HOW TO TURN A BREECH BABY

This is part one of three part series examining how to turn a breech baby.  Part 2 will look at a Chiropractic Method called the Webster Technique and Part 3 will look at Chinese Medical approaches, including acupuncture and moxibustion.

One spring day in the 1970’s……

“Heidi, it’s a foot!”  Those were the first words proclaimed by my father at the sight of my unexpected tootsies as they shuffle-ball-stepped out into the world.  You see, I was born a footling breech, back in the day when such things were simply considered a way to be born, rather than the perilous, surgically warranted, lawsuit-waiting-to-happen that they are today.

I’m not implying that breech births are a breeze… by all means they are trickier than the average, low risk vertex (head down) presentation.  In addition to being challenging and possibly riskier than head down birth, most doctors these days are not very experienced in breech deliveries.  This is because of a decade worth of studies, position papers and retrospectives that went from proclaiming vaginal breech birth universally unsafe, to updated positions concluding that while it might be just fine to deliver a breech baby vaginally, no one is really trained to do it anymore. (source)

In fact, the most recent recommendation from ACOG (American College of Obstetrics and Gynecology) states that the decision to go forward with a breech birth should be based on the experience of the physician and institution.  Here in Los Angeles, where I practice, there are only 2 MD’s who deliberately deliver breech babies (some exceptions are made for twins when baby “b” is breech).  One of them practices in a home birth setting and the other one is nearing retirement, with no predecessor in sight.

So what’s a pregnant lady with a foot (or a bottom) in her pelvis to do?  I took some time to speak with Dr. Jay Goldberg, one of the finest OB/Gyn’s in the LA area, about the practice of External Cephalic Version (ECV).  I have had the pleasure of working with Dr. Goldberg on several occasions, both as a doula and as an acupuncturist co-treating patients for various conditions, including breech presentation, and I can attest to both his uber-exceptional bedside manner and way above average clinical expertise.  Here is what he had to say:

Me: In your opinion, what causes a baby to stay breech instead of turning head down? Is there something the mom-to-be could have done differently?

Dr. Goldberg: There's nothing [a patient does] to cause this.  Sometimes, the baby settles into this position and likes it, so they don't want to move.  Sometimes, there is an architecture to the uterus that doesn't allow the baby to turn.  Sometimes, there may be a short umbilical cord that is preventing the baby from turning to the down position.

Me: What do you recommend to your patients who have a breech baby and really want a vaginal birth?

Dr. Goldberg: [I say] we still have time to try different things.  You can make an effort to help the baby move through chiropractic work or acupuncture, and I have referrals.  We can check every 1-2 weeks and maybe the baby will turn on its own.  OR, I can try to turn the baby through a procedure called external cephalic version (ECV).  This procedure is done in the hospital usually between 36-39 weeks.

I say that there are 4 scenarios that can play out.  1) The baby turns and is not stressed out.  We'll send you home until you go into labor.  2) The baby turns and then shows distress and we'll keep you at the hospital and proceed with induction. 3) The baby does not turn but there is no distress.  We send you home and schedule a C-section for > 39 weeks.  4) The baby does not turn and shows distress.  We proceed with a C-section.

The procedure is performed > 36 weeks because we prefer not to deliver prior to that, and if the ECV results in fetal distress and we have to deliver, we prefer that the patient is farther along.  Our group typically does them around 38 weeks.

Me: What does an ECV entail?

Dr. Goldberg:  An ECV involves the patient going to the hospital and being monitored for 30-60 minutes.  An IV will be inserted and medication is administered to attempt to relax the uterus.  Sometimes an ultrasound will be performed to document the fetal position as well as the fluid around the baby.  Two physicians with then place the patient in the supine position (completely flat on her back), pour mineral oil onto her abdomen, and then physically press on her abdomen to attempt to turn the baby to the head down position.  2-3 attempts will probably be made.  They may try a forward somersault or a back flip of the baby.  The ultrasound machine will be used frequently to check the fetal heart tones and the fetal position.

Me: Is ECV painful?

Dr. Goldberg: Attempting to turn the baby is usually described as quite painful because the physicians will need to push hard to get the baby out of the pelvis and flipped to the vertex presentation.

Me: What is the success rate for ECV?

Dr. Goldberg:  The success is approximately 50/50, but I usually say 60/40 success with multiparous (women who’ve already had at least one baby) women and 40/60 with primips (first time moms-to-be).

Me: Does your group ever do breech deliveries?

Dr. Goldberg: Our group does not deliver singleton (one baby) vaginal breech.  We will deliver a second twin who is breech, but under certain circumstances

Me: Thank you for taking the time to speak with me today.  Your answers have been really helpful.

To ECV or Not To ECV… is that still your question?

I must admit that it would still be mine, too, were I to find myself in such a quandary.  At the end of the day, it’s a really personal choice, and you won’t get any judgment from this Bao either way.  I think it’s important to consider a few things:

1)   Acupuncture, chiropractic and other types of body work can go a long way to loosen up the pelvic muscles & ligaments, which may make it easier for the baby to turn.  I recommend starting these protocols by 32 weeks.  Much of the time, the baby will turn on it’s own and an ECV will never come into play.

2)   If you reach the 38 week mark and you’ve tried these other methods to no avail, you might just want to give ECV a try.   It’s important to keep in mind that an ECV could result in the birth of your child that day, so plan accordingly.

What if my ECV doesn’t work?

It’s so important to remember that, at the end of the day, we cannot control our childbirth.  All we can do is set it up to be the birth me imagine, and then let go.  After all who are we, mere mortals, to determine what’s best for anyone?  Of course, very few wish for a surgical delivery of their baby, but at the end of the day, we must be present to the medical model we are all a part of, and accept that which we cannot change.  While it is my sincere hope that someday, in the near-as-possible future, vaginal breech birth will go back to being just another way to be born, I understand that we are some way from that reality.    Talk to your doctor about your wishes, seek out medical care in your community that supports breech birth, and encourage the few who perform it to train others.  Be the change, even if your baby won’t make the turn.

About Dr. Goldberg:   A Fellow of the American College of Obstetrics and Gynecology, Dr. Jay M. Goldberg earned his medical degree from the Medical University of South Carolina in 1996 after completing his undergraduate education at the University of California-San Diego. He completed his internship and residency training at Kaiser Permanente in Los Angeles. As a founding member of the Cedars-Sinai Center of Excellence in Minimally Invasive Gynecology, he has been at the forefront of laparoscopic and hysteroscopic surgery. Dr. Goldberg has been awarded the Cedars-Sinai Obstetrician of the Year award and was recipient of the Golden Apple Award-given by the resident physicians he teaches. His charity work includes: Autism Speaks, Hirshberg Pancreatic Cancer Foundation, First Ladies Initiative Birthing Center in Namibia, and Hole in the Wall summer camps.

He can be reached through: www.womenscareofbeverlyhillsgroup.com