Why does breech get such a bum rap?
Breech presentation brings with it a set of concerns that are complex. Regardless of mode of delivery, 1 in 500 babies will die and 1 in 50 babies will have neurological issues (SOGC 2009). Breech babies also tend to have lower APGAR scores. Breech birth also requires providers to obtain a specialized set of skills. While vaginal breech birth was already beginning to decline, it was the publishing of the methodologically flawed Term Breech Trial (TBT) study in 2000 that spelled doom for vaginal breech birth. As a result of their recommendation that cesarean is the best option for breech babies, ACOG, hospitals, and providers quickly adopted a policy of cesarean for breech (at least in the U.S.). Medical schools stopped teaching vaginal breech birth. Insurance providers adopted this policy and it became a standard of care. Just two years later, the same researchers did a follow up study to their TBT and found that vaginal breech birth is just as safe as cesarean for breech, provided they are attended by a skilled provider. Another larger and more methodologically sound study (PREMODA) concluded that vaginal breech birth is just as safe, provided the birth be attended by a skilled provider. The PREMODA study actually noted an increase in vaginal breech birth during their data collection due to the evidence indicating its safety with a skilled provider in attendance. Just two years later, there was a significant drop in number of skilled providers as well as skilled providers willing to “risk” attending a vaginal breech birth for fear of losing their license, hospital privileges, and insurance. Even after ACOG released revised guidance regarding breech birth (indicating vaginal breech birth as acceptable, but cesarean for breech as still preferred), most providers and hospitals continued their limiting protocol and policies based on fear and liability, medical schools continued to teach cesarean for breech, and skilled providers fell out of practice. Additionally, insurance providers supported this trend by increasing incentives for cesarean over vaginal birth, in general, and paying little to providers for breech pregnancy skills (e.g., ECV) aimed at increasing vertex birth potential, specifically. All together, the system has failed families searching for options.
What can a doula do to support a breech parent?
As a doula, it is important to not only understand the history of breech birth, but to understand what contributes to a baby’s position as well as how to help a parent address the baby’s position, learn what options she has, and encourage advocacy regardless of that individual parent’s choices for birth. There are several factors contributing to a baby in breech position: gestation, fetal anomalies, twins, location of fibroids or placenta, short cord, bicornate uterus, low fluids, or soft tissues (ligaments, twist in the lower uterine segment). In the current climate, the lack of skilled providers has led to a lack of options and even information about how to address a baby in breech position beyond scheduling a cesarean. This is a critical area for doulas to fill in the gap, providing resources and support: suggest Spinning Babies, chiropractic, acupuncture, craniosacral, moxabustion, websites, providers, and other parents of breech babies. Encouraging body balancing, hydration, their connection to baby, and advocating for their desires (including establishing supportive relationships with providers). Similar to parents seeking a VBAC (as there are many parallels), doulas need to support a breech parent by holding the space around them, providing the safe and non-judgemental place for them to make a decision. Whether that decision is vaginal breech birth or cesarean breech birth or going into labor before cesarean breech birth, it is important for doulas to remind themselves that they cannot want a particular type of birth more than the parent does. Should a parent be unsatisfied with their lack of options, doulas will be a key piece to providing resources for families to demand skilled providers, to demand options. It is equally important to note that doulas will play a crucial role in carefully managing the comparison of individual providers who may support vaginal breech birth with others who may not, with the hope of avoiding any political fall-out for those providers who do support vaginal breech birth.