Dr. Rebecca Dekker – 00:00:00:
Hi everyone, on today’s podcast, we’re going to talk about the evidence on breech birth. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, and welcome to the Evidence Based Birth® Podcast. Before we get started, I am so excited to announce that next week, January 17, is the day that our waitlist gets access to early bird tickets for the 2024 Evidence Based Birth® Virtual Conference happening in March. So if you wanna attend the EB Conference for parents and birth workers, make sure you go to ebbirth.com/waitlist and sign up for the waitlist today before you forget. You’re not going to want to miss this chance to get early bird tickets to the Evidence Based Birth® Conference. It’s been five years since our last conference, and we have an incredible lineup, including some topics that we’ve never published before at EBB. So again, to learn more and get on the waitlist, go to ebbirth.com/waitlist. That’s all one word, waitlist.
In today’s podcast, we’re going to share with you a replay from our webinar this past fall about the evidence on breech birth. This was a super popular webinar that was watched by thousands of people all around the world. And although our Pro Members at EBB have continuous access to the replay plus a certificate for contact hours that they can download, the replay has not been available to the public until now. So this is a really special presentation that I’m excited to bring to you. The webinar on the evidence on breech was taught by myself and Sara Ailshire, PhD candidate and current research fellow at EBB. As a content note, this topic does include a discussion of the statistics on infant and maternal mortality, as well as the statistics on rates of serious illness and injury with breech birth. Also, if you prefer to learn visually, I wanted to let you know that there is a YouTube video of this podcast that includes the presentation slides and you can see my face and Sara’s face as we’re teaching. So just, So just go to the Evidence Based Birth® YouTube channel to find this presentation there.
And now, without further ado, I invite you to join me in listening to the Evidence Based Birth® webinar all about the evidence on breech birth. Hello. Hello, everyone. Welcome to the Evidence Based Birth® webinar about the evidence on breech. We have declared this breech week here at EBB, and we’re so excited to have you with US as we go over some important research information with you that hopefully you can find some practical use for. The chat is flying. We have people from all over the world here tonight. I see US, Australia. It’s going so fast, I can’t read it. Canada, California, Colorado, Mexico, Massachusetts. Louisiana, Florida, California. If you are currently pregnant with a breech baby, let US know and we’ll send our positive energy your way. It’s moving so fast, I can’t keep up, but there are a lot of people here today. We’re expecting a big crowd. This is a really important topic and I’m so happy and honored to be able to share this information with you. I just want a quick introduction. My name is Dr. Rebecca Decker. I’m a nurse with my PhD and I’m the founder of Evidence Based Birth®. Tonight with me, I also have Sarah Ailshire. Sara, do you want to just say a few words about who you are?
Sara Ailshire, MA – 00:03:58:
Hi. Yeah, absolutely. Hi, my name is Sara Ailshire. She/Hers. I’m a doctoral candidate and I am currently the Evidence Based Birth® Research Fellow for 2023-2024. You might have seen me or seen my name in some of the new Signature Articles. So, yeah. Yeah. Nice to meet you. Nice to meet everybody. I’m based out of Danville, Kentucky.
Dr. Rebecca Dekker – 00:04:22:
Yeah, we’re so excited to have Sara with us. Sar has done a lot of work this year. If you’ve seen any of our research on prom or nitrous oxide, and we have a new article coming out soon with her name on it as well. Sara has done a lot of work. So we’re really thrilled to have her here. And now what I would like to do is turn our attention to the Evidence on breech, because I think this information is important. Hopefully it will help someone in this room today. It may help you in the future. It may help you help your clients if you’re a birth worker. So before we get started, I’ve shared a little bit about who I am and you’ve met Sara. And now I want to just run a couple few polls to see who is here today. So I’d love to know if this is your first webinar here at EBB. Yeah, I want to see who’s new here today. And I’m going to go ahead and end the poll. We have a lot. We have hundreds of people here ready to advance their education. All right. It looks like we have a lot of new people here today. 53% of you, it’s your first time attending a webinar. So that’s awesome. Welcome.
And for those of you who are returning, we love having you. We’ve been doing these free webinars twice a year for years now. I think this might be our sixth year of doing this. And we’ve covered a lot of fun topics. And breech is a great topic because we’ve never really published any EBB materials on the evidence on breech. So this is a great opportunity for you all. The next question I have for you is what role do you have in the healthcare system? Select one. And if you have a second or third role, you can add that to the chat. I know a lot of people in the birth world tend to have more than one role. So- Anna says, I love EBB. We love you too, Anna. Oh, we have chiropractors here, pelvic floor, physical therapists, EBB Instructors. Some people are our healthcare workers and pregnant. We got some residents here. Awesome. We got so many amazing people in the room from all over the world. This is a great group. Can you imagine if we were all like, I think of a gymnasium together or something where we’re just all excited about birth. So I’m going to go ahead and share the results and you can see who we’ve got today. We’ve got a lot of doulas in the room. Shout out to all the amazing doulas. We love you. The midwives, the nurses, the childbirth educators, parents, physicians, students, and so many others. So welcome to all of you.
And I guess now you can put hearts when I’m talking. That’s so sweet. Wow, Zoom, you’re just being too nice. And one more question, relationship with EBB. So I know the EBB Instructors and Pro Members might’ve already attended the private showing earlier today, but how many of your parents, general public, just kind of let me know. And I didn’t put podcast listener in there. If you listen to the podcast, you can mention that in the chat. So you probably hear my voice all the time then. But now we get to see each other, which is awesome. And I will reveal a little bit of news, insider info. In January, we’re going to do a little podcast series on breech again. So you’re going to get more of this info in January. So that’s really exciting. Awesome. Okay. We got a lot of parents or parents to be in the room too. That’s, that’s great.
Okay, so to the content. I need a little bit more info. Have you ever had a breech baby yourself at term? So yes, if you have. No, if you haven’t. Input not applicable if you’ve never been pregnant or if you can’t get pregnant for whatever reason. So, let’s see. And feel free to share in the comments, you know, if you had a breech baby, if there’s anything about that, that you want to share, feel free to tell the other people in the room. Okay. I’m going to end the poll results. Okay. So we have some people in the room, about 10% of you who’ve had a pregnancy have experienced a breech baby. And then the next question that I have for you is, have you ever witnessed a breech vaginal birth? Either you were giving birth or you were at someone else’s birth and you watched it. And if you yourself were a breech baby, when you were born, you can put that in the chat as well. I know sometimes they’re like, I was breech. So awesome.
That is very cool. We have a lot of people here, not a lot, but you know, 32% of you have seen a breech vaginal birth. That’s fascinating. Cause it’s actually quite rare now to see that in some parts of the world. So very interesting. Awesome. Okay. So a few more things about how this webinar will work. We’re going to be covering first breech vaginal birth because it is becoming more rare. We want to talk about the evidence on it. We’re going to talk about the external cephalic version procedure, also called ECV. And then we’re going to end with other methods of turning babies. And then also I have for you a bonus topic at the end that will be in your handout. So, hopefully you guys will love having that extra resource. And with that, all those instructions being said, are you ready to get started? Are you ready to learn about breech? If so, put yes in the chat box or some other words of encouragement. Or we can say Andiamo or vamos or whatever it is. However you say yes, let’s go. And that sounds like you’re ready. It sounds like everyone’s ready. Okay.
First, a few statistics. About breech and how common it is. So during the last few weeks of pregnancy, typically the fetus moves their body so that they are head down and being head down, it’s also called cephalic or vertex position, helps them come out head first. Now, some babies do not move into the head down position and instead they orient their bodies to come out of the vagina bottom first. And this is called breech position. breech comes from the English word breeches, which is like the covering of your bottom, the pants, an old fashioned word for pants. And there are very few good graphics online of breech babies. So we commissioned some drawings from Zoe Perryman Perryman, a middle schooler, who drew some amazing graphics for US of breech babies. And so that’s a picture of a complete breech baby where the baby is coming out with their bottom first. And interestingly, when a baby is breech. You know, when a baby comes out head first, we see the crown of their head and we call it crowning when you can see the baby’s head. With a baby that’s coming out bottom first, they actually call it rumping because you see the rump or the behind first. Which I always thought was an interesting difference.
So how common is breech? It’s present in three to 4% of term pregnancies, and that rate has stayed pretty steady over time. Now breech position is common prior to term. 25% of babies are breech before 28 weeks, But by 32 weeks, only 7% of babies are breech. And by term, it’s about 3% to 4%. A lot of you have written in saying you want to know what are the types of breech. And I will be honest, I used to find this really confusing as well. But hopefully Zoe’s drawings will help you get a better visualization. So I already talked about complete breech where the baby’s knees are bent and their legs are kind of crossed in almost like the crisscross applesauce position as my kids call it. This is considered one of the easier breech births if the baby is going to come out vaginally along with the frank breech position where this is also called the pike position, like the dive, the pike dive, where the feet are up by the face and the legs are extended. This is also considered an easier position. We have the footling breech position where one foot is presenting first or both feet. This is considered by some to be a riskier position for a vaginal birth. And the kneeling position, the last one there is quite rare, but that’s where the baby’s knees would be coming out first. One that is not pictured is incomplete breech. Incomplete breech is basically a cross between complete breech and frank breech where one leg may be in the frank position and the other is in the complete position. So the Cesarean rate for breech is very high in most countries.
In particular, the US, this slide shows the data from last year, about 5.6% of breech babies are born vaginally, the rest by Cesarean. In contrast of babies that are born in the head first position, it’s closer to 70% are born vaginally, around 29% by Cesarean. Now, rates of vaginal breech birth are low in the US, low in Canada. But they’re higher in some countries like Japan, Sweden, Norway, Denmark, and Ireland. Some of these countries have rates ranging from 15% to 56% where more than half of breech babies are born vaginally. So let me know in the comments if you think you live in a place where breech vaginal birth rates are low or if it’s actually common. You can let all your colleagues in the chat know. So what’s the evidence on breech vaginal birth versus breech Cesarean birth? And before I get into that evidence, I would love to know how many of you have heard of the breech trial. So it looks like about 33% of you have heard of it and 67% have not. Okay. So the breech trial is an important study that was published in the year 2000 in the The Lancet. The title of the study was Planned Cesarean Section versus Planned Vaginal Birth for breech Presentation at Term, a Randomized Multi-Center Trial.
The purpose of the study was to determine whether a planned vaginal birth versus a planned Cesarean birth has an impact on a combined outcome, meaning they were looking at either stillbirth or a newborn death or serious newborn illness or birth trauma to the infant. And they were looking at measures of serious injury or illness, such as seizures, physical injury to the baby, very low Apgar scores, coma, needing for intubation or ventilator or NICU admission longer than four days. And they also looked at maternity. Maternal mortality and severe maternal injury or illness. This study was fast-tracked for publication, which means they kind of sped through the peer review process and it ended up creating some problems later on that we’re going to talk about. So in this study, they enrolled 2,088 participants from 26 countries during the years 1997 to 2000. And when they approached people, recruited them to be in the study at term, they then randomly assigned them to either a planned Cesarean at 38, 39 weeks or Or they were randomly assigned to a breech . So when I say randomly assigned, it’s kind of like flipping a coin. You know, you either get the Cesarean or you get the planned breech . Most of the people who are assigned to have a Cesarean did have a Cesarean with antibiotics automatically given. Now, some of them did not, you know, if they gave birth too quickly by vaginally, or maybe the baby flipped into a headfirst position. So there were some patients who ended up with a vaginal birth.
Now, the group that was randomly assigned to a breech , about 57% had a vaginal birth. The rest had Cesareans for reasons like the baby was too big to fit through the pelvis breech, or there were heart rate abnormalities, or there was a footling breech where they didn’t think it was safe to do a breech vaginal birth. They were supposed to be in spontaneous labor without the use of Pitocin unless there was a medical reason for Pitocin. They were supposed to be singleton babies, not twins or multiples and no hyperextension of the fetal head. So I’m gonna quickly show you when the baby is coming out. Bottom first. One of the most important things is that you want the chin to remain tucked that allows the baby to easily descend through the pelvis and out. Through the vagina. If the baby’s head is hyperextended like this, they could get what they call head entrapment. So one of the things that a lot of research says is important is to assess to make sure that the fetal head is tucked and not hyperextended looking up. They were supposed to be attended by a provider skilled in breech birth.
The study ended up being stopped early because an early data analysis, which is common in some research studies, they’ll do what they call intermittent data analyses where they look quickly to make sure there’s nothing bad happening in one of the groups. They did find a significant difference between the groups. So they needed 800 more, but they stopped. And then it was fast-tracked for publication because they found a perinatal neonatal mortality rate of 0.3% in the group versus 1.3% in the breech group. And they also found that serious neonatal morbidity. Was 1.4% in the group versus 3.8% in the planned vaginal birth group. They found no difference in maternal mortality or serious morbidity. Now rates of vaginal breech birth had already been on the decline for years leading up to this study, but this study was kind of like the final stamp of… For obstetricians to say we should no longer allow vaginal breech birth. The problem was, is that this was not a good study. And for the next few years, there were so many criticisms published. You know, this study, like I said, was fast-tracked. It did not get the normal peer review. And as a result, the study findings were a little misleading because the study authors did not follow their own protocols.
Most of the deaths in the vaginal breech birth group were not due to the route of delivery. There were a surprising number of infants and women included in the study who should not have been included, such as footling breech, twins, and people who had stillbirths before they were approached to be in the study, intrauterine growth restriction, and anencephaly, which is congenital abnormality where most of the brain is missing. Similarly, among the 29 cases of serious injury or illness in the breech vaginal birth group, 10 of them should not have been in the study in the first place as well. Also, most study locations did not have access to emergency or urgent Cesarean. So if something went wrong with the breech , there was not a way to solve that issue and have an emergency Cesarean. And they did not follow the study protocol for the vaginal breech birth group. No ultrasound was available for more than 30% of the participants. So the fetal head could have been hyperextended. They didn’t know. And there was no skilled breech provider at 18.5% of the planned vaginal breech births. So yeah, a lot of these things were heavily critiqued by other researchers in the field.
The term breech trial was followed up by another famous study called the PREMODA study. This was a prospective observational study from France and Belgium. It took place during the years 2001, 2002 at 174 different centers where breech vaginal birth was still standard of care and the providers were highly experienced in attending breech vaginal births. This was not a randomized trial, but they did want to compare their results. So the breech trial, so they used a lot of the same measurements and they followed everyone who was pregnant at term with a breech singleton baby. They had about 2,500 who were planning a vaginal breech birth and 5,500 who were planning a Cesarean birth. And after excluding fatal congenital abnormalities, they found no difference in stillbirth or newborn death rates between groups. However, they did find higher rates of low five-minute Apgar scores, birth injuries, and need for intubation in the breech group. There have been many studies on breech birth. It would take hours to go over them all. So my final kind of research that I want to share with you on this topic are some meta analyses. A meta analysis is where they take a lot of the research, they put it together, combine the data, and then have one big meta study.
So Fernandez Carrasco et al published a study in 2022 that included studies from a 10-year period, 2010 to 2020. And they found that perinatal death rates were 0.6% in the planned vaginal breech group and 0.14% in the planned Cesarean breech group. So they did find that Cesarean favored the mortality rates. But it was not as anywhere near as high as the breech trial. So instead of 1.3% , they found 0.6%. They also found that newborn morbidity was higher with breech , but that severe maternal morbidity was lower. Lundberg Nordborg et al. In 2022, the study came out of Sweden, and they were looking at all of the research from 1990 to 2021 on breech, found very similar findings that there was a higher perinatal mortality rate and short-term newborn morbidity rate with breech , but no difference in long-term morbidity. Another study I want to briefly mention, I don’t have a slide for, but the breech trial authors did end up publishing a A Population-Based, 2-year Follow-Up Study where they were looking at the research. They followed the infants from the breech trial, and they did not find any long-term differences in mortality or morbidity at two years of age.
So how do we summarize the benefits and risks of having a vaginal breech birth versus planning a Cesarean for a breech baby? I think one of the best resources on this comes from the guidelines from the Royal College of Obstetricians and Gynecologists. And one of the things that they write about that I think is really important is that you shouldn’t just compare a vaginal breech birth to a Cesarean breech birth, but you could compare vaginal breech birth to a cephalic vaginal birth. So let’s compare babies coming out vaginally, both headfirst and breech, and see how different are they. And so they include that in their guidelines. But the benefits of planning a vaginal breech birth include the fact that there is the lowest risk of maternal complications if you achieve a vaginal birth. Also, as the PREMODA study demonstrated in France and Belgium, that when you have a skilled attendant who is experienced in breech vaginal birth and you use strict selection criteria, so only the people who really have good potential for a breech vaginal birth are selected, that planning a breech vaginal birth can be nearly as safe as planning a headfirst vaginal birth. It also allows you to avoid having a uterine scar in the future because uterine scars can have potential negative impacts on future pregnancies and births.
The risks are that pretty consistently, except for the premotus study, which had really skilled providers, there is a higher risk of stillbirth and newborn death. The rates are about two per 1,000 for a planned breech vaginal birth versus 0.5 per 1,000 for a planned breech Cesarean at 39 weeks versus one per 1,000 for a planned headfirst vaginal birth. So the risk goes from one out of a thousand if your baby is head first and you’re giving birth vaginally to two out of a thousand if your baby is breech and you’re giving birth vaginally. There’s also a higher rate of low Apgar scores, birth trauma, and serious short-term complications, but overall the risk of long-term complications does not increase. And about 40% of planned breech vaginal births will end in a Cesarean and unplanned Cesareans carry the highest maternal risks. So they’re less safe than a planned Cesarean. So the benefits and risks of planning.
A Cesarean breech birth, I already went over the benefits of the lower rates of stillbirth and newborn death and share those statistics with you, but you can also avoid complications associated with labor and having an unplanned Cesarean, and you can avoid the risks associated with late-term or post-home pregnancy because typically the planned Cesarean is done at 39 weeks. The risks are related to the short-term risks of surgery, related to having abdominal surgery, long-term health risks to your offspring. There’s some research on higher rates of asthma and other kind of autoimmune conditions. And there’s an increased downstream risk of complications in future pregnancies due to having uterine scar. And you may either be attempting a VBAC in the future or having multiple repeat Cesareans. And those complications can include the need for blood transfusion, infection, hysterectomy, an abnormally invasive placenta, uterine rupture, fetal death, or maternal death. So you’re kind of sending the risk downstream to a future pregnancy. So this really leaves US between a rock and a hard place because debates about safety of vaginal breech delivery continue.
But at the same time, when we’re giving birth, we have the right to bodily autonomy, to inform consent and refusal. We have the right to choose a vaginal breech birth. But there’s fewer and fewer birth attendants who have these skills. So we have providers who are becoming more and more inexperienced because they’ve banned vaginal breech birth. And this means that trainings are more important than ever. And also ending these bans is important because how can providers gain these skills if they’re not practicing them and giving people the choice, the option to choose what they want? So you could ask yourself, what if someone prefers a breech vaginal birth and they really don’t want surgery? But there’s no more skilled providers because we have eliminated this option. But then you still have things like a surprise breech baby. So some babies, we think they’re headfirst, but they’re breeched. What if that surprises a provider and they don’t know what to do because they’ve banned breech birth? Or what if a breeched baby is coming out too quickly to do a surgery? So we really need providers who are more skilled in breech. And there are places like breechwithoutborders.org. They teach vaginal breech workshops around the world. And I had the ability to go a few years ago in Kentucky. And it was really amazing because there was like a full day of training with the content. And then they did another training a whole other day with the skills using models and different equipment. It was fascinating. And it’s really cool what they’re doing. And there are others out there as well who are trying to get the education out there. So I’m going to turn it over to Sara now. So Sara, do you want to talk a little bit about ECV?
Sara Ailshire, MA – 00:28:54:
Sure. Absolutely. So hi everyone. Again, my name is Sara Ailshire and this part of the webinar we’ll be discussing some of the basics about external cephalic version, as well as what some of the research says. I’ll introduce what an ECV is, how it’s performed, and what some of the latest evidence is on ECV as an option for somebody whose baby is breeched towards the end of their pregnancy. So, so far we’ve discussed the evidence on breech of vaginal birth, but what if a breech of vaginal birth is not an option for a birthing person? They don’t have a provider who can do this for them, or maybe they really, you know, they’ve looked at the risks and they say, okay, I want to try to see if I can get my baby in a cephalic position. In that case, an external cephalic version might be their best chance for a vaginal birth. So an ECV, external cephalic version, is when a care provider puts their hands on the outside of the person’s belly and tries to turn the baby. So an ECV is when a care provider puts their hands on the outside of the person’s belly using a forward motion, a backwards motion, a physical manipulation of the baby in utero from breech into a cephalic position.
There’s different ways of doing this. Sometimes providers will use a lot of force and will basically just move the baby inside. But there are some other providers who are interested in taking a new approach to the physicality of ECV. And we have a screen grab from that here. Dr. Larry Hinkson, he is based out of Charity Hospital in Berlin, who’s developing a new type or new approach to ECV, where they use touch, tap, and massage to stimulate what they call the primitive or the fetal reflexes. So think about the palmar grasp, right? So things like this. Using touch, tap and massage too, instead of turning the baby, like inspiring the baby to turn on their own through this type of like, you know, more gentle physical touch. So why might a person want to have an external cephalic version? So as we’ve discussed, Cesarean rates are much higher than it is necessary in the US. And there’s lots of people who are interested in finding ways to reduce these rates.
As we know, many babies who are breeched today are born through a Cesarean. So Cesarean. If we can increase the rates of external cephalic version or vaginal for each birth, the Cesarean rates will in response decrease. However, there are some barriers to accessing an external cephalic version. It’s an underused procedure. So about 20 to 30% of eligible pregnant people in the US are not offered one. And there’s a few reasons for that. Since the eighties, training in medical schools and in residency programs has increased. Not every provider actually gets that training. In one study in the year 2000, they did a survey to see how many medical providers got ECV training, and they found that roughly 65% of their respondents did. So that’s more than half, but it still means that 35% did not report getting this training. In order to address this, some medical schools are developing new approaches, using models, trying to make this training more accessible, but the lack of accessibility and availability, as well as the lack of experience, can be a barrier to accessing an ECV. Another problem is that sometimes health insurance plans, and in some cases that includes Medicaid, don’t consider an ECV to be a part of a regular routine prenatal care. So they won’t cover it, and that can be a difficulty for hospitals or clinics, because if they’re not being reimbursed, then can they offer this procedure?
And finally, an external cephalic version requires time, resources, and talent. So we talked a little bit about the talent, the resources, but you also need the right setting. So you need to be able to do this in a setting where you can have monitoring just to make sure that the infant doesn’t become distressed, that there’s no complications, and that in the event of a complication, you can have an emergent Cesarean birth. So you need to be in a facility that’s set up to accommodate that. So who’s a good candidate for having an external cephalic version? The first question is whether or not you plan or can have a vaginal birth. If you prefer to have a Cesarean birth, or if there’s a reason why a vaginal birth isn’t an option for you, then you wouldn’t be a good candidate for ECV. However, having previously had a Cesarean birth does not rule you out from attempting an external cephalic version in a later pregnancy. If you have an otherwise uncomplicated pregnancy, meaning that you and your baby are healthy, you’re likely to be a good candidate for attempting an ECV.
However, if you have a history of placental abruptions, if there are serious complications, if you’re pregnant with more than one baby, so like we said before, a lot of research on breech that we were discussing today is about singletons. ECV is typically done with singleton pregnancies. Or if there’s a sign of fetal distress, then an ECV is not going to be an option or will not be the best option for you. So talking about the specifics of how do ECVs contribute to reducing Cesareans, what does research say about this? A 2015 Cochrane review combined the results of eight randomized control trials with about 1,300 participants who are either assigned to have an ECV or do not have an ECV. Overall, the researchers found that attempting an external cephalic version at term meant that the relative risk of a breech birth was reduced by 58%, and the relative risk of a Cesarean birth for participants was reduced by 43%. They found no differences in other outcomes, such as APGAR scores, neonatal admissions, or infant deaths. And so that means, you know, there wasn’t really any, what they saw as like major drawbacks to attempting this. However, it’s really important to note that five of the eight studies in this review took place between 1981 and 1991, during a time which breech vaginal births were more common.
So since the publication of the breech trial in 2000, breech vaginal births have become more rare, and most breech babies are born via Cesarean. So it’s possible that even if you were to replicate these randomized trials today, having an ECV might result in an even larger reduction of the risk of Cesarean. So just a moment here, we want to talk a little bit about the success rates for ECV in the US. This data comes from the CDC, and it shows that the overall success rate for ECV is roughly 50%, sometimes higher, sometimes lower. It shows that if you have a successful external cephalic version, you’re pretty likely to have a vaginal birth. So that percentage hovers around 75%. However, even if you have a successful external cephalic version, the baby moves into the cephalic position after the procedure, roughly a quarter of those patients will have a Cesarean birth. So breech might no longer be a factor, but again, we know other things can contribute in a Cesarean birth.
So what are the overall risks? So I saw a couple of people mention risk in the chat, just briefly, it’s going by quickly, so I can’t look as well as I would like, of course. Overall, external cephalic aversions are safe, but again, they should always take place in a setting where an urgent Cesarean could be performed if necessary. So in this 2008 study, the authors combined 84 studies that included roughly nearly 13,000 participants who had an attempted ECV. They found that the average success rate was 58%. They only included studies that reported on complications from attempted versions on single babies done after 36 weeks of pregnancy. So the overall complication rate in this study was 6%, and the rate of serious complications, so things like a placental abruption or a stillbirth, was 0.24%. In all of the studies included, there were 12 stillbirths, and researchers identified two of those cases to be related to the external cephalic aversion procedure. The other deaths were unrelated to the ECV or were otherwise unexplained. Other complications that occurred included a cord prolapse, so 0.18%, temporary abnormal fetal heart rate patterns, so 4.7%, vaginal bleeding, a water breaking. And overall, the researchers found that for every 286 external cephalic aversions that were attempted. There was one urgent Cesarean. So in summary, researchers again have found that an external cephalic aversion is an overall safe procedure, but because of these risks, because of their presence, it’s really important that it should be attempted in a place where you have access to an emergency Cesarean, urgent Cesarean, if necessary. So if you want to learn more about ECV, like what can increase the likelihood of it succeeding, when is the best time to have one, and what techniques can increase its likelihood of success, you can check out the Signature Article all about external cephalic version. You can download a free handout. And we also have podcasts on this topic that go way more into depth. I’ve kind of just scratched the surface here today. Those podcasts are 111, 171, 72, and 73.
Dr. Rebecca Dekker – 00:38:29:
Thank you, Sara, for walking US through the evidence on ECV. Now let’s talk about other ways of turning babies. Go ahead and put in the chat, what methods have you heard of people using to try and turn a breech baby? And if you can think for a moment, you know, maybe you’ve experienced this yourself or you’ve had a client who’s had a breech baby. There’s this sense of urgency, agitation, anxiety often with a breech baby because people are so worried that they can’t, you know, have the birth that they were envisioning. So they want to do everything they can to turn the baby. And I see the chat is just, oh my goodness, it’s my eyes are spinning. Speaking of spinning, spinning babies is one of the resources, moxibustion, cold peas, chiropractor, acupuncture, flashlights, music, rebozo. I think you’ve listed everything I’ve heard of. I’m going to talk about a few of these right now. So moxibustion comes from traditional Chinese medicine, and we do have a lot of research on this. This is when an herb, moxa is the Japanese term for Artemisia vulgaria, also known as mugwort, when it’s burned close to the skin on the outside corner of the fifth toes of both feet. This is acupuncture point bladder 67. And in this picture I’m showing in the video, you can see someone hanging out outside, elevating their feet and burning the sticks on either side. Most of the time the sticks are burned on both sides at once for 15 to 20 minutes, anywhere from one to 10 times a day for up to two weeks, starting at 28 to 37 weeks. This is a very popular intervention for breech babies in China. It’s affordable. It can be done by yourself at home. And so a lot of people try this out. The theory is that it stimulates heat receptors at that acupuncture point that may encourage the release of placental estrogen and prostaglandins, which then may increase fetal movements and inspire the baby to move around and maybe turn into a headfirst position. So the smoke can be irritating. That’s why this person is doing the moxibustion outside, but there are some smokeless sticks available.
And some people may do moxibustion along with other techniques or other aspects of traditional Chinese medicine. So the evidence on moxibustion, there is a lot for such a niche topic. There are 13 randomized trials that were combined in a Cochrane review review that was last updated this year in 2023. And they included 13 studies from all over the world. In some of these trials, they were comparing moxibustion to what we call sham or fake moxibustion. But in others, they could not have that kind of placebo group because the women in those countries were too familiar with the real procedure. They could not be faked out by a sham one. They found that the benefits included a decreased chance of breech positioning at birth. So you’re more likely to have a baby in head first position. There was also a higher number of fetal movements during the intervention, and it was acceptable to everyone in the study with very few side effects reported.
The few side effects included nausea, unpleasant odor, and headache. There was no effect on ECV rates, Cesarean rates, or preterm birth rates, or Apgar scores. In most studies, people found it pleasant. And in one study in particular, people said that they found it relaxing. Doctor of Chiropractic is another thing you often hear, you know, oh, your baby’s breeched, you should see a chiropractor. So let’s talk a little bit about that. Doctor of Chiropractic most often is referring to spinal manipulation, but it can include a variety of other medical therapies. When they are manipulating a joint or the spine, chiropractors use their hands or an instrument to apply a controlled, low-amplitude, high-velocity thrust to manipulate the joint. Doctor of Chiropractic in the US in particular is becoming much more common. Its use increased from 6% of adults in 2008 to 24% in 2012, and I’m assuming it’s even higher 10 years later. I know where I live, there’s a chiropractic clinic on seemingly every corner, and most people that I know in my town have seen a chiropractor at one point. And the research backs that up, showing that a lot of people are seeing chiropractor now or have seen one in their lifetime.
And I find it interesting that about 57% of US-based do recommend Doctor of Chiropractic. They’re more likely to recommend it than obstetricians. Only 40% of obstetricians recommend Doctor of Chiropractic. And interestingly, there is evidence supporting its use in pregnancy. So it’s typically used to treat back pain or pelvic pain in pregnancy. And research has found that it does lower back pain, which can impact as many as 68% of pregnant people. And it lowers the risk of opioid use in pregnancy. And it’s been found to decrease pelvic pain, which impacts about half of all pregnant people. So the Webster technique is a specific chiropractic assessment and adjustment to improve function of the sacrum and pelvis in someone who’s pregnant.
This was developed in the 1980s by Dr. Larry Webster, founder of the International Chiropractic Pediatric Association. Dr. Webster was helping as his own grown daughter was giving birth and he was helping her as a chiropractor. And then he went on to teach this technique to others. And now you can get training in this and get certified in it. And there’s a directory of chiropractors who can use this, who use this technique. But it basically includes a low force drop technique of the sacrum and putting some gentle tissue pressure on the round ligament. If you’re pregnant, you’re going to have to do a lot of work. And it’s a very, very important technique. If you’re pregnant or have been in the past, you may have felt that, you know how you can have that stabbing pain in your side when you shift positions quickly. That’s from the round ligament. So they put a little bit of pressure on the round ligament as part of this technique.
So theoretically, by having a chiropractor correct issues with the sacrum and with the function of the pelvis and by improving nerve entrapments, the theory is the pelvis can be relaxed enough so that the fetus has room to move into a more optimal position for labor. There’s no research I could find on this technique, but it is used by thousands of chiropractors and parents around the world. Some people may use it in hopes that it will make their ECV more successful, but in general, this is something you’ll hear people talk about a lot. We don’t have research on it, but I did want to point out that we do have research on Doctor of Chiropractic in general and pregnancy, and that it seems to be effective for different pain issues. Okay. So some other strategies that were mentioned in the chat include posture, positions, using sound, music, light, or temperature on the belly so that the baby will follow the sound or follow the light or follow the heat or try to get away from the cold.
Massage is something you’ll see people do. Maybe go get a relaxing massage. Some prenatal massage therapists may have special techniques they use if their client has a breech baby. Maybe hypnosis. I put an asterisk by that one because there is research that has shown that self-hypnosis has been shown to increase success rates with ECV. There’s a lot of mindfulness involved in ECV because the more tense you are during the procedure, the harder it would be to relax the muscles and give more room for the baby. Visualization, meditation, talking to your baby, swimming in the pool. And then another technique. I read about online was called acceptance. And some people call it the emotional freedom technique of just accepting the fact that your baby is breech and freeing yourself from the anxiety and agitation and trying to make things change. Sometimes that can have an effect as well.
So I want to mention that inside the Pro Membership, we do have a doula mentorship. So this is a great place if you’re a newer doula to ask more experienced doulas questions. It’s included in our Pro Membership at no extra fee, and it provides a group mentorship model and monthly calls with specific business focuses, breakout rooms, and a learning guide on the evidence. Okay. Up next, I’m excited to announce our bonus for today’s webinar is that we have summarized the top guidelines that are written in English for you. And I thought this would be really helpful for parents who find themselves in this position with a breech baby, but also birth workers, because, you know, sometimes your provider will tell you something and they’ll give their opinion and they might not disclose that their professional guidelines. Actually say something else.
So first of all, I thought it was interesting that there was a paper published in 2022. That is a free full text article that summarizes and compares all the guidelines on breech. And they rated them for their quality using an international quality checklist. And they found the top guidelines came from the United Kingdom and the lowest quality guidelines came from the US. But there were a lot of similarities in the different guidelines. And. So I’m going to go over them in detail right now. But I just thought I would point out that if you’re in the US where we have really low rates of vaginal breech birth, ACOG does affirm that the mode of delivery should consider the patient wishes and the experience of the healthcare provider, and that ECV should be offered to somebody who is a candidate for it. And that’s because the ECV is a very important part of the delivery process. And that planned vaginal delivery of a term singleton breech may be reasonable. So they do not support bans on vaginal breech birth. I thought that was interesting. So I would love to know what’s your number one takeaway. Go ahead and put it in the chat box.
Like we’ve covered, you know, what is breech, the evidence on breech vaginal birth, the evidence on ECV and other ways of turning babies. So let me know in the chat if there’s something you think that is really interesting. The evidence, all of it. breech is safer than I thought. breech should be an option. No one option is the right answer for everyone. The new ECV tap and touch version, ACOG says that breech should be offered. You know, banning vaginal breech birth is not evidence-based. More doctors need training. And then there’s other ways of training that comparing the mortality rates between breech vaginal birth versus cephalic vaginal birth. It’s unfortunate that providers do not always have training in these. And the workshops are available though. Yeah, there are people who are doing the work to try. And one of the sad things that happened when the training came to Kentucky, it’s this world-class training, right? You know who was there at the training? Guess who was at the training? What kind of providers and professionals were at the training? It was midwives and it was doulas who wanted to become midwives. I don’t think a single OB was in attendance other than the one who was teaching it. And we were talking about a state that has two major medical colleges, one within just a few miles away, and not a single resident or student came. And it was very frustrating because we tried to let them know about it. And I’m not saying that happens at every training, but we need to get all the providers in these spaces because these can be life-saving skills if you’re talking about a surprise breech or a very fast breech delivery.
And I think they do want those skills, but it’s not required for their training. And they’re working 80, 100 hours a week. So how are they going to have time for this unless their professors and chairs are prioritizing it, right? So it needs to be paid for for them and prioritized. Wow. Thank you so much, everyone, for listening to this replay of the EBB webinar all about breech. So what do you think? What did you learn? What are you going to take away and put? What are you going to practice? Please let US know. You can message US on Instagram or leave a comment there or leave a review of our podcast on your favorite platform and letting US other people know what you’ve been learning from EBB. Now, you might have heard me mention something about a bonus handout while I was talking. That handout was for people who attended live. Please make sure to get on our email newsletter at ebbirth.com so that you can register for our next free webinar, which they happen twice per year. And we always provide handouts at our free public webinars and then our members have access to them all the time.
However, I will make sure to go ahead and provide links to any resources I mentioned in the show notes for this episode. Just go to ebbirth.com slash 296 to get the transcript of this episode and the links to different resources. And as a reminder, you can always share the YouTube video with friends, family, or clients as well. I have some good news for you. We are continuing with our breech theme for the next few weeks. Next week in episode 297, you will have access to a podcast episode where we will answer your most commonly asked questions about breech. And then in episode 298, we’re going to talk with an OB/GYN, Dr. Emiliano Chavira, about overcoming barriers to breech vaginal birth. And in episode 299, we have a special interview with one of our podcast listeners who was able to attain a breech vaginal birth after listening to our EBB podcast on this subject.
If you’re listening to this episode and you’re an EBB Pro Member, I want to let you know that you can get a contact hour for this presentation inside the Academy. Just go to your monthly training archives, as well as you have access to a brand new two-page handout that is exclusively designed for Pro Members and has the evidence on breeched vaginal birth and breeched Cesarean birth. If you’re not a Pro Member, but you’re interested in becoming one, go to ebbirth.com slash membership. And don’t forget that the conference is quickly approaching in March. So head to ebbirth.com slash waitlist to get on the waitlist before we give access to special early bird pricing on January 17. Thanks everyone. It’s been so much fun learning with you today about this subject and I look forward to continuing to learn with you next week. Bye. Today’s podcast was brought to you by the Evidence Based Birth® Professional Membership. The free articles and podcasts we provide to the public are supported by our professional membership program at Evidence Based Birth®. Our members are professionals in the childbirth field who are committed to being change agents in their community. Professional members at EBB get access to continuing education courses with up to 23 contact hours, live monthly training sessions, an exclusive library of printer-friendly PDFs to share with your clients, and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans, as well as scholarships for students and for people of color. To learn more, visit ebbirth.com/membership.
