Obstretricians debate whether Caesarean section is always best for breech babies

Types of breech births include, from left, complete, footling and frank.
Types of breech births include, from left, complete, footling and frank. (ADAM)
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By Tracy Sutherland
Special to The Washington Post
Tuesday, January 5, 2010

About 32 weeks into her first pregnancy, Christie Craigie-Carter's obstetrician told her that the baby she was carrying was stuck in a bottom-down position -- a breech baby -- and that she'd have to give up her dream of a natural delivery and have a Caesarean section instead.

Desperate to avoid surgery, Craigie-Carter said she wanted to deliver the baby naturally anyway, but her doctor told her that such a procedure was simply too dangerous. "She said I wouldn't find a obstetrician on the East Coast who would deliver a breech baby vaginally," recalled Craigie-Carter. When she asked her obstetrician to try to turn the baby into a head-down position by manually manipulating her abdomen, Craigie-Carter was told that such a maneuver might endanger the baby's life by causing the placenta to separate from the uterine wall.

Craigie-Carter went into labor just before her due date and her son Joshua was delivered -- via C-section -- giving her an adored and healthy baby but also lingering regrets that she hadn't been able to even try to deliver him naturally.

Her experience highlights a debate over whether breech babies should always be delivered by C-section or whether there are cases where a natural delivery is a safe option.

In the United States, such babies are routinely delivered by C-section, in large part because of an international study, published in 2000, that found breech babies faced greater risks when delivered naturally. But the issue has received fresh attention following the decision last June by the Society of Obstetricians and Gynaecologists of Canada to reverse past opposition to natural deliveries and suggest that "planned vaginal delivery is reasonable in selected women."

The American College of Obstetricians and Gynecologists remains firmly opposed to vaginal deliveries of breech babies, warning of the dangers of the head's becoming trapped inside the mother; of neck injuries and paralysis if the baby is extracted incorrectly; and of pressure on the umbilical cord that could shut off blood supply to the baby.

Breech babies account for between 3 and 4 percent of full-term pregnancies worldwide, according to the 2000 study.

There are three typical ways in which a baby presents as breech: frank (with the bottom down and feet up near the ears); complete (with knees bent and feet near the bottom); and footling (with one or both feet pointing down toward the birth canal).

"You may get into a situation where the baby is stuck, and I've been there, and it is a true obstetric emergency," said Helain J. Landy, head of the department of obstetrics and gynecology at Georgetown University Hospital. Landy said she attempts to turn breech babies into a head-down position using external manual manipulation, but if that fails she "would probably recommend a C-section."

She said that she is "a proponent of what the patient wants as long as it makes sense in terms of her safety and the baby's safety." But because the majority of her patients are first-time mothers, often having had fertility treatments to get pregnant, Landy does not get much call for delivering a breech baby vaginally. She hasn't delivered a singleton breech baby naturally for 14 years, although she has delivered breech babies who were the second of twins where the first had come out in a normal head-down position, opening up the birth canal in the process.

"With experience comes a little bit of hindsight, and maybe I'm just not as much of a cowboy as I might have been when I was younger, but I really want to get a healthy baby and a healthy mom," Landy said. And given that breech births are trickier, concern about medical malpractice suits is a big factor behind the doctors' widespread reluctance to perform natural breech births, she said.

Yet some obstetricians believe that breech delivery is reasonable in certain cases and bemoan the loss of this skill among obstetricians trained today.

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