Justifying to a seven-year-old Anubis why I’m going to Germany for my week off – and missing mothers’ day, helped crystallise objectives and motivation for this busman’s holiday* (*a form of recreation that involves doing the same thing that one does at work). “I’m going to see some babies be born bottom-first.” “Don’t you see that […]
In Physiological Breech Birth training, we teach breech practice according to the consensus statements developed with experienced professionals in Principles of Physiological Breech Birth Practice (Walker, Scamell & Parker, 2016), including:
Care providers should not disturb women’s spontaneous movements in an otherwise normally progressing breech birth.
Mother-led positioning offers the greatest physiological advantages.
Sometimes maternal-led positioning is most conducive; sometimes judicious guidance is appropriate, especially to help resolve delay.
When facilitating a physiological breech birth, care providers proactively use maternal position (or change in position) to promote normal descent.
The pictures below demonstrate asymmetrical maternal movement in a normal breech birth, in which the mother assumes an upright, kneeling position, with freedom to move her torso up and down as she feels the need. Study of effective, spontaneous maternal movements during successful breech births teaches professionals about all normal birth. Instinctive maternal movement can be read as purposeful and meaningful, in light of radiological evidence of changes in pelvic diameters (Reitter et al, 2014) — rather than counter-productive and needing professional interruption or guidance.
In this picture series, the mother spontaneously lifts one of her legs into an asymmetrical, ‘running start’ position. If a professional detects a slight delay in descent, it may be appropriate to suggest a change of position by raising one leg or the other, as a first-line intervention, a ‘maternal manoeuvre,’ before hands-on intervention. Often a change in maternal position, or rhythmic maternal movement (“give it a wiggle”) will prompt spontaneous descent to resume.
Thank you to the mother, who gave permission for her birth photos to be used for educational purposes; and to her family and midwives. One of these images appeared in the article, Unexpected Breech: What can midwives do?, in The Practising Midwife.
To kick off the new year, Breech Birth Network are providing a study day in Norwich on 14 January 2017. If you’ve been wanting to encourage your obstetric colleagues or trainees to attend training, this will hit the spot. Our teaching team includes Dr Anke Reitter, FRCOG, Shawn Walker, RM, Victoria Cochrane, RM, and Mr Eamonn Breslin, MRCOG. Send your colleagues the link to our Eventbrite booking page, with a personal invitation! Or download a poster for your work environment.
This study day for obstetricians, midwives, paramedics and students will provide an engaging and interactive update on professional skills to facilitate physiological breech births, planned or unexpected. The study day would be especially useful for clinical skills teachers who want to include physiological breech methods in professional skills updates or student lessons, due to access to resources after the workshop. The focus is on collaborative, multi-professional working to improve the safety of vaginal breech birth using the skills of all maternity care professionals.
Training will include:
* A research update given by leading researchers in the field, including Dr Anke Reitter, FRCOG, IBCLC of Frankfurt
* Thorough theoretical and hands-on explanations of how breech babies journey through the maternal pelvis in a completely spontaneous birth (the breech mechanisms), enabling you to distinguish between normal progress and dystocia
* Hands-on simulation of complicated breech births and resolutions, using narratives and videos of real breech complications, to enable you to practice problem-solving in real time
* Models of breech care that work within modern maternity services
* An accompanying booklet containing handout versions of all of the slides and resources used in the training
* One year’s access to the on-line learning space following the training, to continue viewing and reflecting on birth videos (one per month) in a secure forum, and resources for sharing teaching with professionals in your practice community
* Lunch and refreshments
Registration begins at 8:30 for a 9:00 start
Hosted by the University of East Anglia University Midwifery Society. Profits from the study day will benefit the UEA Midwifery Society annual charity, the Orchid Project. See here for directions to the Edith Cavell Building, and to Norwich from further afield.
Feedback from study days in Christchurch & Auckland, October 2016:
My main concern was lack of training of staff leading them to believe that breech birth is an emergency. Our RMOs and MWs loved the day and I think feel more empowered. — SMO (Consultant Obstetrician, Senior Medical Officer)
Thank you so much, this has been the best study day ever! — Midwife
Information was clear and concise and well presented. Myths dispelled and physiological VBB and when to intervene very clearly explained. Methods to resolve when there are issues during delivery explained and demonstrated. Clear examples given with supporting video and photographs. Extremely valuable. — RMO (Registered Medical Officer)
Honest, real explanations. How to intervene in a timely manner as opposed to be hands off the breech. — Midwife
Thank you for a brilliant day of teaching and training. You covered a lot of material not taught as part of our training and it has been valuable. — RMO
Learning about manoeuvres to use in upright position, eg. shoulder press; visual components have been amazing, the broken down physiology of a breech birth. — Midwife
- Dr Anke Reitter, FRCOG
- Shawn Walker, RM, MA
- Victoria Cochrane, RM, MSc
- Mr Eamonn Breslin, MRCOG
Dr Anke Reitter, FRCOG, IBCLC, is the lead Consultant Obstetrician and Fetal-Maternal Medicine Specialist at Krankenhaus Sachsenhausen, Frankfurt am Main. Although originally from Germany, she worked in India and the United States during her medical studies, and in England (including Liverpool) for 4 years during her obstetric training. After returning to Germany, she specialised in perinatal medicine. Prior to her move to Krankenhaus Sachsenhausen, where she initiated a new breech care pathway in a unit which had not supported breech births for years, Reitter practiced in the Obstetrics and Gynaecology department at the University Hospital Frankfurt. A large observational study of the hands/knees breech births in Frankfurt is due to be published soon in the FIGO journal. Her special interests lie in breech, multiple pregnancies, high risk pregnancies and prenatal ultrasound. She is an internationally known speaker, teacher and researcher in several areas, but especially breech birth.
Shawn Walker, RM, MA is a UK midwife and PhD candidate researcher who studies how professionals learn skills to safely facilitate breech births. Clinically, she has worked in all midwifery settings – labour wards, freestanding and alongside birth centres, and home births. She led the development of a breech clinic pathway at the James Paget University Hospital (2012-2014), where she worked as a Breech Specialist Midwife. Her research focus on breech birth is part of a wider interest in complex normality – working with obstetric colleagues to enable women at moderate and high risk to birth and bond physiologically where possible. She currently works as a bank midwife at the Norfolk & Norwich University Hospitals NHS Foundation Trust, in addition to periodic teaching, consultancy and breech support across the UK and internationally.
Victoria Cochrane, RM, MSc is the Consultant Midwife for Normality at the Chelsea and Westminster NHS Trust. RM, MSc, Supervisor of Midwives. The majority of her clinical career has been working in and developing caseload and continuity models for women and their families in the community. She is deeply passionate about working with colleagues to support women making pregnancy and birth choices that sit outside of routine guidance. In her current role she works to support normality for women in all aspects of pregnancy and birth. Breech presentation became a special interest in 2009 when her daughter spent a few weeks in that position at the end of pregnancy; it’s amazing what one can learn in a short space of time when faced with challenging choices. This led to carrying out a cross-site service evaluation of the management of undiagnosed breech for her MSc dissertation.
Reitter, A., Daviss, B.-A., Bisits, A., Schollenberger, A., Vogl, T., Herrmann, E., Louwen, F., Zangos, S., 2014. Does pregnancy and/or shifting positions create more room in a woman’s pelvis?Am. J. Obstet. Gynecol. 211, 662.e1-662.e9.
Walker, S., Scamell, M., Parker, P., 2016. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery 34, 7–14.
Walker, S., Scamell, M., Parker, P., 2016. Principles of physiological breech birth practice: a Delphi study. Midwifery 43, 1-6. FREE DOWNLOAD until 13 December.
Walker S, Cochrane V (2015) Unexpected breech: what can midwives do? The Practising Midwife, 18(10): 26-29
So pleased to receive news via Twitter that physiological breech birth skills are being taught in Bangladesh! Tanya (@midwifeinbd) is doing a wonderful job collaborating with obstetric colleagues to change the way breech is taught and enable active breech birth.
— Tanya (@midwifeinBD) June 1, 2016
Integrated training in Bangladesh: a midwifery teacher, a doctor & the Labour Room manager/nurse. pic.twitter.com/QbHsji1Ki6
— Tanya (@midwifeinBD) June 1, 2016
— Tanya (@midwifeinBD) June 1, 2016
— Tanya (@midwifeinBD) June 1, 2016
— Tanya (@midwifeinBD) June 1, 2016
— Tanya (@midwifeinBD) June 2, 2016
— Tanya (@midwifeinBD) June 10, 2016
Videos used in the training described above include The mechanisms, simplified, The Birth of Leliana and Shoulder Press and Gluteal Lift. You can read about ‘prayer hands‘ in this blog about assisting the birth of the arms.
Thank you once again to the mothers, midwives and doctors who have shared videos and birth images to enable health care practitioners all over the world learn these important skills.
This Tuesday, 1 March 2016, Breech Birth Network travelled to Portsmouth again. The guest speaker was lovely doctor Ms Arti Matah, who spoke about an obstetrician’s view of vaginal breech birth, and led a lively discussion around whether the breech team / care pathway model might work for Portsmouth. Watch this space! I am incredibly impressed with the commitment Portsmouth midwives have shown to developing sound breech skills to support women who choose to birth their breech babies actively.
The skill which captured the group’s imagination most was how to resolve a situation where the head is extended and impacted at the inlet of the pelvis. My research suggests that identification of optimal mechanisms is a core skill for practitioners attending breech births. Therefore our approach to teaching this skill is:
- Identification of optimal mechanism — The aftercoming fetal head normally rotates to the oblique/transverse diameter as it enters the pelvic brim, just like the cephalic-presentation head does when engaging.
- Identification of deviation from optimal mechanism — In this complication, the fetal head is pinned in the anterior-posterior diameter, with occiput anterior, over the maternal symphysis publis, and chin or brow on the sacral promontory. The bottom of the fetal chin is felt like a ‘bird beak,’ pointing towards the sacrum. The maxilla bones are difficult/impossible to reach, so flexing the head using the usual techniques will be a challenge.
- Restore the mechanism — See below.
The RCOG guideline suggests delayed engagement in the pelvis of the aftercoming head should be managed using one or both of the following techniques:
Suprapubic pressure by an assistant should be used to assist flexion of the head. Given our understanding of the head as impacted at the pelvic brim and our goal of restoring the mechanism by rotating the head to assist engagement, we suggest that the goal of suprapubic pressure should initially be to encourage this rotation. This mirrors the understanding we have of suprapubic pressure to resolve a shoulder dystocia by rotating the impacted shoulder off the symphysis pubis. Forcible pressure on an impacted fetal head is unlikely to be beneficial for the baby.
The Mauriceau-Smellie-Veit manoeuvre should be considered, if necessary, displacing the head upwards and rotating to the oblique to facilitate engagement. We use a doll and pelvis to explore why this elevation and rotation prior to re-attempting flexion is necessary. Watch the video below to see this demonstrated.
When a woman is birthing her breech baby actively, we facilitate the head to enter the pelvis using the same principles. Watch the video below, where Midwife Olivia Armshaw is teaching how to intervene in the case of an extended head at the inlet, when the woman is birthing on hands/knees. In this video, the midwives are discussing how maternal movement – in this case, the woman shuffling her bottom back towards the midwife slightly – helps to elevate the head off the pelvic inlet to facilitate engagement, a technique we learned from the midwives of Sheffield. The principles – elevate, rotate & flex the head – are the same.
Thank you to the Practice Development Team at Portsmouth for organising the day. And thanks to the following midwives for assisting with the day:
- Claire Reading, midwife in Somerset, who shared her breech experience gained working abroad, and facilitated one of the hands-on stations
- Olivia Armshaw, midwife from Gloucester, who facilitated one of the learning station and presented on the process of developing a breech team in her local area
- Tess McLeish, midwife from Lewisham who helped the day run smoothly
Our one sadness on this study day was that we were not joined by any of Portsmouth’s obstetric staff, aside from Ms Arti Matah, who needed to leave early because she was good enough to present at the study day following a night on-call. Across the UK, midwives are trying to engage their obstetric colleagues in a discussion about how to improve things for breech babies and their mothers, and we really need more doctors to come to the table for that discussion to result in a service which is as safe as possible.
BONUS was meeting and relaxing with Midwife Jenny Hall in Portsmouth after the study day!
Feedback from the Study Day:
“the group work was excellent Overall I thought the day was was a good balance of theory to practical”
“very interactive. realistic rather than textbook. real life experiences.”
“perfect study day. Interesting and kept my attention all day!!!”
“visual with the film clips and hands on with the doll and pelvis. Was very good to see normal and abnormal films and great discussion with colleagues to share experiences and what to do in that situation.”
“I also thought Shawn’s attitude to breech was very refreshing. I half expected it to be a bit like “you can have a vaginal breech no matter what”. this was not the case. She had a very safe and sensible approach.”
This post builds on my primary research, Standards for maternity care professionals attending planned upright breech births: A Delphi study. The research reports an experienced panel’s consensus on the skills required for midwives and obstetricians supporting physiological breech births. The practical content of the article is my personal application of one of the findings to clinical teaching.
“Health professionals attending upright breech births should be competent [to assist] rotation of the fetal back to anterior (when the mechanism has deviated from normal)” (p 5). 77% of the panel agreed that this is an important skill. This standard of competence combines two skills: 1) recognising deviation from normal mechanisms; and 2) assisting by restoring the mechanism to normal.
- Recognising deviation from normal mechanisms
Within the past two weeks, two people have discussed with me concerns about an incorrect understanding of the correct position for the fetal back when a woman is in a hands/knees position. First, a Practice Development Midwife (PDM) says she advocates teaching breech in ‘only one way’ (eg. lithotomy) because people get confused. A midwife attending training advocated for hands/knees positioning, but when questioned about where the fetal back should be, replied, “The fetal back remains uppermost.” Similarly, a student I am mentoring in practice attended sessions on breech at university. Her lecturer suggested hands/knees may be a more advantageous positioning, but later she is told, even in hands/knees, “The fetal back remains uppermost.” The student had worked out that this couldn’t be correct and sought more information. Excellent critical thinking, Charlotte!
These are signs of a practice in transition, and the PDM and Charlotte are right to be concerned. Rotating the fetal back uppermost in a hand/knees position is a dangerous but not uncommon mistake. Even in textbooks, such as this German textbook for midwives (Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Göbel & Hildebrandt, 2007), the woman’s position is changed, but the professional is still following the rule of, “The fetal back remains uppermost.” (Just to reassure you, once the arms are born, they advocate rotating the fetal body 180° so that the head is born occiput-anterior.)
A physiology-based understanding of the normal mechanisms comes from closely observing spontaneous births which are not interrupted. In a spontaneous breech birth, the most common and most optimal (a.k.a. ‘normal’) rotation of the fetal back is to anterior after the sacrum is born, regardless of the position of the mother.
The simplest way for teaching this aspect of the mechanisms I learned from midwife Jenny Davidson. The baby should rotate “tum to bum.” In other words, the baby’s tummy (stomach/front torso) should be facing the mother’s bum (bottom/posterior), no matter what position the mother is in. If those teaching breech can adopt this language to describe mechanisms and positioning, fewer dangerous misunderstandings, and more flexible thinking mayoccur. Teaching breech as a set of rote manoeuvres leads to automatic behaviours, which are sometimes counter-productive. In my research, I am observing that the path to acquiring breech competence and expertise involves learning to problem-solve in complex, unique clinical situations, often un-learning ‘rules’ that one was taught in skills/drills — because the rules don’t always work (eg. ‘the fetal back remains uppermost’ does not apply in every situation). Experienced professionals replace inflexible rules with more flexible understandings and principles, over a period of time, and through much reflection with peers and mentors. Perhaps teaching should be about patterns and principles, rather than prescriptions?
2. Assisting rotation of the fetal back to anterior — restoring the mechanisms to normal
You should rarely have to do this, but if you do, this principle may be helpful: “Rotation, not traction.” You can assist rotation with your fingers on the bony prominences of the baby’s pelvic girdle, as for any breech manoeuvre. Consider as you do what is happening at the inlet of the pelvis – have the shoulders already engaged, or are they just beginning to enter the pelvic brim?
Safe facilitation of physiological breech births depends on the ability to determine when intervention will be beneficial, and when it is unnecessary and potentially harmful. A breech baby will normally rotate spontaneously, with the back to the anterior (“tum to bum”), as the shoulders engage in the transverse diameter of the pelvic inlet. Pulling or manipulating prior to this spontaneous rotation could cause problems. But if the rotation is to the posterior, it may be beneficial for attendants to intervene at this point rather than rotate an occiput-posterior head mid-pelvis. Or at least 77% of an experienced panel think so …
Gibes E & Hildebrandt S (2007) Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Thieme
Questions for reflection:
- Watch the videos in this collection. Identify the normal mechanisms, beginning with descent of the sacrum transverse (to the mother’s side). As you are watching, identify which way you will expect the rotation to occur, anticipating the normal rotation. Did the baby rotate as you expected?
- Imagine you are attending one of the births in the videos and quietly communicating with a colleague who has no previous breech experience, about what you are expecting to see, and what to document during the birth. What do you whisper to your colleague? Do this simultaneously with your colleague/fellow student as you both watch the video
Watch this obstetrician (Diego Alarcon) facilitate a complete breech birth. He is touching more than is advocated by physiological breech-experienced providers – the mechanism has not yet deviated from normal – but his hands tell you what he is thinking. The baby’s right foot is behind the left, indicating that rotation is tending in this direction – sacral anterior, good. However, he is closely guarding this. Watch when he puts the forefinger of his right hand on the baby’s right hip bone to ensure that the rotation will occur in a counter-clockwise direction when the contraction begins. His actions are gentle, not forceful, and they work with the mother’s expulsive efforts.
In this birth, as the sacrum is born, it is mostly transverse (normal), but somewhat posterior, to the mother’s left. The baby does not rotate to sacrum anterior, as we would expect as the arms enter the pelvis to be born. The obstetrician (Michel Odent) recognises that the mechanism has deviated from normal and immediately intervenes to restore the mechanism by sweeping down the anterior arm under the symphysis pubis, across the baby’s face.
This video is much more hands-on than a physiological approach, but it provides a good example of a normal mechanism of sacral rotation following rumping when the mother is in a supine position — and how to assist, because the midwife’s (Renata Hillman) hands are positioned to assist rotation using the bony prominences of the fetal pelvis.
Tonight, I met with some students from the local midwifery school who are preparing for their final OSCE. How exciting! They wanted to review mechanisms and manoeuvres so that they feel confident performing for their exams.
The students will be expected to demonstrate their knowledge of supine/lithotomy skills, so we created a new video to help them remember what we practised.
For those wanting to review the mechanisms when a woman is in a supine position, this video, filmed with midwifery students at the University of Salford last year, may also be helpful.
The next study group, for professionals, students or women in and around Norwich, will be on Monday, the 8th of February, from 10am – 1pm. For more resources to prepare for OSCE’s, click on the OSCE tag.
You may also find this video helpful, made by Joy James, a midwifery lecturer at the University of Glamorgan:
And from Maternity Training International:
This blog will discuss how to recognise the need to intervene to deliver the arms in a vaginal breech birth which has been physiological up until that point. Descriptions are provided as if the woman is in an upright kneeling position, facing away from the attendant midwife or obstetrician. I have been somewhat prescriptive about how delay and dystocia can be evaluated. Experienced practitioners will have their own comfort levels. My intention is to stimulate discussion among modestly experienced practitioners, to help distinguish patterns calling for intervention from those which do not. Once the umbilicus is born, depending on the condition of the baby, unnecessary delay in identifying dystocia could be dangerous.
Recognising what is normal …
Midwives and obstetricians attending vaginal breech births need to learn to ‘read’ what is visible (eg. outside the vagina), as it provides clues about what might be happening at higher levels in the pelvis. In the normal breech mechanisms, the breech descends sacrum transverse, with the fetal back to one side or the other. A rotation occurs as the shoulders engage in the pelvis in the transverse diameter, just as they do in a cephalic birth. The fetal torso fully rotates, finishing fully facing the attendant — “tum to bum.” When this rotation is observed externally, it provides reassurance that the birth is progressing internally. Once the umbilicus is born, there will be a short pause (usually less than 30 seconds) before gravity will begin to pull the unimpeded fetal body down further in the pelvis.
When the shoulders reach the pelvic floor, restitution will occur, just as it does in a cephalic birth. Simultaneously, internally, the aftercoming head is rotating to enter the pelvis in the transverse/oblique diameter, just as it does in a cephalic birth. Externally, this is observed as a slight rotation, in which the anterior fetal arm is released under the pubic arch. Almost immediately (usually less than 30 seconds), another rotation occurs in the opposite direction, and the posterior arm is released under the perineum. This coincides with the final internal rotation of the head, as it realigns to an occipito-anterior position ready to be born, just as it does in a cephalic birth.
A thorough understanding of what is ‘normal’ in a vaginal breech births helps attendants to be aware of when deviations from expected patterns may indicate a threat to fetal well-being. The video below repeats the above information, so that you can recreate it with a doll and pelvis in order to thoroughly understand why this mechanism unfolds in the way that it does.
… and what is not normal.
A deviation from the mechanism described above may indicate a problem, if it is accompanied by a delay. In some cases, when women give birth in upright positions, the combination of a roomy pelvis and the effects of gravity creates a situation in which the fetus can tumble through almost all at once, and the mechanism remains unobserved or seemingly irrelevant to this baby and this mother. If the birth is proceeding rapidly, and the baby is in good condition, there is no need to intervene unless progress stops. Just prepare to break the baby’s fall.
The signal to intervene is an observed variation in the mechanisms, accompanied by a delay (> 30 seconds), unresponsive to spontaneous maternal movement — or any occasion in which the fetus appears compromised. In other words, you observe that descent has stopped and encourage the mother to wiggle, lift a leg, shift her torso, or some other gentle method of shifting the limb which is stuck – but it remains stuck. Some variations suggesting intervention may be necessary include:
The baby has been born to the umbilicus. However, the torso has not completely rotated to face the attendant; the shoulders appear to be in the oblique or A-P diameter of the pelvis. You may need to restore the mechanism. Remember: the shoulders engage in the pelvic inlet in the transverse diameter, visible externally as a complete rotation to face the attendant. If the rotation is not complete, and progress does not resume with spontaneous maternal movement, assume one or both arms are caught up on the pelvic inlet. You can encourage rotation with your hands on the bony prominences of the pelvis (much like Løvset’s), but if this is not easily effective, do not risk twisting the fetal spine. Instead, use ‘prayer hands,’ with your fingertips against the bony prominences of the shoulder girdle, palms flat to avoid fetal organ damage. Elevate slightly to disimpact, and rotate the fetal torso so that the shoulders are in the transverse diameter. Descent should resume following this rotation. Once you have started to intervene, continue to assist the head to be born by manually flexing the head and controlling the delivery, or using shoulder press.
Posterior arm born first
This is not always a problem, but it often happens because the anterior arm is nuchal, eg. raised beside the head. Again, not always a problem. Sometimes an arm in front of the face helps to keep the head flexed, and they can be born simultaneously. If descent and rotation continues, and the baby appears to be in good condition, watch and wait. However, if the posterior arm (closest to the attendant) is born first and there is a delay (> 30 seconds) before the birth of the anterior arm (nearest the symphysis pubis), intervention is likely required. Suspect a nuchal arm, raised alongside the head. Insert your hand behind the fetal back on the side of the arm which needs to be released. Sweep down, in front of the fetal face, and out. This will restore the mechanism and enable the head to descend to the pelvic outlet. If the arm is positioned behind the head and cannot be swept down, rotational manoeuvres may be required, using prayer hands.
One arm born with shoulders in the anterior-posterior (A-P) diameter
Sometimes, the posterior arm is born and the fetus has not rotated at all; the shoulders appear to be in the A-P diameter, with the posterior shoulder visible under the perineum. This is because the anterior arm is nuchal, stretched alongside the fetal head, and prohibiting further descent. It has become wedged tightly against the symphysis pubis, and it is not possible to sweep down in front of the fetal face. This situation will not respond to subtle maternal movements and requires immediate and assertive intervention, in the form of elevation and rotation. In my own experience of using rotational manoeuvres in this situation, I have used ‘prayer hands’ to rotate the fetus into an occipito-posterior position, where it becomes possible to sweep the nuchal arm down in front of the face and out under the pubic arch. The head should be kept in alignment and rotated back to an occipito-anterior position, where shoulder press or manual flexion can be used to deliver the head without delay.
A pause after the birth of the anterior arm, lasting >30 seconds
After the birth of the anterior arm, most of the baby is out. Gravity will usually do its magic, continuing to bring about steady but gradual descent. As the head is rotating into A-P alignment internally, ready to be born, the second arm will release under the perineum. If this process does not resume soon (< 30 seconds) after the birth of the anterior arm, and progress promptly, it suggests two possible problems. Either the posterior arm is blocking the head from descending and rotating, in which case sweeping the second arm down in front of the fetal face should result in both the delivery of the arm and alignment of the head. Or the head has not completely descended into the pelvis. In which case, delivery of the second arm will enable you to get on with assisting the head to be born.
Mechanisms appear normal, complete rotation, umbilicus born, with no further descent for >30 seconds, and especially after the onset of the next contraction
This is when apparent problems with the arms are not actually problems with the arms. The arms are under the sacrum, ready to be born, but they have not been born yet because the head has not entered the pelvis. Although it is possible to sweep them down, this will not solve the underlying problem that the head is extended at the inlet and impacted in the A-P diameter. As described above, the head needs to rotate into the oblique/transverse diameter to enter the pelvis. Begin by lifting the fetal torso to elevate the head off the pelvic inlet slightly. Then rotate to release the arms and enable the head to engage. As you have started to intervene, continue to assist the head to be born, flexing the head manually or using shoulder press once the head has entered the pelvis.
Thank you to Joy Horner, for sharing the photo on which the sketch above is based. And to Mary Cronk, who shared her slides and experience of managing a nuchal arm with me before I encountered it myself, enabling me to resolve it successfully. I am very grateful for the sharing of midwifery knowledge, so I am doing my own sharing in the hope that it will be helpful to another midwife or doctor in a tricky birth.
In this video, the posterior arm is born first, and the obstetrician (Diego Alarcon) gently assists the anterior arm by sweeping it down across the baby’s face.
In this video, the baby is born with the sacrum to the mother’s left and slightly posterior, it looks like due to the positioning of the feet. When the normal rotation to sacral anterior does not occur, the obstetrician (Michel Odent) immediately recognises that the mechanism has deviated from normal and intervenes. He assists the anterior arm to be born by sweeping it down across the baby’s face, restoring the mechanism.
Over and over again, in my research and in personal conversations, I hear how important videos are to health professionals who are self-educating themselves about breech birth. I am still exploring the role of video as a learning tool, but they seem to assist professionals to develop pattern recognition abilities, and enable discussions about clinical decision-making. By watching and talking through what happens in birth videos, these skills can be practiced before they are required in a real-life context.
Here is a list of publicly available on-line videos for health professionals to watch when preparing to attend a breech birth, or to periodically update. Some of them may be close to your idea of ‘ideal,’ and some of them may present a different perspective, or an opportunity for discussion. All of them offer learning opportunity.
- Identify key movements and rotations in the mechanism of breech birth
- Consider and discuss what prompted intervention, if the video includes intervention
- What would you do?
You can link to the original posting of the YouTube videos by clicking “View on YouTube” in the bottom right hand corner of the viewer.
Birth Video of a Breech Baby – Lisa Barrett’s Blog
Frank Breech Birth Video – Lisa Barrett’s Blog
Frank Breech Home Birth – Spinning Babies Blog, with Gail Tully
Thank you to the very brave and generous mothers, fathers, midwives and doctors who have shared these videos so that others can learn about breech birth.
If you have posted a video of your breech birth, and would like to share that with others, please do include a link in the comments below. Alternatively, if you would like it to be used only in secure circumstances, you can e-mail to discuss using the link below.
In an active breech birth, we aim to support and encourage the physiological process as long as it appears to be safely unfolding. When practising in this way, we have to understand why some variations occur, when they may threaten the safety of mother or baby, and how clinicians might intervene to safely assist the birth when necessary.
Breech deliveries are not associated with an increased incidence of severe perineal damage (Jones 2000), and compare favourably to instrumental cephalic deliveries and persistent posterior positions. However, in a lithotomy (supine, legs in stirrups) breech delivery, episiotomies are commonly used to assist with manoeuvres. Manual assistance at some stage is almost always necessary when women are in this position, and an early episiotomy is considered by many to be beneficial. So much so that ‘inappropriate avoidance of episiotomy’ has been identified as a common mistake in breech simulation exercises (Maslovitz et al 2007). However, current RCOG guidelines indicate that episiotomies should not be performed as a matter of course, but according to clinical indication. So what are these indications?
In contrast, active breech births (where women assume upright positions) are associated with lower rates of perineal damage than cephalic births. In a recent study (Bogner et al 2014) comparing a small series of all fours breech births with lithotomy deliveries, serious perineal lacerations occurred only 14.6% of the time when women were in all fours, compared to 58.5% of the time with lithotomy deliveries. A majority in the latter category were due to episiotomies, rather than the mechanical process of birth.
The breech stretches a perineum differently from a head. A well-flexed, round head will displace the fanning perineum more or less evenly, spreading the tissue during the crowning process. In contrast, a bottom is softer and flatter. And other limbs provide irregular pressure.
When might intervention be helpful?
I became interested in this question due to differing information from several experienced clinicians. Mary Cronk MBE, with whom I had the great privilege to teach a few years ago, explained in her inimitable way that she was a bit more ‘scissor-happy’ with breech babies, so there must be good reason. However, other experienced clinicians feel that an intact perineum is important to maintain fetal flexion for as long as possible, and needing to cut an episiotomy should be a very rare occurrence. (See a previous discussion.)
One of Mary’s classic slides includes a birth where she cut an episiotomy because the perineum had become overstretched and was tearing in a button-hole pattern. Especially when nulliparous women give birth to frank breech babies, this overstretching may occur because the perineum does not spread and recede over the comparatively flat bottom in the same way as it does a head.
The illustration to the right depicts an abnormally distended and overstretched perineum. The baby’s bitrochanteric diameter (the distance between the outer points of the hips) has already descended past the ischial spines, and we have passed the ‘point of no return’ – the baby will be born vaginally.
The potential risks with an abnormally distended perineum are:
- Delaying the birth at a point when the umbilicus has already descended into the pelvis and may be compressed. The fetal heart may no longer be reliably auscultated due to descent into the pelvic brim. If this is the case, assistance is warranted.
- A button-hole tear in the mother’s perineum.
Are there alternatives to episiotomy?
When we recently met up at the RCOG and Oxford Breech Conferences this October, I asked Anke Reitter what she would do if she felt that a tight perineum was holding up a birth at a crucial point. She described to me what might be called a ‘perineal sweep.’ Similar to a cervical sweep, (with consent) the clinician inserts one finger between the breech and the tightly applied perineum, and sweeps around the perimeter, encouraging the border of the perineum to recede over the presenting part and allow the birth to proceed. She explained that this often causes progress to resume without the need to perform an episiotomy.
I found this really helpful to consider as part of my breech midwifery toolkit. As we re-develop our professional cultural knowledge about breech, it is important we continue to talk about what we do and how we do it, even those skills we feel will be rarely needed. While we strive to create the conditions for those 85% of women to give birth to their breech babies over intact perineums without assistance, we also have to be able to recognise the perineum/bottom combination which may occasionally present a problem, and how we might address this for the best possible outcome.
I would love to hear your thoughts and experiences.
Update, October 2016: This would be a good topic for a systematic review. Bogner’s study demonstrated that breech deliveries (supine & upright) had the lowest rate of perineal trauma AND highest rate of episiotomy in the local population (eg. compared to cephalic births). I have seen Bogner’s statistics (eg. simultaneous lowest rate of perineal trauma AND highest rate of episiotomy in the population) replicated in an audit from Sydney, and now again in this study out of Pakistan. Please be in touch if you are looking for a systematic review topic and would like to collaborate.
Jason S, Khan Jadoon S, Shah R. Maternal and neonatal complications in term breech delivered vaginally. Journal of the College of Physicians and Surgeons–Pakistan : JCPSP. 2008 vol: 18 (9) pp: 555-8
In July, Gerhard Bogner of Salzburg presented data at a Breech Birth Network study day. Although the series is small, the data indicate that when the mother is in all fours position to birth a breech baby, approximately 70% of those births will occur completely spontaneously, eg. without the need to perform assisting manoeuvres at all. Use of upright positioning also reduced the rate of maternal perineal damage from 58.5% to 14.6%, which is actually better than cephalic births!
The reduced need for manoeuvres potentially reduces iatrogenic damage to babies associated with interference at the time of birth, such as birth injuries and inhaled meconium. That’s great for that 70%, but what about the other 30%? The babies born with upright positioning in Bogner’s study had a slightly higher rate of low cord blood gases, indicating hypoxia, although no consequences for the infants or differences in 5 minute Apgar scores were observed.
If a woman is birthing her baby in an upright position, how do we assist the birth confidently and safely when delay is identified? How do upright manoeuvres differ from those performed when the woman is supine? To address a growing need for more practical training in upright breech birth, City University are offering Physiological Breech Birth Workshops in London and taster days around the country. The next one is on 2nd of December at the Whittington in Central London. Lots of hands-on training with a small group of doctors and midwives committed to extending breech skills. We also post conferences and workshops provided by others when we can.
Several people have been in touch to ask about the How and When to Help handout. I disabled the link because it is constantly being updated! Please feel free to download this one and use it in your practice area. But keep in mind understanding in this area is constantly expanding, and this is just one midwife’s current approach. I’m working on research to understand others’ approaches as well, but it will be some time until this is finished.
Look out for two articles appearing this month. In The Practising Midwife, I present a summary of current evidence related to ECV (external cephalic version), with some excellent photos provided by Dr Helen Simpson and Midwife Emma Williams of South Tees Foundation Hospital. In Essentially MIDIRS, Mariamni Plested and I talk about issues in providing innovative care for higher risk birth choices.
Finally, shameless plug: Today (30/9/14) is the last day to vote for my, um, remarkable cousin Jake in the NRS National Model Search. Read all about him here, and then click on the link at the bottom of the article to VOTE FOR JAKE!
Favourite quote from the article: “The funny thing is, some bulls are just like big dogs. They come up to you, put their butt in your face and say, ‘Scratch my butt.’ But as soon as they get that flank rope on them, it’s like, ‘Game on. I’ve got something to do now.'”
Awww. Gotta love a bit of passion, of finding your niche and loving it … We love you, Jake! (Just what every 18 year old boy always wanted, a plug on a breech birth information site. We clearly share a common love of butts.)
Update: He won! Go Jake!
Bogner, G., Strobl, M., Schausberger, C., Fischer, T., et al. (2014) Breech delivery in the all fours position: a prospective observational comparative study with classic assistance. Journal of perinatal medicine. [Online] Available from: doi:10.1515/jpm-2014-0048
Helping the aftercoming head to flex in upright breech births
When women are in upright positions, many breech births will proceed completely spontaneously because the birth canal follows the flow of gravity. However, the attending clinician may need to assist, either because maternal effort no longer results in steady progress, or because the baby appears compromised and assistance will result in a quicker delivery. In this blog, I describe one manoeuvre I have learned to help in upright breech births.
The shoulder press is very effective in the following circumstances:
- The aftercoming head has descended through the pelvic inlet and is either on the perineum (chin visible) or mid-pelvis (chin not visible, but easily reached in the sacral space); and the occiput is anterior
- The mother is in an upright, forward-leaning position (e.g. hands/knees or kneeling)
- The clinician facilitating the birth is behind the mother, and the baby is directly facing the clinician (‘tum to bum’ with mother), with head and body in alignment
In this scenario, the maternal pubic arch is directly behind the baby’s occiput. When pressure is applied to the baby’s torso just below the clavicular ridge, guiding the baby’s body straight back through the mother’s legs, the pubic arch will push the occiput up and forward. This causes the aftercoming head to flex and descend, following the curve of the birth canal. The sternocleidomastoid muscles (SCM), responsible for head flexion, attach to the superior aspect of the clavicle and keep the head in alignment throughout this process.
Gluteal Lift – If descents stops with the perineum tight on the baby’s forehead (bregma), and the shoulder press alone has no further effect, an assistant can augment the manoeuvre by lifting the woman’s buttocks up and out. This lifts the perineum over the bregma as the primary attendant performs the shoulder press, moving the baby in the opposite direction. This assisted manoeuvre is especially helpful when the woman has a very full figure, or the perineum is especially tight and intact.
The feeling and effectiveness of this manoeuvre is very easy to replicate using an obstetric model, turned upside down, as in the video below.
Preserving an intact perineum. An intact perineum helps to maintain beneficial fetal flexion, and routine episiotomy should be avoided for this reason. However, when the aftercoming head has descended onto the perineum, reaching the maxillary or malar bones to perform a modified Mariceau-Smellie-Veit (MSV) can be difficult. Therefore, many clinicians will cut an episiotomy early in order to avoid cutting one while the baby’s face is on the perineum. However, this is not necessary. When the chin is visible, pressure on the maxillary bones through an intact perineum is possible, in combination with upward pressure on the occiput behind the pubic arch, enabling descent to continue. However, the shoulder press is more effective.
Clinicians who are inexperienced or untrained in manoeuvres specific to upright birth will be tempted to pull down on the baby’s torso to deliver the head. However, this does not follow the direction of the birth canal in the same way as the shoulder press as described. Pulling rather than pushing is potentially more likely to result in severe perineal damage, and may also cause cervical nerve damage in the baby due to increased resistance from the intact perineum.
Fractured clavicle. When applying pressure on the clavicle, fracture is an obvious potential risk. This potential risk can be minimised by spreading the fingers to apply even pressure just below the entire ridge, or by applying pressure with fingers or thumbs at the distal aspect, near the glenohumeral joint. The pressure exerted is firm but is not significantly different to that applied when delivering an anterior shoulder in a supine cephalic delivery, and therefore no more likely to result in trauma. The shoulder press minimises the amount of force needed to achieve delivery by promoting maximum head flexion and descent in the direction of the birth canal.
The shoulder press as described, on its own, may not resolve a dystocia caused by a deflexed or hyperextended aftercoming head. A very high chin, pointing upwards, identifies a hyperextended head; only the bottom jawbone (resembling a ‘bird beak’) is felt at the very top of the maternal sacrum. If the deflexed head has impacted at the pelvic inlet, the baby’s whole body may need to be lifted in order to flex and/or rotate the head to oblique so that it can enter the pelvis before the shoulder press is useful. Additionally, suprapubic pressure performed by an assistant may help flex the head enough to pass through the pelvic inlet.
The practice of supporting breech births with the mother in an upright position is somewhat controversial, as minimal research evidence regarding effectiveness exists. Although breech experience is generally at a very low level, most clinicians are only trained to perform lithotomy manoeuvres, and therefore the RCOG recommend lithotomy as the preferred maternal position (RCOG 2006). However, increasingly women are requesting freedom of movement and their own preference to be upright, which is potentially a more satisfying birthing position (Thies-Lagergren L et al 2013). In the absence of evidence that such an approach increases risks, introducing upright manoeuvres into mandatory training will enable this option.
In addition, through discussions with other midwives and participation in the risk management process for various Trusts, I have been informed of several cases of undiagnosed breech births where women were instructed to get onto their backs on their floor following the diagnosis of a breech in labour, due to lack of an obstetric bed in that setting. In some cases, this has been associated with severe delay in delivering the aftercoming head. In true lithotomy, head flexion is promoted by allowing the baby to hang off the end of the bed, where the maternal pubic arch again is responsible for lifting the occiput as gravity gently pulls the baby through the birth canal. This cannot occur on the floor, and the head becomes deflexed. In these cases, the midwives were only trained to perform lithotomy manoeuvres, and instructed that guidelines required them to manage breech births in this way, but the births occurred in settings with no obstetric bed. Providing mandatory training in upright breech to those working in midwifery-led settings will potentially improve outcomes in emergency cases in the short term, and increase maternal choice in the long term.
I first learned about this mechanism from Dr Anke Reitter, FRCOG, of Frankfurt, Germany, and Jane Evans, an experienced UK Independent Midwife. At the University Hospital Frankfurt a similar technique is called ‘Frank’s Nudge’ after the lead obstetrician, Prof Frank Louwen, who introduced the upright management of breech birth to their unit. I do not refer to the manoeuvre as ‘Frank’s Nudge’ because my technique may differ slightly, and that team has yet to publish their own description of their manoeuvre. Some have described the mechanism as a reflex action, but my hands have experienced it as purely mechanical, and much more effective than Mariceau-Smellie-Veit when women are upright. I can only speak for my experience.
Need a Reference?
Evans J. (2012) Understanding physiological breech birth. Essentially MIDIRS. 3(2):17–21.
RCOG (2006) The Management of Breech Presentation. RCOG Green-top Guidelines, No. 20b. London, Royal College of Obstetricians and Gynaecologists.
Thies-Lagergren L et al (2013) Who decides the position for birth? A follow-up study of a randomised controlled trial.” Women and Birth 26(4): e99-e104.
Walker, S. (2015) Turning breech upside down: upright breech birth. MIDIRS Midwifery Digest 25(3):325-330. This is the first time shoulder press is mentioned in print & contains a photo series.
“[B]irth attendants can assist the head to flex using forward pressure on the fetal chest — ‘shoulder press .’ This is applied in the sub-clavicular space, using either the fingers along the ridge, or the thumbs at the distal end of the clavicle, with the attendant’s fingers wrapped around the fetal shoulders. When the fetal body is brought straight back through the maternal legs and towards the maternal abdomen, the pubic bone will assist head flexion. However, if the fetal head is extended and caught at the inlet, the attendant may need to lift the fetal body to displace the head to a higher station, and rotate into the oblique or transverse diameter to assist engagement, before the flexion described above can be achieved — ‘elevation and rotation .’ (p 328)
Walker S, Scamell M, Parker P. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery. 2016 Mar;34:7–14.
(‘Using subclavicular pressure to flex the head’ is an agreed manoeuvre professional should be taught in this consensus research involving an experienced international panel of midwives and obstetricians)
Updated 15 June 2016
Introducing more support for planned breech birth in your hospital setting? This post is for you.
The management of breech presentation is undergoing an important transition. In the past twenty years, we’ve gone from:
- Management according to the preferences of individual consultants and/or units, tending increasingly toward caesarean section
- Blanket caesarean section policy following the publication of the Term Breech Trial
- A recognition in more recent guidelines that vaginal breech birth should remain an option for women
- Increasing demand from women for more choice and involvement in decision-making around how they birth their breech babies
As a result, health care providers are needing to re-skill in the facilitation of breech birth, and in a way which matches women’s expectations. This requires introducing entirely new skills to manage breech births when the mother is upright and active, as women who choose to birth vaginally usually expect to be.
But transitions can be de-stabilising. Doing things ‘as they are always done’ provides some protection because team members are familiar with their roles. Each professional knows her/his place on the team. They are familiar with the range of events that might happen in this scenario, and they know by repetitive practice exactly how they will need to communicate and respond. The emergency caesarean section for the undiagnosed breech discovered at 9 cm – the team has been here before many times, and swings comfortably into action.
In contrast, a planned breech birth is novel territory. This is even more the case if the woman has planned to be upright and active, as many teams will have rehearsed emergency breech drills with the mannequin in a lithotomy position (legs in stirrups). Therefore, teams supporting this choice will need to employ different strategies to ensure effective teamwork around the time of birth.
Identify your breech birth dream team
Ideally, the entire second stage and the birth of this breech baby will be primarily supported by three people. These three should be familiar with and aligned with the woman’s birth plan and each other, as any task or relational conflict will compromise decision-making ability (de Wit et al 2013, Puck & Pregernig 2014). They should each have a clear understanding of what their role in the team will be, and they should have rehearsed together the management of some common emergencies. They should have clear eye contact with each other throughout the birth, in order to confirm in an unobtrusive way the on-going evaluation that the birth is going well, or to prepare each other for the possibility that it might not be.
Each team member has a different primary responsibility:
1) Management – This person is primarily responsible for facilitating the birth, and may be an experienced midwife or an obstetrician. Ideally, this person will be known to the woman and have experience with breech birth in general (and the type of birth the woman has requested). The birth facilitator will be intimately familiar with the woman and her wishes, as well as the mechanics of breech birth, how to anticipate possible problems, and how to assist when required. They are responsible for co-ordinating care and preparing the rest of the team to assist when required.
2) Support – This person, usually a senior midwife, is responsible for taking over monitoring of the woman’s and baby’s well-being throughout the second stage, frequently relaying this information to the rest of the team and reassuring the woman. Positioned beside the woman, they are an important communication bridge, especially when the woman is in a kneeling position, facing away from the person managing the birth. In this position, the support professional is also placed to assist with applying suprapubic pressure and/or change of maternal position.
3) Perspective – This person is responsible for documenting the birth and providing a second evaluation of progress. This role requires breech experience because in order to document appropriately and accurately, the person needs to understand what they are seeing. Similarly, in order to assist with the evaluation of progress, this person needs to be familiar with normal progress in a breech birth. Because of their perspective, this person is also an important communication bridge with the rest of the team outside the door (eg calling for further help, alerting paediatricians to possible complications, etc.), and may alert the managing professional to potential problems. Therefore, this role is often taken by the most experienced person in the room, such as the obstetrician or the experienced midwife who is supporting another midwife to develop her skills.
The triangle: nature’s most powerful structure
Most normal births are attended by two midwives, and this is more than adequate. But a breech birth is not an everyday occurrence. Documentation will need to be of a gold star standard. Yet in most hospitals, each person in the room will still be developing their skills with breech and will therefore need to concentrate on the task at hand, making attendance to paperwork tricky. It is also easy to become enthralled with the beauty of an unfolding breech birth.
Therefore, supporting breech births with a primary team of three strengthens a situation made vulnerable by its novelty. A triangle is one of nature’s strongest structures; this mini-team is strengthened, given a base by the addition of perspective. Given the importance of documentation in any higher-risk birth, triangulation of data (eg strengthening the accuracy by using different sources) also makes practical sense. The triangulated team increases everyone’s safety in a novel situation.
Interestingly, many women instinctively form their own triangles, involving two supporters. The third person in this triangle also provides additional support, strength and perspective for both her and her partner.
Continuity: the way forward
Continuity of carer – ensuring a woman knows the professional who will be facilitating her birth, and ideally the entire team – has known, evidenced benefits. Fewer interventions, greater satisfaction. Knowing who else will be in the room, and what their role will be, will also help the woman to feel more relaxed and reassured about the upcoming birth.
Continuity has benefits for providers as well, especially when it comes to facilitating non-standard care. A number of sources have suggested on-call teams for breech births as the way forward (Kotaska 2009, Daviss et al 2010) and on-call midwives are a middle ground. Especially when experience is minimal, preparation is key. Where an on-call team is not available, the entire team who will be attending the birth should be identified when the woman is admitted to hospital, and again at handover if appropriate. This team should have a thorough discussion about roles and responsibilities, and a run-through of the ‘fire drill’ if things do not go as planned, well before second stage requires the additional team members to attend.
The team should meet afterwards to review the birth and identify if any group work issues have been identified that can be improved for future births. This review should involve the obstetric labour lead, a midwifery manager and/or risk management midwife if the breech service is new to the maternity team. A reflective approach in the early stages will pay off in increased safety and a more confident, united team in the long run.
Further information and inspiration for your dream team
Teamwork is crucial to the safety of breech births. Michael West has written extensively about the characteristics of ‘real teams,’ as opposed to ‘pseudo teams.’ Real teams have clear, shared team objectives; role interdependence and role clarity; and they meet regularly to review and improve performance (West, 2014). If we are to successfully change the culture of breech birth, and support women as safely as possible as we develop our skills and experience, we must function as real teams.
West, M.A., & Lyubovnikova, J. (2013). Illusions of Team Working in Health Care. Journal of Health Organization and Management, 27(1), 134-142. (more from West)
You may also be interested in this article: Plested M, Walker S. Building confident ways of working around higher risk birth choices. Essentially MIDIRS 5(9)13-16.
How have you prepared your teams to support planned breech births?
This post is about dolichocephaly, a form of positional molding which affects some breech babies – how it happens, why it may be important, and how to recognise it.
Everyone is concerned about entrapment of the after coming head in a breech birth. And it seems so unpredictable. Many breech babies, even large ones, seem to just fall out. And then others, not so large, get stuck. RCOG guidelines suggest an estimated fetal weight above 3800 g is ‘unfavourable’ for vaginal breech birth, but goes on to say, “If the baby’s trunk and thighs pass easily through the pelvis simultaneously, cephalopelvic disproportion is unlikely.” (Easily is undefined, but in light of the evidence against augmenting breech labours, I interpret it as occurring spontaneously within about an hour of active pushing.)
Can we predict which babies’ heads are more likely to have difficulty passing through the pelvis? I don’t know, but I feel one phenomenon in particular deserves more attention – dolichocephaly.
Technically, dolichocephaly is a mild cranial deformity in which the head has become disproportionately long and narrow, due to mechanical forces associated with breech positioning in utero (Kasby & Poll 1982, Bronfin 2001, Lubusky et al 2007). This change in shape is more commonly associated with primiparity (first babies), larger babies, oligohydramnios, and posterior placentas, all of which result in greater forces applied to the fetal head.
(Note: Like all positional molding which occurs in utero, dolichocephaly does not in itself cause nor indicate abnormal brain development. The head shape is highly likely to return to completely normal in the days and weeks following birth, especially if baby receives lots of holding and cuddles to permit free movement of the head.)
Following the birth of the arms in a breech birth, the head will be in the anterior-posterior diameter of the pelvis. When the head shape has become abnormally elongated, the longest diameter of the fetal head will meet the shortest diameter of the maternal pelvis at the inlet. Unless the baby is still on the small side and the pelvic inlet very round, the chin may get stuck on the sacral promontory, preventing head flexion. A very experienced breech provider will have encountered this situation before, and should be able to assist, but it is quite a tricky place to be. The head may need to be rotated into the transverse diameter to safely enter the pelvis. A very elongated head can have difficulty passing through the lower pelvis as well, and can cause damage to the maternal pelvic floor, unless appropriate techniques are used to assist the head to flex.
Estimation of fetal weight by ultrasound is notoriously inaccurate. However, a lack of proportionality between the head circumference and the biparietal diameter is more obvious to spot (e.g. HC=90th percentile, BPD=60th percentile; or a difference in correlating dates of two weeks or more), and may be a more relevant indication that this baby is too big for this particular woman. Dolichocephaly can be discerned on palpation as well, as the occiput is prominently felt above the fetal back, the head is not ballotable, and may feel unusually wide. I would suggest caution where estimated fetal weight is above 3500 g and a difference in HC and BPD, or careful palpation, indicates abnormal cranial molding has occurred, especially for women who are having their first baby, have a low amniotic fluid index, and/or a high posterior placenta; and in situations where imaging pelvimetry is not used to confirm an ample pelvic inlet.
Women instinctively do not like weight limits used as ‘selection criteria.’ One woman (Ann, multip, 6’1”) looks at another (Carol, primip, 5’0”) and they both think – We can’t possibly be expected to have similar-sized babies. While Ann may carry a 4000 g baby with no abnormal head molding, and expect a straightforward birth, Carol’s baby may begin to show signs of dolichocephaly at 3300 g, especially if she has low levels of amniotic fluid and a posterior placenta. Carol may still have a successful birth, but it will more likely depend on the skill and experience of her attendant in assisting the aftercoming head to flex, rotate and negotiate the pelvic diameters, and the pelvic diameters themselves.
We need to move away from the concept of ‘selection criteria,’ which are used by professionals to make decisions for women, and towards an understanding of what is ‘normal for breech.’ We need to understand more about which babies are more likely to experience those beautiful, often-easier-than-cephalic, dancing-into-the-world births, and which babies are truly being put at additional risk by their in utero conditions.
Then we will be able to explain to women the benefits of a caesarean section for pregnancies which have become ‘abnormal.’ Women will be able to approach this intervention with an open heart when they observe professionals are truly supporting ‘normal’ breech births and providing individualised care and screening to those which are not.
I would love to know what others think about this.
The Dutch in Old Amsterdam do it .. not to mention the Finns .. The folks in Bergen, Norway, do it .. They’re not even second twins …
This Valentine’s Day over 100 obstetricians, midwives, student doctors and student midwives assembled at Crosshouse Hospital in Kilmarnock to show some love to breech babies.
We were privileged to be joined by Dr Susanne Albrechtsen, Head of Obstetrics at Haukland Hospital in Bergen, Norway, home of Jørgen Løvset. She has written extensively about the practical management of breech presentation and authored several epidemiological articles. Dr Albrechtsen is responsible for the Norwegian breech guidelines, and shares her expert knowledge of breech and operative vaginal deliveries through practical training throughout Scandinavia and beyond (details available through the Norwegian Medical Society). Her hospital in Bergen, which currently enjoys a CS rate of 13%, is a mecca for trainees hoping to improve their hands-on skills. Haukland, with an annual birth rate of 5000, sees 150-200 breech deliveries per year and Dr Albrechtsen herself has attended over 500 breech deliveries.
How do they do it? Dr Albrechtsen tells us: “You just have to decide that it is good for babies to be born vaginally, unless there is clearly a problem, and commit yourself to developing the skills to enable that to happen.” As she explained, a normal vaginal birth is an important programming event with life-long consequences. Evidence is growing about the links between caesarean section and future disease in the child, such as Type 1 diabetes, asthma, allergies, gastroenteritis and obesity (see Ulander et al, 2004). Dr Albrechtsen also presented her epidemiological data, demonstrating the way CS rates and rates of vaginal birth have changed over the last 40 years in Scandinavia. Particularly interesting were the way the Finns have been able to make a dramatic change within a few years, simply by making the decision to do so.
Dr Michele Mohajer, whose unit in Shropshire currently enjoys a 14.3% CS rate, shared with us the work of her breech clinic and her extensive experience with ECV, having performed over 1500 procedures herself, in addition to attending hundreds of breech deliveries in her career. It is reassuring to know that these skills are being maintained by expert practitioners.
Feedback from the day suggested that those attending had concerns about managing an undiagnosed breech birth, and interest in developing skills had been driven by recent experiences. This is a real concern. Approximately 3-4% of babies present breech at term, and 25-30% remain undiagnosed until labour. Consequently, an undiagnosed breech presents in labour approximately 1:100 of all births. It is in everyone’s interests that we do our best to support all women wishing to make the informed choice to labour with their breech babies, putting plans in place so that skills can be developed for when women cannot make a measured decision.
In my view, organising small on-call teams for breech, involving both doctors and midwives, is the best way to accomplish the re-introduction of breech skills. Some research and professional opinion supports this view (Kotaska 2009, Maier et al 2011). Neither all doctors nor all midwives will be confident and keen to attend a breech birth. Ideally all staff involved will be both, but at least one well-prepared and experienced person at every breech birth is essential, for both safety and the reassurance of the woman involved. At the conference, we also reviewed the mechanisms of breech birth, counselling for informed choice, and how to help in a complicated breech birth, particularly when the woman births in an upright position. I’ve noticed more doctors attending these study days each time we do it. One young obstetrician said to me, “I needed you here about a week ago, when I got hauled over the coals for supporting a woman to [successfully] have her breech baby vaginally.” This threatening cultural atmosphere needs to change. We need obstetricians and midwives who are willing to develop the skills to facilitate breech birth in the safest possible way.
Let’s do it .. Let’s fall in love … with breech babies
This study day was organised by Geraldine Butcher, Consultant Midwife for Ayrshire and Arran, and a passionate advocate for the rights of women to make informed decisions about how to have their babies. Feedback from the study day:
“It has been a very fruitful day for me and I will use the presentations and practice to update my own. I will feel more confident in supporting upright breech birth.”
“It gives me more confidence to promote breech delivery and services surrounding breech as an option.”
“Video scenarios were very helpful. Recent undiagnosed breech presentations have encouraged us to review / update knowledge.”
‘Into the Breech’ Workshops in Perth and Melbourne, December 2013
This month has seen a small series of Australian workshops, hoping to increase confidence among those already working to modernise breech birth in Australia. The ‘Into the Breech’ conferences were instigated by Dr Rhonda Tombros, an academic lawyer with an interest in human rights and the mother of a breech born baby, and organised by Barbara Glare. The conferences coincided with a six month research fellowship visit by Dr Anke Reitter (FRCOG) of the Frankfurt team, whose MRI research will soon be published, concerning changes in pelvic diameters with maternal position changes.
The Perth workshop, on 3 December, was held in the Perth Zoo and was opened by midwife Danielle Freeth, also the mother of two breech babies. As for obstetricians, it was quality rather than quantity on this occasion. One of the participants, Dr Liza Fower, Head of Obs and Gynea at the Armadale Hospital, gained significant experience facilitating breech birth in South Africa and has been able to continue to offer support. She also contributed to one of our practical workshops with some useful tips.
Dr Andrew Bisits (FRANZCOG) presented in Perth, on pathways for women and complications. Bisits is one of the Directors of the ALSO (Advanced Life Support in Obstetrics) course in Australia, which will be updated to include emergency manoeuvres when a woman is in an upright position. He and his team, including Midwifery Professor Caroline Homer, have launched an intensive course for professionals in Australia, the BABE (Become a Breech Expert) course. I am very much hoping to bring this course to the UK at some point in the future, and in the meantime will be ensuring that the information presented at the Breech Birth Network study days is in line with the systematic approach they are developing.
Melbourne attracted more consultant obstetricians, GP obstetricians and a lively group of midwives. Many conversations occurred during the break, suggesting a critical mass in this location, likely to move on with a more organised and collaborative approach to supporting women with breech presenting babies. This may require more working together across traditional boundaries if women are to have adequate support for viable choices, especially as breech services are reintroduced among teams with minimal recent experience.
A highlight of both days was Dr Rhonda Tombros’ presentation on the legal aspects of informed consent and negligence focusing specifically on issues around breech birth. We all hope she writes this up for publication in the near future.
Although I present at these conferences (in this case, on the evidence base and ‘normal for breech’), I find them invaluable to developing my own practice. The two messages I found most interesting with this visit concerned timings and episiotomy.
Timings: Bisits and Reitter gave increased focus to achieving a prompt delivery, suggesting that 3 minutes from the birth of the umbilicus to the birth of the aftercoming head is ideal. “Three minutes is ideal, you are probably okay with five, but after that most babies will experience some sort of compromise.” This aspect has not been previously emphasised at the conferences I have attended, but the intense dialogue which has developed between midwives and obstetricians supporting breech has revealed differences. It seems that timings are almost taken for granted in obstetric training for breech, whereas midwives have a much higher tolerance for a ‘wait and see’ approach, emphasising the ‘hands off the breech’ philosophy. In reviewing the anecdotal experiences where breech is being reintroduced, the current consensus among our small collective of professionals is that, while a ‘wait and see’ approach will often result in a spontaneous resolution, it will also more often result in a severely compromised baby when that spontaneous resolution does not occur. Therefore, following the birth of the umbilicus, if the birth does not continue to progress promptly or you are not confident of the condition of the baby, intervening to facilitate the birth is recommended, using the systematic approach we are advocating:
- Try to sweep down the arms in front of the face
- If not possible, rotate in the direction of the nuchal arm (modified Lovesets)
- Ensure the head is aligned with the body and the mother’s birth canal
- Deliver the head using classic or modern techniques to achieve flexion
The skill of an experienced practitioner is in holding back from intervening when the birth is progressing normally, balanced with effective intervention when it is not, and developing this judgement is a key aspect of breech training days.
Episiotomy: In Melbourse, Consultant Midwive Michelle Underwood presented data from the Westmead Clinic which she runs with Dr Andrew Pesce in Sydney. While all of their statistics were fascinating – especially demonstrating a reduction in CS for breech from 90% to 63% in the first year of the clinic – I was intrigued by their stats on perineal damage. It seems that, compared to all births, the breech births have the highest rate of episiotomy AND the highest rate of intact perineum. This suggests to me that the majority of perineal damage from vaginal breech births may be iatrogenic, which is not surprising given that cutting a timely episiotomy is an over-emphasised part of some obstetric training for breech (Deering et al 2006), as is the use of forceps.
But is it necessary, or helpful (in most cases)? In his own practise, Bisits avoids episiotomy because he feels the perineum has an active role in encouraging breech babies to remain well flexed throughout the birth. Reitter also discussed her own personal stats – three (3) episiotomies cut in the last 10 years, a period which has included management of over 300 breech births and countless cephalic complications. The episiotomy rate in her unit in Frankfurt is exceptionally low overall. Change was accomplished when the Lead Obstetrician (Prof Frank Louwen) insisted that episiotomies would not be cut unless absolutely necessary, and that each episiotomy would need to be justified personally to him. That’s what leadership can do.
Wow! On my way home to Norwich after an amazing day in Brighton.
The day was organised by Jenny Davidson, currently Acting Deputy Head of Midwifery at the Royal Sussex Hospital in Brighton. Jenny is an inspirational midwife, and doing great things to empower both midwives and women with breech babies. She’s nearing the end of a PhD and started the study day off with a research round-up, exploring why the heavily criticised Term Breech Trial has had such an impact on breech practice, and presenting other evidence which widens the discussion and decision-making process for breech. (See Premoda and Toivonen for a start, but Jenny had several pages of references.) The increasing amount of qualitative research revealing women’s experiences of breech pregnancy and childbirth was also discussed. (See Guittier for a start.)
Following this, Benna Waites discussed ‘talking breech’ – how we counsel women with breech-presenting babies. She stressed the importance of recognising that the risks to women of CS are not inconsequential, and of remaining non-judgemental even when women are making decisions which professionals may not feel are the ‘right’ ones. Benna, author of the ‘breech bible’ – Breech Birth – is a Consultant Clinical Psychologist, as well as the mother of a breech-born baby. She brings these important perspectives into her presentations. I hope that well-informed, deeply immersed service user advocates like Benna can in the future participate more fully in discussions around national guidelines, such as those written by NICE and RCOG.
Jane Evans continues to inspire a new generation of midwives presenting her excellent knowledge of the mechanisms of breech birth, and how to assist when help is required, built upon decades of clinical practice. Jane has authored many articles, but her more recent publications in Essentially MIDIRS should be essential reading for professionals seeking to modernise their breech practice.
Today was the first time I have had the opportunity to hear from Dr Michele Mohajer, co-author of this UK-based study) and Consultant Obstetrician at the Royal Shrewsbury Hospital in Shropshire. Michele has run a breech clinic there since 1997, where both breech and ECV have been well supported. Her ECV success rate is excellent, approximately 60%. She shared with us several of her methods for increasing the likelihood of succeeding. There are few things I like more than hearing someone with excellent clinical skills discuss their techniques. I especially admired Dr Mohajer’s discussion of the influence of gaining the woman’s trust and co-operation to her success rates. Her ECV films were excellent and a really useful practice update. I hope Dr Mohajer is also able to reach wider audiences to share her classic obstetric skills. Women who wish to have their babies turned deserve for the practitioners attempting this to have success rates as high as possible.
Hopefully others will share their personal highlights from the day. And (although this study day was sold out), we all look forward to more obstetricians and midwives attending future study days. Please do get involved, share your experiences, develop your services. As several people remarked today, it really does feel like the green shoots of change are growing for breech.
(Another post in response to discussion on the Coalition for Breech Birth Facebook Page.)
Breech births are few and far between, and there are very few ‘experts’ in the world to learn from, so staying updated is a real challenge. Especially if you do not live and work near others who are supporting breech births regularly.
Updating has two purposes: keeping up to date with current evidence and best practice; and reminding yourself how to use skills you use infrequently. Many breech babies, especially those whose mothers are active and upright (e.g. knees/elbows), can be born spontaneously. But those who cannot need calm, considered help in a timely manner. The same applies to external cephalic version – ECV. Both practices benefit from regular performance and knowledge sharing among those who are practicing.
Here are my suggestions on keeping your practice as safe and supportive as possible:
- Attend study days. Many individuals offer study days to develop breech skills. Breech Birth Network days concentrate on lots of practical skills, but also have an emphasis on care pathway planning in the UK, aiming to encourage more Trusts to adopt an organised, committed approach to breech.
- Share your work. If you are doing research or working with breech and would like to share your experiences, get in touch and present at one of the study days. I am not an expert, but an experienced and passionate believer in the idea that the more we share, the more we talk about it, the more normal it becomes. The best study days have a wide variety of speakers and reflect a wide community dedicated to developing and sharing skills.
- Share your experiences. If you learned something at a breech birth you attended that might help us to make our practice safer, share it! Publish it if appropriate, but if you need to share anonymously to protect your client’s and your confidentiality, I can give you space on this blog. It is wonderful and encouraging to hear stories of triumphant breech births where the baby just fell out singing. But we need to hear the stories of doubt and sadness as well, and often these are the ones you learn the most from.
- Create your own network. It’s been so valuable to me to have colleagues who I can phone up to debrief the breech births I’ve attended. I learn so much more by doing this. And so valuable to hear their stories, how they have approached certain complications, how they support women, their thoughts on what makes breech birth safe. Keep a record of these sessions and document them; they are part of your professional updating. Write an article about what you have learned together, so that others can respond to it. We need more voices talking about breech skills.
- Organise your own study day. Bring the conversation to you. Empower those local to you to share their skills by asking them to present. Inspire your local community to think more about breech.
If you don’t have anyone local to ask questions or debrief with, my number is 07947819122 (in the UK) and I’m always happy to listen. I’m sure most of us are. Good luck!
Some friends of mine at the Coalition for Breech Birth (a consumer advocacy organisation) have been discussing the role of practitioner experience in reducing risk associated with vaginal breech birth. My response is a bit longer than Facebook will permit, so I’m putting it here.
The study I find most useful in this discussion is here:
Su M, McLeod L, Ross S, Willan A, Hannah WJ, Hutton E, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol. 2003 Sep;189(3):740-5. PubMed PMID: 14526305. Epub 2003/10/04. eng.
Overall, the team found very few factors associated with an increase or reduction of risk of adverse perinatal outcome. They did find a dose-reponse relationship between amount of labour and adverse outcome. In other words, a pre-labour CS seemed to afford the most benefit, followed by early labour CS. By the time you are in active labour (>3 cm), there is no longer a statistically significant difference between CS and vaginal birth. So I get particularly annoyed when this study is used to tell women who arrive in advanced labour with an undiagnosed breech that a CS is the safest option.
They also found, contrary to popular belief, that big babies (>3500g) fared no worse than more averaged weight babies, but small babies (<2800g) did. Makes sense to me. Generally but not always, babies who are very small at term may already be slightly compromised; labour may be an additional stress. On the other hand, if a chunky 9-pounder folded in half can fit both his abdomen and his legs through your pelvis, chances are his head is going to fit, especially if you are with someone who knows how to help it into an optimal position.
He also needs to fit without help, because the study also revealed that using augmentation to enhance a labour which is not progressing well enough on its own was associated with over twice the risk of labours which proceeded spontaneously. Similarly, longer second stages increased the risk, so our baby needs to be descending fairly easily in the second stage, without help, or a CS may be the better option.
But the only factor shown to reduce the risk associated with a vaginal breech birth (by over 2/3) is the presence of an experienced clinician at the birth. This person need not be a licensed obstetrician, and the years of experience did not make a difference either – the TBT team specifically looked at these factors. The risk reduction occurred only when ‘an experienced clinician was defined as a clinician who judged him or herself to be skilled at vaginal breech delivery, confirmed by the Head of Department.’ Midwives were among those included in this definition.
Although we do not (yet) have any research (get back to me in a decade or so) which looks at the results of spontaneous breech birth with experienced clinicians at term, this analysis of the TBT suggests that this scenario is significantly less risky than many of the births included in the trial which were responsible for adverse outcomes. Add to that the further benefits we are seeing emerge with upright breech (reduction in need for manoeuvres and the minor injuries these can sometimes cause), and vaginal breech birth is a realistic option for many women.
One further comment on the research: Many are frustrated because the results of retrospective observational studies overwhelmingly indicate similar outcomes for vaginal breech birth and planned CS. These have comparatively little influence on guidelines because they are considered ‘biased.’ However, understanding why they are biased is sometimes useful. Retrospective studies are most often done by experienced practitioners who feel their own results conflict with the lowest common denominator represented by a large multi-centre RCT like the TBT. They present these results to illustrate that a comparatively safe vaginal breech service is possible, despite the fact that breech is often grossly mismanaged in many areas. Retrospective studies do not necessarily represent the ‘norm.’ But they do suggest, along with the TBT’s own data, that if your provider feels confident supporting you to have a vaginal breech birth, you can probably feel pretty confident as well.
Update 2015: A meta-analysis of observational studies indicates significantly better short-term outcomes when CS is planned than when VBB is planned. However, the rate of complications following planned VBB is much less than reported in the Term Breech Trial and similar to the results when a cephalic birth is planned. Read Berhan et al 2015 by clicking the link.
I always smile when people say, “It’s all well and good to support natural breech birth, but what happens if the head gets stuck?” Those of us who are supporting woman-centred, modern breech birth take an equally realistic view about the need to intervene in a skilled and confident manner when help is needed, although we are probably more realistic about the frequency with which such intervention is required. We also obsess about creating trusting relationships and environments which facilitate more spontaneous, easier births, with the end result that we need to use our skills less often.
However we sometimes rely on these skills to achieve a safe outcome. Therefore we share our experiences with others, for when they might be needed. And we know that supporting others to confidently support more breech births will create new knowledge which will in turn help us to improve our own practice.
Where does this knowledge come from? Hint: not Randomised Controlled Trials. One of the many ways midwives create knowledge about practice is by listening to each other and listening to women. For example, in the training aid linked above, one of the options involves assisting a woman who is on all fours to become straight upright on her knees, and applying suprapubic pressure. This is how my own personal learning about that happened (participants not identified to maintain confidentiality):
The baby’s head was hyperextended at the time of delivery, but not before. Woman on all fours, no progress with the next contraction, no spontaneous movements from the baby to assist his own flexion. Neither the midwife managing nor the Registrar who was supporting could reach the baby’s chin, just what felt like a bird beak (the lower jaw bone) pointed up to the sky, so Mariceau-Cronk was not an option. All present were fairly inexperienced, and no training aids were available, so the decision to get the woman upright was instinctive. The decision to apply suprapubic pressure while doing so was based on RCOG guidelines about how to help when the woman is in lithotomy, transcribed to the current situation. The occiput was felt during suprapubic pressure. Then suddenly the baby’s head dropped into the pelvis, and was immediately born wearing his placenta like a hat. Several minutes of resuscitation were required. Baby recovered quickly and well.
Following on from this story, I returned to the sources I use over and over again. Anne Frye’s Holistic Midwifery described how some midwives get the woman upright (for breech and shoulder dystocia) because this tightens the abdominal muscles, promoting head flexion. So someone else has a theory for how it works. There is also increasing radiological evidence that when upright or prone (e.g. shoulders, pelvis and knees in a straight line), the pelvic inlet is largest, while squatting significantly enlarges the mid-pelvis and pelvic outlet. The strategy of assisting the woman to move into an upright posture and use suprapubic pressure may have resulted in an even better outcome if performed earlier, as soon as the dystocia was identified.
Once you begin to see the patterns, they emerge in the stories you immerse yourself in. Reading Jennie Clegg’s story about her ‘Breech VBAC at home,’ I found this:
The next push I gave it everything I had and rumping happened very quickly followed by the body; the relief of the pressure was immense. Two sharp sensations happened which were the legs releasing, I remember looking through my legs and seeing a little body! Then there were a few sharp uncomfortable movements which were caused by the baby wriggling its arms out. My contractions at this point had stopped.
Debs could see no chin on the chest to examined me and found the head to be extended. An ambulance was called and Debs started manoeuvres to birth the baby. No movement was felt so I was encouraged to change position and Michelle tried nipple stimulation to get contractions coming. Michelle and James helped me to stand, Debs attempted head flexion, movement was felt and I was encouraged to push, baby was born immediately followed by the placenta! (Midwifery Matters, ISSUE 135, Winter 2012)
This scenario was slightly different, but maternal movement was again helpful. Jane Evans, a midwife with many years of breech experience, writes and talks about how her understanding of the physiology of breech birth has been informed by listening to and close observation of women (Evans 2012a, Evans 2012b).
Listen to women. Listen to midwives. Share your stories. Share your skills.
Feel free to share your own stories in the comments below. Community support for breech professionals is available via a Breech Birth Network Facebook group.
Michel, S. C., Rake, A., Treiber, K., Seifert, B., Chaoui, R., Huch, R., . . . Kubik-Huch, R. A. (2002). MR obstetric pelvimetry: effect of birthing position on pelvic bony dimensions. AJR Am J Roentgenol, 179(4), 1063-1067. doi: 10.2214/ajr.
Anne Frye’s Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice, Vol II is now available to download as a PDF, you lucky ducks! My father still complains about having to transport the heavy tome across London on the underground when he brought it to me from America one Christmas.