"Birth Options Limited when Baby is Breech"
by Guinevere A. Murphy, PhD
Two small, shiny mounds slowly emerge, surprising despite their being expected. One spindly leg slithers out, then another, followed rapidly by the torso. But now the progress of baby’s entrance into the world stalls. Relaxation music plays, now largely ignored, in the softly lit hospital labour room. Mandy Jeffries, an experienced doula, recalls this moment in the delivery of soon–to–be second time mother Janet Arnold’s son. His head was still inside. Was it stuck?
Dr. Michael Hall, attending obstetrician, had been a calm, reassuring presence here since Arnold’s arrival two hours earlier in the frosty January pre-dawn at Swedish Medical Center in Englewood, Colorado. “Just let her keep doing her thing,” he intoned. With a solid 40–year career in obstetrics, Dr. Hall was the seasoned veteran of the proceedings. A collective sigh of relief was released from assembled medical staff when a pink, perfect little head popped into view.
Breech births, where the baby is in a foot– or butt–down at the time of delivery instead of the typical head-down position, account for 3 to 4% of all births. Yet despite the movement towards more birth choices today, a third of babies are born by caesarean, itself a major (not to mention expensive) abdominal surgery with the potential for serious complications. And for a variety of reasons, the movement hasn’t extended to breech births: upwards of 90% of breech babies are delivered by caesarean today. These statistics are reversed from a generation ago, when most breech babies were delivered vaginally. Yet safety statistics haven’t changed much since then, and the study that precipitated the move to caesareans for almost all breech babies has come under fire in recent years.
Arnold, an office manager from Denver, Colorado, was thirty four weeks along with her second baby when she learned that he was breech in November 2011. Arnold had planned to deliver at Mountain Midwifery in Englewood, Colorado, the only free standing birth center in the state. “I was expecting and looking forward to a natural water birth,” Arnold recalls.
Arnold spent the next weeks of her pregnancy trying to turn her baby: headstands in the pool, acupuncture, herbal remedies, hypnosis, and chiropractic. But nothing worked, so at 36 weeks pregnant, she turned to Dr. Hall, where Mountain Midwifery refers their high risk patients. Dr. Hall attempted external cephalic version, the only medical procedure widely used to turn breech babies. This technique works about 60% of the time, and it has drawbacks, though complication rates are relatively low. Women report it can be quite painful, and sometimes the baby returns to an unsuitable position afterwards. The procedure failed in Arnold’s case. The baby had already “dropped,” i.e. his bottom was so firmly lodged in the pelvis that Dr. Hall’s team couldn’t budge him.
At this point, most women would schedule their caesarean, but here is where Arnold’s story takes an unusual turn. Dr. Hall is one of a dwindling number of obstetricians willing to allow vaginal breech birth, provided the pregnancy fits stringent selection criteria necessary for the safety of mother and baby.
Since 2000, caesareans have been the gold standard for breech deliveries,5 but there’s growing controversy over the risks of breech vaginal delivery versus caesarean to women and babies.6 Dr. Stuart Fischbein, a 28–year private practice obstetrician who made the decision to leave clinical practice in Los Angeles to exclusively attend home births a few years ago, is a self–styled birth activist, citing hospital policies not conducive to labouring and birth. In sharp contrast to hospital breech birth statistics, he estimates a >80% vaginal delivery rate of his homebirth breech deliveries with no emergency transports to the hospital required7 (although women who plan deliveries at home have lower risk pregnancies). In a 2011 interview, Dr. Fischbein discusses doctors’ practical considerations in the hospital setting.8 Not like the unpredictability of a natural birth process, the typical 45–minute caesarean is routine, can be scheduled, and there’s a high comfort level with the procedure among obstetrics professionals. Today about a third of all US births are done by caesarean, almost three times the rate considered medically necessary by the World Health Organization.
Despite the large number of surgical births today, “We really haven’t done much better in terms of infant or maternal morbidity or mortality,” says Fischbein. However, obstetricians have the highest malpractice risk among physicians in the US, “fostering a ‘more is safer’ attitude,” concludes a front-page 2013 New York Times analysis.
Critics argue that studies of vaginal versus caesarean birth for breech babies fail to take into account the long term risks of caesarean, such as potentially life–threatening ruptured uterus or placental issues in future deliveries, and future fertility issues. Potential side effects of surgery may be downplayed in counselling. “No operation where the skin is cut and the abdomen is entered should be considered routine,” says Dr. Fischbein.
Further, emerging research suggests a link to longer-term health issues possibly related to caesareans. Lack of exposure to maternal fecal matter during birth combined with antibiotic exposure may make babies delivered by caesarean prone to poor early gut colonization by “beneficial” microbes. But it is hard to pin down a connection to caesareans because many factors affect early intestinal health, including breastfeeding and presence of older siblings, among others. There is also some research pointing to possible links between caesarean and a variety of conditions like childhood obesity, allergies, asthma, eczema and diabetes.
Why are almost all breech births delivered by caesarean today? Probably most important, there’s a greater chance of short-term injury to a breech baby compared to those born head down.15 Birth providers inexperienced with breech birth may intervene unnecessarily when the baby is partially born. With breech babies, the policy is “hands off until you absolutely have to do [something],” Dr. Hall explains, something many obstetricians find uncomfortable. “[T]he more you try to help, the more issues you can actually cause,” Jeffries adds. Breech babies also average lower Apgar scores, a test that assesses newborn health immediately after birth.
The question of breech delivery seemed to be definitively settled by results from a large, 26-country clinical trial, the Term Breech Trial, conducted in 2000. The trial changed the way obstetricians around the world handled breech births almost overnight. One study in the Netherlands showed a 60% jump in caesareans for breech birth only two months after the original publication, an almost unheard-of speed of impact for one study. Before year’s end, the American College of Obstetricians and Gynecologists, the body that regulates obstetrics practice in the US, had changed their recommendations to caesarean for virtually all breech births, with two exceptions: when a woman was in “advanced labour,” with no time for a caesarean, and in the infrequent case of a smaller second breech twin.
The trial came under fire vociferously by a Term Breech Trial study collaborator, Dr. Marek Glezerman, who in 2005 published a highly critical rebuttal concluding that the study’s methodology was so deeply flawed that its conclusions should be formally withdrawn.6 He cited longer term follow-up data that didn’t support improved outcomes, and study irregularities including fetal deaths unrelated to delivery mode, inclusion of hospitals with substandard medical facilities, and vaginal births attended by doctors untrained or undertrained in breech birth.
In light of the new data, in 2009 “the Society of Obstetricians and Gynaecologists of Canada has reversed its decision and told its residency programs it needs to start retraining breeches today,” says Dr. Fischbein, but that has not happened yet in the US. In 2006, the breech recommendations were pulled back from the hard line drawn immediately after the Term Breech Trial’s publication, supporting breech birth in cases where the woman meets all the selection criteria, and where the practitioner is skilled in breech birth. Yet the recommendations concede that caesareans would continue to be the likeliest outcome “because of the diminishing expertise in vaginal breech delivery.” Despite this acknowledged lack, most hospitals simply can’t adequately teach hands–on breech birth today since the vast majority of breech births are delivered by caesarean. A consensus opinion published in April 2014 by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine urged reducing the overall caesarean rate, and concluded that external cephalic version was underutilized, but they stopped short of recommending vaginal trial for breech deliveries.
Dr. Hall is bucking the national trend in the United States: he has begun teaching breech births to obstetrics residents at the University of Colorado in Denver. In a recent interview, Dr. Hall cites institutional challenges that may be hard to overcome in making breech vaginal birth more widespread. For example, although many of the breech birth manual techniques are still widely taught (because they are used in caesareans; if you think about it, pulling a baby out vaginally is similar to pulling it out of a low abdominal incision), other standard obstetrical procedures for rare but dangerous situations have changed over time in a way that is not consistent with safe breech birth. For example, rarely a baby’s head becomes stuck in the birth canal. Traditionally forceps would be used to help extract the baby. But forceps have fallen out of favour in recent years, replaced by vacuum extraction, a procedure that can’t be used for breech births. Since the biggest worry of breech birth is the head getting stuck, young obstetricians will need to be competent with forceps delivery.
Dr. Hall also cites paediatricians’ lack of comfort with bedside resuscitation (as opposed to incubator resuscitation) as an impediment to safe breech birth, as in some cases it can be important to delay cutting the cord. Further, nervous administrators have for now confined the training program to admit only women who have previously had at least one baby vaginally. This significantly reduces the learning opportunity, says Dr. Hall, since those deliveries are usually faster and easier. And perhaps the most significant challenge is the low numbers of breech vaginal deliveries: he estimates that a resident would need to lead at least 10 breech deliveries to be sufficiently confident and competent to perform breech deliveries on their own. Since he delivers only 2-3 breech babies per month, obtaining sufficient experience is a very slow process for young residents.
Critics of the breech policy argue that the loss of breech birth skills is dangerous for women and babies. What if a baby presents breech unexpectedly, or if labour progresses too fast for a caesarean to be performed? During the brief but tense period when Arnold’s baby was partially born, Jeffries recalls her relief at Dr. Hall’s expertise, acknowledging the possibility of a different outcome “had we not had someone who knew what they were doing [with breech delivery]” present.
The breech recommendations suggest counselling women of a higher risk of death or serious short-term injury to their babies if they choose a vaginal birth. Despite this stark warning, it is unclear whether lumping all breech births together makes sense; footling breech, preterm and small babies, and caregivers inexperienced with breech birth, for example, may be much higher risk than breech pregnancies that meet all the requirements. “When you meet all the selection criteria,” Dr. Fischbein says, the risks of breech delivery “are really no different” from that of a head down baby.
Arnold met all the criteria for a breech natural birth; no other pregnancy complications, a “proven pelvis” since she had delivered her first son naturally, and importantly, she had a high comfort level with a breech delivery. “I was determined not to have a C-section unless it was medically necessary,” she says.
Arnold awoke in labour around midnight, more than a week overdue, and met Jeffries and Dr. Hall at the hospital. She delivered a perfectly healthy baby boy less than three hours after arrival. She says it “didn’t feel much different” from the natural birth of her first, head down baby. Later that day, in the relative quiet of her hospital bed, Arnold snuggled her newborn, marvelling, “[G]oing through it the second time, you forget how small they are when they first come out.”
It seems that medicine, like most things in life, isn’t cut and dry. Yet the move to caesarean for breech babies has major life consequences for women and their families, and there is a growing clamour to rethink the one-size-fits-all “caesarean for all breech babies” policy. And despite the uncanny speed with which the Term Breech Trial changed medical practice recommendations around the world over a decade ago, the change back has been glacial. Says Dr. Fischbein, “Ultimately the medical profession will make changes if people make demands.”
Gwen is a PhD biochemist, writer, and mother of three young children: a 7-year-old daughter, and 3-year-old boy/girl twins. Having undergone what she will always suspect was an unnecessary C-section with her breech twins, she became passionate about learning more about breech vaginal birth and spreading the word that surgery really isn’t (and shouldn’t be treated as) a no-brainer for breech birth.
Reprinted with permission.
First published in Birth Issues, Spring 2015;XXIX(2):38-41.
Editorial notes:
Dr. Michael Hall, attending obstetrician, had been a calm, reassuring presence here since Arnold’s arrival two hours earlier in the frosty January pre-dawn at Swedish Medical Center in Englewood, Colorado. “Just let her keep doing her thing,” he intoned. With a solid 40–year career in obstetrics, Dr. Hall was the seasoned veteran of the proceedings. A collective sigh of relief was released from assembled medical staff when a pink, perfect little head popped into view.
Breech births, where the baby is in a foot– or butt–down at the time of delivery instead of the typical head-down position, account for 3 to 4% of all births. Yet despite the movement towards more birth choices today, a third of babies are born by caesarean, itself a major (not to mention expensive) abdominal surgery with the potential for serious complications. And for a variety of reasons, the movement hasn’t extended to breech births: upwards of 90% of breech babies are delivered by caesarean today. These statistics are reversed from a generation ago, when most breech babies were delivered vaginally. Yet safety statistics haven’t changed much since then, and the study that precipitated the move to caesareans for almost all breech babies has come under fire in recent years.
Arnold, an office manager from Denver, Colorado, was thirty four weeks along with her second baby when she learned that he was breech in November 2011. Arnold had planned to deliver at Mountain Midwifery in Englewood, Colorado, the only free standing birth center in the state. “I was expecting and looking forward to a natural water birth,” Arnold recalls.
Arnold spent the next weeks of her pregnancy trying to turn her baby: headstands in the pool, acupuncture, herbal remedies, hypnosis, and chiropractic. But nothing worked, so at 36 weeks pregnant, she turned to Dr. Hall, where Mountain Midwifery refers their high risk patients. Dr. Hall attempted external cephalic version, the only medical procedure widely used to turn breech babies. This technique works about 60% of the time, and it has drawbacks, though complication rates are relatively low. Women report it can be quite painful, and sometimes the baby returns to an unsuitable position afterwards. The procedure failed in Arnold’s case. The baby had already “dropped,” i.e. his bottom was so firmly lodged in the pelvis that Dr. Hall’s team couldn’t budge him.
At this point, most women would schedule their caesarean, but here is where Arnold’s story takes an unusual turn. Dr. Hall is one of a dwindling number of obstetricians willing to allow vaginal breech birth, provided the pregnancy fits stringent selection criteria necessary for the safety of mother and baby.
Since 2000, caesareans have been the gold standard for breech deliveries,5 but there’s growing controversy over the risks of breech vaginal delivery versus caesarean to women and babies.6 Dr. Stuart Fischbein, a 28–year private practice obstetrician who made the decision to leave clinical practice in Los Angeles to exclusively attend home births a few years ago, is a self–styled birth activist, citing hospital policies not conducive to labouring and birth. In sharp contrast to hospital breech birth statistics, he estimates a >80% vaginal delivery rate of his homebirth breech deliveries with no emergency transports to the hospital required7 (although women who plan deliveries at home have lower risk pregnancies). In a 2011 interview, Dr. Fischbein discusses doctors’ practical considerations in the hospital setting.8 Not like the unpredictability of a natural birth process, the typical 45–minute caesarean is routine, can be scheduled, and there’s a high comfort level with the procedure among obstetrics professionals. Today about a third of all US births are done by caesarean, almost three times the rate considered medically necessary by the World Health Organization.
Despite the large number of surgical births today, “We really haven’t done much better in terms of infant or maternal morbidity or mortality,” says Fischbein. However, obstetricians have the highest malpractice risk among physicians in the US, “fostering a ‘more is safer’ attitude,” concludes a front-page 2013 New York Times analysis.
Critics argue that studies of vaginal versus caesarean birth for breech babies fail to take into account the long term risks of caesarean, such as potentially life–threatening ruptured uterus or placental issues in future deliveries, and future fertility issues. Potential side effects of surgery may be downplayed in counselling. “No operation where the skin is cut and the abdomen is entered should be considered routine,” says Dr. Fischbein.
Further, emerging research suggests a link to longer-term health issues possibly related to caesareans. Lack of exposure to maternal fecal matter during birth combined with antibiotic exposure may make babies delivered by caesarean prone to poor early gut colonization by “beneficial” microbes. But it is hard to pin down a connection to caesareans because many factors affect early intestinal health, including breastfeeding and presence of older siblings, among others. There is also some research pointing to possible links between caesarean and a variety of conditions like childhood obesity, allergies, asthma, eczema and diabetes.
Why are almost all breech births delivered by caesarean today? Probably most important, there’s a greater chance of short-term injury to a breech baby compared to those born head down.15 Birth providers inexperienced with breech birth may intervene unnecessarily when the baby is partially born. With breech babies, the policy is “hands off until you absolutely have to do [something],” Dr. Hall explains, something many obstetricians find uncomfortable. “[T]he more you try to help, the more issues you can actually cause,” Jeffries adds. Breech babies also average lower Apgar scores, a test that assesses newborn health immediately after birth.
The question of breech delivery seemed to be definitively settled by results from a large, 26-country clinical trial, the Term Breech Trial, conducted in 2000. The trial changed the way obstetricians around the world handled breech births almost overnight. One study in the Netherlands showed a 60% jump in caesareans for breech birth only two months after the original publication, an almost unheard-of speed of impact for one study. Before year’s end, the American College of Obstetricians and Gynecologists, the body that regulates obstetrics practice in the US, had changed their recommendations to caesarean for virtually all breech births, with two exceptions: when a woman was in “advanced labour,” with no time for a caesarean, and in the infrequent case of a smaller second breech twin.
The trial came under fire vociferously by a Term Breech Trial study collaborator, Dr. Marek Glezerman, who in 2005 published a highly critical rebuttal concluding that the study’s methodology was so deeply flawed that its conclusions should be formally withdrawn.6 He cited longer term follow-up data that didn’t support improved outcomes, and study irregularities including fetal deaths unrelated to delivery mode, inclusion of hospitals with substandard medical facilities, and vaginal births attended by doctors untrained or undertrained in breech birth.
In light of the new data, in 2009 “the Society of Obstetricians and Gynaecologists of Canada has reversed its decision and told its residency programs it needs to start retraining breeches today,” says Dr. Fischbein, but that has not happened yet in the US. In 2006, the breech recommendations were pulled back from the hard line drawn immediately after the Term Breech Trial’s publication, supporting breech birth in cases where the woman meets all the selection criteria, and where the practitioner is skilled in breech birth. Yet the recommendations concede that caesareans would continue to be the likeliest outcome “because of the diminishing expertise in vaginal breech delivery.” Despite this acknowledged lack, most hospitals simply can’t adequately teach hands–on breech birth today since the vast majority of breech births are delivered by caesarean. A consensus opinion published in April 2014 by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine urged reducing the overall caesarean rate, and concluded that external cephalic version was underutilized, but they stopped short of recommending vaginal trial for breech deliveries.
Dr. Hall is bucking the national trend in the United States: he has begun teaching breech births to obstetrics residents at the University of Colorado in Denver. In a recent interview, Dr. Hall cites institutional challenges that may be hard to overcome in making breech vaginal birth more widespread. For example, although many of the breech birth manual techniques are still widely taught (because they are used in caesareans; if you think about it, pulling a baby out vaginally is similar to pulling it out of a low abdominal incision), other standard obstetrical procedures for rare but dangerous situations have changed over time in a way that is not consistent with safe breech birth. For example, rarely a baby’s head becomes stuck in the birth canal. Traditionally forceps would be used to help extract the baby. But forceps have fallen out of favour in recent years, replaced by vacuum extraction, a procedure that can’t be used for breech births. Since the biggest worry of breech birth is the head getting stuck, young obstetricians will need to be competent with forceps delivery.
Dr. Hall also cites paediatricians’ lack of comfort with bedside resuscitation (as opposed to incubator resuscitation) as an impediment to safe breech birth, as in some cases it can be important to delay cutting the cord. Further, nervous administrators have for now confined the training program to admit only women who have previously had at least one baby vaginally. This significantly reduces the learning opportunity, says Dr. Hall, since those deliveries are usually faster and easier. And perhaps the most significant challenge is the low numbers of breech vaginal deliveries: he estimates that a resident would need to lead at least 10 breech deliveries to be sufficiently confident and competent to perform breech deliveries on their own. Since he delivers only 2-3 breech babies per month, obtaining sufficient experience is a very slow process for young residents.
Critics of the breech policy argue that the loss of breech birth skills is dangerous for women and babies. What if a baby presents breech unexpectedly, or if labour progresses too fast for a caesarean to be performed? During the brief but tense period when Arnold’s baby was partially born, Jeffries recalls her relief at Dr. Hall’s expertise, acknowledging the possibility of a different outcome “had we not had someone who knew what they were doing [with breech delivery]” present.
The breech recommendations suggest counselling women of a higher risk of death or serious short-term injury to their babies if they choose a vaginal birth. Despite this stark warning, it is unclear whether lumping all breech births together makes sense; footling breech, preterm and small babies, and caregivers inexperienced with breech birth, for example, may be much higher risk than breech pregnancies that meet all the requirements. “When you meet all the selection criteria,” Dr. Fischbein says, the risks of breech delivery “are really no different” from that of a head down baby.
Arnold met all the criteria for a breech natural birth; no other pregnancy complications, a “proven pelvis” since she had delivered her first son naturally, and importantly, she had a high comfort level with a breech delivery. “I was determined not to have a C-section unless it was medically necessary,” she says.
Arnold awoke in labour around midnight, more than a week overdue, and met Jeffries and Dr. Hall at the hospital. She delivered a perfectly healthy baby boy less than three hours after arrival. She says it “didn’t feel much different” from the natural birth of her first, head down baby. Later that day, in the relative quiet of her hospital bed, Arnold snuggled her newborn, marvelling, “[G]oing through it the second time, you forget how small they are when they first come out.”
It seems that medicine, like most things in life, isn’t cut and dry. Yet the move to caesarean for breech babies has major life consequences for women and their families, and there is a growing clamour to rethink the one-size-fits-all “caesarean for all breech babies” policy. And despite the uncanny speed with which the Term Breech Trial changed medical practice recommendations around the world over a decade ago, the change back has been glacial. Says Dr. Fischbein, “Ultimately the medical profession will make changes if people make demands.”
Gwen is a PhD biochemist, writer, and mother of three young children: a 7-year-old daughter, and 3-year-old boy/girl twins. Having undergone what she will always suspect was an unnecessary C-section with her breech twins, she became passionate about learning more about breech vaginal birth and spreading the word that surgery really isn’t (and shouldn’t be treated as) a no-brainer for breech birth.
Reprinted with permission.
First published in Birth Issues, Spring 2015;XXIX(2):38-41.
Editorial notes:
- Phone and email interviews of Mandy Jeffries and Janet Arnold conducted in May and June 2013.
- Reviewed in Richard Fischer, MD. “Breech Presentation” July 9, 2012. http://emedicine.medscape.com/article/262159-overview
- Luz Gibbons, José M. Belizán, Jeremy A Lauer, et al. (2010) “The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage” World Health Report, Background Paper, 30. http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf
- American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. (2014), “Safe prevention of the primary cesarean delivery.” American Journal Obstetrics and Gynecology, 210 (3): 179-93.
- Hannah ME, Hannah WJ, Hewson SA, et al. (2000), “Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.” Lancet, 356 (9239): 1375-83.
- For example, see the rebuttal of the Term Breech Trial results in Glezerman M. (2006), “Five years to the term breech trial: the rise and fall of a randomized controlled trial.” American Journal of Obstetrics and Gynecology, 194 (1): 20-5.
- Personal communication. Email dated November 10, 2014.
- “A Conversation with Dr. Fischbein,” Gena Kirby, Progressive Parenting Podcast, December 20, 2011. http://www.blogtalkradio.com/progressive-parenting/2011/12/20/breech-birth-a-reality-a-conversation-with-dr-fischbein
- Elizabeth Rosenthal, “American Way of Birth: The Costliest in the World” July 1, 2013, New York Times, New York edition, page A1.
- National Institutes of Health Consensus Development Conference statement: vaginal birth after cesarean: new insights. March 8–10, 2010. Obstetrics and Gynecology, 115 (6): 1279–1295. http://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf
- American College of Obstetricians and Gynecologists (2010). “ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery,” Obstetrics and Gynecology, 116 (2 Pt 1): 450-63. Available at: http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Obstetrics/Vaginal-Birth-After-Previous-Cesarean-Delivery
- Pandey PK, Verma P, Kumar H, et al. (2012), “Comparative analysis of fecal microflora of healthy full-term Indian infants born with different methods of delivery (vaginal vs cesarean): Acinetobacter sp. prevalence in vaginally born infants.” Journal of Bioscience, 37 (6): 989-98.
- Makino H, Kushiro A, Ishikawa E, et al. (2013), “Mother-to-infant transmission of intestinal bifidobacterial strains has an impact on the early development of vaginally delivered infant's microbiota.” PLoS One, 8 (11): e78331.
- Reviewed in Neu J, Rushing J. (2011), “Cesarean versus vaginal delivery: long-term infant outcomes and the hygiene hypothesis.” Clinical Perinatology, 38 (2): 321-31.
- Reviewed in reference 2, and see literature references as early as mid-century (e.g. Wright RC (1959), “Reduction of perinatal mortality and morbidity in breech delivery through routine use of cesarean section,” Obstetrics and Gynecology, 14: 758-63. External cephalic version was first practiced in the 16th century (reviewed in Ghosh MK (2005), “Breech presentation: evolution of management,” Journal of Reproductive Medicine, 50 (2): 108-16.)
- Phone interview conducted November 6, 2014.
- Rietberg CC, Elferink-Stinkens PM, Visser GH (2005), “The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants,” BJOG, 112 (2): 205-9.
- Committee on Obstetric Practice (2001), “ACOG committee opinion: number 265, December 2001. Mode of term single breech delivery,” Obstetrics and Gynecology, 98 (6): 1189-90.
- Maternal Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada (2009), “Vaginal delivery of breech presentation,” Journal of Obstetrics and Gynaecology Canada, 31 (6): 557-66, 567-78.
- ACOG Committee on Obstetric Practice, “ACOG Committee Opinion No. 340. Mode of term singleton breech delivery,” Obstetrics and Gynecology, 2006, 108 (1): 235-7.
