In breech birth, the first stage should be progressing smoothly. If you have a start and stop first stage, that may be a signal that the second (pushing) stage will be the same way. You do not want this scenario with a breech — it could be a valid indication for a cesarean. Most OBs, in hospital, want Pitocin running during breech births to make sure there is no stalling at the end. This use of an artificial hormone, of course, can cause a lessening of the oxygen supply to the baby and has no place in homebirth or midwifery practice. It’s reassuring if it is a second (or later) baby that is presenting breech and not the first because the pushing stage tends to be more rapid and smooth.

Breech is the ultimate time in birth where we must practice the 3 Ps: “patience, patience, patience.” The birthing woman should avoid bearing down for 45 minutes after full dilation is achieved (or when she first feels rectal pushiness) to avoid the possibility of the head becoming trapped if the cervix still has another cm of dilating to do. Have the birthing woman get into knee/chest to get as much control over her pushing urge as possible. Even with this “no push” effort, the baby’s bum will be at the introitus after 45 minutes, but you’ll be assured that full dilation has been accomplished by waiting the 45 minutes. The baby’s body should be birthed in 4-7 minutes after the body is out to the umbilicus.

The mother should be instructed to slowly pant the top of the head out. Great care must be taken with the birth of the top of the baby’s head because a sudden great push that completely expels the head can result in a tear of the cerebral tentorum (a drumskin-like membrane that protects the brain) when the overlapping bones of the skull are suddenly freed. Bringing the nose and mouth out is all that’s necessary to establish breathing for the baby, and then the mother should be instructed to halt all pushing effort and let the top of the head ease out slowly.

I have attended water and land breech births and have come to the conclusion that breech birth is best done out of water. The airway needs to be established for the baby as soon as possible. Again, the top of the head should not be hurried out. On dry land, the baby can stop at the nose and the mother can slowly pant the top of the head out. I ascribe to “hands off the breech” but the reason it’s tricky is that sometimes the baby descends in a posterior position (back of baby to mom’s back) and that is not ideal or the arm(s) can be above the head. It’s not always “hands off”. Sometimes the practitioner has to do maneuvers. There’s also a big difference between a 4th baby coming breech and a first or VBAC baby coming breech. A first baby can certainly be born smoothly and easily in the breech position but the first stage should go well in order for the birth to continue on into the second and third stages.

There are a lot of fine distinctions in keeping breech birth as safe as possible. It’s very helpful to do mockups of breech birth with other midwives/students.

The breech baby has weaker neck muscles, keeps his little feet up near his face for a few days, has a greater likelihood of having dislocated hips, and has a flatter top of the head than the vertex baby. They march to the tune of a different drummer but are sweet as can be.

The art of catching breech babies is being kept alive by some special midwives around the world. You can see photos of a midwife-attended breech birth at Lisa Barrett’s website. Mary Cronk, a UK midwife, is a recognized expert in natural breech birth. Maggie Banks of New Zealand is the goddess of breech in that country.

My friend, Patricia Blomme, of Calgary, Alberta had a vaginal breech birth with her third pregnancy. She has a blog on the subject . Patricia had a vaginal breech birth and subsequently gave birth to twins, one of whom was breech.

*some parts of this post have been previously published in Midwifery Today.*