Tag Archives: clinical skills

The Birth of Leliana

Jessica with Leliana

Image: Jacqueline Sequoia, used with permission

From Atlanta, back to Asheville

Jessica’s baby remained persistently breech at term, and she was unable to find a provider in South Carolina to facilitate a vaginal breech birth. When she attempted to decline a CS and negotiate a vaginal birth, she was informed that if she came into the hospital in labour, she would be given general anaesthesia and her CS would be ‘a lot rougher.’ (Folks, the ACOG published something just for you: Committee Opinion No. 664: Refusal of Medically Recommended Treatment During Pregnancy.)

This was Jessica’s first baby, in a frank breech position (extended legs), with no additional complexities. Her sister, Family Practice Doctor Jacqueline Sequoia MD, heard about Dr David Hayes and Harvest Moon Women’s Health because they were hosting my physiological breech birth training. Jacqueline includes obstetrics as part of her practice and booked to attend the workshop with some colleagues. Jessica and her husband Brian met with Dr Hayes to consider their options, and once Jessica made her decision, found a rental apartment in Asheville on Craigslist.

Let’s contemplate that for a moment. In order to have support for a physiological birth, rather than the threat of a coerced CS, women are having to relocate to another state and rent temporary accommodation, because the baby is presenting breech.

When Dr Hayes and I arrived at Jessica and Brian’s apartment, Jessica’s labour appeared to be progressing well. As people entered her space, Jessica gradually moved into the tiny bathroom at the back of the apartment, reminding me of Tricia Anderson’s metaphor of cats in labour. I turned off the light. This labour had a journey, as all labours have. Throughout her journey, Jessica was surrounded by people who love her. At the end of it, Jessica beautifully and instinctively birthed her little girl, Leliana, who weighed 7lbs 8oz.

This video contains graphic images of a vaginal breech birth.

Being attuned to the general lack of training in physiological breech birth among health professionals, and the consequences for women and babies, Jessica and Brian were keen to share this video of Leliana’s birth to help others learn. If you would like to read more about the minimally invasive manoeuvres used at the end of this birth, you can read our blog on Shoulder Press and Gluteal Lift.

brian

Thank you, Jessica, Brian, Leliana, Dr Sequoia and Dr Hayes for sharing this video. The link to this blog post can be shared, but the video cannot be downloaded or reproduced without permission.

Shawn

The midwives of Portsmouth and the aftercoming fetal head

Claire Reading sharing her skills

Claire Reading sharing her 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:

  1. 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.
  2. 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.
  3. Restore the mechanism — See below.

ShawnPortsmouthThe 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.

Shawn Walker, Olivia Armshaw & Jenny Hall

Shawn Walker, Olivia Armshaw & Jenny Hall

BONUS was meeting and relaxing with Midwife Jenny Hall in Portsmouth after the study day!

— Shawn

Further Study Days are listed under Events. View our Training page for more information.

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.”

Assisting rotation of the fetal back to anterior in a breech birth

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.

  1. 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!

Geburtshilfliche Notfälle, Göbel & Hildebrandt, 2007

Geburtshilfliche Notfälle, Göbel & Hildebrandt, 2007

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

tum2bumYou 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 …

Shawn

References:

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

 

Videos:

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.

Arms: Identifying the need to intervene

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 …

birth of the extended fetal legs

birth of the extended fetal legs

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.

birth of the umbilicus - fetal torso fully rotated, "tum to bum"

birth of the umbilicus – fetal torso fully rotated, “tum to bum”

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.

the anterior arm is caught up on the symphysis pubis - rotation is incomplete

the anterior arm is caught up on the symphysis pubis

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:

Incomplete rotation

prayer hands

prayer hands

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.

I have heard several midwives use the term ‘prayer hands,’ including Helen Dresner-Barnes and Gail Tully.

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

fingertips help to maintain alignment of the fetal head during the rotational manoeuvre

fingertips help to maintain alignment of the fetal head during the rotational manoeuvre

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

if a delay occurs, the second arm may need to be swept down in front of the fetal face

if a delay occurs, the second arm may need to be swept down in front of the fetal face

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.

— Shawn

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.

Read More

Visualizing the obstructed breech: Read Dr Rixa Freeze’s blog on how Spinning Babies midwife Gail Tully explains how to free the obstructed arm.

Videos

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.

The breech and the perineum

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.

If the perineum has become abnormally distended and is causing significant delay, consider a 'perineal sweep.' If not successful, an episiotomy is indicated.

If the perineum has become abnormally distended and is causing delay, consider a ‘perineal sweep.’ If not successful, an episiotomy is indicated.

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.

Shawn

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

Shoulder Press and Gluteal Lift

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:

Deflexed head in mid-pelvis

Deflexed head in mid-pelvis

  • 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
When baby's head has descended into the pelvis, the pubic bones are directly behind the occiput

When baby’s head has descended into the pelvis, the pubic bones are directly behind the occiput

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.

Potential benefits

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.

The path of the head must follow the arc of the pelvic cavity

The path of the head must follow the arc of the pelvic cavity

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.

Potential risks

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.

Limitations

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.

Uses

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.

Read more

Visualizing the obstructed breech: Read Dr Rixa Freeze’s blog, on how Spinning Babies midwife Gail Tully teaches this manoeuvre.

Sources

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.

Shawn

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

Breech birth team work

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:

  1. Management according to the preferences of individual consultants and/or units, tending increasingly toward caesarean section
  2. Blanket caesarean section policy following the publication of the Term Breech Trial
  3. A recognition in more recent guidelines that vaginal breech birth should remain an option for women
  4. 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

(These suggestions apply to a planned breech birth which occurs in a hospital setting, particularly one where a planned breech service is being introduced.)Breech 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.Team Triangle

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 2009Daviss 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?

Shawn

Dolichocephaly – understanding ‘breech head’ molding

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.

Dolichocephaly developing due to positional pressures

Dolichocephaly developing due to positional pressures

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 2001Lubusky 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.)

Clinical Importance

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.

Effects of abnormal head molding in some breech-positioned babies

Abnormal head molding in some breech babies

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.

Counselling Women

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.

A 'normal' breech baby - well-flexed, with lots of room to move

A ‘normal’ breech baby – well-flexed, with lots of room to move

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.

Shawn

Listen to midwives, listen to women

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.

References

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.