This week, our guest writer and award winning prenatal chiropractor Dr. Elliot Berlin, takes us through a hot button topic: breeched babies.
By Elliot Berlin | DC
Early in pregnancy, your baby has plenty of room to move, as you’re probably well aware. My patients often share that it’s not unusual for them to feel a sharp elbow jabbing into their ribs, some swift kicks to their belly, and even complete somersaults going on in there!
Usually, by week 34, the combined forces of gravity and the decreased “room to move” in your uterus leads your baby to settle head-down (in a vertex presentation) in preparation for birth. At term, around 3-5% of babies are not vertex, and those babies are said to be in a breech presentation. There are three common breech presentations: frank breech, complete breech, and footling breech.
If you ask a midwife, you are likely to hear that a breech presentation is just another variation of normal; ask most OBs, and you’ll hear that a breech presentation is abnormal. You’re also likely to hear that if your baby doesn’t turn before your “guess date,” you’ll be delivering via cesarean – and you have no other choice.
It wasn’t always this way.
Breech babies are a little more difficult to deliver vaginally than babies in a vertex position; as Jennifer Block writes in her book Pushed: The Painful Truth about Childbirth and Modern Maternity Care: “The breech baby demands patience; she rejects active management; she demands normal, physiological birth.” Many midwives talk about a “hands off the breech” approach for delivering breech babies vaginally. From years of observation and sharing their collective wisdom, midwives know that the more a woman and her baby are free to do their own thing, the more successful the outcome is likely to be.
The perceived ‘dangers’ of vaginal breech delivery had their roots in the first half of the 20th century; the ‘assisted breech’ techniques of the day, which often combined heavy anesthesia, manual pressure on the uterus, and the routine use of forceps to force the delivery of the baby’s head, could not be further away from the normal, physiological birth that Block describes. One 1953 study found that “the more manipulation is performed and the earlier this manipulation is instituted, the greater is the fetal mortality and morbidity, to say nothing of maternal injuries.” But even in 1953, Europe was already far ahead of the US in their understanding of breech birthing – a full fifteen years earlier. In 1938, the German obstetrician Erich Bracht presented an analysis of 206 successful vaginal breech deliveries, without one fetal injury or death. Interest in the “Bracht maneuver,” essentially another version of “hands off the breech,” led to more than 30 trials in Europe and South America, all resulting in dramatically better outcomes for babies and mothers.
Not one of those studies was translated into English.
The result? In Europe, breech birthing techniques continued to improve, while in the US, doctors increasingly turned to surgery. By 1978, 60% of breech babies were born via cesarean in the US, and by 1990, that number was 85%. Andrew Kotaska, MD, a strong critic of the “breech = automatic cesarean” attitude of most American OBs, had to travel to Germany to gain experience in vaginal breech delivery; not one North American program existed to accommodate him.
As Dr. Paul Crane, one of the few doctors in the greater Los Angeles area who will (very rarely) attend a planned breech delivery within a hospital, explains, “The problem is,there’s nobody who’s going to get enough training to do vaginal breech deliveries in the modern world. Ask people who are my vintage and perhaps ten years younger, they’ve all stopped practice. There won’t be anybody really willing to do vaginal breeches.” Dr. Ronald Wu, another LA-area doctor who still attends planned breech births vaginally within a hospital, concurs: “There’s no more knowledge, the skill level is being lost. Not too many people will do a vaginal birth any longer, so the experience of seeing one is not available. And if it’s not available, how can you train anyone? It [vaginal breech delivery] is a dying art.”
It’s a dying art for one particular reason: the Term Breech Trial. Mary Hannah,MD, a well-respected obstetric researcher, led a randomized controlled trial involving more than 2,000 women carrying in breech presentation in 121 hospitals and birthing facilities around the world. The study, published in 2000 in the medical journal The Lancet, seemed to show a significantly higher chance of “serious neonatal morbidity” in breech babies who were born vaginally. In the wake of the study, The American College of Obstetricians and Gynecologists (ACOG) recommended that planned vaginal delivery of a breech baby at term was no longer appropriate.
The standard of care changed practically overnight.
Hospitals, insurance companies, and collective practices would no longer allow OBs to deliver a breech baby vaginally unless a woman arrived at the hospital with her baby already virtually out of the birth canal. Universities and teaching hospitals stopped training students in vaginal breech delivery altogether. As Dr. Crane explains, “In 2001, [ACOG] came out with a position paper, and that paper said that unless the baby just was falling out upon arrival, we should section all breeches.”
The problems with the Term Breech Trial became apparent almost immediately. Professor Marek Glazerman, a researcher from Israel, re-analyzed all of the data from the Term Breech Trial, and he was the first to say ‘we made a mistake here.’ As Dr. Stuart Fischbein explains, “they took a critical look at that study and found that they included a lot of things in there that shouldn’t be included, like unplanned breech deliveries, preemie breech deliveries, breeches with congenital abnormalities, and once they had corrected for those things they found that this isn’t the way it should be.”
In 2006, ACOG renounced their original opinion and declared that vaginal breech delivery was safe in the care of an experienced physician. “But by then the damage was done,” Fischbein says. “I don’t think anyone coming out of a residency program now has certainly done or necessarily even seen a breech.”
Only ‘renegade’ doctors and midwives were left to attend planned vaginal breech deliveries, which today almost always occur at home.
As Jennifer Block puts it, “it is independent home-birth midwives, some of whom practice illegally, who are left attending these higher-risk vaginal births. And they are surpassing physicians in experience and expertise in the delicate matter of vaginal breech delivery. What has become a lost art in the delivery room is kept alive in women’s homes by care providers who are largely unrecognized by the obstetric profession and even criminalized in several states.”
Dr. Fischbein gave up his privileges to attend hospital births and quickly became a leading force in the underground movement to keep options available for women. “All things being equal,” he says, “breeches should be born in a hospital setting because you have the ability to have general anesthesia should you have an emergency. The problem is all things aren’t equal.” He acknowledges that “there are risks to breech delivery, but the risks are minimal if you follow tight protocols. We all know that planes fly safely most of the time, but we only talk about planes that crash. It’s the same thing here. When there’s a tragedy in any birth it’s sad, but they can happen just as easily from a cesarean section in the hospital or a breech birth in the hospital, or at home for that matter.”
Dr. Fischbein is clear in his mission: “Ultimately whatever a doctor feels, or whatever a hospital committee or administration feels, the decision really doesn’t belong to them. It belongs to the individual patient, and [in the future] people in labor are going to be coming into the hospital breech and not knowing it, and no one is going to know what to do, and that’s going to be a real tragedy.”
If you are late in pregnancy and your baby is in a breech presentation, you do have options. You can seek chiropractic care, acupuncture or moxibustion (offered at Berlin Wellness, of course!) to try to gently turn your baby. You can attempt “spinning babies.” You can ask for an external cephalic version (ECV), which should only ever be attempted by a highly trained doctor and assistants in a hospital setting; it is often painful, but the commonly referenced success rate is around 50%.
If your baby will not turn, you can also seek out care from doctors willing to attend a vaginal breech delivery. Dr. Wu and Dr. Fischbein are your best options in Los Angeles. Homeland star Morena Baccarin hired Dr. Wu 39 weeks into her pregnancy, and she delivered her healthy, breech baby vaginally with his assistance. You do have choices. They are not always easy or cheap, and nothing is guaranteed – but at least for now, you still have some choices.
I hope that the demand for vaginal breech deliveries will lead more care providers to offer them to women. There are a lot of benefits and reasons why the birth process is the way it is, and when we bypass them, we lose a lot of the benefits. I’ve been busy recently creating a documentary film about what went awry with vaginal breech delivery in the US, and I consider that film part of my contribution to keeping the choice alive. But here’s the real truth: I’m a man. I have worked with many, many women who are carrying breech, but I will never be in that position myself (actually, that’s not entirely true – I was a breech baby, and my mother delivered me vaginally!)
It is up to you to stand up for choice.
It is up to you to demand more, and better, if you discover your baby is breech late in pregnancy. I hope that if you find yourself in that situation, you will speak up and make yourself heard – you want options. You demand options. Only a united chorus of women will bring the option of vaginal breech back, and I ask you to join that chorus – even if you do not want to birth your breech baby vaginally, or you are not carrying breech, stand up for choice. Be heard. Make it just a little easier for the next mother who finds herself with a breech baby in late pregnancy… you can do that! You, mothers and mothers-to-be, can do anything. In all my years working with pregnant women, I am inspired over and over by what my clients achieve. You humble me every day. So stand up for choices. Stand up for heads up!
Best,
Elliot Berlin | DC
Dr. Elliot Berlin is an award winning prenatal chiropractor, childbirth educator and labor doula. His Informed Pregnancy® Project aims to utilize multiple forms of media to compile and deliver unbiased information about pregnancy and childbirth to empower new and expectant parents to make informed choices regarding their pregnancy and parenting journey.
Find more informative media at InformedPregnancy.com and learn about Dr. Berlin’s unique wellness care at DoctorBerlin.com
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.