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.

2 thoughts on “Listen to midwives, listen to women

  1. Eli

    I was watching call the midwife and had to google extended head. I came across your site and couldn’t stop reading. What amazing sharing of work is going on. My first was a homebirth with midwife which was a wonderful experience. My second unfortunately had to be born in a filthy cold noisy hospital which were I not already sure of myself would have been terrifying. Midwives do the most amazing job and I hope insurance allows the home birth to continue to exist. I wonder also are there any movements the mother can dk herself to facilitate some of the different issues you speak about. I did belly dancing when I was pregnant and realised how flexible and controllable that whole area can be. Just a thought … Maybe some small changes in positions and movement sequences done by mothers would be useful to help the midwife manipulate things along. Wish you and all midwives the best what wonderful amazing creatures you are.

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    1. midwifeshawn Post author

      Hi Eli –

      Thank you so much for such a kind and thoughtful message. I wrote that post in June of 2013 and have continued to think about extended heads in my research and clinical work.

      These days, when we ‘teach breech,’ we use an algorithm. You can see a working version (comments welcome) here: https://breechmidwife.files.wordpress.com/2018/11/algorithm-nov-2018.pdf

      If an attendant judges that the birth is not progressing at a safe pace, or has concerns about the fetal heartrate, the first recommended actions are to encourage 1) spontaneous maternal movement; and 2) continuous pushing. We too feel that maternal agency is the most effective and safe way of moving the baby down and out. And if maternal movement and effort is not effective, professionals can feel confident that there is indeed an obstruction requiring our assistance.

      This is a blog about asymmetrical positioning, which we feel is particularly effective for relieving delays due to an arm that gets a bit stuck coming down, but with a little more space and wiggle can come down on its own. https://breechbirth.org.uk/2017/03/17/running-start/

      Another important element of this story took me a little longer to recognise as a common pattern in stories of difficult head extensions in breech births. Just prior to the baby’s emergence, the baby’s heart began to beat very fast (a tachycardia), and there were 2.5 minutes between the birth of one arm and the other. I would now recognise that the tachycardia indicates the baby is becoming compromised, and the time between one arm and the other is way too long — in 75% of upright births, the arms are born within 3 seconds of each other (my current research)! The baby is an important agent in this dance too, and she was too worn out to assist her own birth by pulling that second arm down, along with her head. Important to know how to resolve a head extension, also important to know how to prevent it by being swift to assist if necessary so that the baby does not lose tone.

      I too hope that we continue to be able to support home births — I had four of them myself! But because of the greater likelihood of needing resuscitation, I hope we can continue to create safe, welcoming (and clean!) spaces for women to birth — actively and intuitively — in hospitals.

      Thanks again for your support.

      Warm wishes,
      Shawn

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