#128 | Vaginal Breech Birth with Dr. Stu of Birthing Instincts: Why It's Safer Than you Think

October 6, 2021

Dr. Stu Fischbein is an OBGYN in California and one of the very few providers who will attend home breech and twin birth.  Breech babies make up about 6% of pregnancies at term but few women will experience a vaginal breech birth.  98% of providers will not support a vaginal breech birth, not because it is dangerous (because it is not); but rather, because OBGYNs and most midwives no longer have the skills to safely support it.  Dr. Stu has a 100% vaginal breech birth success rate for moms who have already had one baby and an 80% success rate for first-time moms.  He believes we are doing a huge disservice to women by not offering them the option to give birth vaginally with a breech baby because we are not thinking about the down-stream effects, including that the mother will likely have a repeat cesarean if she plans to have more children. Today, Dr. Stu walks us through the myths and misconceptions around breech birth and helps us understand why vaginal breech birth is safe and deserves the same care and support as a head-down vaginal birth. 

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View Episode Transcript

The medical model has one goal. And that goal is that baby in the bassinet crying. How it gets there doesn't matter to them. That baby's journey doesn't matter to them. What happens to the mother's experience doesn't matter to them. And what happens to that mother's future babies doesn't matter to them. This is the the way the system is set up, that the baby doesn't turn, you're going to be told that a C section is the only safe way to deliver it. And that is a lie. breech birth for those of us that do them regularly, are fun. If that baby gets a job, I can get that baby out because I know how to do it. And it's beautiful to watch. It's very, very rewarding to do breech birth.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Dr. Stu, thank you so much for coming back on the Down To Birth Podcast. Your last episode with us was a very popular episode. And we have a long list of topics. We are really excited to talk to you about that we know we'll have to break into various conversations. But for today, we would love to talk with you all about breech baby. So why don't we just start off with you telling everyone who you are, what you do and why you are a really good person for us to speak to about breech vaginal delivery.

I'll try to keep it short because I could talk. My story is a long one. But I will just say that, that I've been practicing obstetrics for finished my residency in 1986. So this is my 36th year, the first 24 years I was in the hospital the last 11 and a half I've been in the home setting. So I am a home birth obstetrician. I work with midwives, I believe in the midwifery model of care. This is not how I was trained, I was trained in a medical model of care and that pregnancy is an illness that needs to be treated. And I've slowly but surely morphed over the years into realizing that pregnancy is a normal function of the body that occasionally goes awry. And it's great, we're grateful we have medical care for those people. But most people don't need that. And in the process of my transition, I ended up probably pissing off a lot of people in the organized medical community. And they made it very difficult for me to stay in that community because they kept restricting what I was trained to do. And I was lucky because I was trained in an era where breech and forceps and second twin extractions and the things that make my profession unique. We're being taught routinely. And those things that pretty much disappeared from most residency programs in the Western world. And so physicians coming out now don't know these things. And so they skew their counseling. And I've seen there's a lot of this going on. And I'm trying to right the wrongs by putting information out there so that people can make an informed decision because the midwifery model is all about shared decision making and giving women the power back to make their own decisions. But you can't make an informed decision. I know it's cliche, unless you have the information. And so what I do now is I'm still practicing, I'm still doing home deliveries. And I also advocate I go around the country up until obviously the last year and a half, teaching breech seminars. You know, I have a I have a weight event. I published a few papers I have written a book called fearless pregnancy. Anyway, breach in breach and twin burst makeup about 6% of births, about 3% of term babies are breech and about one out of one in 30 to one and 40 pregnancies are now twins because of IVF and stuff. So it should be about 6% of the average practice it makes up about 45% of my practice, because there are so few choices. And again, there are so few choices because it's not being taught. It's not being taught not because it's dangerous. That's a misconception. It's being taught because it's misunderstood, or it's just expedient or economically not feasible to teach it anymore and so they're not doing it And it's taking away a really viable choice and actually putting women and babies at greater risk, because it's not an option out there. And, when physicians don't know how to do these procedures, we again, I guess it just I'm just repeating myself, it just puts people at risk. This is what my profession should be doing and people who don't know how to do this, I still don't really understand how they call themselves obstetricians. And the people that are leading my profession are leading toward obsolescence and I am trying to keep the skill alive. So I'm glad we're talking about breach today. That's my passion.

This makes me wonder why are we spending so much time teaching external cephalic version instead of just teaching? How to deliver a breech baby?

Yeah, well, first of all, it's the reason it's an option is because there's no other option. If you don't, if the baby doesn't turn, you're going to be offered and about 98% of practices in the country, you're going to be told that a C section is the only safe way to deliver it. And that is a lie. That is not true. And not even the organizations that that represent obstetricians around the world will say that they all support breech delivery. They all admit that breech delivery is going to be rare because the skills are disappearing, even though they're not doing anything to bring the skills back. And none of them obviously support home breech birth. That's just not within their purview. And I understand that. But when they say home breech birth is dangerous. They're also not telling you the truth. Because there's no data on that. So it's opinion. So when you say ECV, they, some people may not know what that means. It's called external cephalic version. It's a procedure that's done at term. When the baby's discovered to be breech. It's offered to people because really, the only other option is cesarean section. And what it is, is where they try to relax your uterus in some way. And then they try to use their hands to turn the baby from the position the baby's sitting in, which is breech. And we'll talk about the different types of breech and a second, to bring the head back down toward the cervix. It's successful and probably multipurpose women about maybe 50 60% of the time and in primates that very often. There's, like a scoring system. I don't use it, but there's a scoring system they use to predict the success rate. This is what doctors do, they like to have algorithms. It's a plug you into an algorithm we have algorithms for breach or VBAC or whatever, we'll plug it in, and we'll see if you fit and then we'll give you a risk. You know, we'll give you your success rate. And that's not how it works. It's in our model, we individualize care. statistics don't mean anything to the individual. There's no such thing as 50% success rate, it's either zero or 100%. For that individual woman,

I imagine you would probably say that the success rate of actually just having the baby vaginally breech is greater than the success rate of the external cephalic version.

Brilliant. By far, I will just tell you that in my own practice my success rate to this point in the last 12 years of doing home breech birth, for women that are multiple multiple woman's already had at least one vaginal birth is 100%. It won't always be that way. And sooner or later, I'll have one that isn't successful. We almost had one recently, but then she got a second wind and maybe within an hour the baby was out there almost ready to transport. And with prime apps first time moms, it's 80%. So we have a C section rate in first time breech moms of 20%. Which is better than hospitals have of all moms coming in and labor. You know, there are a few universities and stuff that have breech programs. But what I find amazing about them is the only do Multics. Now, what's so sad about that, to me is it's the primate that needs the breech delivery. Because if you section all private breaches, you may save a certain percentage of babies, if you take large numbers, like if you took 10,000 women and you sectioned all of them for breach at 3839 weeks, you probably save a certain number of babies than if you had 10,000 Women who went into labor. But if those 10,000 women decided they wanted a second pregnancy, everything that you gained by this doing a C section, the first one you lose in the second pregnancy, because now they have a scarred uterus. You gain nothing if a woman wants a second baby. And one of the questions that when I do a breach console when somebody comes into me for breach console, especially the prime app and I asked them this question, I get a universally and the universal answer is always the same. I asked them did your physician ask you if you want more children? And the answer is always no. He or she never asked me that. Right? Because and this is a basic tenet of The medical model, they may, they may disagree with it. But I can tell you that this is what from my experience over 40 years, is the medical model has one goal. And that goal is that baby in the bassinet crying. How it gets there doesn't matter to them. What happens to that baby, that babies journey doesn't matter to them? What happens to the mother's experience doesn't matter to them. And what happens to that mother's future babies doesn't matter to them. Because and I'm not saying this that they're mean are they thinking like, oh, let's be dastardly, no, no, this is the the way the system is set up. Because in the obstetrical world we don't look at we don't look at mother baby as a unit. The baby is out, it's now fine. It belongs to the pediatric department. It's not my problem anymore. Okay, midwifery model, mother and baby are a unit. So we care more about the journey and how it gets there. And is it okay for a baby to be induced? And is it okay for a baby to have a pre labor cesarean section? And what does that do to its epigenetics or its microbiome? We care about that sort of thing. The medical model does not in general care about it. There may be isolated medical schools and residences that talk about it, teach it, and that's great. But it's not widespread and it shouldn't be widespread.

Such a good point. Um, can you talk to us about why people are so afraid of breech birth? What are the big fears? What are the dangers, the reason that people are usually fearful of something is either because they've been indoctrinated to believe it or they had a bad experience? And it may very well be that that many people who teach breach or I mean, I don't teach you teach residents may have had a bad experience with a breach where where there was a head entrapment on a premium breach, or somebody didn't know what to do, and they got a bad injury, or they ended up with a stillbirth. From a from a delivery that happens, which happens, and head down babies too, but they don't seem to be fearful of well, they are actually, when the medical model is fearful of pregnancy in general, that's their whole their whole their bathe in fear, and then they project it onto the women of that they care for, but specifically breech, it's, it's the way you envision things. It's kind of like, if your head were stuck in a log Trish, you'd be panicking. So they've envisioned that the heads coming out last the baby's gonna suffocate, or, or something like that. Not realizing the baby like anything else. It's getting its oxygen through its core. It's not getting its oxygen through its lungs at that point. Anyway. So they project and it's the same sort of thing with when a nuchal cord is seen on ultrasound, the doctor says, Oh, we that that's a problem, what we need to do a section because the baby has the cord around the neck. And people think that the baby could choke on the cord. And it's like, wait a minute, what do you have to be doing in order to choke, you have to be breathing. Babies aren't breathing through their trachea in utero, they cannot choke on their core, you could have a cord accident, that happens. But it's not me. But they have a anthropomorphic size the baby, they give it the same feelings that they would have because they if they had something tight around their neck, they would worry about it, because it's going to choke you. And it's the same thing. If their head were stuck there, they're fearful that they would be not be able to breathe. So they project that fear and that sort of, then it gets propagated. And there are some bad outcomes with breech. And especially with you know, undiagnosed or unplanned preemies that the baby the body can fall through in completely dilated cervix and you really have a problem. But those are really, really rare. And if you follow the basic tenants of guidance for how to select properly, proper term breaches for breach delivery, you don't see that problem hardly at all. And I'll go through the numbers later as we go along.

Dr. Sue, can we talk about the different types of breech babies some of the misconceptions around each one?

Sure, yeah. If people want people who are listening to podcasts, they can always go to the internet and they can search images of breech and they'll be able to see what I'm talking about. So, the most common position for babies are breeches Frank breech, and that is where the butt presents and the legs are up, the hips are, are flexed and the knees are extended. That's the most common where the feet are up by the face. The second most common is complete breach to complete breaches where the baby's sort of kneeling, and that's often mistaken as a footling breech because someone will examine a baby's breech and they'll feel a foot and they'll say oh, it's footling? No, no, no footling breech is completely different and very, very, very rare at term. Because footling breech means the hips and knees are both extended. That means the baby's standing and there just isn't really room for baby to be standing in a term. uterus, just there's not room for that. So they're folded up. And they're in that somersault position. Those are the two most common sometimes you have an incomplete breech where one leg is up and where legs folded down. And rarely you can have things like a footling breech, which is rare, you can have a few neck presentation, which is where the cord is actually below the buds. That is a problem. So though those babies probably should have one that probably those babies should probably have a C section and generally a C section either very early in labor or prior to labor. Because if the cord is presenting then when the cervix begins to dilate, the cord can fall out. And you can have a cord prolapse, which is something else that scares doctors who don't understand breech birth. If the butt is down, it blocks the cervix, just like the head would do. Frank breech and complete breech are equally desirable. When people don't understand they think, well, the body comes out well. Isn't the head bigger and won't the head possibly get stuck? And the answer is actually no, it won't. But the cervix is completely dilated by the butt. If you take a tape measure, and you take a tape measure after the baby's born and you go around the baby's butt and thighs, or Fold the legs up and go around the baby's butt thighs and calves, you will find that that diameter is bigger than the head. Excuse me that circumference is bigger than the head. And what people often don't know about breech babies is they have actually what are called Cardinal movements. People heard of Cardinal movements of the head down baby where now there's, you know, descent and internal rotation and extension and all that the breech babies have Cardinal movements as well. And, and it's so easy to watch a breech baby as they come out. They're telling you whether they're going to need help, or they're not going to need help. Especially if a woman's on all fours, which is now sort of the recommended position for breech delivery because it uses gravity to your advantage. But I will tell you that not all women like the forest, not all women can push well on all fours. And I would say that half of my women who start pushing on all fours end up on their side or their background or stool. They don't like being on all fours. But all fours is the easiest way to see if the baby's doing this rotations and things that tell you that the arms are in front and not one of the arms or both of the arms behind the head. And these are very easy things to learn. And then the maneuvers are actually quite easy as well. If we could get into residencies and and have a week with the residents, we could make this more common. Because if doctors don't learn this in their training, they're never going to learn it afterwards. There's too much liability, not enough economic benefit for them to do anything but a C section which takes 45 minutes, as opposed to a breech birth where a hospital is going to have a policy that says if you have a breach in labor, you have to be here the whole time. So you get paid the same if you're there for 45 minutes or 14 hours.

And they're not learning anymore how to do it. They're not learning at all. Right? They're very if a doctor wants to learn breech delivery of resident, they usually have to go outside of their program to do it. Let's talk about the criteria for breach selection. There are nine criteria that I use for home breach, and I'll go through them real real real quickly. One is term two is franker, complete breach. Three is an estimated fetal weight between five and nine and a half pounds. Would I tell a woman who has a baby who's estimated at 10 pounds that you can't have a vaginal drop? No, because that would be wrong. But we know, you got to have some sort of guideline, flexed head. So it's part of the workup for a breech, you want to do an ultrasound toward the term either at the time you're trying to version or just when you diagnose breech and you want to be sure the baby's able to put its chin down toward its chest. It doesn't have to be that position all the time. You just want to be sure that baby's able to do that. There are some babies born with a congenital problem of their neck called torticollis. Where they have their head is always extended or they could have a congenital goiter, which is a big thyroid and that could push their chin back. Because unlike babies that are delivered head first which deliver their which the head comes out by extension, breech babies heads delivered by flexion. And they know this, how they know this, but they know this. And that's that's their motion of how they do it. So they got to be able to flex their head. There can be no gross anomalies of the baby. So we I mean, we're not talking about some minor defect like six fingers or something like that. We're talking about spina bifida, an abdominal wall defect, we don't know, you don't want to be dealing with that sort of thing at the time of a breach of a vaginal breech birth. Then you need to have what what is often called the clinically adequate maternal pelvis. I hate the term. But essentially, to me a clinically adequate maternal pelvis is a woman's pelvis who hasn't been run over by a pickup truck. Because any woman's pelvis is a dynamic Oregon. It's not frozen. It moves it stretches it and in all fours position. There's probably 20 to 30% more space than when you're laying flat on your back. Here's a basic tenet of breech birth breech birth succeeds or doesn't for the same reason that head down baby succeeded. Period. Mobility, position, right? Some babies that are head down won't come out. Some babies that are breech won't come out. All right, but they're the same. It's the same mechanism, the same reason. So that's six, seven and eight are essentially no brainers for the homebirth. World labor has to start spontaneously, because we don't induce really, you know, in our world, and eight is a really no brainer. And Zoom's mom and baby have to tolerate labor. You can't have baby will have a deep variable decelerations at five centimeters when you're doing them, you can do that. And number nine is this nebulous thing, which is what I call the right parental mindset is that people have to believe in themselves, trust their practitioner, be amenable to home birth, not be saying, well, how can I do this without an epidural not have that, that mentality, that fear mentality, really. And that's true for all home births. So actually, so those are the nine criteria. And so getting back to your question, which which was, oh, just about, you know, this, we already discussed the the fear around head entrapment as far as, like, suffocation and how that's That's right. But how about like, after the body is born, there is still this risk of the head not delivering as easily what how do you recognize that you manage that, if the baby is able to flex its head, and you know what you're doing, you're not going to get head in trouble. And a trap and occurs in the people who don't know what they're doing, you start pulling on the baby. If you've ever seen a newborn baby do a what's called the Moro reflex, you know what the moral reflex is? It's a startle reflex, you kind of pick them up and you set them down, and their arms go out and their head goes back. Their head extends. And so when you start pulling on a baby and not knowing what you're doing, what is the baby going to do? It's going to put its head back. So if you know what you're doing, you're not going to have an entrapped head. It really isn't. And you know that there's no anomalies, there's no hydrocephalus, there's no greater. Keep your hands off. Yeah, well, you can, and babies will tell you whether you need to have your hands on or not, because of the way they rotate. And Cynthia asked about the cardinal movement. So we can talk about that in a second. But you you had a question.

This will hopefully tie into that, can you just help everyone to understand why it's so important in the case of a breech birth that the chin be able to tuck, it just help people to understand if the head is back, it won't fit to the pelvis the same, it could have the the back of the head can be caught on the sacrum.

Okay, and then it's extremely difficult to get the baby out or what happens when that does show up that says no, if you know your maneuvers, you can still get the baby out. And if you that's why you need well trained people at breech births.

So we're talking about the difference between an easier and a more difficult breech birth, potentially successful and an unsuccessful one. But that's what we're talking about. Like, it would take the skill. That's the kind of scenario where you are now suddenly very dependent on the provider skill to get the baby out. So that's why it's ideal upfront to make sure that baby's head will flex and today innately know to tuck their chin even when they're coming out that way. I know when their head down, they do. They still innately know that um, it's one of the it's one of the cards a little bit. It's interesting that you say that though. I mean, the torchbearers of the breech skills right now are midwives because Oh, bees don't have it anymore. And there are many, many skilled midwives out there. And then what state legislatures do they go and pass laws that say that midwives can't do breech births, they restrict the more Yeah, you're not sharing a lobby with the pharmaceutical industry.

And one of the skills that you really need to have as a any practitioner, which is not taught in any residency program is the skill of doing nothing. And keep your hands off. As you said earlier, most of the time with a breech birth. If they're on all fours, if they're on their back, you're gonna have to use your hands because you don't have gravity. But if they're on all fours, and the baby's doing all the right cargo movements, you don't really have to do anything.

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So Dr. Stu my daughter was breech until very much near the end and I had this like three hour from beginning to end first birth with HypnoBirthing changed my life plan to home birth for my second in part because my first birth was so precipitous, I didn't want to travel, my birth center was an hour away. And I was teaching HypnoBirthing every week of the pregnancy, everyone knew I was having a home birth. And then I had this breech baby and my midwife suggested an ECV, which we talked about earlier in the episode. And for some reason, I just refused. My instinct just said, Don't do it, which is strange, because I'm supportive of clients doing it. But my instinct said, just don't do that and look into a breech birth. And I'll turn the details of this story into a mini episode in the next few weeks because it deserves its own 10 minute time slot, I would say. But basically, I had a lot of those, quote, risk factors, you know, I had an anterior placenta, I had a very big baby. My daughter was born at 39 weeks, nine and a half pounds. I had strong abdominal muscles. From years of yoga. I had one other risk factor that you mentioned, and I'm forgetting what it was. But anyway, what I was saying was, we called this woman from Utah who was Nancy's mentor, and long story short, the details are very important. And again, I will tell them in a mini episode, she coached my husband over the phone in turning our baby. It was as gentle as can be, I hardly felt anything happening. He was just placing his hands on me gently, and just coaxing the baby. And we got this head down, baby. But anyway, here's what I wanted to ask you about that. Even though I was a second time mom and I had really had been so skilled and HypnoBirthing. I was facing a fear in my mind. I was planning a breech vaginal birth at home doctors too, but I was fearing a much more intense birth, dare I say painful the word I never used? Like, I was thinking, what is this gonna feel like? Can you just talk to talk to that point?

I can talk about it. Since I've obviously never had a baby. I can't, you can't.

But you have been with all these into you know, when when through all these instances observed.

I will tell you, like everything else in life, it varies. There's someone who has said it was the easiest birth they've ever had. And there are some women who say that it was very, very painful that the bony legs with bony knees were pushing on something, and it was really uncomfortable until they got to a certain point. So there is no rule as to whether breech births are easier or less discomfort or more or greater discomfort there is. There isn't a rule on that.

I want to throw out just a couple of things that got your responses to it. I did have a client who planned a home breech birth. Some years ago, she flew in a midwife named Sherry Holly from the west coast to attend her birth in Connecticut.

I know I know of Sherri Holly. For a while but yeah, yeah. So Sherry Holly attended that birth it was a singleton footling very arduous labor, the client said to me, I I don't have any regrets, but I wouldn't wish it on anyone. It was really difficult getting that second leg out. So I think I'm hearing what you're saying about there's just variation in every birth and we can't name what those variations are going to be. Can you come up with what you just said it was a singleton footling? Yeah, it probably wasn't. Oh, what probably it was probably a complete breach. If you're squatting over a hole in somersault position and you suddenly when you're completely done, you can extend one leg and out it pops and you think that's a footling breech. But no, I mean, it's it's it's a complete breach where the foot comes out first. Yeah, that makes sense. Because remember footling breech has to be where, where the legs are both the hips and knees are extended in the uterus. Not when it's fully dilated. It's coming out of the out of the labia that's different.

Let me ask you about this. Now I've had numerous clients with twin babies and I have a really hard time when doctors say we need Baby B to be head down as well. And then they say this, this really is too much for me and you have to comment on it and set me straight on it. They will say if you have a vaginal birth with Baby A and Baby B is breech, you're going to get a vaginal birth followed by a C section. So let's just plan the C section. I just need you to please respond to that. Yeah, that's how I feel we're looking at each other with the same expression. It's hard to say it it's hard to hear it but please respond.

I was pausing for the for the radio or for the back. You know I'm holding my forehead and I'm shaking my head. This is negligence. This is fun. unethical behavior to be telling people this if you don't know how, as an obstetrician to deliver a second twin, who doesn't come down, head down, you have no business offering your services to twins. The ethical thing to do in that situation would be to say, I'm not comfortable with twins, because even if their vertex vertex it doesn't mean after the first one comes out that the second one will turn a different position, they can do that. And I was reading an article recently in the green journal about the safety of model chorionic dyadic, twin vaginal delivery versus DIE DIE twin vaginal delivery, and they say it's equal, there's no increased risk with Moto die. And in their study of was over like 16 years, they had only 1% of their patients had a vaginal cesarean delivery, we're in the national average is 14%. So that means 14% of twins who have a bachelor's degree, twin a are getting a C section for twin B, those people should never have been in labor with that, with that practice. I shouldn't say never, every now and then there's there. There's a reason where even if you try to get the baby out, you can't get the baby out. That's a different story. But I'm talking about prepping a woman ahead of time saying that if your baby's B isn't in the vertex presentation, head down presentation, then then we'll have to sectioning for baby. That's an abomination. And those people should like I said, I never said this before, I think in any podcast, but it just came to me those practitioners should not be doing twin births.

Oh, they're happy to do twin surgical births. Doctors too. Of course they are doesn't cross their mind that they shouldn't be doing twin births.

There is no indication there is no indication for just because you have twins to have a C section, right? Even a breech first twin is supported by the American College of OB GYN. Now I can tell you that most obese would not know that. They're going to tell you that no one's going to do it because no one has the skills to do it. Or the patients or the financial incentive, or the liability though. Non fears or whatever. That's such a word to do it. Right. But there's lots of papers including papers in the green journal that talk about delivering breach first twins reach to brief bursts for those of us that do them regularly, are fun. Because they either go or they don't go if the baby gets to the point where it's completely dialed in the butt is beginning to protrude from the labia. If that baby gets a child, I can get that baby out because I know how to do it vaginally. And most of the time he like I said you have to do very little or nothing. And it's beautiful to watch. And the advantages to all her future pregnancies are so great. It's very, very rewarding to do breech birth. I love doing breech birth. And if you don't push the envelope, the key about breech birth is to not go crazy. If labor stalls out if labor stops if if dilation arrests. If you're hearing fetal variables early in labor. Don't be a hero. Those are babies that should be sectioned. There's no question about it section isn't the devil for breech birth. But it should not be the default position for breech birth distributor counseling to tell them that a cesarean section is indicated. And this is this. This is what passes for the mainstream medical model. And these are the people that sit in judgment of people like me or midwives, who are offering people alternative choices. They're the policymakers. They're the ones that legislators turn to, for advice. the silliest stupidest thing that they could do is have obstetricians giving advice on midwifery legislation. But that's what they do, because they because in the medical model, they consider Midwifery, a lesser subset of obstetrics as opposed to a separate profession. And it's really interesting when they do legislation regarding obstetrics, they never asked midwives. What the ACOG guidelines added, they added a couple of sentences about the importance of informing the patient about the risks of vaginal breech birth, and blah, blah, blah, blah, blah, blah, blah. And I think that that's perfectly fine. But there's something that's missing in that consent form. And that is the sentence that says, informing the patient about the risks of Cesarean birth, or this pregnancy and all future pregnancy, not in there.

They do the same with induction the risks of letting you stay pregnant any longer can reduce this risk of stillbirth they never study or discuss the risk of inducing all those 10s of 1000s of women. That's that work is never done.Right? Not only just on the mother and stuff like that, but on the fetus the epigenetics, the by the microbiome, all that stuff is never discussed. And the last thing I'll say because we people talk about risk and and people will, doctors will say well breaches high risk. So let's just talk about what the numbers are. And the Royal College of OB GYN has the best statistics on it and they've rounded them out. And again, because the endpoint in medicine is alive, baby, they look at stillbirth. Right, because the injury rate is about the same whether you delivered vaginally or by cesarean section two babies were breech. So when they looked at the the stillbirth rate, by delivering breech babies by cesarean section is about one in 2000. All right, and the stillbirth rate of having babies delivered breech vaginally. Again, I'm not sure that they controlled for planned or unplanned skill of the practitioner, whatever else but let's just assume these numbers are correct, is one in 500. So that's a four fold increase over the risk of cesarean section. But with breech delivery, you don't have standardized procedures or tactics with C section. Everything is pretty much done the same worldwide. So it's really wrong to compare a breech vaginal delivery versus the breech syringe that what you should do is complete compare breech vaginal delivery to head down vaginal delivery. Because nobody's saying you should do a section for all head down babies yet. Okay. Yeah. I mean, it's coming. So the risk for a stillbirth a head down babies they they calculated to be about one and 1000. So the risk is actually twice as great for vaginal breech birth of stillbirth than it is for vaginal than it is for vaginal head down baby. Now that may sound like number but relative risk means absolutely nothing. Let's look at the risk of it not happening. The risk of it not happening with a C section is 99.95%. The risk of it not happening with a vaginal head down baby is 99.9%. And the risk of not happening with a breech baby is 99.8%. Right? If you told a woman she has a 99.8% chance of not having this devastating outcome. Would you think that that's high risk? No. And I might, and that's fine. But most won't. Yeah. And they're not given that information. They're told that it's riskier.

They're not given it in that frame, you know, very well, they're just say they just use words like it's risky, or it's high risk. And if you ask a physician who says it's riskier what the actual risk is and can you give me a reference, they're gonna hate you because they don't know the answer. And they don't want to take the time to give you a reference.

And also is that that number, that statistic, one in 500, including all kinds of breach, we know that some breach is not. So I don't know where they got their number. So I don't know if that breach breaches. I don't know if that included, like I said, who was delivering the breach? Was it planned unplanned, right. Again, that's probably less than that. It's certainly less than that in with with skill breach practitioners in the hospital setting.

Right, if that had included footling breech that might have been 75% of the adverse outcomes that we saw there. And they're not including that but the bigger point once again, that we always have to come back to is this should be up against what happens to all those women who have C sections instead. Now let's look at the risk of that outcome because they're always saying this is the risk of a vaginal breech delivery. And the presumption is there is no risk in the alternative and there is risk in the alternative there is risk of giving all this woman C sections and that's the number that they never study or reveal or let women consider it they always assume that it will mean a safe outcome otherwise it gets it gets back Cynthia to what I said at the very beginning of our conversation is that the way the medical model looks at it is live baby and bassinet right what is going to be the stillbirth rate on the risk of of hemorrhaging after a C section of infection after C they don't care. But that's and that's my point issue. They can sew it up I can fix it. That's that's the thing. We're talking about relative versus absolute risk. We're not even looking at the adverse outcomes when we go with that alternative, which is the C section instead of the vaginal birth. Women can't even be given that information. This is my risk. If I deliver vaginally, this is my risk if I deliver surgically they're not showing what can happen with that and they do the same thing with induction and everything else we they the assumption is always that it's safe, just right the only number the only number that doctors will talk to a mother about is the is the stillbirth rate. That's the only number because clearly that matters. And you know, the minute that they start talking about an injury to your baby the conversations over because they pull out the you know, we it's the trump card I mean there's nothing by with women even could consider that there's a potential risk of hysterectomy if they get that seat shut section. There's a risk of some other kind of adverse outcome.

There's a risk in all their future pregnancies. Correct. There's a risk of bowel obstruction, there's a risk of bladder injury, there's a risk of chronic pain, there's a risk of wound infection. There's a risk of, as we said, placenta accreta was sent a, there's a risk of plantation problems maternal. You just start uterus is infertility, and all comfortable. So today, and just to be clear, this conversation isn't to indicate to women that they should be having vaginal breech births. It's that they should be given full information and listen to their instincts and decide for themselves, what makes the most sense for them. It's not that they shouldn't go with the alternative, if that's the right decision for them. It's that unfortunately, they're not even presented with full information. But them as though they are, I want to be sure that people understand that all these risks we're talking about, they're all small. And we're not doing we're not we don't in our model, we don't try to do to women, what the medical model tries to do, we don't try to scare women out of a hospital birth, we don't try to scare we want them to ask the questions. We want them to be informed so that they can make a decision and with breech birth. It is just a variation of normal if you have a skilled practitioner, and what we need to do is get more skilled practitioners involved and people need to learn the skills. Because as I always say, every now and then a woman will show up in labor and delivery with a breech sticking out of the vagina. And if if no one knows what to do, that's the tragedy. That's the problem. There you know, the not know what to do, when that happens. Is, is so unnecessary. And you have four years of medical school and four years of residency to teach people this skill which we can teach people in two days. And they still don't teach it. Now there aren't there aren't. There aren't different choices in the world, there's basically one choice, do what I say or you're a bad parent, do what I say we're calling Child Protective Services, do what I say or your baby will die. If your gut is telling you what you're hearing from your your practitioner is not sitting well with you get a second opinion, get an independent second opinion seek out somebody else. I would tell all women who are pregnant unless they have significant medical issues, that they should seek out midwives first. And at least at least consult with a midwife during your if you're going to go with an OB consult with a midwife. You might find that the prenatal care that you get or even have collaborative care. But seek out a midwife and if it turns out your baby is breech. Do what you can to find a breech practitioner if you have to travel, you have to drive 100 miles to do it. It's why wouldn't you do that? It's for your benefit. It's for your baby's benefit for your future baby's benefits. So make the effort because it's the most important thing that happens in your life. The memory of your birth of your children will be with you for always.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.

When I was a brand new midwife, I was only a couple months into practice. And I got called to a home birth and I was the first midwife there, because the senior midwife lived an hour away. And I did a vaginal exam on the mom. She wanted one at one point and I I felt something squishy. And I was like that's not a head and I thought oh my god. I have a cord prolapse, like right here right now and brand new midwife cord prolapse and then I took a breath and I thought about it for a minute and I'm like I don't feel any pulsation. It doesn't really feel like a cord. So oh my god, what am I feeling what could this possibly be? And then it just hit me. I don't know where I was feeling a scrotum. scrotum. I was feeling the baby scrotum. And then I'm done. I thought oh my goodness. I haven't breached baby here at home. What do I do? I'm alone. I'm a brand new midwife. Unfortunately, the senior midwife was on her way. She was only about 20 minutes away. I did end up calling the paramedics just in case since this was totally unfamiliar to me. I was not breech and the mom refused for the hospital. She was you know, she was pushing she was ready to have this baby. She's like I am not transferring right now. And baby just came out. Nobody even had to do a thing. You know, she just it was just this beautiful breech birth it didn't even pushing, pushing Back when she had a barstool he was actually squatting hands free or she was like you know leading her back up against a wall and sort of squatting she didn't even have a barstool and that was that was I got to see breech birth which was fabulous.

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About Cynthia Overgard

Cynthia is a published writer, advocate, childbirth educator and postpartum support specialist in prenatal/postpartum healthcare and has served thousands of clients since 2007. 

About Trisha Ludwig

Trisha is a Yale-educated Certified Nurse Midwife and International Board Certified Lactation Counselor. She has worked in women's health for more than 15 years.

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