Q&A with Dr. Freeze

by Rixa Freeze

If you're ever wondering what I do on an average day, one of my tasks is answering questions. It could be something technical, or something simple, or anything in between!

Here's a series of questions that I responded to yesterday, submitted by a mother of several children who had a C-section for "footling" breech presentation. She participated in a recent live session, which prompted several questions:

1. Is it possible for there to be a cord prolapse without there being a desire to push? If so, how would the birth have been handled in such a case?

Yes, sometimes cord prolapses happen long in advance of full dilation. If it happens with a frank breech or a head-down baby, it would be a true emergency and would warrant an immediate C-section. If the baby is nonfrank, the cord is less likely to be compromised due to a looser fit in the lower uterine segment. Depending on the situation with a nonfrank breech, a vaginal birth may be possible. If it's a multip and she's already feeling pushy and heart tones are great even after the prolapse--yes, this would likely be appropriate for a vaginal birth. On the other hand, if the prolapse occurs early in labor, it might end in C-section (in a developed country context where we have access to C-section). But it probably won't need to be quite as rushed unless the baby's heart rate is showing signs of compromise. 

In a resource-poor country where C-sections are done only for maternal indications, a cord prolapse wouldn't change the mode of birth. Kristine Lauria has attended cord prolapses that lasted up to 17 hours with no fetal compromise. (This particular situation was a nonfrank breech, primip, 28 weeks gestation. Heart tones remained stable in the 140s throughout labor and the mother gave birth vaginally.)

2. Would or could the position in which the woman is birthing influence the baby's head being entrapped? 

With an inlet head entrapment, I don't think a certain position can be definitely said to cause it. This is a very rare situation so we can't look it up in a medical article and cite from hundreds of examples. Certainly maternal positioning can help open different parts of the pelvis but I'm doubtful that it would cause an entrapment in this case. It's more likely due to what the baby is doing as it descends. 

With an outlet head entrapment, maternal position changes wouldn't cause it, but may be more effective in helping alleviate the entrapment (alone, or in combination with maneuvers such as the shoulder press, Ritgen, the Crowning Touch, etc.)

3. This might be an uncomfortable question for you, since I don't know what you think about unassisted birth. For a woman who is freebirthing and finds herself in a similar situation (specifically with the head being trapped), is there anything she could do herself to untrap the baby? 

Keep in mind when you say "head entrapment," there are 3 totally different situations that all fall under that umbrella. 

1. Inlet entrapment with a hyperextended head, which is what we likely saw last night and which is rare
2. Cervical head entrapment, where the cervix makes a tight band around the baby's neck and will not allow the head to pass through (still relatively rare; most often seen in premature babies or in term babies that are asymmetrically growth restricted)
3. Outlet entrapment with a deflexed head, which is relatively common; the head is much lower in the pelvis than situation #1 and needs additional flexion to come out. Or it may be due entirely to soft tissue dystocia (such as a very tight perineum). 

Each of these 3 scenarios requires different solutions. If you're birthing unassisted, #1 and #2 cannot resolve themselves without skilled assistance and even #3 may need quite a bit of assistance, depending on how deflexed the baby's head is. I'm not saying this to be fearmongering (I had my first baby unassisted and 4 home births total) but to be realistic. Yes, often breech babies do just come out. But when they don't, they need skilled assistance immediately. We at BWB have first-hand knowledge of several unassisted breech births that ended in demises. Yes, I know it's anecdotal but it also happened within the past 2 years. We want skilled assistance to be available to everyone. 

4. How long can a woman (with a breech baby) have her water broken (naturally) without labor beginning before she can start to worry about the wellbeing of her baby? Can it happen that labor just doesn't start? 

The answer to this question is identical to cephalic babies. If nothing goes into the vagina at all after ROM, then the risk of infection is quite low and it's likely that labor will commence within 24-48 hours. Sometimes it takes longer, but absent signs of infection or indications that the fetus is not doing well, you can choose to wait. Labor will eventually happen; it's not like you will be pregnant indefinitely! 

5. I also would like to ask about transverse breech. My understanding is that a baby can not be born in this position.

A baby is either longitudinal (cephalic or breech) or transverse (lying sideways in utero). Most transverse presentations will settle into a longitudinal lie, either before or during labor. An ECV could help the baby to turn longitudinal, either breech or cephalic. If this doesn't happen and baby remains transverse during labor, then a C-section would be indicated. 

6. Is a cesarean ever necessary in a breech birth? If so, when would that be? ( I am sure this is not so simple to answer, but just sharing one of the questions that is forever in me with birth in general.)

Yes, there are definitely times when a C-section is indicated for a breech presentation. The general categories would be

1. Nonreassuring fetal heart tones
2. Frank breech cord prolapse, or a nonfrank prolapse where baby is compromised due to the prolapse. I suppose this could be filed under category #1. 
3. Lack of progress (this is a very loose category--one person's lack of progress is another person's "rest and be thankful" phase). But sometimes some breech babies truly get stuck and won't descend any further, just like with some cephalic babies. Kristine Lauria's blog post discusses the occasional complete breech that gets itself wedged into the pelvis and won't descend any further. If poor progress is due to poor contraction patterns, sometimes augmentation may help, if that is an option available to you locally. 
4. A maternal or fetal indication for C-section, independent of the presentation

7. How often is a C-section necessary for a breech baby when the mother has planned a vaginal birth? 

Again, "necessary" is a rather loose term. In highly experienced maternity centers in France, a rate of around 15% is typical. In a 2020 study by Ghesquière, examining outcomes of all term breech presentations at their hospital in France, the CS rate was 16.4% for complete [meaning nonfrank in this context] and 12.6% for frank. The difference in rates was almost entirely due to a higher rate of cord prolapse among the complete breeches.

Among highly experienced home birth providers--with decades of experience and hundreds of VBBs--the rate can be as low as 3-5%.