| Musing
Reclaiming Breech Birth
"Shifting birth culture back towards women requires us to remember herstory and understand where and how particular beliefs and practices emerged. We also need to look back for clues about what we need to reclaim in order to move forward" – Reclaiming Childbirth as a Rite of Passage p.270.
Before the medicalisation of childbirth, variations were largely expected and understood. Midwives knew how to support normal physiology, including working with variations and identifying and managing complications. However, the wholesale redefinition of variations as complications enabled obstetric takeover of midwifery knowledge and practice. Modern maternity systems are increasingly intolerant of variation, resulting in many women being labelled 'high risk' and deemed outside of the scope of midwifery. Or, normal variations to labour patterns, such as an OP position, being redefined as a problem to fix.
However, there is an exception to the rule - breech birth. I have a lesson in the Collective that explores how the perception of breech birth shifted from a complicated malposition to a physiological variation. The evolution of breech birth knowledge and practice is an example of 'weaving ancient wisdom with modern knowledge' to reclaim birth.
Breech as a complication
From as far back as recorded birth history, a breech presentation was considered 'unnatural' and a 'malposition'. Although the term 'breech' was not used until fairly recently, being born bottom first or feet first was considered dangerous, requiring increased rites of protection. Midwives across the globe attempted to turn breech babies in late pregnancy using interventions that we now call external cephalic version. Soranus of Ephesus (a Greek physician) instructed midwives to manage a breech labour by 'bringing down the head' or 'turning the foot'. This is the first recorded description of internal podalic version and required the mother to be on her back on a hard, flat bed. Routine interventions aimed at turning breech babies in pregnancy, or removing them by their feet during birth, continued for hundreds of years. Jane Sharp describes these methods in her book for midwives in the 1600s. During this time, as we now know, the interventions carried out during a breech labour increased risks, and poor outcomes were common, reinforcing the belief that breech was a dangerous complication.
Attempts at a gentler approach
Justine Siegemund, a Polish midwife practising in Europe, made a significant contribution to the development of breech birth practice. Like Jane Sharp, she advocated podalic version during labour if cephalic version failed in pregnancy. However, she developed a two-handed rotation technique and advocated a gentle, less forceful approach. Justine also made a distinction between a frank breech and a footling breech. She recommended that a hands-off approach should be used for a frank breech and warned against pulling. However, Justine like other midwives throughout history, endured persecution from obstetricians and was unable to influence the increasing medicalisation of breech birth. By the 1900s babies were routinely pulled out by their feet and forceps were used for the 'after-coming head'. Various breech manoeuvres were invented by medical men (and named after them) - Løvset, Burns-Marshall, Rojas, Bracht, etc.
Pioneers of physiology
However, in the 1900s a growing backlash to medicalisation saw an alternative approach to breech birth emerge supported by new understandings of physiology. Breech pioneers including Maggie Banks, Jane Evans, Mary Cronk, Betty-Ann Daviss, Anke Reitter, Andrew Bisits and Peter Young shared knowledge about the physiology of breech birth. They called on care providers to support physiology as a means of reducing risk whilst also having the skills to identify and manage complications if they occurred.
A spanner in the works
However, as the perception of breech as a variation gained traction, the highly controversial and influential Term Breech Trial was published, and breech practice changed almost overnight. The study provided the justification for maternity systems to stop supporting vaginal breech birth. Recommendations for a breech presentation at term shifted from vaginal birth 'if all goes well', to a planned c-section without labour. I was a hospital midwife at this time, and went from supporting vaginal breech births to never seeing them. The development of breech knowledge and practice amongst care providers stalled. Practitioners working within maternity systems were unable to gain experience and skills in supporting breech births.
A turning tide
It has taken more than 20 years to get back to a place where breech is increasingly considered a variation, and the knowledge of the 1900s pioneers has finally made it into textbooks and mainstream maternity education. We now have midwifery texts depicting upright breech birth and explaining breech physiology. There is also a renewed interest from care providers and educators in supporting vaginal breech birth. Breech Without Borders is a great example of an initiative that centres physiology, research and woman-centred care. This global nonprofit brings together experts from diverse backgrounds to re-establish breech as a variation. They conduct research into breech physiology and provide training and resources for care providers to rebuild skills. Today we have the opportunity to use modern knowledge to reclaim breech birth. I urge anyone who attends births to learn how to support physiological breech birth and how to identify and manage a complication.
If you are interested in learning more about breech and many other topics, the Collective contains a library of in-depth and evidence-based lessons. |
