First written in 2020, this post has been refreshed and republished.
I started my career as a specialist obstetrician a few months after the Term Breech Trial was published (Hannah, et al., 2000). I made a determined effort during my training to acquire the knowledge and practical skills I needed to support women during their vaginal breech birth and worked hard actively maintain those through my clinical career (mostly through teaching and simulation practice). It wasn’t always easy and at times I was criticised by my obstetric peers for persisting. (Including an APHRA investigation where the complainants used this blog post as proof that I was “dangerous”. Being free of my registration means I no longer give two hoots about whether this post leads to obstetricians wanting to come after me!)
A phrase I heard more often than I cared to over the past 20 years was some version of “I don’t do vaginal breech birth”.
Let’s look at what is going on in that statement and see why I think it is morally reprehensible for an individual practitioner or maternity service who provides birth care to say this.
Looking from the woman’s perspective
When you are pregnant you don’t get always get a choice about whether you get to “do vaginal breech birth”. Most of the time, your care provider will recognise that baby is breech well before labour starts, discuss your options, and develop a plan. Which is great. This might include lining you up with a practitioner who has breech birth expertise. But that’s not the case for all women with a breech presentation.
Why?
You have no control over whether or not your baby will turn bottom down before labour starts. You have no say in when or where your labour starts, or in how quickly it progresses. As a consequence, every day some women find themselves in need of a practitioner who can competently support them when it is simply too late or just plain inappropriate to do anything other than give birth to their breech-presenting baby vaginally. If, for example, you arrive at the hospital in preterm labour at 36 weeks, fully dilated, with a breech presenting baby beginning to make an appearance, you deserve to be cared for by someone who knows what to do if the birth gets a bit complicated.
What people are really saying when they say “We don’t do vaginal breech birth”
When a practitioner, or an entire maternity service, makes the statement “we don’t do vaginal breech birth”, what they are really saying is that at some point they decided to not invest in developing a set of skills required by a competent clinician who provides birth care. Because birthing women can’t opt out of vaginal breech birth 100% of the time, neither can clinicians. “I don’t do vaginal breech birth” is equivalent to saying, “evidence shows you are likely to have a better outcome in this unplanned and urgent situation if I had learned and practiced breech birth skills. But that would take me outside my comfort zone, and so I decided instead that it was OK for you to face the consequences of my lack of skill”. Ethical care provision doesn’t look like that.
Some pregnant women do know in advance that their baby is breech, weigh up their options, and make a decision that vaginal breech birth is right for them. When their care provider then says “I don’t do vaginal breech birth”, this is equivalent to saying, “I don’t consider your decision to be valid, so I am going to back you into a corner where your options are to agree to a caesarean birth, travel to somewhere else where you can get skilled care at your own expense, or give birth without a skilled attendant. And oh, by the way, if you pick the last option and something goes badly, it’ll be your fault, not mine.” Respectful maternity care isn’t picking the women that you agree with and ignoring the rest.
Know better and do better
What happens in labour and birth is by nature unpredictable. “I don’t do vaginal breech birth” is not all that different to saying, “I don’t do instrumental birth” or “I don’t do shoulder dystocia”. I recommend you either commit to having the most comprehensive skill set you can for every possible eventuality so you can provide good care in all situations, or you get out of the birth room.
If you are a practitioner providing labour and birth care, or manage a service that provides birth care, and you want to do better, there are options. Midwives: I encourage you to reclaim these skills – they are in your scope of practice! Do some research about training courses in your location. Set up a local network of interested practitioners and educate yourselves and others and practice in simulations regularly.
Want to learn more about fetal monitoring for your birth?
Planning your birth is an important part of getting the great birth you are dreaming about. Access to accurate information about fetal monitoring options for labour in the current maternity care system is a bit hit and miss. Your maternity professional may or may not know the evidence, and they may or may not make it clear that this is your decision to make – not theirs.
One way to prevent getting railroaded into a birth plan you don’t want is to know your options and communicate your decisions clearly and confidently. This course – Fetal monitoring: Informed decisions for your birth – will make sure you don’t miss out on the knowledge and communication skills you need. Fully online, with instant access that lasts for the life of the course.
Evidence and support for your decisions
References
This post was prompted by reading this commentary, which is free to read: Leeman, L. (2020). State of the breech in 2020: Guidelines support maternal choice, but skills are lost. Birth. doi:10.1111/birt.12487
Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., Willan, A. R., & Term Breech Trial Collaborative Group. (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet, 356(9239), 1375-1383. https://doi.org/10.1016/S0140-6736(00)02840-3
Categories: Breech birth, Reflections
Birth Small Talk 
Thankyou for this birthday gift Loving your work
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I’m confident you’ll be sharing this gift with others!
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Hell yeah! I was not satisfied with the local maternity services response, which felt effectively ‘we forgot to train the midwives, but we have remembered to train the obstetricians’. I did not appreciate being laughed at when I reiterated that I intended to have my baby at home. Fortunately I was able to get support from independent midwives Mary Cronk and Lynn Walcott. It was worth every penny, but such excellent care should not be restricted to those who have the knowledge to seek it out and the money to pay for it.
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You are quite right. Every woman should be able to access safe maternity care.
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Great article Kirsten. I have often thought along those lines.
If a midwife in birth suite said that the women she cares for can’t have an epidural because she felt it was not safe so she won’t ‘do’ them, she wouldn’t last long there.
Obstetricians, as you do, need to have a full range of skills and have a desire to care for women in all situations.
Chhers
Judy
PS. I will never forget our first breech together.
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Neither will I!
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Thank you Kirsten — for your kind words and for doing the right thing. ❤️
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At some point during our careers most privately practicing midwives, and even hospital midwives, will be confronted by a surprise breech, or a breech baby that isn’t waiting for anyone, or a mother who simply isn’t going to line up for a Caesarean. It has happened to me more than once, in hospital and in the community. We need to know what to do – which is why most of us have done courses and refreshers over the years to keep our skills up. Mothers have a right to expect this of anyone who calls her/himself a birth professional.
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Wish there were more OB like you around that’s for sure. My first baby was breech – and just like that my OB was booking me for a c/section – no options / no choice – until I started asking questions, I did my research – I pushed back – until she finally said “I haven’t ever attended a breech birth, so I am not comfortable with it”. I changed providers at 39 weeks and had a beautiful natural vaginal breech birth.
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I’m pleased you were able to find a provider who supported your decision Jackie
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Thank you for sending this message into the world! Better breech training and appreciation for this presentation is absolutely overdue. I was very fortunate to have a wonderful vaginal breech birth supported by my private midwife, but I know many families don’t have the same choices available to them due to care providers’ lack of skills. I’m aware that https://www.breechwithoutborders.org/ provides worldwide breech training, research and advocacy too 💙
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Thanks for sharing Shay – the more resources the better!
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So good to hear your thoughts on this Kirsten. How lucky we are to have such a progressive, skilled and woman centred clinician in our community. I just listened to an interview with the founders of Breech without Borders, the work they are doing in (Re)education and Training for supporting physiological breech birth is amazing.
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