The Undervalued Art of Vaginal Breech Birth: A Skill Every Birth Attendant Should Learn

Little did I know, when I witnessed my first vaginal breech delivery at a small county hospital in middle Tennessee in 1972, that I was seeing a physiological process that was being rapidly phased out in the US. The birth was to a mother having her first baby. She had planned a homebirth, with me as her midwife. I discovered in early labor that the baby was a frank breech (buttocks first, legs straight up), and my training had not included how to deal with such a presentation. Off we went to the hospital. When we arrived, no one there even considered a cesarean section as an option. At the time, I didn’t know anyone who had had a cesarean. This isn’t surprising—30 years ago, the cesarean rate in the US was a little more than 5 percent, and then as now, women with breech presentations accounted for only 3 to 4 percent of all births.

Over the next two years, six more breech babies in our practice were vaginally born at that same hospital, and a surprise breech fell into the hands of my midwifery partner, Pamela Hunt, at the mother's home. There was never a hint from any of the several physicians involved that a cesarean might be better or safer for the baby. At our local hospital, it appeared that all physicians attending births, whether they were family doctors or obstetricians, were expected to be competent in the art of vaginal breech birth. It was the policies of other US hospitals that later made us aware of the trend taking place in the rest of the country vis-a-vis breech birth—the increasing use of cesarean section, without a trial of labor.

During the mid-1970s, one of the doctors in our area—our mentor, John O. Williams Jr.—taught us midwives how to attend vaginal breech births at home. He had had to provide that service for many years to the Old Order Amish community, population 5,000, which meant caring for Amish women, some of whom had 15 babies or more. When he passed part of his practice on to us midwives, he knew that the women in the Amish community would now and then continue to need midwives who were expert in the art of breech delivery. During this same period, women from different parts of the country began applying to come to us for vaginal breech deliveries, making me aware that some doctors were calling for routine cesareans for all breeches, no matter what this meant for the women involved.

The first call for mandatory cesarean for breeches in this country actually had come in 1959, in an article written by Dr. Ralph Wright. Wright provided case studies of three stillbirths after vaginal breech deliveries that had recently taken place at his hospital. Each was a forceps delivery, with the mother under general anesthesia. What Wright left out of his argument was any recognition that other services were apparently able to handle breech deliveries without fatal injuries to babies. He never commented on whether there had been any serious or fatal injuries to babies after cesarean sections. ₁ Wright's argument boiled down to this: The recent bad outcomes from attempted vaginal breech deliveries at our hospital demonstrate that the process of breech birth is inherently flawed; because of this, all breech babies should be surgically delivered. At no point did Wright entertain the possibility that a conscious mother, better obstetrical technique, and less anesthesia might have produced better results. Never did he examine what the consequences might be if the next generation of obstetricians never had the chance to witness a vaginal breech birth.

Wright's article came only three years after the publication of two major articles on a large series of breech births at several major hospitals at which the cesarean rates for breech ranged between 6.8 and 18.8 percent. _2,3 One of the authors, Dr. Goethals, pointed out that maternal deaths were more likely to occur after cesarean than after vaginal birth, and he offered evidence of this fact gathered from his hospital. Wright, in making his call for the elimination of vaginal breech delivery, had built his argument partly upon the alleged safety of the cesarean. As evidence, he cited a single study that included 1,826 elective cesareans with no maternal mortality, ignoring the case of maternal death (from pulmonary embolism) previously reported by Dr. Goethals in his small series of elective cesareans for breech babies. In fact, no study of as few as 2,000 women can be regarded as significant when looking at the important subject of maternal death and injury. At least