Resources for parents and providers

Research

Editor’s Choice

Turning breech upside down: upright breech birth.
Walker, Shawn. 
MIDIRS Midwifery Digest. 2015;25:3; 325-330. (Link will take you to password protected page for login)

Understanding Physiological Breech (on the cardinal movements of hands and knees breech birth).
Evans, Jane. 
Essentially MIDIRS. 2012;3:2; 17-21. (Link will take you to password protected page for login)

Spinning Babies Breech Birth Quick Reference Guide and Digital Download

Handout by Shawn Walker: Upright Breech Birth-How and When to Help (Updated).

Exciting update on breech birth from around the world from the Oxford Breech Conferences, including the latest evidence and care guidelines.

Organizations

American College of Obstetrics and Gynecology (ACOG) recommendations for breech birth.

Society of Obstetricians and Gynecologists of Canada’s (SOGC) statement about vaginal breech delivery including information about the Term Breech Trial and clinical guidelines. You might have to search “SOGC breech” for it to come up in your browser.

Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for breech presentation and birth.

Netherlands Association of Obstetrics and Gynaecology (NVOG) guidelines on breech presentation (in Dutch).

Royal Australian and New Zealand College of Obstetricians and Gynaecology guidelines on breech presentation.

Breech Birth UK  has links to UK study groups, sources of training, teaching aids and resources. It also has a print-out on upright breech birth, when and how to help.

Journal Articles

The Term Breech Trial (TBT) changed the way the medical world looked at and managed breech birth.  It was later noted for its errors and misinterpretations.  For more detailed information, click here.

Curated list of articles about vaginal breech birth since the TBT.
Stand and Deliver website: http://rixarixa.blogspot.com

Vaginal breech birth: can we move beyond the Term Breech Trial?
Hunter, LA.
J Midwifery Womens Health. 2014 May-Jun;59(3):320-7. Vaginal breech birth: can we move beyond the Term Breech Trial?

“This article reviews the controversies surrounding the ideal mode of birth created by the Term Breech Trial. Criteria for vaginal breech birth are summarized and the role of simulation explored. Implications for midwifery practice when a breech presentation is diagnosed are also included.”

The risks of planned vaginal breech delivery versus planned cesarean section for term breech birth: a meta-analysis including observational studies.
Berhan, Y., Haileamlak, A.
BJOG. 2016 Jan;123(1):49-57. The risks of planned vaginal breech delivery versus planned cesarean section for term breech birth: a meta-analysis including observational studies.

“Perinatal mortality and morbidity in the planned vaginal breech delivery were significantly higher than with planned caesarean delivery. Even taking into account the relatively low absolute risks of vaginal breech delivery, the current study substantiates the practice of individualised decision-making on the route of delivery in a term breech presentation.”

Management of breech presentation at term: a retrospective cohort study of 10 years of experience.
Burgos, J.; Rodriguez, L.; Cobos, P.; Osuna, C.; del mar Centeno, M.; Larrieta, R.; Martinez-Astorquiza, T.; and Fernandez-Llebrez, L.
Journal of Perinatology. 2015;10.1038. Management of breech presentation at term.

“Management of breech presentation with a protocol that includes ECV, careful selection criteria and active management of vaginal delivery achieve a great decrease in the rate of CS for breech presentation.”

Vaginal breech delivery: results of a prospective registration study.
Ingvild Vistad, Milada Cvancarova, Berit L Hustad, and Tore Henriksen
BMC Pregnancy Childbirth. 2013; 13: 153. Results of Norway’s study.

“Our findings reflect a well-functioning health care system where vaginal delivery of breech babies has been practiced even after the results of the TBT was published.  The present study does not have enough power to make a definite conclusion that vaginal breech delivery is completely safe.  Yet, our results indicate that vaginal delivery of term breech infants is acceptable provided the following conditions: Selection guidelines are followed, the fetal monitoring is of high quality, and the volume of breeches delivered vaginally is sufficient to maintain a high level of competence among obstetricians.  The women should also be counseled about the increased risk of short-term NICU admission.”

Maternal deaths after elective cesarean section for breech presentation in the Netherlands.
Schutte JM, Steegers EA, , Santa JG, Schuitemaker NW, van Roosmalen J
Maternal Mortality Committee Of The Netherlands Society Of Obstetrics
Acta Obstet Gynecol Scand. 2007;86(2):240-3.Pub Med abstract.

“Elective cesarean section does not guarantee the improved outcome of the child, but may increase risks for the mother, compared to vaginal delivery.”

Routine cesarean for breech: the unmeasured cost. Kotaska, Andrew.
Birth 38(2), June 2011. Routine Cesarean for Breech: The Unmeasured Cost.

“During the decade since publication of the term breech trial, it has become commonplace in many jurisdictions for specialist obstetricians to advise performance of cesarean section as the only option for breech presentation at term.  In a misunderstanding of informed consent, the 2001 American College of Obstetricians and Gynecologists’ breech guideline advised cesarean section for all breeches, suggesting informed consent be obtained only if the woman refused cesarean section (9).  For consent to be informed, a woman must first be made aware of her options, including the option of doing nothing; and the risks and benefits of each option must be discussed.  She should then have the freedom to choose without prejudice, even if it is not the option recommended by the consultant.  This has not been occurring for breech presentation. “

Neonatal outcome of singleton term breech deliveries in Norway from 1991 to 2011.
Vistad, I., Klungsøyr, K., Albrechtsen, S., Skjeldestad, FE.
Acta Obstet Gynecol Scand. 2015 Sep;94(9):997-1004. Neonatal outcome of singleton term breech deliveries in Norway from 1991 to 2011.

“Overall intrapartum and neonatal mortality decreased during the entire period. Higher mortality in planned vaginal delivery relative to planned cesarean delivery in the second period was not statistically significant. However, neonatal morbidity was significantly higher in planned vaginal than planned cesarean deliveries in both periods. This warrants continuous surveillance of breech deliveries.”

Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study
Floortje Vlemmix, Lester Bergenhenegouwen, Jelle M. Schaaf, Sabine Ensing, Ageeth N. Rosman, Anita C. J. Ravelli, Joris A. M. van der Post, Arno Verhoeven, Gerard H. Visser, Ben W. J. Mol, and Marjolein Kok.
Acta Obstet Gynecol Scand. 2014;93(9):888-896. A retrospective cohort study.

“Adjustment of the national guidelines after publication of the Term Breech Trial resulted in a shift towards elective cesarean and a decrease of perinatal mortality and morbidity among women delivering a child in breech at term.  Still, 40% of these women attempt vaginal birth.  The relative safety of an elective cesarean should be weighed against the consequences of a scarred uterus in future pregnancies.”

Response to the flawed retrospective cohort study.

“If this study does not address the central concerns of women and their partners, why should it take precedence in the information given to aid informed decision-making? If the authors have not performed an intention-to-treat analysis, how can they possibly claim to know that their treatment will have the predicted result? If the study has demonstrated a risk similar to that of planning a VBAC, why are both choices not considered equally reasonable?

Can cesarean section improve child and maternal health? The case of breech babies.
Vibeke Myrup Jensen and Miriam Wust.
Journal of Health Economics. 2014;10.1016.Regression discontinuity design study.

“We find that CS decreases the child’s probability of having a low APGAR score and the number of family doctor visits in the first year of life.  We find no significant effects for severe neonatal morbidity or hospitalizations.  While mothers are hospitalized longer after birth, we find no effects of CS for maternal post-birth complications or infections.  Although the change in mode of delivery for the marginal breech babies increases direct costs, the health benefits show that CS is the safest option for these children.”

Response to the concerning regression discontinuity design study.

“So Jensen and Wust have given us more research indicating an increase in short-term morbidity (with mortality being rare and insignificant?) but no difference in significant neonatal morbidity and the need for increased medical care after 2 years. This matches the information from the Term Breech Trial. Despite the authors insistence they have uncovered evidence that CS is best for all breech babies, and that it is ultimately cheaper (based on their non-evidence-based speculation on future costs of CP only), it actually adds to the literature confirming no concrete evidence of a difference in long-term outcomes for breech babies.”

Cesarean without labor safest for breech delivery.
Jenni Laidman
Medscape. Apr 17, 2015. Review of current research study titled:

Delivery of breech presentation at term gestation in Canada, 2003-2011.
Janet Lyons, Tracy Pressey, Sharon Bartholomew, Shiliang Liu, Robert M. Liston, and K.S. Joseph
Obstetrics & Gynecology. 2015. Abstract of Canada’s study.

“Among term, nonanomalous singletons in breech presentation at term, composite neonatal mortality and morbidity rates were significantly higher after vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.”

Response to the misleading review and cohort research study.

“These [assumptions of the qualifications of practitioners, planned/unplanned vaginal or cesarean delivery, parity] are some of the same major flaws of the Term Breech Trial (TBT) and are inherent when using a retrospective review of discharge records. Thus, this paper is open to some of the same critiques used to discredit the TBT…

There are many limitations to any scientific study. It is impossible to control for all variables. The authors here admit to this and other weaknesses and I believe did not have any conformational bias when they set out to look at the numbers. Dr. Lyons concludes that composite risks [death, assisted ventilation, convulsions, or specific birth injury] were “significantly higher after a vaginal breech delivery and after a cesarean delivery in labor as compared with cesarean delivery before labor onset. The risks associated with vaginal and cesarean delivery should be carefully considered by women contemplating a singleton breech delivery at term gestation and by their physicians.” I agree that all risks and benefits of reasonable birth choices should be carefully considered by women and their families but her last few words are very concerning to me. Although Dr. Lyons does not and would not say vaginal birth is contraindicated her message will almost certainly be construed that way.”

Breech delivery in the all fours position: a prospective observational comparative study with classic assistance.
Bogner, G., Strobl, M., Schausberger, C., Fischer, T., Reisenberger, K., Jacobs, V.R.
J Perinat Med, September 2014. Breech delivery in the all fours position: a prospective observational comparative study with classic assistance.

“This is the first clinical evaluation of breech delivery in the all fours position. It is a feasible non-interventional obstetric delivery method. It seems to be safe for the fetus with reduced maternal morbidity. Vaginal delivery of fetal breech presentation, even in the all fours position, creates stress for the newborn.”

Anke Reitter: New Insights from Pelvimetric MRI Studies and Maneuvers for Upright Breech Birth

Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?
Louwen, F., Daviss, B-A., Johnson, K. C., Reitter, A.
Int. Journal of Obstetrics & Gynecology, 10.1002/ijgo.12033Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?

“Upright vaginal breech delivery was associated with reductions in duration of the second stage of labor, maneuvers required, maternal/neonatal injuries, and cesarean rate when compared with vaginal delivery in the dorsal position.

Maternal Experiences of Vaginal Breech Delivery.
Toivonen, Elli; Palomaki, Outi; Huhtala, Heini; Uotila, Jukka.
Birth 41(4), December 2014. Maternal Experiences of Vaginal Breech Delivery.

The birth experience of vaginal breech birth seems to be at least as positive as the vaginal vertex birth experience.

Women’s Experiences of Planning a Vaginal Breech Birth in Australia.
Homer, Caroline SE; Watts, Nicole P; Petrovska, Karolina; Sjostedt, Chauncey M; Bisits, Andrew.
BMC Pregnancy and Childbirth 2015, 15. Women’s Experiences of Planning a Vaginal Breech Birth in Australia.

Women seeking a VBB value clear, consistent and relevant information in deciding about mode of birth. Women desire autonomy to choose vaginal breech birth and to be supported in their choice with high quality care.

‘Stress, anger, fear, and injustice:’ An international qualitative survey of women’s experiences planning a vaginal breech birth.
Petrovska, Karolina; Watts, Nicole P; Catling C.; Bisits, Andrew; Homer, Caroline SE.
Midwifery 2017, Jan; 44: 41-47. ‘Stress, anger, fear, and injustice:’ An international qualitative survey of women’s experiences planning a vaginal breech birth.

“For women seeking vaginal breech birth, limited system and clinical support can impede access to balanced information and options for care. Recognition of existing evidence on the safety of vaginal breech birth, as well as the presence of clinical guidelines that support it, may assist in promoting vaginal breech birth as a legitimate option that should be available to women.”

Supporting Women Planning a Vaginal Breech Birth: an International Survey.
Petrovska, Karolina; Watts, Nicole P; Catling C.; Bisits, Andrew; Homer, Caroline SE.
Birth 2016, Dec; 43 (4): 3. 53-357. Supporting Women Planning a Vaginal Breech Birth: an International Survey.

“The women who responded to this international survey sought the option of a vaginal breech birth, were subsequently happy with this decision, and would attempt a vaginal breech birth in their next pregnancy. Access to vaginal breech birth is important for some women; however, this choice may be challenging to achieve. Consistent information and support from clinicians is important to assist decision-making.”

“Home birth” with an Obstetrician: A Series of 135 Out of Hospital Births.
Fischbein, Stuart J.
Obstetrics & Gynecology International Journal, July 2015. “Home birth” with an Obstetrician: A Series of 135 Out of Hospital Births

“The births include singleton, VBAC, breech, and twin deliveries… Birth at homer properly selected women with a skilled practitioner is a reasonable and ethical option.”

Lessons to be learnt in managing the breech presentation at term: an 11-year single-centre retrospective study.
Barbolla, Foster A., Bagust, A., Bisits, A., Holland, M., Welsh, A.
Aust N Z J Obstet Gynaecol. 2014 Aug;54(4):333-9. Lessons to be learnt in managing the breech presentation at term: an 11-year single-centre retrospective study.

“The births include singleton, VBAC, breech, and twin deliveries… Birth at homer properly selected women with a skilled practitioner is a reasonable and ethical option.”

What is the evidence for using an External Cephalic Version for turning a breech baby?

External cephalic version: is it effective? is it safe?

Maternal thyroid function related to breech presentation

Midwife from the UK, Mary Cronk, explains her guidelines for hands off vaginal breech birth.

OSCE Preparation- Supine

Slides on vaginal breech birth updates by Frank Louwen form the Australian conference showing the preliminary data from the Frankfurt study on hands and knees breech delivery in the hospital.

Summary of international providers experiences and research in vaginal breech birth.

Midwifery Today Magazine, Number 106, Summer 2013.  Includes an article by Gail Tully, “Identifying and Resolving Obstructed Breech Birth:  When to Touch and Be Hands Free”  deals with head entrapment at the inlet, mid-pelvis and outlet)

British Journal of Midwifery article titled “Undiagnosed breech:  Towards a Woman-centered Approach” by Shawn Walker describes that 1 in 4 women have a surprise breech in labor and ways of giving informed consent as best as possible with evidence based principles.

Maggie Banks’ discussion about provider loss of skills and building confidence.

Maggie Banks’ discusses the lack of skilled providers for women with breech babies.

Midwife Shawn Walker on dolichocephaly which is rarely discussed as far as head molding affecting breech descent.

Midwife Shawn Walker on breech and the perineum.

Midwife Shawn Walker on vaginal breech birth after cesarean birth.

The Midwife, The Mother and the Breech: Shoulder Press and Gluteal Lift

Spinning Babies Blog: Waterbirth and Breeches

Other Research

External cephalic version for breech presentation at term.
Hofmeyr GJ, Kulier R and West HM.
Cochrane Database of Systematic Reviews, Issue 4, 2015. [DOI: 10.1002/14651858.CD000083.pub3]

An observational study of the success and complications of 2546 external cephalic version in low-risk pregnant women performed by trained midwives.
Beuckens A, Rijnders M, Verburgt-Doeleman GHM.
BJOG DOI: 10.1111/1471-0528.13234, 2015.

‘Ideas or Concepts’ associated with ‘Breech Presentation At Birth’: Top Publications.
Cooper IF, Siadaty MS.
BioMedLib Review; IdeaOrConcept;BreechPresentationAt:706251327. ISSN: 2331-5717. 2014/8/24.

‘Pathologic Functions’ associated with ‘Breech Presentation At Birth’: Top Publications.
Cooper IF, Siadaty MS.
BioMedLib Review; PathologicFunction;BreechPresentationAt:706254636. ISSN: 2331-5717. 2014/2/24.

Term-breech presentation: predictive factors of cesarean section for vaginal-birth failure.
Broche DE, Ramanah R, Collin A, Mangin M, Vidal C, Maillet R, Riethmuller D.
J Gynecol Obstet Biol Reprod (Paris); 2008 Sep;37(5):483-92.

Who limit vaginal birth for breech presentation: medical practice or Law? Discussion between a medical doctor, a lawyer and the head chief of an university hospital.
Delotte J, Oliver A, Boukaidi S, Mialon O, Breaud J, Benchimol D, Bongain A.
J Gynecol Obstet Biol Reprod (Paris); 2011 Oct;40(6):587-9.

A project for future life-Swedish women’s thoughts on childbearing lacking experience of giving birth and parenthood.
Söderberg M, Christensson K, Lundgren I.
Int J Qual Stud Health Well-being; 2012;7.

Congenital uterovaginal prolapse present at birth.
Hyginus EO, John CO.
J Surg Tech Case Rep; 2013 Jul;5(2):89-91.

Childbirth via the vagina birth canal. Breech presentation through the cervix uteri.
Martínez Galiano JM, Herrera Gómez A, Pacheco Adamuz MJ.
Rev Enferm; 2008 Jun;31(6):9-12.

Common determinants of breech presentation at birth in singletons: a population-based study.
Cammu H, Dony N, Martens G, Colman R.
Eur J Obstet Gynecol Reprod Biol; 2014 Jun;177:106-9.

Breech presentation – more than just caesarean vs. spontaneous birth.
Louwen F, Leuchter LM, Reitter A.
Z Geburtshilfe Neonatol; 2012 Aug;216(4):191-4.

Vaginal breech birth: can we move beyond the Term Breech Trial?
Hunter LA.
J Midwifery Womens Health; 2014 May-Jun;59(3):320-7.

Breech birth: an unusual normal.
Walker S.
Pract Midwife; 2012 Mar;15(3):18, 20-1.

Thoughts and emotions during traumatic birth: a qualitative study.
Ayers S.
Birth; 2007 Sep;34(3):253-63.

Previous cesarean section increases the risk for breech presentation at term pregnancy.
Kalogiannidis I, Masouridou N, Dagklis T, Masoura S, Goutzioulis M, Prapas Y, Prapas N.
Clin Exp Obstet Gynecol; 2010;37(1):29-32.

Caesarean section for preterm birth and, breech presentation and twin pregnancies.
Biswas A, Su LL, Mattar C.
Best Pract Res Clin Obstet Gynaecol; 2013 Apr;27(2):209-19.

Is breech presentation a risk factor for cerebral palsy? A Norwegian birth cohort study.
Andersen GL, Irgens LM, Skranes J, Salvesen KA, Meberg A, Vik T.
Dev Med Child Neurol; 2009 Nov;51(11):860-5.

Vaginal breech delivery in very low birth weight (VLBW) neonates: experience of a single center.
Stohl HE, Szymanski LM, Althaus J.
J Perinat Med; 2011 Jul;39(4):379-83.

Neonatal outcomes of preterm infants in breech presentation according to mode of birth in Canadian NICUs.
Lodha A, Zhu Q, Lee SK, Shah PS, Canadian Neonatal Network.
Postgrad Med J; 2011 Mar;87(1025):175-9.

Breech presentation at term: caesarean section or vaginal delivery?.
Djurić J, Arsenijević S, Banković D, Protrka Z, Sorak M, Dimitrijević A, Zivanović A.
Srp Arh Celok Lek; 2011 Mar-Apr;139(3-4):155-60.

Neonate–newborn condition and prematurity with breech delivery.
Dordević M, Jovanović B, Sazdanović P, Dordević G.
Med Pregl; 2009 Sep-Oct;62(9-10):456-60.

Breech delivery before and after the term breech trial recommendation.
Sobande A, Yousuf F, Eskandar M, Almushait MA.
Saudi Med J; 2007 Aug;28(8):1213-7.