Medical Examiner

Breech Babies Don’t Always Require C-Sections

As a doctor, I knew the data. As a woman, I knew my body.

A woman looks down at her pregnant belly.
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I am a doctor specializing in women’s health, so when I became pregnant for the first time, I thought I would be the perfect patient. My pregnancy was healthy and normal. I was planning for a natural birth. Then, in my third trimester, it turned out that my baby was breech.

Picture a tiny fetus, squirming and flipping somersaults in the womb for the better part of nine months. As it grows larger, it gradually has less room to move around. By the final weeks of pregnancy, most babies have arranged themselves in a head-first (“cephalic”) position. Curled in a tight ball, they are prepared for a smooth, skull-first entry into the world. But a few—somewhere around 3 percent of all babies—never quite get there. For whatever reason, they remain in a butt-first “breech” position. Mine was one of them.

I asked my obstetrician if she would still consider delivering the baby vaginally. “No,” was her simple answer. “You know the data as well as I do. It’s too risky.”

I did know the data—better, perhaps, than the obstetrician did. When I was a medical student, I worked under a physician named Dr. Juan Vargas at San Francisco General Hospital. Vargas was a firm believer that women with breech babies should be equipped to make their own decision about whether to give birth vaginally or via cesarean section. He asked me to develop a decision-making aid for these women, to help them understand the risks and benefits of each option.

The studies on modes of breech delivery are complex and conflicting. Though rare (again, just around 3 percent of babies are breech at term), breech vaginal deliveries used to be fairly routine, performed by both doctors and midwives. Then, in the year 2000, a large, randomized clinical trial called the Term Breech Trial compared two groups of women and their breech babies—those delivered by planned C-section and those delivered vaginally. The results were alarming: The babies in the vaginal delivery group had significantly higher rates of injury, illness, and death.

The study caused a pendulum shift in obstetrics. The American College of Obstetricians and Gynecologists quickly issued a statement saying that breech vaginal delivery “may no longer be appropriate.” Doctors began scheduling virtually all breech babies to be delivered by C-section.

It is important to note, here, that any birth can be risky. “Fetal death” is not a risk any doctor or woman wants to take, ever. In the case of breech vaginal delivery, the mode of fetal death (at least theoretically) can be particularly gruesome. When the body comes out first, the head can get stuck inside, the baby’s jaw acting like a lever against the woman’s pelvic bones. The baby is stuck, half in, half out. In this scenario, called “head entrapment,” it is too late to switch to a C-section. The cervix clamps down around the neck and the umbilical cord, cutting off the blood supply to the baby’s brain. The baby dies.

When my obstetrician told me a vaginal delivery was “too risky,” I knew she was referring to the Term Breech Trial. And in my mind, I was picturing the worst-case scenario: head entrapment. A dead baby. But I knew there was more to the data—and to this decision—than that.

While the results of the Term Breech Trial were alarming, over the next several years, a number of follow-up studies called its findings into question. One analysis showed that the different rates of fetal death between the vaginal delivery group and the C-section group could not be directly attributed to the mode of delivery. (For example, two babies in the vaginal delivery group died at home after hospital discharge, one apparently from a diarrheal illness.) As far as anyone could tell from the reported data, there had been zero cases of head entrapment in the vaginal delivery group. Later, the original researchers from the Term Breech Trial conducted a two-year follow-up study, which found that none of the differences noted at birth between the babies born vaginally and by C-section had persisted over time—at 2 years old, they were all basically healthy kids. In light of these findings, ACOG reversed its prior recommendation in 2006, stating that in the hands of a skilled provider and in the right circumstances, breech vaginal delivery was a reasonable option to offer women. In 2018, an updated ACOG recommendation affirmed this position.

But a strange thing happened: The pendulum never shifted back. Breech vaginal delivery never became the norm again. The widely accepted explanation is that it’s a problem of lost skills: An entire generation of obstetricians had been trained without the skills to perform breech delivery maneuvers. The reality is more complex. As a doctor, I believe it’s partly a problem of legal risk—i.e., obstetricians’ fears of being sued. As a woman, though, I believe it is, more than anything, a problem of trust.

Again, consider the example of “head entrapment.” As gruesome and horrible an outcome as this sounds, head entrapment is exceedingly rare—so rare that it has been described only in case studies. Even in the large Term Breech Trial, none of the fetal deaths were known to be related to head entrapment. Yet it serves as a dramatic way to illustrate the risks of a breech vaginal delivery—and thus doctors use it frequently to explain to a woman why a C-section is recommended.

But a C-section, though considered a “routine” surgery, is not risk-free. It involves all the risks to the mother of a major abdominal surgery, plus some risks to the baby, which many women (myself included) would like to avoid if possible. Some of these “risks” are so common and well-established it may be more appropriate to call them “consequences.” Women who deliver by C-section stay in the hospital longer and have longer recovery times and higher pain scores than women who deliver vaginally. Babies born by C-section have higher rates of admission to the neonatal intensive care unit and are more likely to have transient breathing difficulties after birth—effects that may not persist over time but that have enormous consequences for the mother and baby in the first hours after birth, when bonding and breastfeeding would otherwise take place. Additionally, about 1–2 percent of babies born by C-section will have a minor injury during the surgery (such as nicking from a scalpel).

In my experience, doctors do not routinely present each set of risks to the woman whose baby is breech, so that she may consider her options for delivery. Instead, they simply tell her a breech vaginal birth is too risky and that a C-section is recommended. Many women are already vaguely aware of this “recommendation” (perhaps from friends who have had breech babies), and all of them know someone who has had a C-section. (Roughly one-third of babies in the U.S. are delivered by C-section.) So this major surgery may not seem like a big deal to women, especially when it’s presented as just another way to get the baby out. Without further discussion, a surgery date is put on the schedule. The discussion is closed.

In any other area of medicine, to send a patient to surgery without her informed consent would be a gross violation of medical ethics. But somehow, pregnant women are an exception. Perhaps this shouldn’t be so surprising. Our country and our medical culture have a problem trusting women—pregnant women in particular. Consider state laws that enforce a “waiting period” prior to terminating a pregnancy, or regulations that force women to listen to their fetus’s heartbeat as part of “pregnancy counseling.” These laws may be designed to limit access by those ideologically opposed to abortion. But they also arise in part from an erroneous fear that women are likely to make hasty or irresponsible decisions about their pregnancies. In response, the phrase “trust women” has become a rallying cry for abortion access and reproductive rights. But trusting women does not just mean letting them decide whether and when to have children—it also means trusting them to decide how to have children.

By 36 weeks, I had tried everything: yoga, acupuncture, ice packs, handstands in the pool. Every night my husband lit a moxibustion stick and swirled it around my big toe, then lay next to me on the couch while I tried to imagine the baby flipping somersaults inside my uterus. None of it worked. Which is how I finally found myself driving an hour out of town to see an obstetrician, Dr. Annette Fineberg, who I’d heard was skilled at breech vaginal deliveries.

She recommends first trying to turn the baby. She makes three attempts, pushing on my belly with her hands, before giving up. “This baby doesn’t want to move,” she says. “I don’t want to hurt you.”

Fineberg then offers to deliver the baby vaginally, if that is what I want. Or I may schedule a C-section. I tell her I don’t know what is the right decision. Instead of pressuring me one way or the other, she speaks to the issue of trust and patient autonomy. She points out that how to bring a breech baby into the world is really a decision about whether to let a natural (and usually safe) process take its course or to intervene with a major surgery. Like any medical intervention, this is a choice to be made by the patient, not by the doctor or the hospital. She leaves the decision up to me—which is all I wanted in the first place.

Everyone tells me to just have the C-section. I print out all the studies for my husband, who is also a doctor. He reads them carefully. (He didn’t read the books I gave him about natural childbirth or mindful parenting, but he reads the medical studies.) I even give him the pamphlet I wrote, as a medical student, outlining the risks of each path. And still, he says he thinks the answer is obvious: The safest thing is to have a C-section.

But it’s not obvious to me. I know the data, as my first doctor said. And I know something even better, something that has nothing to do with being a doctor: I know my body. I know my gut. And I trust it.

This is what I want. I don’t want to bypass a natural process. I don’t want someone to take a scalpel to my abdomen and yank my baby out of me like a melon from a grocery bag. I don’t want to make a decision based on fear. Even though I am terrified.

When the contractions begin, I do not think about the breech, the fact that this baby is coming out bottom first. Only that it is coming.

At the hospital, Fineberg tells me the baby is safe and the heartbeat is excellent; I do not look at the monitor because I do not want to interpret the tracing myself. The contractions are nothing but a game of endurance and positioning. Surviving each one, not thinking about the next. At some point when I’m bent over the edge of the bed, leaning on my arms, my hips rocking in the air behind me, someone places a paper towel on the bed in front of me. Upon it is a slice of peeled orange. The cold membrane on my tongue and the burst of its juice are like a gift, the sweetest thing I’ve ever tasted. I eat another slice, and another.

A short time later, I throw them all up. Then they tell me my cervix is open. It’s time. “Push!” they say. But there is nothing, no space to push into, only pain and a dead end.

They move me into the operating room as a precaution, the bed banging through the swinging metal doors. Suddenly there are more people, and many wires are attached to me. Still I am trying to find direction and strength, a place I can push into. Fineberg presses her hand inside of me, spreading her fingers, as she tries to give me direction and encouragement. She’s saying the same things I’ve said a thousand times to so many women in labor. Push against my fingers! Push right into my fingers! But even though I know exactly what she’s telling me to do, I can’t feel it, can’t respond to it. All I can feel is the pain. “Please, stop!” I cry out. The nurses keep trying to turn me onto my side, but that’s where the pain is the worst. I beg them, “No! Please! I don’t like it there!”

Fineberg’s voice rises above everything else, suddenly stern: “I know you don’t like it, but your baby likes it.” I hear the change in her voice, and I recognize what it means. The nurse leans down and says to me, almost in a whisper, that the baby’s heartrate has dropped. It has been below 90 for two minutes, and now it’s time for the baby to come out. “Do you understand what we’re saying, Chrissy?” she asks me.

“They want to do a C-section,” I say. Suddenly I am a doctor again, not just a woman in labor.

“Yes. Is that OK with you?”

“Yes, that’s fine. Just do it. Whatever you need to do.”

I know what a heartrate below 90 means: It means a blue baby, a baby that needs to come out now. I am resigned to it.

The anesthesiologist is pulling up his medications. The nurses are preparing my body for a surgery.

Then the next contraction comes, a contraction unlike any of the others because it brings something with it: that “urge.” The “urge to push” that everyone talks about. What I feel is an involuntary heaving, like vomiting up those orange slices a few hours earlier. Only this heaving is in my pelvis, then my whole body. “Can I try one more push?” I ask Fineberg.

“Yes,” she says. “If you feel the urge to push, you can push.”

On my hands and knees on the narrow bed, I resolve, like every woman before me, to get my baby out. I let those urges swallow me whole, and I open. I feel the tremendous, burning pain inside my vagina that I recognize as “the ring of fire.” I know then that I have gotten the baby where it needs to be and it is coming out of me. After one great urge and opening, I hear someone say, “Body is out, head is still inside.”

So there it is: my baby. Dangling by its neck from my vagina.

They yell at me then to “Push!” again. But I’m not listening. With the next contraction, it becomes almost … easy. I open again. More than the pain I am focused on the movement: the sensation of it happening, the speed and the elemental transformation of it. Then I feel an instant closure and emptiness in my pelvis and my vagina, the sealing shut of a potential space. The head is out. My baby is out.

Then a calm voice tells me, “Chrissy, you’re not going to hear her crying, because she’s not breathing.”

It’s like I’ve been knocked down by a wave into a churning ocean. I am searching for my husband’s voice and face, asking him, “Why isn’t she breathing? Is she OK? Is she OK?” He leans over me and says he doesn’t know, he isn’t looking at her, he is afraid to look. The nurses have her, someone says, and they are breathing for her with a bag. It might be a few seconds or a few minutes that pass in that silent ocean, when I don’t know: Do I have a baby, or do I have nothing?

Then someone says, “Dad, come over here! Come see your baby girl!” And right then I hear a little gurgly yelp and then a wail. It’s her. And for that instant, everything else slips away. There is just that cry, that voice, that breath.

They slide her up on the table so she is below me. I am crouching over her on my hands and knees, and I can see her: this squirming, blood-smeared human being, my baby, still tethered to me by her white, pulsing cord. I let my head drop between my arms and cover her with my whole self.

Since my daughter was born, I have spoken with several pregnant women who want to know whether it is possible to deliver a breech baby vaginally. As a doctor, I have little to offer them. Although I see pregnant women in the office, I no longer deliver babies. And none of the doctors in my practice will perform a breech vaginal delivery.

But as a woman, I feel I do have something to offer. My answer is this: Yes, it is possible. And it is your decision. Ask. If the doctor says no, ask for another doctor. If the hospital says no, tell them you will find a different hospital. It is not easy, but it is possible.

Until pregnant women ask for this most basic thing—the trust to make decisions about our own bodies, our own pregnancies, how we bring our own babies into the world—we won’t get it. This trust will not come easily. But we have to start somewhere. For me, it started with a mentor, all those years ago in medical school, who trusted women—and it ended with a lesson in trusting myself. The decision wasn’t easy, and neither was the labor. But finally, under a full moon and with the help of Fineberg’s skilled hands, I delivered a baby girl into the world: safely, vaginally, butt-first.