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.
Study
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 sections.
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 across.
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 does.
Research Studies Supporting Safety of
Vaginal Breech Delivery
The Farm
Midwifery Center is famous for continuing to assist women in
birthing breech babies naturally.
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".
[from ob-gyn-l]
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 possible.
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.
[from ob-gyn-l]
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 the breech.
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 or two?
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.
[from ob-gyn-l]
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."