labor and delivery.

    • Young CC Prof

      In the MANA data set, out of 222 breech babies, 5 died, and half were delivered by c-section anyway. In addition, there were 3 babies whose outcome was unknown.

      Doctors used to handle breech babies. But no matter how skilled the doctor was, a few of them always got their heads stuck and died, especially in first-time mothers. Breech births also increased the risk to the mother! With c-sections as safe as they are, there’s no reason to go back to the older, riskier way of doing things.

      • Thanks for your reply! is good to engage! agree with how safe csecs can be… what would you think of allowing labor to start spontanously and the perform c section rather than scheduling c section before labor onset?

        • Young CC Prof

          To my way of thinking, the major disadvantage of letting labor start spontaneously is that it so often starts in the middle of the night. Surgery during the day, with a team who are all awake and working their regular shifts is just inherently safer than surgery at three in the morning with a team who might have been dragged out of bed and thrown together half an hour ago.

          Also, I know it’s taboo to talk about convenience in childbirth, but if you know you’re going to have a c-section anyway, you might as well choose the day in advance, especially if you have other children and need to arrange for their care.

          If you are certain of your due date, there’s really no down side to just scheduling the c-section for 39 weeks.

          • Ash

            Also helps in case the hospital is overwhelmed with cases. If your schedule C-section prior to labor has to be delayed due to the ORs being full, you can wait instead of having to deal with something like precipitous birth without an OR being available at the moment.

          • Do you have no regards for the impact of hormones in maternal behavior?

            plus only 4% of babies are born on their due date, don’t the last days of gestation are were maturity of lungs and brain is obtained? because messured i regards of last period would a safer range be 41 weeks?

            i’m sorry to be a voice of discent but if the impact of birth happening without the engenous oxitocin via induction or schedule c section cannot be known, interference for medical practicality should be a moral issue. Since I’m not a doctor, i’m in no place to take a stand. but others are.

            to conclude: Inducing fear based decisions is not required, the factual and the empirical can be shown and each person takes responsability for their choice. Woman should be informed to make their own choices. Observance ad Interference has a negative influence of birth phisiology, it needs a safe, warm, intimate to function at its best.

          • Young CC Prof

            Lung and brain maturity is 100% at 39 weeks, every day after that is risk to mother and child with zero benefit. And nowadays, women who get prenatal care early and/or used assisted reproductive technology or natural family planning can have due dates much more precise than LMP. I knew my due date to within just a couple days.

            The impact of prelabor cesarean CAN be known. For the child, there is a slightly higher risk of TTN and a lower risk of several other newborn issues. For the mother, the exact same hormones are released when the placenta detaches, whether labor occurred or not.

            Women should be informed to make their own choices, but with real data, rather than rampant speculation. Honestly, you sound like you’re the one fear-mongering, with your claims that c-sections could do some unspecified harm not known to science. I’m talking about avoiding real, proven risks, you’re talking about avoiding speculative risks.

          • The Computer Ate My Nym

            if the impact of birth happening without the engenous oxitocin via induction or schedule c section cannot be known

            Everything after “if” in this sentence is counterfactual. We know the consequences of not inducing labor or providing a c-section for women who are post-dates or have breech presentation. The answer is that the fetus is more likely to die in utero or in labor and delivery. It’s not a mystery and the mandate for an ethical provider is very clear: decrease the risk of death via intervention.

        • The Bofa on the Sofa

          what would you think of allowing labor to start spontanously and the perform c section rather than scheduling c section before labor onset?

          Why?

          As YCCP notes, hormones kick in regardless, so what is the benefit of letting labor start and risking complications associated with it?

        • moto_librarian

          I know that one reason that people complain about scheduled c-sections is that labor can help to prevent airway issues like TTTN, but even a vaginal birth doesn’t always prevent this. I ought to know – my first child was born at 38 + 3 after SROM and a totally unmedicated labor. He still did two days in the NICU because he was grunty. It happens, and I’d prefer a brief NICU stay over the possibility of head entrapment should labor with a breech baby proceed too quickly for a c-section.

    • Stacy21629

      Address the MANA study please. At least two people have referenced it in their comments to you. At home deliveries attended by home birth midwives presumably with breech experience several babies died and they still had a 50% csection rate. We’re these women too “afraid” even in their own homes and so their babies died? You seem to place quite a lot of guilt on those mothers. I mean, if they just trusted more their baby would be alive after all

      Yes I “fear” breech because I read scientific literature not outdated books written by misogynists. I prefer a LIVE child at the end of my delivery TYVM and, believe it or not I will still retain the capacity to love and bond with my child whether it exits my vgina or my abdomen because I’m a mother and I love my children no matter what.

  • Concerned Uncle

    Dr. Amy – thanks for the article – wish I had seen this 5 days ago – my brother-in-law and his wife decided to do an at home birth because she didn’t want another c-section (and possibly because they didn’t have health insurance) (ignore the fact she had risky deliveries in two previous births). The baby presented feet first, reportedly with strong heart beat until going through the cervix (apologies if I have the process wrong) – heartbeat was lost on monitor, but expected at this point due to location of the baby.

    Baby was put on mom’s chest – and mom noticed baby was not breathing (NOT the midwife!) – midwife tried to get baby breathing with chest compressions while dad called 911 and 4 year old “big sister” looked on – asking her dad if her little brother died.

    Baby was taken by ambulance to hospital where breathing was eventually started…after 30 minutes without oxygen. Baby was life-flighted to children’s hospital where he remains in NICU, sedated, on Oxygen, in a “cool room” until 72 hours have passed so that they can evaluate him for brain damage. And by the way – he hasn’t really moved since being delivered.

    If she had only been in a hospital – our entire extended family would not being facing what it is right now.

    On the other hand, my wife was about to deliver our last child (in the hospital) and the doctor determined he was breech (via ultrasound). Dr. explained our options and left us for the night (wasn’t safe to go right to c-section due to her having recently eaten). We exercised a lot of faith through prayer and miraculously the baby turned without her feeling it (full term 11+lbs, 25 inches long – no gestational diabetes – wife is well over 6 feed tall). Dr. did ultrasound the next day and about fainted when he saw baby head down in birth canal ready to go.

    I am certain if she had tried to deliver breech, I would have lost both her and the baby.

    • Dr Kitty

      I’m so sorry for your family.
      I hope your nephew recovers.
      No doubt your BIL and his wife weren’t told the true risks of HB in the USA. I’m so sorry they have found out first hand.

    • areawomanpdx

      I am so sorry to hear this, concerned Uncle. Do you have an update on how the baby is doing?

  • Emma

    Evelyn great Post!

    I have been trying to get pregnant for 3 years, and finally I am pregnant with 35 weeks and last week my OB told me that my baby is in Frank Breech position, that we have to plan for a C-Section, if the baby turns we can have a normal delivery.

    I was now looking for information in the web about breech babies, and found a lot of information, but this article is simply EVIL! what is the message that this MD wants to give? OMG would you talk like that to your daughter when she tells you that she has a Breech baby? Would you give her that message? That her baby have now a higher risk of congenital anomalies?? What is this higher risk number “Doctor Amy”? I am sure is not even higher than 3%…. That is why your message is not only wrong is EVIL.

    • Dr Kitty

      Emma, babies who are breech at term DO have a higher rate of congenital abnormalities.

      Sometimes babies with abnormalities are breech BECAUSE the abnormality itself prevents them from turning cephalic. That isn’t scare tactics or misinformation, it is truth.

      Babies who are breech tend to walk later than cephalic babies. This still seems to be the case when the breech babies are delivered by CS, so the argument that the developmental delay is due to birth injury seems to be less compelling than the argument that being breech at term may be a soft marker for mild impairments of motor skills.

      Of course no woman carrying a breech baby wants to hear that. But that doesn’t make it untrue.