Delivering a Breech baby
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STEPHANIE GLOVER: Fetal presentation and position are often overlooked until an expectant mom is told that her baby is breech. What does breech mean? What are the delivery options for breech births? Today we will be discussing breech presentations and late pregnancy and childbirth.
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Stephanie Glover: We have a special format today on Preggie Pals. We are learning all about breech presentations and delivery options for breech babies from not one but two experts today. Dr. Stuart Fischbein, a fellow of the American Collage of OB/GYN and Dr. Elliot Berlin, doctor of Chiropractic.
Dr. Fischbein has collaborated with midwives for thirty years and currently supports women with informed birth choices in the home setting. Dr. Berlin is a prenatal chiropractor, child birth educator and labor doula. He is also an executive producer of the film ‘Heads up- the disappearing art of virginal breech delivery.’
Welcome to Preggie Pals gentlemen.
DR. ELLIOT BERLIN: Thank you.
DR. STUART FISCHBEIN: Good morning.
STEPHANIE GLOVER: So, Dr. Fischbein, let us start by explaining what breech presentation means.
DR. STUART FISCHBEIN: Well breech presentation means that the baby is in a bottom down position as opposed to the normal presentation where the head is down. There are many different forms of breech presentation, most common which is something called Frank Breech where the baby's feet are up by the space and complete breech where the baby is sitting on the u-turn position almost like ready to do a summersault. There are other variations of that position which is incomplete breech or [inaudible] breech, those are much less common. Frank breech babies is certainly a little bit more common than the others.
STEPHANIE GLOVER: Okay, I was going to ask at what point in pregnancy is a baby most likely to settle into that breech position and stay there.
DR. STUART FISCHBEIN: I am going to answer that then I want to go to the earlier statement about that
STEPHANIE GLOVER: Sure
DR. STUART FISCHBEIN: Breech is not concerning to me until maybe you reach 32 to 34 weeks at which point if the baby is still breech then we begin to minimally offer suggestions on how we can get that baby to be turn. The main reason that we offer this suggestions is because breech skills are disappearing and the only action available for delivery is cesarean section yet this is the most expensive in the country. If we had skilled practitioners then the baby decides to be in breech we won’t have this panic that goes on in the last couple of months of pregnancy to try and get that baby to turn.
STEPHANIE GLOVER: Because you start really paying attention to breech presentation around thirty two to thirty four weeks is it just less likely for them to turn because of there is not enough room for them or what?
DR. STUART FISCHBEIN: Yes I think that the best part of it is they are in that position for a while they settle down and then perhaps [inaudible] gestation it gets a harder to do and so when they are smaller and there is more fluid in relation to the size of the baby it is a little easier to encourage that baby to turn.
STEPHANIE GLOVER: Sure, to swim around a bit.
DR. STUART FISCHBEIN: Let’s hear what Dr. Berlin has to say
STEPHANIE GLOVER: Sure
DR. ELLIOT BERLIN: Yes, I mean Dr. Stuart is definitely out of the ordinary when it comes to an obstetrician. In my experience most of the OBs that I work with don't really check for breech until 35, 36 or 37 weeks, and I think it is primarily because there is nothing that they can do about it until 37 weeks.
The medical approach to getting breech babies to turn head down is not typically done before 36-37 weeks. The other part of it is because the baby's got great chance of turning spontaneously earlier than that. I agree, I have a little campaign on Facebook for a while check for breech at 32 weeks and usually obstetricians or midwives sometimes do at 32 or 33 or 34 weeks they start wondering about the position and it is true, at 32 weeks there is a greater than fifty percent chance the baby will still turn even if we don’t do anything. But the thing is number one, there is a lot you can do at 32 weeks to encourage the baby into the ideal position so our patients that we see at 32 weeks, we have more that ninety percent success rate at getting them head down at that point rather than the fifty percent that seems more typical.
So, at 32 weeks I will tell our patients there is no red flag at this moment but there is a pink flag. Ninety percent or so of babies are head down already at that point and now is a good time to start exploring the things you can do to encourage the baby to get into that head down position and by 34-35 weeks I will definitely be looking at if the baby is still breech, options for delivery in case the baby doesn’t turn into the head down position.
STEPHANIE GLOVER: Since you are a prenatal chiropractor, what are some chiropractic techniques to encourage a breech baby to flip?
DR. ELLIOT BERLIN: There is a technique called the webster technique that dates back to the 1970s of chiropractor of Dr. Larry Webster and it is not a breech specific technique, it has become known that because many babies turn into the ideal position after receiving it. Dr. Webster was sort of looking at the pelvic paradox, how come sometimes you have a really roomy pelvis and relatively small baby that gets stuck on the way out and sometimes you have a more complex smaller pelvis with a larger baby and they come through very smoothly.
There is a field of pelvimetry trying to measure the size of the baby and the size of the pelvis and sort of guessing which babies will make it through and which babies will not. Often over the years, we have done that in different ways using x-rays or more recently using ultrasound and now MRI. We get these really clear beautiful pictures but they don't tell us very much, babies that we think won't make it through surprises and come through sometimes really easily than babies that seem like they are a great fit get stuck.
In the 1970s Dr. Webster was wondering what is the difference between a baby that will make it through and a baby that won’t. One of the factors that nobody is really looking at in pelvimetry is a function. We look at it from a muscular skeletal perspective, we look at trying at giving birth as trying to squeeze a large basketball through a small rubber band and if that rubber band is elastic and stretchy and the basketball is not overly inflated then functionally it is not a problem. However, if the basketball were to be very hard and inflated which a baby's head isn't, and the pelvis was rigid, didn't move or stretch at all, it would be very hard to get that basketball through the rubber band.
The webster technique is a chiropractic approach to looking at the joints of the pelvis and the ligaments of the pelvis and making sure that they are functional, that as the baby tries to come down they are not tight and rigid. If they were and if there is a lot of tension down there and there is a significant amount of amniotic fluid then why would babies choose to be down there? They would go under the rib cage where there is a lot more space but even if they were trying to get head down, it would be difficult to do in that rigid situation.
The chiropractic technique is an analysis of the joints of the pelvis making sure that they are functional and moveable like they are supposed to be so that when the baby tries to move they accommodate this movement. I added to that a massage technique, I have a massage and chiropractic background, and since the pelvis is muscular skeletal in nature, the chiropractic portion is addressed by the webster technique and we do this uterine release technique where we massage and release the muscles of the lower back hips and pelvis.
Everybody leaves our office with a much stretching and elastic rubber band than they came in with and it makes it more inviting for the baby to be able to come head down and it makes it much functional for them to be able to get head down.
STEPHANIE GLOVER: Sunny I can't remember and I know we have talked about chiropractic's in the past when you were pregnant did you receive chiropractic care?
SUNNY GAULT: No, I did not. I really wish I would have especially towards the end when it starts feeling really uncomfortable. I know that it is probably good to have it though out but when you start into that third trimester especially when I was pregnant with the twins, I really think that it could have helped. I only went up to 35 weeks with the twins so it was not a full term, but I totally believe in the benefits of it and I wish I would have invested more time in it.
DR. ELLIOT BERLIN: The only way we can fully tell is if you have another set of twins
SUNNY GAULT: Which is not going to happen.
STEPHANIE GLOVER: I received some chiropractic care towards the end of my pregnancy because I was going for a VBAC and my first who ended in a C-section was sunny side up. We did not realize until labor so I was really trying to pay attention to fetal positioning and doing what I could so I did see a chiropractor who practices webster technique and I was able to have my baby the way I wanted and she ended up still working on turning throughout labor and came out with a sideways con but we worked it out. So, I definitely do see the benefits.
Now, Dr. Fischbein if chiropractic care does not seem to help babies settle into a favorable position what can be done maybe on the OB/GYM side of things to encourage baby to turn?
DR. STUART FISCHBEIN: Trying to get into the OB/GYM side there are other things that go on with the chiropractic care than we often just find with a breech baby to work from. Trying things like acupuncture, this is often a technique that helps babies to turn their head down. They also combine that with something called moxibustion which is burning moxa on the toes of the mother, I am not exactly sure how that works.
DR. ELLIOT BERLIN: I don't know if anybody is exactly sure how that works, there are both Eastern and Western studies on that that have been published. There is at least one in the journal of American Medical Association and it also concludes that we are not quite sure how it works. Statistically, it does seem to work. It typically makes the baby moves spontaneously, there points that we are warming up in the toes are uterine points and so we use this burning herbal stick called a moxan stick and it heats up those points and the uterine walls start to relax and the baby starts to turn around in there.
The combination of using chiropractic and massage to loosen up and create a more functional space and then using Chinese medicines to stimulate naturally more movements in that space is very synergistic and that is how we get most of our babies out without touching them.
DR. STUART FISCHBEIN: Another thing we can do is just that they go to website www.spinningbabies.com and see the exercise that they are supposed to there about invasions maybe in the swimming pool doing some head stands or some gentle summersaults in the swimming pool where you are in a zero gravity environment. Those are some things that we often suggest
DR. ELLIOT BERLIN: I could add to that that hypnosis and meditation can be very helpful. Often times there is internal tension because sometimes you are just holding on to some things, sometimes you are just anxious or fear and this can be very powerful. Sometimes on a table wall while people are meditating and getting into a more relaxed place you can just feel everything relax and the baby responds and moves around more with that as well.
STEPHANIE GLOVER: I can actually completely agree, I did use a lot of visualization for my VBAC in pregnancy, a lot of meditating on it and just visualizing my birth, visualizing what my baby working with my body and I will tell any mom who has any sort of fear or anxiousness around her birth to do that. I really believe it has helped.
DR. ELLIOT BERLIN: My wife used to listen to a meditation like that during her first pregnancy towards the end of the third trimester to help decrease any fears about birth and I used to listen to it too and it also helped me relax and there is a lot of breathing then starting to visualize each muscle group relaxing. The first time I heard it and they got to now 'looking inside your uterus,' but it was relaxing for her
DR. STUART FISCHBEIN: Usually [00:16:25] is something that I do because as the hospital birth practitioner when it gets to somewhere all other things are not working and then the possibility is to do an external cephalic version which is a hand-on technique to try and turn the baby, and that is usually done in the hospital described that in just a second but the way I do it because I don't use meditation, I often will have a woman spend at least thirty minutes prior to the procedure with a medical therapist to put her in a relaxed state, I do believe there is pretty good evidence out there that this increases the success rate by just being totally relaxed.
In the hospital setting however when you do a general external cephalic version it is considered to be a major procedure with a small risk of having the baby go into some form of stress, if you know that is going to happen and they do this with the operating room team standing by, often they will even put an epidural in place they will use something called trebudeline which is a medication to make the uterus relax but also make your heart raised. It is always a very exciting and provoking to be in that setting and my own personal experience that can be used to having relaxed and be able to succeed.
I don't like the use of an epidural because it has become common as it removes all feedback from the mother as part of all this trying to turn around. I think that is something that is hands on and was common when I was being trained, it is something that has disappeared now and we are into more technology now. I will often see a patient who has breech at 37 or 38 weeks and I will ask permission to examine the mother and I would put my hands on her belly and she will say what are you doing, and I will say I am just checking the position of the of the baby and she would say oh how often do we do that before, I mean she would be 37 weeks pregnant and you have never touched her belly, because every time she comes she would get an ultrasound or something of that nature.
As soon as the [inaudible] can be very successful, it is much more successful in a complete breech baby than in a frank breech baby and it is more successful when you have already had a baby what we call altiperus than a mother that is pregnant risk.
In my practice specifically, if a woman is pregnant and she is breech and the fluid level is not pretty high we have the option of not doing a diversion because they have the option of doing a delivering virginally. I spoke briefly earlier that there is a desperation that comes into play in most of our country about breech and if that baby does not turn or is not turnable, then they are going to end up with a C-section which puts a lot of pressure on this moms.
STEPHANIE GLOVER: When you are talking about the external procedure when is that typically done in pregnancy? I think you mentioned maybe 37 weeks
DR. STUART FISCHBEIN: Yes it is around 37 weeks because at 37 weeks we have to remove the baby least the baby gets into stress or distress. You don't want to have a premature baby and also the ratio of the size of the baby to harmonic fluid at 37 weeks is probably better that it would be at 38 or 39 or 40 weeks but that does not mean that his head is down and suddenly they come in at the 40 weeks visit the baby is breech
STEPHANIE GLOVER: When we come back we will go over the delivery options for breech babies.
We will be right back
STEPHANIE GLOVER: Welcome back, today we are talking about breech presentation and childbirth options with Dr. Stuart Fischben and Dr. Elliot Berlin.
So it seems when that when a baby is a breech it is a common practice for moms to schedule C-section, we talked about that earlier. So Dr. Fischbein why is that?
DR. STUART FISCHBEIN: Well everybody who is listening should go and watch Dr. Berlin's ‘Head – the disappearing act of breech deliveries'. He probably explains really well but it is a skill that is basically not being taught anymore.
Sometimes I feel like [00:20:22] think about which position would you lie in and things that you are doing and they are not doing. They are busy out there recommending that all women be induced at 39 weeks more than teaching skills that may not obstetricians need such as concepts which delivery, but the real reason that breech disappeared was, it was already on the downside anyway because it is inconvenient. It is much more convenient to do a cesarean section for breech within a scheduled time generally.
A sessional paper that came out in 2001called the [00:20:55] which initially shown that breech babies birthed by cesarean section had [00:21:00] because in my opinion that is not the moral by which doctors wanted to practice because everything was breech about liability it was the option worldwide and breech teaching in hospitals and later obsolete and almost disappeared.
A couple of years later they looked at it and they realized that there was a lot of problems with that and they treated to [00:21:25] recommendations that [00:21:27] should be done and hidden knowledge in plenty of studies think that breech delivery has turned into a very safe and reasonable [00:21:36] any more. If you know how to do it then you should be doing it and there is no outcry from residents in medical students and provide but the public basically doesn't know that breech has an option. It seems as if it permissive now that if a woman is breech her immediate [00:21:53] position is necessarily C-section.
STEPHANIE GLOVER: Right, so when you say virginal delivery is an option how would a woman go about attempting this when it seems so one sided towards C-section:
DR. STUART FISCHBEIN: [00:22:04] skilled in breech delivery and that is even becoming more. They can tell [00:22:09] for instance, meanwhile, it requires skill in breech delivery [00:22:14] in 2014 they passed a law in health that made it illegal to [00:22:18] breech delivery. This is not based on anything scientific, this is based on politics [00:22:25] in my own opinion. If they have to find a skilled practitioner, once they find one then there is a criterion that the actual breech delivery for mother and baby is safe in both short and long term then the necessary[00:22:39]
STEPHANIE GLOVER: Dr. Berlin with your experience as an educator and labor doula what would you say to the mom who hopes for a virginal birth of a breech baby, what steps does she need to take to make that a likely option?
DR. ELLIOT BERLIN: You can take out the breech baby in that question increasingly. The policy that we have on childbirth, the fear that we instill in women about childbirth having to go in terrified. We also have our provider's terrified doctors and younger resident's in particular just look at the whole thing as a train wreck waiting to happen. Once a doctor said this if everything I learned about flying in an airplane I learned from watching TV, movies, newspaper headlines or from friends who had terrible near death experiences in airplanes you'd never get me on an airplane.
I would think that every is either going to have engines failure and fall out of the sky or be hijacked or have snakes on it. That is what we have done with childbirth we have made both the providers and patients so incredibly terrified of the whole process and when you are in fear, everything, all your body reacts to fear by going to fight or flight mode. Getting ready to run or fight for survival and all the blood flow and nerve flow that supposed to be going to your core, to the muscles but also the organs of the core are going to your arms and legs and they leave you incapacitated both with fear and physiologically not having the tools you need to be able to labor.
So you can almost take out the breech out of that question. How do you have a virginal delivery these days it’s getting harder and harder and the statistics show that it’s now one out three babies is born by cesarean. I would say that these tips almost apply to everybody who would like to give themselves normally a good shot out of virginal birth but like an enjoyable experience, a meaningful experience. The one that is specific to breech is what we mentioned earlier is check early, check at 32 weeks, don’t be terrified at 32 weeks, it is just a pink flag but learn what your options are at 32 weeks and some of them like the chiropractic, acupuncture, the massage and a homeopathic positions which you can start at 32 weeks safely.
The second thing I would say is when you pick your provider if you are going to have virginal birth an empowered birth of any kind, pick a provider who is on the same page us you. Sometimes I see people just open up the insurance book and pick a provider by throwing a dart at that book as long as they are an insurance then they will go with that provider but often times you are not on the same page at all with that provider.
They may not support natural birth virginal birth in general certainly not if you start to go outside the textbook a little bit for example if you have already had a cesarean and you want a virginal birth if your baby is breech or if you have twins. You need to know those things a head of time so you don't have to panic in the final moments of your pregnancy. Certainly with breech, there are still and we have a website that hosts the film is called heads up film.com and we have a growing list of providers in the United States and Canada who still attend a breech birth, who still offer that option when you meet certain safety criteria.
Those who are good practitioners to within general so that when you get to the end of pregnancy it doesn't matter. They are very much used to people switching [00:25:56] literally because they are the handful who are left to have the skills to safely deliver breech babies.
Then the other thing I would say is consider the various options, the natural means of getting the baby into the ideal positions and medical things that doctors do talk about the external version for getting the baby into a head-down position and figure which one makes sense to you and explore them and go for them sooner than later.
Finally, I would just say also to consider the cesarean. I don't by any means that cesarean is a bad technique. I think it is a great miracle technique that was are able to offer in medical [00:26:34] to safely and quickly get a baby out surgically when we need to. It is a wonderful thing and if it was used sparingly when it was needed to be used or when someone really wanted it to be used then I think we would all be praising the cesarean. The problem is one in three is overuse and when you overuse the medical technology we end up doing more harm than good.
Just like CPR if I do it on someone who is not pulsing or breathing even if I break all the ribs I'm still a hero but if I just take a random person put him down and start doing CPR I am going to go to jail for assault and battering even though it's the same technique, It's the wrong person I end up doing more harm than good. Those are my things that I educate when I teach childbirth education or I get referrals. I see about three breech visits a day in my office even before the movie came out but now even more, and that's what I tell them whether they come in at thirty-two weeks or thirty-nine weeks, here are the things that you can do naturally and here are the things you can do medically, here are the providers who can help you if the baby doesn't turn and usually it would have gone a lot better if they would have had that information significantly earlier.
DR. STUART FISCHBEIN: One of the thing I have learnt in my training experience in this process is that if you have a skilled practitioner and if your baby needs the standards criteria for a healthy breech delivery, I always tell my clients that breech delivery succeeds or fails for the same reasons that virginal babies succeeds or fails. There is no real difference in the labor pattern, there is no significant difference in the way they dilate or the pushing stage. People's biggest fear is that the head will get stuck. That is not the case if you have a skilled practitioner the reason being that surprisingly if you put the legs together its actually bigger than the head. People think that the head is the biggest part and if it comes out last and it is going to get stuck and the truth is you do something called anti premobilization which is your head and my head were stuck in a log I think we would be panicking because we might think we are going to choke or suffocate because our heads are stuck in a hole.
Babies are not using their [00:28:48] breathing air because the head comes out last does not make it more dangerous for the baby if you know what you are doing.
[00:28:56] the sad part is that we have academic programs that we haven't met in. I have said this a thousand times there are people that are going to show up in the emergency room or show up in the breech but partly speaking out of the Virginia and the tragedy Is going to be If you don't know what to do and they are going to pull out the baby or they are going to push the baby back at the side and they are going to do a c- cesarean section.
which Is going to cost more damage to the mother and baby than It would just lift their hands and let the baby come up by itself and the only way we are going to give back Is to bring back to the training centers which in breech centers were in big city's we have a center where everybody is breech while you can come and evaluate and see the baby's criteria and if they do you are going to have a natural breech delivery. Then students, mid wife's, residents and OBGYM during their training period that they're going to feel more comfortable coming out leaving back this very valuable skill.
STEPHANIE GLOVER: Dr. Fischbein, what would you say the risks and benefits out for each delivery option for breech because I know a lot of providers are not really trained they are nervous with liability what are providers seen as a risk for a breech delivery you did mention a head getting stuck are there any other risks?
DR. STUART FISCHBEIN: Yes I think that's the biggest fear if you do know what you are doing is that head is going to get stuck and part of it is the misconceptions of how babies are being oxygenated through the umbilical cord which is compressed in labor but its scientific compressed in labour because it has this jelly in it. It is rare that you can often hear that ahead of time that the baby is in trouble but that again is no different for a head first baby or a breech baby.
There are risks of injuries to a baby, they could probably break a bone or an arm just like any other delivery with the head first baby you could have a shoulder dislocation so no form of delivery once the sperm and the egg meet there is always risk and whenever you see that happen it is a tragedy but it does do necessarily mean there is negligence or you could have been prevented. Some of the worst outcomes in a twin breech delivery were of breech babies born with a cesarean. There are risks in virginal birth and there could be tearing, poor healing that sort of thing. There are risks in cesarean in short and Long-term for both mother and baby which are sparring in emerging hospitals for breech pregnancies fear in rapture which is something that everybody is always worried about which often overblown.
Overall home forms of delivery are quite safe and the thing is you end up in a world where you end up with information and people talk about the thing that goes wrong and they don't talk about things that go safely. Everybody goes into this with the worst form of scenario in their mind and that is a very unhealthy way to go into this process but the most part whether you have a virginal breech delivery or a cesarean breech delivery you and your baby are going to be fine, and ultimately that is important.
STEPHANIE GLOVER: This wraps up our episode of Preggie Pals for today. Thank you, Dr. Fischbein and Dr. Berlin for joining us today and sharing some awesome light on breech delivery option.
For more Information about our show as well as information about any of our experts, panelists visit the episode page on our website. This conversation continues for members of our Preggie Pals club. After the show, we are going to talk about breech home birth options.
SUNNY GAULT: Before we wrap up our show we do have a submission from one of our listeners for a segment that we call pregnancy brain blunders. If you have been pregnant before you know how this feels. It is like everything is going to create you baby and sometimes your brain just doesn't seem to function properly. So we love to hear the funny stories that you send us of proof that pregnancy brains do exist.
This comes from Mary who drives a truck. She owns a truck and she says "I went through a car wash with about two hundred dollars' worth of groceries in the back of the truck." That is all she says so I am assuming there wasn't like anything covering the groceries. She obviously thought her truck needed to be washed and I guess that the positive side is that the vegetables got an extra wash in there, maybe some other stuff she did not have to do so much prep that night for dinner, but then again two hundred dollars hopefully not everything went down the drain there. I can only imagine how she felt when she got at the other end. I am surprised no one flagged her down.
So, anyway Mary, we fell you, we feel you. Thanks so much for sending this in, we appreciate it. If you have a funny pregnancy brain blunder that you would like to share with our audience we would love to hear it too. You can email us through our website on www.NewMommyMedia.com . Also through our website, you can send us a voice mail if you want to tell the story yourself because you will always tell it better than I would. You can go ahead and leave us a message on our website and we will put it on a future show.
STEPHANIE GLOVER: That wraps up our show for today. We appreciate that you listening to Preggie Pals.
Don’t forget to check out our sister show:
• Newbies for newly postpartum moms
• Parent Savers for moms and dads with infants and toddlers and
• Twin Talks for parents with multiples.
• Boob Group for Moms who Breastfeed
This is Preggie Pals, your pregnancy your life
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