This page is not finished, but my preliminary comments and links are available. I have become much more cautious about breech birth at home over the 12 years that I have been involved in homebirth support, because I believe the anecdotal and limited statistical evidence we have suggests a higher rate of problems than for the usual alternative - elective caesarean. There have been cases where gentle, spontaneous labours, with gentle, careful midwives, have still ended in tragedy. Sometimes all the midwifery skills in the world are not enough.
Breech birth at home is unusual because breech babies are at higher risk of injury or death during birth compared to head-down babies. Note that the vast majority of breech babies will be safe and well after a vaginal birth, but there is statistical evidence that they are at higher risk than a head-down baby. There are several reasons for this:-
Mechanical problems during the birth - the baby's arm or head getting trapped, delaying the birth. The reason this is dangerous is that the cord may be compressed between the baby's head and the pelvis, depriving the baby of oxygen. In addition, the placenta may start to detach as the uterus shrinks down rapidly (because most of the baby is out) and contracts strongly in an effort to expel the baby.
Need for resuscitation after the birth - breech babies are more likely to need resus after birth, partly because of the risk of cord compression. Community midwives are all trained in neonatal resuscitation and generally will carry equipment to ventilate a baby who is slow to breathe - usually a bag-and-mask, and oxygen. In the vast majority of cases, the only resuscitation required at home is stimulation, clearing the airways, or the use of the bag-and-mask (see 'what if my baby needs resuscitation?'. If the baby does not respond well and quickly then an ambulance will be called to transfer to hospital while paramedics and the midwife continue with resus efforts. However, it is obvious that in severe cases, access to further support can make a difference. In hospital, a paediatrician who is very experienced in resuscitation can intubate a baby, providing effective mechanical ventilation very quickly. It is extremely rare for such measures to be necessary after low-risk, straightforward homebirth - but it is more common with breech babies.
Congenital abnormalities - there are some birth defects and conditions which make breech presentation more likely, eg congenital dislocation of the hips, hydrocephalus, or poor muscle tone. A scan can eliminate many of the possible physical causes of breech presentation, but cannot tell you if the baby has some neurological difference which might also make him prone to breathing problems at birth. Sometimes it is said that a breech baby who did not breathe after birth, might have been breech because he had some such pre-existing condition. However, it seems to me that this must be relatively rare as a proportion of overall breech babies, because the Term Breech Trial (Hannah et al) found very low rates of perinatal death amongst breech babies delivered by elective caesarean. If these babies were breech because of developmental or brain abnormalities, then we would expect them to still have breathing problems after birth by elective caesarean - indeed, as prelabour caesarean section is known to increase the risk of breathing problems at birth generally, if this was a significant factor then we would expect it to be especially common in breech babies born by caesarean, but I am not aware of any evidence that this is so.
Around 4% of babies are breech at term, and approximately 1 in 4 of these are undiagnosed until labour - so 1 in 100 labours will turn out to be a surprise breech, although most women will still have time to choose a caesarean section in this situation. Relatively few midwives are experienced in attending a natural breech birth; sometimes manouvres are necessary to free a trapped arm or head, and depending on the position of the baby and the mother's pelvic dimensions, in some situtions even an experienced birth attendant may not be able to help. Breech babies are more likely to need resuscitation, as explained above. For all these reasons, a midwife who does not feel confident would usually ask a mother to transfer to hospital in this situation. As always, it is your decision whether to go, but it is entirely understandable that relatively few midwives would be happy to stay at home in this situation.
The possibility of a surprise breech is one reason to consider having an internal exam in labour, so that you have more time to think about your options and to transfer if necessary. In addition, your midwife may ask you to have a scan in late pregnancy to check presentation. It is your decision whether to accept such a scan - but given the rate of undiagnosed breeches even with experienced midwives and doctors, it could give you useful information. If you are worried that this scan might be used as an opportunity to go 'looking for trouble', you can specify to the sonographer that you only want the baby's presentation to be checked, and do not want a growth scan, for instance.
Your chances of a surprise breech will depend in part on your body. If you are a first-time mother with tight abdominal muscles, it may be harder to tell the baby's position; if you have had children before and your abs are more lax, you may be entirely confident of his position.
For more on breech birth, see Breech Birth Issues from the UK Midwifery mailing list, a very thorough breech overview from e-medicine (aimed at health professionals) and Home Birth in the News.
Some women, like Sophie, choose to change to a hospital setting, but with the right midwife may still have a completely natural breech birth. In these cases the mothers booked with independent midwives who were experienced in attending natural breech births. Others stay with the NHS, eg Ruth changed her plans and went to hospital when her first baby decided to arrive breech, five weeks early. Louise only realised her baby was breech when a foot arrived after a very fast labour, and she transferred and gave birth in the ambulance outside the hospital.
Home Birth Reference Page