This Birth Love Column by Leilah McCracken appeared in Issue 25.5, June 25, 2001 of the OBCNEWS. For a full listing of columns, go here.
The Hannah study (Lancet, 2000), the large, multicenter trial that found that breech babies are best born by elective cesarean versus hospital vaginal birth, has eliminated hospital vaginal breech births in many regions. And this is just heartbreaking, because this study does not make sense in so many ways.
All of the studied vaginal births were medically managed- with a full 64.7% of the women having their births induced or augmented with drugs, 46.3% having epidurals, and 22.4% of the women having their membranes artificially ruptured (AROM). It is no wonder that the women attempting vaginal births had labor difficulties- all of these interventions are anomalous to the normal birth process: induction drugs create fetal distress and abnormal labor patterns (as well as extreme maternal pain); epidurals retard the normal progress of labor, and create low maternal blood pressure and fetal distress- ushering in even more dangerous interventions; AROM causes the baby to go into odd positions, diminishes the baby’s instinctive biological approach to descent, and greatly increases the chance of cord prolapse (possibly resulting in death- now did the babies in the study who died in their vaginal breech births die because their mothers’ physicians broke their bags of waters?- the study, of course, does not say).
The women attempting hospital vaginal breech births were also used as teaching fodder for medical students. So create a mental image of these women in the Hannah trial: rigorously observed because they are part of a huge medical trial; induced or “augmented” by powerful drugs; confined from normal, healthy movement by monitor straps and tubes; most likely denied food and drink; medical students “observing” them (and their cervical dilation) intensively; their birth sensations and instincts deadened by epidural and other painkilling drugs. Not surprisingly, about half of the women attempting vaginal breech births were sectioned for “failure to progress”: the very nature of these hospital vaginal births precluded easy, smooth births from happening. Even in cephalic (head down) presentations, the medically managed mode of birth makes giving birth normally very difficult for many women. But a woman trying to give birth breech?... with extra fear added to the already inhibitive stew of iatrogenic birth difficulties?... normal birth may well become impossible.
This study is just so frustrating to read through, because it is solely rooted in the belief of the rightness of medically managed birth, and the most basic medical tenet of the female body being an accident waiting to happen (an accident requiring medical manipulations to correct). There is no provision for births that are not medically managed; there is no mention of births that happen outside of the hospital setting. I personally know several women who had their breech babies born at home- and without exception, their births were smooth, safe, gentle. At home there were no monitor straps, knives, or drugs- and no scrutinizing researchers or doctors to create the bad outcomes that the Hannah study talks about- the bad outcomes engendered by the fear, paranoia, and interventions of the birth institutions and their practitioners themselves.
It is heartbreaking to me that this flawed, myopic, aggressive study will dictate in no uncertain terms how many babies will be born for many years- through their mothers’ abdominal wounds. And most surprisingly of all- there is no mention at all in the study of how dangerous cesareans are; how invasive they are; how they put mothers and babies at risks that no vaginal birth could engender. Nowhere is it discussed that cesareans make women up to 16 times more likely to die, or their babies more likely to suffer from the dangerous respiratory distress syndrome. Nowhere is it mentioned that breech babies are 5 times more likely to be accidentally cut by the scalpel in a cesarean birth. Nowhere is it mentioned that women who have cesareans are more likely to have problems with infertility in the future, and placental difficulties if they actually manage to conceive. It is not mentioned anywhere that elective cesarean greatly increases a baby’s risk of being born prematurely, or the mother to have permanent intestinal or pelvic floor difficulties. This study is so narrow in its scope...
My friend Jamie, who had studied childbirth education and midwifery for years, was expecting her 7th child three month ago. Her first four babies were born in hospitals- with her 3rd child being taken by emergency c-section for fetal distress: the oral oxytocin she was given caused her to have tetanic (massive) contractions, and her baby’s birth environment quickly became severely oxygen deprived. Her 5th was born at home with a midwife, and her 6th was born at home unassisted. She was planning another unassisted birth- but when her water broke, she saw meconium in the waters. She felt inside, and knew that what she was feeling was not a head... she had a baby in the Frank breech position.
She chose to go to the hospital (a decision she now regrets). Once there, a young female OB tried with all her might to force a c-section down Jamie’s throat. But Jamie, who was educated and full of confidence in her birthing abilities, and who suffered so terribly after her 3rd child’s c-section, refused. The doctor was very aggressive with her, and hostile to her choice- but Jamie did not want to be cut again. Soon, Jamie gave birth vaginally to her daughter- despite being browbeaten by frightened birth attendants, and lying flat on her back. A less educated woman would have gotten cut, with the myriad risks and dangers that are inherent to the cesarean operation. (Interesting aside: the OB, without warning nor permission, gave Jamie an episiotomy. She did indeed have a need to cut my friend...)
And there’s another point. In the Hannah study, there is no mention as to what birthing positions the women attempting vaginal breech birth assumed. One can only imagine that they were flat on their backs, the most common hospital birthing position- and the worst possible position (short of a mother standing on her head) for breech babies (or any babies) trying to be born. A woman needs to have physical freedom for a smooth breech birth: she must be able to stand, squat, gyrate, shift, kneel or bend- to move in the ways her instincts dictate- to help her baby's smooth descent. That’s another major problem with the Hannah study- it didn’t in any way factor in how crucial a woman’s birth position is for the passage of her breech baby. (Yes, Jamie’s breech baby came out okay with Jamie on her back- but she was a grand multipara!!!)
We must do all we can to educate about vaginal breech births. Midwives, many of whom have great experience in attending breech home births, must speak out about what they know. Ironically- if they “come out” and discuss their wisdom, many of them are putting themselves at risk of legal recourse: “lay midwifery” is a crime in many places. But come out they must: women’s and babies’ births are at stake here- and a beautiful, baby-chosen variation of the normal will irrevocably become a melancholy, forgotten memory. Midwives can make videos, write books, publish papers, have photos and stories on the Internet- do what know they must to serve their calling, and protect birth. They can speak anonymously if they must- but speak they must.
Confidence in the Hannah study will only live as long as women’s confidence in the medical model of birth does. Once women understand the true nature of childbirth- the genuine ease, straightforwardness and awesome beauty of what birth can actually be- they will no longer seek out “expert” advice for their births at all. Breech presentation or not- our babies and our bodies are built for birth.
(End note: if I had to choose between a cesarean for my breech baby or a typical hospital breech vaginal delivery, my answer might surprise you. If I had to pick between drugs, monitoring, medical students, lithotomy, and my baby being mauled by inexperienced attendants, I would choose a cesarean- it would actually be safer than a brutal rape of a vaginal birth, for me and my baby. Which of course leads my ultimate conclusion: if I were having a breech baby, I would go nowhere near a hospital. I’d stay safe and sane at home.)
End Notes
So you want a cesarean for your breech baby? Well. Learn what happens in a cesarean section- and then make a genuine informed choice. This page also includes references for the cesarean dangers discussed here. See Cesarean Section: The Anatomy of a Choice.
Excellent critiques of the Hannah study:
From the AIMS Journal, Winter 2000/2001, Vol 12 No 4: “...there was a large difference in risk between more developed and less developed countries. There was a huge difference between comparative risk in areas with a low perinatal mortality rate (2 damaged caesarean babies v. 26 vaginal) and those with a high perinatal mortality rate (12 v. 13). So breech babies born vaginally in richer countries were twice as likely to be damaged as babies in poor countries.”View page here
From Breech Birth Beyond the ‘Term Breech Trial’ by Midwife Maggie Banks: “The medical literature frequently acknowledges doctors lack expertise in vaginal breech birth. Obstetric training schemes are inadequate due to the proliferation of delivery by elective Caesarian section which means doctors are simply not able to develop the skills necessary for safe vaginal breech birth...The report notes reduced benefit of Caesarian section in some countries - the authors postulate ‘possibly because of higher levels of experience with vaginal breech delivery in those countries.’”View page here
Maggie Banks has also written an outstanding book for birth attendants about breech birth. It contains many photos and diagrams too. 'Breech Birth Woman-Wise'
Read my friend Jamie McRae’s breech birth story here.
The Heads Up! Breech Birth Website: Note that this website by Patricia Blomme contains many breech birth resources, including a video list, links, birth stories and breech birth photos.
Midwives and Mothers: use the BirthLove site to share your wisdom about breech birth. I will publish all you need to say- as anonymously as you wish. And I am in the early stages of creating a book all about vaginal breech births. Send me your stories to share- and together we will put the Hannah study to shame.
