The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
An interactive resource for moms on easy steps they can take to reduce exposure to chemical toxins during pregnancy.
Other excellent resources about avoiding toxins during pregnancy
These are easy to read and understand and are beautifully presented.
Heads Up! - All about Birthing
Breech - a new web page with lots of resources.
Footling Breech - This is a home delivery of a posterior footling breech. The parents were informed of the risks of breech birth, and wishing to avoid a cesarean, chose to deliver at home with trained and experienced midwives .
Here's the mom's web page: Home
Birth of a Footling Breech Baby with an experienced midwife.
You can also buy her My
Footling Breech Birth DVD.
I think the best resources are Breech Birth by Maggie Banks and Valerie El Halta's Breech scoring system and video presentation.
Or if you are present at cesarean deliveries for breech watch the manipulations
and mechanisms of delivery. Not so different when there is a pelvis around
the baby. Also train your hands. Take naked newborns and close your eyes
and memorize how the breech, knee, heel, sacrum etc. feel. For estimation
of fetal size as well as position do the same with width of the back and
shoulders in every aspect (side, back, upper, lower). If that arm was nuchal,
how could you draw it down physiologically? What if leg were frank?
Practice practice practice with a doll and then patience patience patience...and
be prepared to resuscitate.
The researchers at the National Maternity Hospital in Dublin followed all 641 women with breech presentation after 37 weeks during the four years from 1997 to 2000. Computerized records provided perinatal and labor outcomes.
A trial of vaginal breech delivery was allowed only if the presentation was extended type and if the estimated fetal weight was less than 3.8 kg. When vaginal delivery was attempted, labor induction was avoided as was the use of oxytocin, for either the first or second stages.
Slow labor was not an immediate reason to go to C-section. The threshold to send a woman in slow labor for a Cesarean was 6 hours for the first stage, and 60 minutes for the second stage, for a first birth. A woman who had already given birth before was allowed to labor in first stage for 4.5 hours.
Of 298 women who tried vaginal delivery, 146 succeeded.
"There are well-known criteria to have a safe, vaginal breech birth," said Dr. Karin Blakemore, of Johns Hopkins in Baltimore, Maryland, who commented on the poster presentation. "You don't offer vaginal delivery for big babies."
The Irish study presented here found "no perinatal death and no poor outcomes," as defined by an Apgar score of less than 7 at 5 minutes, or cord venous pH of more than 7.2, or abnormal neonatal neurology, Dr. Blakemore pointed out. "Zero is a powerful number," she said.
Claims "C-Section Best for Breech Babies" [Lancet registration is free]
Can it be possible that I am alone in wondering how this study might
have turned out if there were breech-experienced midwives (rather than
doctors) at the bed of these women? I also see they don't mention the nature
of the injuries, did the doctor panic and get his hand in there breaking
bones and stressing spinal cords? or was the vaginal canal the culprit
(like it sounds). I am a total skeptic. I would like to hear
your take on this.
It is interesting that these guys said this is the first study done.
If you look at Henci Goer's Obstetric myth v Research reality, and look
at the citations & reviews of those citations, there are numerous studies
which demonstrate the opposite. In the book on Evidence-Based Practice,
they state that in a frank breech position, c-sec is NOT warranted.
2000 women isn't a great sample. My fear would be that docs continue
to not recognize breech early, encourage slant/visualization/etc, make
no attempt at version, then, based on one study, of 2000 women, do more
I had the same kinds of questions. It is difficult to know any of those answers. But I once did a report on studies that I had researched that showed basically NO difference between vaginal and Cesarean delivery on the babies, IF the babies were full term and there were no other complications, AND they were attended by a competent practitioner.
I don't know if I would assume the doctors who were experienced with breech deliveries were necessarily bad practitioners-I think a lot of those guys are the older, GP, type of docs who can actually be more classified as midwives in actual approach. I could be wrong.
But I do wonder how the numbers are skewed when it turns out that only
about half of the women "attempting" vaginal delivery actually did give
birth vaginally. And what were the deciding circumstances?
And, how much were they supported emotionally to do so? Or were they,
throughout the study, given to think that they were in the least likely
position to succeed. Many, many subtle factors take place to determine
whether a woman can give birth to a breech baby vaginally-the first is
an absolute confidence that she and baby will be ok. That might
be difficult to achieve in a study trying to disprove that very thing.
I think there is a strong prejudice among some in the medical community -- and certainly in the legal community -- that cesarean is "safer" or "easier" on the baby. They are rapidly convincing the public that surgery is perhaps the safest option, and is the best way to "guarantee" a healthy baby.
A good section of the public is coming to think of vaginal delivery as second-rate to surgical birth and far more dangerous for the baby.
We have a lot of education to do!
Just ask Ina Mae Gaskin. She's got the very best stats I've come
it looks to me (from condensed version, not original) that they simply randomized breeches without picking out the good candidates for vaginal birth. up here where we do many, folks are very picky about which breeches they offer vaginal birth to. i think that's why we do so well. if you just deliver all comers, well, i would expect the outcomes to be not so hot.
there's something else weird in this study, the injured/dead rate was
high even in the control group, wasn't it? something like 1.2 %?
i remain skeptical.
I am *very* bothered by this trial, in part because the very *moment* that it was halted, the hospital where I mostly attend births NEVER did another vaginal breech again (it was one of the trial hospitals, although I don't think that they, in fact, recruited many women). This despite the fact that many of the OB's were proud of the fact that vaginal breech was offered and often successful. In the space of a week, they weren't done anymore -- fear of lawsuit, don'tcha know. I don't blame them.
The disturbing thing about the deaths were that if a baby died and it wasn't from lethal congenital anomalies, then it was from vaginal breech birth, right? There were several quite small babies in the "dead baby" group -- 2500 gm or less at term. Among the deaths after vaginal breech were a 2000 gm term baby that was sent home well and later died in its sleep, another small baby sent home apparently well but developed severe vomiting and diarrhea and died, another baby with a "small head, low-set ears and deep-set eyes" that also died. Another one that was included was an IUD of a *cephalic* baby that occurred, by the author's admission, probably prior to enrollment (like they didn't *know* for sure??). Another was an IUD of a twin probably before enrollment, baby weighed 1150 gm at term. So we have a bunch of potentially IUGR babies that died for a variety of reasons (two from "respiratory problems" -- from what??), but they're all attributed to being as a result of vaginal breech birth. EXCUUUUUSE me....
As well, in the morbidity section, the trial makes a big deal about increased morbidity to babies born vaginally. But the numbers that make the difference in birth trauma is long bone fractures or fractured clavicles -- now granted, that's not nice, but it's very rarely a long term problem for babies. Similarly, it appears that the vaginal born babies have worse Apgars and cord gases, but then there's a little teensy weensy asterisk that notes that there were "a few" missing Apgars, and that cord gases weren't taken on all babies -- in fact, they were done on less than half of them. So how the *hell* can you posit any kind of statistical statement when you don't know what they were for *all* the babies in the trial?
Oh, and as well, despite the fact that they were *supposed* to be screening for this, there were twice as many >4000 gm babies in the planned vaginal group as in the planned C/S group. There were supposed to be none.
It's very, very disappointing to me. I know some of the people
who ran this trial and I am *appalled* at the quality of it (apart from
the fact that it was never completed). And yet, because Mary Hannah is
so respected in the world of RCT's, we will live and die by the work she
Research Studies Supporting Safety of Vaginal
The Farm Midwifery
Center is famous for continuing to assist women in birthing breech
You may already know that the perceived hazard of breech birth comes
from the fact that many premature babies are still breech when they're
born, so breech statistics tend to reflect lots of premature problems.
There is a doctor in Ostend, Belgium who is experienced assisting delivery
of both breech
and twins in water.
This article contains a level of anxiety about birth that is unsettling. However, evaluated as an obstetrical document, it has a relatively non-interventive attitude.
Waterbirth Increases Safety of Breech Birth
As a labor nurse, I had 2 moms who lost breech babies in just this way. One was a primip who came in fully with breech distending the perineum. Body delivered nicely, cervix clamped down on the head and there was a considerable delay to delivery of the head. Resuscitation was not successful.Can you explain more about the cervix clamping down on the head?
Do you believe that the cervix was actually closing back up, even with the pressure of the baby's head on it? Or was the cervix not really fully dilated - just enough to let the body through but not the head? Oxorn-Foote says that this "clamping down" is more likely in a premature birth because the body is skinnier. This makes it sound as if the cervix isn't really fully dilated in these cases. However, they do continue to call it a cervical "spasm", implying that it was actually closing up.
It seems odd that this would happen only in breech births. No one ever talks about the cervix "clamping down" around the baby's shoulders in a vertex birth.
Do you think the "hour of patience" would have helped? I can imagine that it might take an epidural to relieve the urge to push, in some cases, but I've heard "the hour" recommended for all breech births in order to avoid head entrapment. I think it would be somewhat easier in a knee-chest position where the baby's body could be kept off the pelvic floor.
Later in that same shift a multip who was slightly preterm (ie 35-36 weeks) went into labor. Because the EFW was approx 6 lbs, the decision was to deliver vaginally. Again, nice straight forward labor, cervix trapped the head. Mom had Duhrssen's incisions, halothane anesthesia...the whole deal. Head was delivered after 14 minutes. Baby survived the initial code and expired the next day.Wow! Two tragedies in one day. It's almost enough to make you think that vaginal breech birth is inherently dangerous.
Was there anything that could have been done differently to increase the safety of these births? Does 14 minutes for delivery with Duhrssen's incisions seem right to you? Was an airway established?
From a theoretical point of view, it seems that there are lots of ways of ensuring that head entrapment doesn't kill the baby. Do you think these things just don't work, or were they not implemented properly in these cases?
Both these births were done in an institution which regularly did vaginal breeches.Did the institution recognize them as a statistical anomaly, or did they re-evaluate their breech statistics and change their policy?
What conclusions did you draw from this experience? Were you able to weigh the risks of breech birth against the risks of cesarean birth, including the possibility of the rupture of the uterine scar in future pregnancies?
We all hope for the ideal healthy head-down singleton in a healthy mom,
and sometimes it's hard to be objective about relative risks in less-than-ideal
circumstances. This has been easier for me, personally, since there was
a maternal death due to infection following Cesarean at our local hospital.
same here, for a smallish footling, 4th baby, automatic csec. Massive
infection, mom lingered for about a month till dying in the tertiary care
hospital she'd been transferred to. With the breech we just had die, when
people bring up the "fact" that the baby would have lived if only a csec
had been done, drives me crazy! NO guarantees, tho the public still see
csec as the "safe" and guaranteed way to do births. And are still so ignorant
about them that I get asked all the time if we do csecs at home!
[from an OB who attends vaginal breech births] Respectfully can
I suggest that the cervix doesn't close down. Its' actually about an incompletely
dilated cervix which the breech comes through rather than the cervix closing
down after the breech has gone through.
I'm wondering if you use nitroglycerine for uterine relaxation in such
cases. I've heard about its use around these parts, especially w/ unexpected
preterm breeches. (Clearly outside the scope of midwifery practice [Grin]!)
I used to keep some in my locker on delivery suite, but never got to
use it before it expired. My reading is of value to relax uterus in hypertonus
and internal version and other problems with second twin.
Could you be willing to take a well-educated guess on how frequently
this happens in a term delivery? Do you think there's far greater risk
with non-frank breech or only a "little" greater? and .... what can be
done to avoid it?
It is very rare. I think I've only really seen one case. That was a patient of mine delivered by one of our residents under the (telephone) advice of one of my consultant colleagues, when I was on leave last month. Another case occurred of delay in delivering head but it was due to inappropriate technique and an uncooperative hysterical mum which panicked everyone.
My non-EBM view is that it's only a problem with real footlings (may
be a problem in defining a real footling) and in such cases can be potentially
avoided with an epidural.
It seems to be a peculiarly american teaching that the cord will become pinched quickly in breech births, but actually the cord usually doesn't have much pressure on it until the head engages deep into the pelvis. The baby's head doesn't even begin to enter the brim until the baby is born at least to the umbilicus.
Older US texts and Myles (UK) agree that the baby will stand 8 to 10
minutes of cord compression rather than our US dogma which is almost
"deliver in three minutes or the baby is dead".
Do you ever allow footling breeches to labour and deliver vaginally?
Not in this country with the legal system. [from U.S. OB]
I would add: Not in this country, where obstetricians have been cowed by the legal system, and thus are inexperienced.
We just delivered a footling breech at 37 weeks who came in fully dilated with membranes intact until the foot was about 5 cm outside the vagina. There are clearly selected footling breeches that CAN be delivered by experienced personnel.
[from a Canadian OB I do deliver breeches vaginally and feel that it is fast becoming a lost art (along with a lot of other things that are being replaced en bloc by C/S). Standard of care in Canada is not to allow footling breeches to deliver vaginally (unless they are precipitous). My senior partner has been at this for 19 years; he used to deliver selected footlings vaginally (basically if they were multips with previous medium to large babies and the present one was not large). He quit doing them when the SOGC (Society of O&G of Canada) came out with a statement against vaginal delivery of footling breech. There have been times when the lady had a good pelvis, was a multip, and I knew the baby was not large that I was sorely tempted to give it a try, but it would be considered malpractice here.
Precautions - don't have an epidural service therefore cannot offer one. I would like the option and would probably use it. All breech deliveries are done in our "High Risk" room (we do all C/S on the Mat floor and this is also our High Risk room). Anaesthesia is made aware of Breech delivery, and if Anaesthesia is not in house strong consideration is given to calling them in on standby. IV started, paediatrics ready, pipers ready.
Literature - There was a recent consensus conference on breeches by
the SOGC. I will try to find it and look at the references for you. This
spawned the Term breech trial being run out of Toronto, but footling is
an exclusion criteria.
[from a French OB] I saw as much prolapses in both types of breeches.
It happens mainly at complete dilatation. I saw more prolapses in vertex
presentation than in breeches. These breech prolapses are seldom severe
because the presenting part is not so hard than the head, so if an elective
CS is necessary I would say it is rather in vertices. Anyway a CS is always
I inflate the bladder with sterile saline (+/- 500 cc). Works very well
and leaves the whole team very calm to prepare the C-section. I have not
the ref in mind but could find it.`
[from an OB]
With regard to the brouhaha over breech vaginal births...
I had the good fortune of doing my residency where we were able to graduate having done a goodly number of vaginal breeches. I would estimate that between residency and private practice (now 7+ years) I've had 30-40 vag breeches.
Now I realize this in no way approaches any statistical significance but I must say all breeches I've done vaginally went without a hitch.
Which makes me think that our esteemed Dr. Abe Velkoff (of private practice/Emory University fame in Atlanta) wasn't just bullsh***ing when he told me how in the early sixties their section rate was ~5 % and ALL breeches were given a trial of labor, most delivering no matter how they came down the pike...
Now of course there were no lawyers back then.
There are far too many extenuating circumstances in play nowadays to be able to have a uniform approach to breeches. If you are in a situation where nobody does them, it might be going out on a limb to start doing them, especially if you haven't done them in a long time.
We also have the sad situation where fewer and fewer graduating
residents get vaginal breech experience, in which case it may become a
dying art, in the same way many graduating residents get very few vaginal
surgery cases under their belts, and end up doing a lot of TAHs or LAVHs
because they never developed the skill.
In Carbondale, we were training our family practice residents to do
vaginal breech deliveries and those that did ob afterward in practice were
doing both multip and primip breeches without any difficulty. An obstetrician
had to be around for primip breeches; but were rarely needed. All changed
when the Illinois State Medical Insurance Company told the family practice
physicians that they would not insure them if they did any breeches. The
number of vaginal breech deliveries dropped to 0 for family practice and
almost 0 for the obstetricians. In Illinois the tail wags the dog.
It is sad when we let managed care companies OR lawyers decide for us
what is best for a patient. Since vaginal breech delivery carries lower
morbidity and mortality for the mother and in term fetuses, has no difference
in outcomes for the fetus, then we are letting business decisions and lawyers
force us into hurting patients.
I heard of a case in our hospital where a new registrar diagnosed a
breech, & fixed a fetal scalp electrode in anticipation of a vaginal
birth (as per normal practice). The woman was eventually sectioned for
slow progress, and all present in theatre laughed at the poor registrar
as the head came first. However, he had the last laugh, as the babies buttocks
appeared with the electrode in situ. Since the FSE is only disconnected
immediately prior to LSCS, the baby (term) must have turned en route to
theatre. Its a shame that it took such an invasive procedure as applying
an FSE to demonstrate the exception to the commonly quoted rule (that babies
don't turn after 36 weeks) but it was instructive anyway...
When I was a third year medical student and barely knew which fingers were mine and which were my patient's, I did a VE in the ER and told my senior I thought I'd found my first breech. He said to run her by x-ray to confirm (I'm dating myself) and she got to L&D sporting a film with head in pelvis. I caught the appropriate amount of flak. After change of shift, but with me still on call, a resident checked her and said, without knowing the previous, that she was breech and cussed out the unnamed ignoramus who'd admitted her without finding it out. I said nothing. Another trip to X-ray, another film with head in pelvis. Resident rechecked her and swore she'd turned to vertex. I believed him; everybody else said it was a flimsy story. During second stage the nurse got suspicious, did a VE, and swore she was FOOTLING. Big panic, stat rush to OR, (couldn't let one of those be born, you know) and as we were prepping, the foot presented at the introitus.
The part you won't believe is that after three people actually saw the foot, and the pace picked up to a roar with the section prep, with knife poised over belly while the induction crashed, the belly gave a sea-sickening roll, and the resident stared at me, then ordered me under the drapes to look again. I just barely got under there in time to avoid a completely uncontrolled vertex birth.
But the part comment that grips me was the part about not being believed.
By the next day people were denying that it happened, and a year later
when I brought up the subject with people who were IN THE ROOM, they couldn't
remember the case until I showed them the birth log. It shook my confidence
enough that I went to medical records to review the case and make sure
I didn't dream it all.
Is it an absolute requirement that radiographic pelvimetry be performed
prior to trial of labor of a breech presentation? Should a hospital's radiology
dept. be required to perform this service if the hospital has a labor and
delivery? In what time frame?
I never use radiographic pelvimetry !!!
I always offer vaginal delivery :-)
No I do not believe it is. As a matter of fact, the Multi-centre study
that our hospital is participating in does not feel that it is an absolute
necessity either. I don't think you'll find any well-done studies that
affirm xray pelvimetry over clinical pelvimetry.
Radiographic pelvimetry was standard about 25 to 30 years ago, and my generation was well trained to do our own. We were always better than the radiologists. There are still some of us that can use the Snow Calculator!
I would not rely on present day radiologists to do this study in any
hospital. The figures were never exact, anyway. At best you got data that
would give you a definite go ahead for C-section, was borderline (another
definite go ahead for C-section), or obviously large enough for trial of
labor. I did pelvimetry on every breech delivery for years, finally decided
that a reasonable trial of labor for any complete breech presentation was
adequate to determine those that needed C-section. However, always make
the decision on the side of safety (C-section) than persist with a difficult
labor and delivery.
I don't think that it is a requirement. However, all of the studies
in the literature that say vaginal delivery of a breech is safe(Collea,
Gimovski, et al.) either used X-Ray pelvimetry or CT pelvimetry as part
of their criteria for deciding to allow a vaginal delivery. So, from a
medico-legal point of view, if you don't get one or the other of those
and have a problem, you were not following the protocol that has been shown
to be safe. I would like to be the plaintiff's lawyer in that case. $$$$$$$$
I think the service should definitely be available, to do an erect lateral pelvimetry when the clinician requests (I'd aim for 36 weeks).
How many vaginal breech deliveries without prior ELP would you have to do to prove that not doing one does NOT increase the incidence of rare adverse events - such as entrapment of aftercoming head?
And I guess most experts would testify in court that an ELP 'could'
have helped in avoiding such an outcome.
Keep Your Hands off the Breech By Mary Cronk, MBE - AIMS Journal Autumn 1998, Vol 10 No 3
Mary Cronk, MBE is a well known and well respected independent midwife.
During her many years of practice she has acquired a vast experience of
birthing breech babies vaginally. In this article, which is an edited version
of a talk which she gives to accompany her unique and revealing set of
breech birth slides, she explains how babies can be born presenting by
A useful book on singleton breech "birth" rather than breech "extraction"
is Breech Birth Woman-Wise by Maggie Banks, Publisher Birthspirit
Books, New Zealand, 1998 ISBN 0 473 04991 0 .
"breathing the head out".... using supra-pubic pressure "if needed".
( I know most of the US readers here are starting to hyperventilate! )
Myles says "the use of the Burns-Marshall maneuver has reduced the perinatal mortality rate, because the unhurried gentle delivery of a well-flexed head prevents intracranial injury". AND this makes me wonder if this might be one of several reasons to explain the discrepancy between the US stats on breech and the UK stats.
I can't think of any method of breech delivery taught here which is remotely similar to Burns Marshall...
In Myles, there are some amazing pictures showing a hanging baby... (even the photos of an assisted breech delivery show this downward direction).
READY FOR "real" CONTROVERSY? Catch the following.....
This is a VERY different. method. I think you will find agreement here that we are taught to complete delivery of a breech within 3 "to 5" minutes of the umbilicus. Most of us are taught to maintain traction and manipulations without stop from then, until the head is completely born. Yet, (everyone now take a deep breath!) Myles says that after the birth of the umbilicus -- when the cord is pinched as the head enters the pelvis --- "The cord pulsations are certain to be slow, but the midwife should not become agitated, because, if the delivery is hurried, intracranial hemorrhage will probably occur and the baby be less likely to survive. The fetus will stand 8 to 10 minutes of cord compression and more babies die of intracranial damage, due to rapid extraction, than of anoxia because of cord compression" (gasp, gasp, gasp... I think I need my asthma medication[Grin])
Ah!.... but our UK friends who were taught this way -- Do you actually use this method or has it changed with time (my edition of Myles is old -- 1972), or have you modified it with use? D YOU think Burns-Marshall is all wet or the cat's meow?
PS -- all the usual disclaimers -- I'm not advocating intentional breech
delivery etc etc etc by midwives or anyone else etc etc; but I AM curious
about methods used. I think, we all need to know the safest and best methods
for breech delivery -- in case of surprises (or intentional delivery).
The British method is radically different from ours... Is it better? Do
we need to learn it in addition to ours? (The UK breech stats are sure
better). But ours methods are so different -- can you imagine the community
wide hollering if one of us said we were going to allow up to 8 minutes
from the umbilicus? Or we were going to let the "head hang" for a minute
I had always heard standing was a good position.
The 3 breeches I have done have all been sort of a standing/supported
squat position. The first two were primips with frank breeches and the
third was guess what- a second twin footling! All went very well, in that
position. I wouldn't do it without very experienced help though.
MANA Conference--Chicago--Oct '94. This was one of the topics for a small group lecture. There was a physician there (can't remember his name) who brought a video of twin home birth. Second baby was breech. He put mom in knee chest position. He felt that since we elevate the trunk and thighs of a breech, after they have delivered, to keep the head well flexed, that turning the mother to knee chest would naturally do the same thing. And then just let the baby dangle with minimum support for body weight, it will come perfectly. Made sense to me. But then what did I know. I was a new CNM grad, and quite frankly, everything I was learning at the conference was all new to me.
So I went home and spoke with one of the OBs that I know. He is one of the few docs I know who will do breeches vaginally. No epis. Even footlings. Wonderful man. He said it made absolute sense to him. But because he does the breech deliveries in the DR/OR on the narrow bed with NICU and anesthesia present, he would like to raise as few eyebrows as possible. Once the hospital comes up with a 'fewer spectator' policy he would give it a try.
Haven't done any breeches myself as a midwife. But in my mind this would
be the perfect position.
That physician was the incomparable Dr. Gregory White. He also wrote
the book EMERGENCY CHILDBIRTH for firefighters and EMTs. He is quite advanced
in age now and doesn't accept new patients, but he will always say yes
to the family that wants twins or breech homebirth--he has done so many
of them. He is a homebirth family practitioner--he doesn't have hospital
privileges coz the hospital thought he was too far out. He is a wonderful
man, and he never says no when a midwife calls and says "AAAAHHH! We have
a primip double footling SURPRISE breech in labor, and she wants to stay
home!" He did this for me and my client last year. And that twins/breech
video he showed you at the conference was the homebirth of this list's
own [anonymous midwife] and her twin sons...the birth which preceded her
delving into midwifery. Bless him.
I did this with the last breech I attended (second twin 7#6). There is one main problem with this. The mom (G4P3) had a very distended abdomen and uterus which caused the baby to drop down towards the bed. If you are going to use this position, I would recommend resting the abdomen on a pillow or something that would provide support. We had a very difficult time delivering the baby in this position. Not only were the mom's muscles shot, which made it difficult for her to push, but the baby was hanging so low that it was like pushing up hill.
I had the mom in this position because I was not comfortable with the presentation. I thought I felt a shoulder which turned out to be a knee. I repositioned the knee and brought the leg down. The other leg was positioned correctly and came down spontaneously.
If I could replay this birth, I would have the mom upright from this point or at least had support for her belly. Oh yeah, I would also have another midwife there! This was a long distance birth that I agreed to attend without doing the prenatals the last trimester. Although she was receiving pnc, it was from a very inexperienced midwife.
The first twin (6#1) was vertex and mom was semi sitting He was slow
to deliver to a crown and then shot out like a rocket.. It was almost like
baby two was holding on to him and then let go :-)
But to confuse the waters a bit - - - In the UK, the technique for breech is to LOWER the trunk! They let it hang DOWNWARD and don't elevate it as we do (Burns-Marshall method). They elevate only after the "nape of the neck" is visible.... This is a very amazing bit of difference in management -- and their breech stats are much better than ours.... Sure makes me think... Myles' text reports that this Burns- Marshal method has remarkably lowered mortality/morbidity of breech babies.
A number of folk-midwives advocate standing or squatting for breech -- this (I think) would allow for a more downward hanging of the baby, rather than our US advocated lifting of the baby.
i don't know what to think, myself. Both our "lifting of the breech"
and their "lowering of the breech" are supposed to "flex the head"
This is what I thought Ina May Gaskin teaches on her video. Am I right?
From my memory of that video she demonstrates pulling the baby with a side to side shaking movement as soon as legs are reachable; a very "Hands On" method. If there is any "lowering of the head" I think it is right at the end, after the entire body is delivered. (But it's been a long time since I've watched that video -- perhaps memory fails here).
The Burns/Marshal UK method advised in Myles and Wilson Clyne is "HANDS OFF THE BREECH" -- you do not touch the baby (unless indicated) -- until the nape of the neck is visible..... Then the method advises delivery similar to Prague Seizure, (lifting by the legs) but our UK MD says that smellie-viet works better; and I wonder if this isn't a good time for Bracht's method. Gee, maybe we can work out a bi-hemispheric agreement on best methods for breech[Grin])
another difference... While we (US) routinely "break up" a breech; they seem to do this only if there is undue delay; and do it later - - when the knees appear at the vulva.
(and they seem to feel that we can allow more time for delivery than
we do. We use Three minutes as a rule - - Myles encourages "gentle delivery"
and says the baby "will stand 8 to 10 minutes of cord compression and more
babies die of intracranial damage, due to rapid extraction, than of anoxia
because of cord compression."). Just more food for thought.
About all I can remember from that video (possibly erroneously) is that
she sort of "shakes" the baby side to side while pulling on it... Against
all the rules of the books of course...
She does hold the baby by the hips once it's born to the umbilicus and "wriggle" it back and forth. I remember her saying if the head didn't come easily to let the baby hang until you could see the nape of the neck.
The part I liked was where she explains how to manage those arms that
are up over the head.
In Ontario, although we do not, as a rule, manage breech births, we are taught how to handle them in unexpected situations. We are taught the Maggie Myles method of "hands off the breech", and to let the body of the baby hang until the nape of the neck is visible. Then we are taught to do the "Mauriceau-Smellie-Viet" maneuver (fondly known as "Morris' Smelly Feet") which involves hooking a finger in the baby's mouth and putting pressure on the occiput to maintain flexion, during a slow birth of the head.
If you look at Williams, even with the "lift" technique, a Mauriceau maneuver with hooking the finger in the baby's mouth is advocated, in order to maintain flexion, often combined with supra-pubic pressure (which you can see in the Farm video of breech birth).
I have seen several breech births, since where I come from frank breeches
are routinely given a trial of labour. I have always seen the body left
to drop, as described above. The one time that the resident was a little
too hasty, and didn't let the body drop long enough, forceps became necessary
to flex the head and finish the birth.
the way I was taught was to sweep the anterior arm down and out then
rotate the baby to make the other arm anterior and repeat
It is rotation away from the arm you want to deliver (clockwise if sacrum to the left as an example) - I had to look it up also - and found it in Plauche's Surgical Obstetrics - but not in Williams or in Hankins' Operative Ob
I never heard this maneuver given a name before, but I was taught that it was the only way to deliver a breech. So I have used it for 30+ years and never knew there was any other way to do it.
Joergen Loevset Prof GYN/OB at UiB Norway (1896-1981) He wrote a book " Vaginal operative delivery" 1968 Scandinavian University Books.
In case it should interest anyone , I permit me to quote from his book about rotating method (Loevset`s maneuver)
" It consists of making the posterior shoulder the anterior one by rotating
the body of the baby 180° or a little more. The rotation should take
place in the hollow of the pelvis where all diameters have the same size.
The rotation starts as soon as the angle of the scapula has arrived under
the pubic arch. The baby's body is kept horizontal and that keeps the posterior
shoulder fairly well beyond the linea terminalis. To prevent it gliding
above the pelvic inlet, the body should be kept in the horizontal plane
during the first 90° of the rotation. If it were kept horizontal during
the next 90° of the rotation, the shoulder would find its way above
the symphysis. Therefore, the body of the baby is lowered as far as possible
during that part of rotation. To get hold of the now anterior elbow without
breaking the arm, rotation is continued until the elbow has come under
the symphysis. As soon as the first shoulder and arm have been delivered,
the body is rotated 180 - 200° in the opposite direction. The same
rule applies for direction of the body, horizontally the first 90°
and lowered during the next 90-100° In primiparae with an unprepared
birth canal, it may be difficult to carry out the rotation in one movement.
If the resistance seems to be quite strong, it is better to rotate back
again from where the resistance seemed too strong to continue. This may
be repeated several times until the rotation goes smoothly. This repeated
rotation is only necessary for delivering the first shoulder in primiparae.
This method is successful if the mother does not have a flat contracted
pelvis. In that case, the shoulder will be blocked in the transverse diameter
and the rotation will be impossible. But where the pelvis is not flatly
contracted or where disproportion between foetus and pelvis does not make
delivery per vias naturalis impossible, rotation will succeed, The first
baby delivered by this method weighed 6 kg."
Hi all, I am in Michigan and was just visiting with Rahima and valerie,
and they have made a new breech video and i watched it today. Val teaches
hands off till see cord, then pull down legs and length of cord, then hands
off till see nape of neck. she also shows a video where the baby turns
tummy up and she turns the baby to back up and finishes the birth easily.
good video. i bought it.
I really enjoyed this tidbit from a British list: "We do have to remember that when we refer (defer?) breech presenting babies to obstetricians we are referring by and large to surgeons for surgery. Few obstetricians know how to facilitate a head presenting normal birth let alone a breech presenting one. A Consultant remarked to me when I spoke on Breech at the RCOG that breech birth was a midwifery skill."
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