Last week, we covered the evidence on breech vaginal birth. This week we are answering your questions!
Can a baby spontaneously flip from breech back to head-first position before birth? Is home breech birth safe or not? Which methods can help a breech baby turn? On today’s podcast, join us on a Q & A all about breech birth!
If you want to get informed and empowered on the topic of breech positioning in pregnancy—either for yourself or for your clients—then this podcast is for you!
Content note: Discussion of statistics on mortality and serious morbidity (illness/injury) related to breech birth.
- Watch the video of this podcast episode on the EBB YouTube channel here!
- Access the EBB Signature Article: Evidence on Breech Version with a free handout here.
- Join the EBB Pro Membership and get access to contact hours, a doula mentorship, live trainings, and a PDF Library with exclusive handouts (including a 2-page handout on breech) by joining here.
- Learn advocacy techniques through the EBB Childbirth Class.
- EBB Podcast 111: Positioning Breech Babies with Dr. Elliot Berlin
- EBB Podcast 171: The Experience of a Unique Vaginal Breech Birth with Janae and Andrew Rick
- EBB Podcast 172: Breech Vaginal Birth with Dr. Rixa Freeze and Dr. David Hayes
- EBB Podcast 173: Evidence on Breech Version
- EBB Podcast 296: The Evidence on Breech Birth with Dr. Rebecca Dekker and Sara Ailshire, MA
- EBB Podcast 298: Overcoming Barriers to Breech Vaginal Birth with Dr. Emiliano Chavira, OB/GYN and Maternal Fetal Medicine Specialist [Coming soon!]
- EBB Podcast 299: A Breech Vaginal Birth Story with EBB Parents Naoma and Mohamed [Coming soon!]
- Check out the workshops at Breech without Borders here.
- Watch a video of Dr. Larry Hinkson teaching the gentle External Cephalic Version Technique here.
- Better Birth Blog with a directory of “Friends of Breech,” click here.
- Curated list of breech resources from Dr. Freeze’s blog, click here.
- Gottlicher, S., Madjaric, J. (1989). [Published in German]. “Vertex presentation in the morning–breech presentation at noon: a nursery tale? A prospective study of 1,019 patients.” Geburtshilfe Frauenheilkd 49(4): 363-6. Click here.
- Collins, S., Ellaway, P., Harrington, D., et al. (2007). “The complications of external cephalic version: results from 805 consecutive attempts.” BJOG 114(5) 636-8. Click here.
- Ben-Meir, A., Elram, T., Tsafrir, A., et al. (2007). “The incidence of spontaneous version after failed external cephalic version.” Am J Obstet Gynecol 196(2): 157. Click here.
- Cheyney, M., Bovbjerg, M., Everson, C., et al. (2014). “Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009.” J Midwifery Womens Health 59(1): 17-27. Click here.
- Fischbein, S. J. & Freeze, R. (2018). “Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births.” BMC Pregnancy Childbirth 18:397. Click here.
- Nordtveit, T. I., Melve, K. K., Albrechtson, S., et al. (2008). “Maternal and paternal contribution to intergenerational recurrence of breech delivery: population based cohort study.” BMJ 336(7649): 872-876. Click here.
Dr. Rebecca Dekker -00:00:00:
Hi everyone, on today’s podcast, we’re going to answer your questions about breech birth.
Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Decker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, and welcome to the Evidence Based Birth® Podcast.
Before we get started, I am excited to announce that today is the day that our waitlist gets access to early bird tickets for the Evidence Based Birth® Conference. So if you are on the waitlist, make sure you check your email for the registration link. If you did not get on the waitlist, but you want to attend our virtual conference in March for both parents and birth workers, make sure you go to ebbirth.com and sign up for our email newsletter on the homepage so that you can get a notification when the next tickets drop.
In today’s podcast, I’m going to answer your questions about breech birth by playing the Q&A replay from our webinar this past fall about the evidence on breech birth. If you haven’t listened to episode 296 yet, where we share the detailed research on breech birth, I strongly recommend that you listen to that episode before you listen to this one, because that will provide you with important context and information to understand today’s Q&A.
So today’s episode 297, is a Q&A about breech. Then next week in 298, we’re going to talk with Dr. Chavira about overcoming obstacles to breech vaginal birth. Then in EBB 299, we’re going to feature a birth story from EBB parents who had to drive to a hospital in another state in order to access support for a breech vaginal birth. The questions that we are featuring today were answered by myself and Sara Ailshire, a PhD candidate and research fellow at EBB. We’re going to talk about babies flipping spontaneously, the evidence on home breech birth, whether breech runs in families, and what things can increase the risk of having a baby with breech positioning. As a content note, this topic does include a discussion of statistics on infant mortality, as well as statistics on rates of serious illness or injury related to breech birth. A few acronyms and definitions you might want to know before you listen to today’s Q&A.
ECV, which you’ll hear Sara referring to stands for external cephalic version, which is a medical procedure when the baby is monitored while a provider puts their hands on the outside of your belly to try and turn the baby from breech into cephalic. Breech position is when a baby is presenting with their bottom or feet first, and cephalic position is when the baby is presenting with their head coming out first. And now with that information, you should be ready to start listening to the Q&A from our webinar all about the evidence on breech.
Sara Ailshire, MA – 00:03:07:
So I saw one earlier, I saw a mention in a chat about a person having ECV and the baby turning back. So we did a little bit of research about the likelihood of what could a baby flip spontaneously pre-labor? Can they flip after an ECV? And for the most part. Once babies get into position, they’re not likely to spontaneously flip, but it doesn’t mean it never happens. So there’s one study from 2007 that suggests that the likelihood of a spontaneous conversion from the cephalic presentation to the breech presentation before birth is around 3%. And just like it’s pretty unlikely for a vertex baby to spontaneously flip, it’s pretty unlikely for a breech baby to spontaneously flip, but it does happen. And they estimate it can happen in between 2% to 5% of all cases.
Another study looked at attempted ECVs at one hospital from 1997 to 2006, and they found that of those babies who had a failed ECV, meaning just that the baby did not flip as a result of the procedure, that 6.6% of those babies did end up flipping on their own into the cephalic position after the procedure. So it’s pretty unlikely, but it doesn’t mean it never happens. And it does. It does. Just pretty low percentage points for that.
Dr. Rebecca Dekker – 00:04:32:
Okay, cool. Thanks for sharing the stats on that.
Sara Ailshire, MA – 00:04:34:
Dr. Rebecca Dekker – 00:04:34:
I am looking through the questions because some people wanted to know the name of the massage technique and it will be in their handout. But what’s the name of that doctor again, Sarah?
Sara Ailshire, MA – 00:04:45:
His name is Dr. Hinkson. I dropped it into the chat, but let me drop it into the chat again. They’re calling it the Charité, and I might be mispronouncing that, Hospital Charité External Cephalic Version. So that’s the link to that study. And it looks like there’s a free full text available, maybe
Dr. Rebecca Dekker – 00:05:05:
Okay. Yeah. And there’s also, if you search for it on YouTube, Dr. Hinkston’s name and External Cephalic Version, you should find it. They have some free teaching videos on YouTube as well. I actually forgot to mention, so I’m glad you brought it up. The Breech Without Borders is a nonprofit that their goal is to train people around the world in the skills for breech vaginal birth. So I had the privilege to attend one of their trainings in Kentucky a few years ago, and it was incredible. I was so amazed by the quality of the class. So there was a whole day of just learning all the evidence on breech, which we’re just, like you said earlier, Sara, just scratching the surface, really deep into the research and the history and the strategies and the techniques. And then a whole day of training using models and different really innovative teaching tools.
And to me, it feels like a no brainer that that should just be mandatory for every, you know, maybe not exactly their training, but trainings like that should be given around the world to all providers. And it was really fascinating to be there because does anybody want to guess how many OBs were at the training? So when I was there, there were zero. There were zero. So other than the one who was doing the training, and yeah, just the instructor, there were midwives and doulas there. And doulas, I just am so impressed by you how you’re always trying to expand your knowledge. And I know a lot of doulas also want to become midwives someday. So that was really fun to see. And the midwives, a lot of them want to really keep their skills up in case there’s a surprise breech, which I think is just so smart.
So sadly, most residents are not supported in pursuing trainings like this, even though they were invited, the obstetric residents work so many hours and it was not required and they weren’t gonna be given time away from clinic to do it. So it really needs to become a priority if we’re going to make birth safer for everyone. So yeah, and there are some OBs doing the trainings, but I think, one of the difficulties with finding a provider who does breech vaginal birth is often they want it kept a secret. They don’t want it advertised that they do this because their hospital, their administrators, their colleagues, there’s such a bias against breech vaginal birth that they’re seen as an unsafe provider if they offer that practice and they could be ostracized by their community. So that is one of the difficulties in finding a provider. But Sara, did you have a question in there or didn’t you look up some info about how people can find a breech provider if you’re looking for a breech vaginal birth?
Sara Ailshire, MA – 00:07:45:
Yeah. So we were talking about that a little bit with the EBB staff and kind of like picking the collective brains of birth professionals in our networks. And overall, word of mouth was really the best way. There can be reasons why providers who may be willing to offer this procedure may not want to advertise or put their name out there in some type of public fora. So oftentimes that can be the reason why there are no directories, why the directories that do exist might be a little limited. You know, the other thing too is that they can face retaliation from colleagues or administrators at their hospital who are concerned about perceived risk. There are a few blogs. The betterbirthblog.org has a list of friends of breech babies. So these are doulas and acupuncturists who might be well connected in their community, and be able to help connect you to a provider. The Stand and Deliver blog by Dr. Rixa. Again, I apologize if I mispronounced her name. R-I-X-A-F-R-E-E-Z-E. Has a few articles about this. If you’re a birth worker, building up community knowledge in a referral list can be a really important thing. And it’s kind of frustrating. There’s no easy fix, but sometimes that word of mouth and that local knowledge is useful. If you’re a parent, birth workers, and then I think, Rebecca, your suggestion was in your hometown, the prenatal yoga studio.
Dr. Rebecca Dekker – 00:09:04:
Yeah, we used to have one. There’s usually one place or one or two people in a community that just know everybody. And they’re great, what I call connectors. So if you’re looking for a breech provider or you want to have one on your referral list, just start talking to people and find out who is the person who knows everyone. Like for example, in my state, there’s an amazing person named Mary Kathryn DeLodder who connects people with home birth midwives. She knows all of them in the state. There’s these connectors and they do exist. So sometimes it’s just a matter of finding out who knows everybody. I wish it was easier, but let me see. There’s another question I wanted, speaking of home birth. This one’s a little controversial, but I know a lot of people are really curious what’s the evidence on home birth with a breech vaginal baby.
And this is still pretty rare, but there was a large study published by Cheney et al in 2014. They were looking at nearly 17,000 home births from the years 2004 to 2009. And they found really a substantially higher risk of infant death or stillbirth during labor with the breech home delivery. The risk ended up being five deaths out of 222 births. This is about a 1 in 50 chance of the baby dying. And it was substantially much, much higher than cephalic babies. But a lot of people advocate for home breech birth because they say it’s not, if it’s not available in the hospitals, at least we’re keeping the skills alive at home. So there’s a lot of debate over whether that should be somebody with a breech baby should be a candidate for home birth. There was one other study published by Fischbein and Freeze in 2018. This is a very small study with just 50 home breech births. They found a transfer rate was 20%. So 20% had to transfer during labor, all of them for like prolonged labor or failure to progress. There were two birth injuries among the 50 breech babies, which seemed somewhat high to have a one in 25 chance of a physical injury. And there was one baby that died, when it was transferred to the hospital for a non-urgent Cesarean. Also, they noted that the two people who had Pitocin during labor, like who were transferred to the hospital for Pitocin with their breech baby had extremely difficult vaginal breech birth. The babies ended up admitted to the NICUs.
They felt that if you’re trying to do a home breech birth, and if the labor stalls and does not progress, that a Cesarean would be preferable to Pitocin. And I think that’s something that a lot of the guidelines talk about. And I think that’s something that a lot of the guidelines talk about, just being really careful with the breech vaginal birth, because if any sign of the labor slowing down or arresting, as we call it, stopping, might be a sign that the baby is not going to be able to come out in the breech position. So that’s an important point to discuss, I think, for people who are, you know, wanting to know what the guidelines say. Sorry, I think we have time for one more question. Do you want to pick one out?
Sara Ailshire, MA – 00:12:01:
Yeah, I saw somebody mention a short cord and ECV, and it kind of made me think the questions about, you know, are there things that make you more likely to have a breech baby, and what those are, maybe, and what does the research say? So in exploring that, there’s a couple interesting things. There’s some evidence that suggests that breech can run in families. A study from Norway looked at all births from 1964 to 2002 and found that people who were themselves born breech had twice the risk of a breech birth in their own pregnancies or children if they were not the birthing parent. So that was kind of interesting.
Other things that we’ve discussed or we’ve heard is can a sedentary lifestyle make you more likely to have breech birth? And we didn’t find any evidence or research that supports that. Other things that we found that could be a factor in a breech or have increasing your likelihood is being pregnant for the second, third, fourth time, having more than one baby in the uterus, having too much or too little amniotic fluid, having a uterus that isn’t the typical shape, so bicornuate or having some other uterine structural difference, having growths like fibroids, having placenta previa, having a preterm baby who hasn’t had the time to flip down before they’re being born. And finally, some differences of development can make a baby less likely to turn into a head down position before birth. But most of the time, breech babies are congenitally typical. And sometimes there’s no clear reason. So these are just things that are associated with an increased likelihood, but not necessarily causal if A then B, if that makes sense.
Dr. Rebecca Dekker – 00:13:35:
Yeah. And I think it’s important for people to know, like, I don’t know if we have anybody listening who has a breech baby right now, that it’s not your fault. You know, some babies just are breech. It’s just a fact of nature. It’s been going on for so long that, you know, it’s recorded in very old documents and the rates have really not changed that much since they’ve been tracking it, it’s around 3 to 4%.
So I know some people are like, I feel like I’ve had so many breech babies lately. That can just sometimes be a fluke, you know, where if you flip a coin enough, you end up with certain patterns and things. So I think that it can be reassuring to know that, you know, there’s not necessarily things we’re doing that are causing this. I guess it’s possible, but like you said, I would be hesitant to put any blame on people for something that just happens in nature sometimes. And I hope that this has been helpful though, because I feel like this topic is so important. And as I mentioned earlier, when it happens, it’s like, it’s, it’s super stressful. Some people are saying in the comments, they really liked having the, like even knowing about the acceptance or emotional freedom technique. And it reminds me of in therapy. And I know a lot of religions, they talk about sometimes suffering is caused by fighting the thing that, you know, you can’t control. And so I don’t know, in therapy, I’ve learned a lot about acceptance. And I think it’s an interesting strategy to try for breech as well.
Dr. Rebecca Dekker – 00:15:01:
All right, everyone, thank you so much for listening to this Q&A all about breech. So what did you think? What did you learn? Please let us know. Send us a message on Instagram or leave a review on our podcast. And if you didn’t check out episode 296 yet, make sure you do since that’s where we covered the evidence on breech.
And stay tuned for the next two episodes where we will talk with an OB who attends breech vaginal birth and two parents who had to cross state lines in order to find a supportive breech provider. If you’re listening to this and you’re an EBB Pro Member, I wanted to remind you that you can get a contact hour for the evidence on breech inside the Academy, as well as access to a new two-page handout that is exclusive for Pro Members and has the evidence on breech vaginal birth and breech Cesarean birth that you can share with clients and colleagues. If you’re not a Pro Member, but you’re interested in becoming one, just go to ebbirth.com/membership. And the conference is approaching in March 2024. So head to ebbirth.com and get on our email newsletter list so you can get notified about the next ticket drop for parents and birth workers. Thanks, everyone. And I look forward to continuing the breech topic next week with you all. Bye.
Outro – 00:16:18:
This podcast episode was brought to you by the book Babies Are Not Pizzas. They’re Born Not Delivered. Babies Are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence-based care. In this book, you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics, and how we can prevent preventable trauma in childbirth. Babies Are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover, and Audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.
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