Tag Archives: shoulder press

Compassionate breech birth in Bangladesh

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.

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.

Shawn

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

Stop 4: Asheville

Brunch with the Masterchief at Tupelo Honey Cafe

Brunch with the Masterchief at Tupelo Honey Cafe

Taking breech training into the Blue Ridge Mountains of North Carolina …

We had to make a pit stop at a Motel 6 around 11 pm, but my Dad and I arrived in Asheville in time to have grits for breakfast. Asheville is an amazing town with a real ‘alternative’ feel about it, so I was anticipating a very receptive crowd. Already, what was supposed to be one study day on Sunday turned into two, as more doctors wanted to attend but it was already fully booked.

A few of the participants in the Saturday workshop

A few of the participants in the Saturday workshop

So at Harvest Moon Woman’s Health we had a 4-hour condensed training on Saturday, attended by one board-certified obstetrician, one resident at a local hospital, two family practice doctors from South Carolina, and a handful of midwives. This was followed by the full-day training on Sunday with midwives who came from as far as Tennessee and Virginia. With 39% of the respondents (across all of the six training days) indicating they had NEVER had any training in vaginal breech birth, the need and demand for such training was very strong.

We again discussed the subtle difference between these two ways of performing the manoeuvre often referred to as Frank’s Nudge:

  • Sub-clavicular pressure and bringing the shoulders forward to flex an extended head
  • Pressure in the sub-clavicular space, triggering the head to flex
  • (Walker et al 2016)

The first of these involves rotating the shoulders forward, as described by Louwen and Evans (Evans 2012), minimally lifting the baby, and initiating flexion in the thoracic and cervical spine. This action is often performed with a rocking motion, nudging the aftercoming head around the pubic bone, mimicking the way a head is normally born, in reverse. Mary Cronk used a ‘stuck drawer’ metaphor to describe why rocking rather than steady pressure is sometimes more effective. Participants felt that the description ‘shoulder press‘ is effective for communicating the simpler manoeuvre (#2), where the head has stopped at the outlet of the pelvis. South Carolina Midwife Gayling Fox then suggested the term rock’n’roll manoeuvre for the other skill (#1), more useful where the dystocia has occurred at higher levels of the pelvis. Only in Asheville! I have to admit, the phrase is both fun and functional …

The Sunday crowd

The Sunday crowd

The law of ‘attracting breeches’ was in full swing in the mountains, as OB-GYN Dr David Hayes reported having received multiple enquiries from women seeking support for a vaginal breech birth, just from having hosted this training. In addition to being a sensitive and woman-centred obstetrician, David is an experienced breech catcher, having worked in both high-risk Western settings and abroad with Medecins Sans Frontiers. While he was open to physiological breech methods due to his familiarity with physiological birth in general, he had never attended a breech where the woman birthed in an upright position.

One of the women who contacted him was full-term with her first baby in a frank breech position (both legs extended). David asked if I would attend to support the birth in a teaching capacity, if available. Although we still had a couple more stops on the road trip, I tend to believe what will be, will be … if the stars align in just the right way … I said, Yes!

Tomorrow: Last stop: Atlanta. Or so we thought …

Shawn

References:

Evans J. Understanding physiological breech birth. Essentially MIDIRS. 2012;3(2):17–21. (Frank’s Nudge)

Walker S (2015) Turning breech upside down: upright breech birth. MIDIRS Midwifery Digest, 25(3), p325-330. (shoulder press)

Walker S, Scamell M, Parker P (2016) Standards for maternity care professionals attending planned upright breech births. Midwifery. Vol 34, p1-7. (using subclavicular pressure to flex the aftercoming head)

 

Second stop: Tillsonburg, Ontario

Celebrating Norfolk Roots Midwifery!

Celebrating Norfolk Roots Midwifery!

From Montreal, it was on to Tillsonburg, Ontario, ‘near Toronto’ — because in Canadian terms, within 3 hours is ‘near.’ The places around Tillsonburg are confusingly called things like London, Norwich, and Cambridge. The lovely Norfolk Roots Midwifery team gave me one of their bags to remember my visit. Can’t wait to take it back to Norfolk, England with me!

 

Midwife Joanna Nemrava came from British Columbia to share breech skills!

Midwife Joanna Nemrava came from British Columbia to share breech skills!

Again, the training was attended by midwives who came from various places throughout Canada and the US, including Alberta, British Columbia and Michigan, south of the border. I was privileged to meet Stacia Proefrock, a breech-experienced midwife from south-central Michigan. In addition to attending breech births, Stacia has experience teaching others about physiological breech birth and is the current president of the Michigan Midwives Association – a great person to be in touch with if you would like to organise a study day of your own in this area.

 

Teaching in Tillsonburg; photo: Sheila Stubbs

Teaching in Tillsonburg; photo: Sheila Stubbs

While in Ontario, I picked up a Deverra birth stool for use in teaching and births. The stool is visible in the photo to the right. I love their design, which features a wooden seat and 360º visibility. The Deverra birth stool is also completely portable; the legs unscrew and it comes in its own carry bag. When professionals are making the transition to active breech birth but can’t quite wrap their heads around facilitating a breech birth from behind the woman, I often recommend a birth stool as a good compromise — the woman remains mobile and upright, while the baby emerges facing a direction familiar to the attendant. While other birth stools are available, I am quite happy with this one, another reminder of my trip to Ontario!

At the end of each study day, we spend some time discussing how professionals acquire breech experience when breech births are not very common, including the concept of ‘attracting breeches,’ emerging in my current research. I know several of those attending this study day have sharpened their skills, reflected on the experiences they have already had, and are open to attracting breeches, so I look forward to seeing what happens among this group. Of course, in Ontario, activists have a great model in the Ottawa-based Coalition for Breech Birth and Midwife Dr Betty-Anne Daviss, who have worked together to enable midwife-facilitated breech births in hospitals in that area. Join forces with each other and work together for change!

practising

practising breech manoeuvres

The training was held in the house of author, speaker and birth activist Sheila Stubbs, who holds regular Birth Nerd gatherings in her home. The warmth and sisterhood in this community was very strong, and Sheila reminded me of Norwich’s beloved doula mother, Rachel Graveling. Thankfully, Sheila gave me a signed copy of her book for the Norwich Birth Group lending library.

Thanks also to Christine McGillis, who organised this training in Tillsonburg. ❤️

Tomorrow: On to Philadelphia, and the start of my Father-Daughter road trip!

Shawn

a walk around beautiful Tillsonburg

a walk around beautiful Tillsonburg

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