Breech Birth in Yemen – what I learnt as an MSF Gynaecologist taking physiological breech birth from theory into practice

Dr Sabrina Das

Sabrina is a Consultant Obstetrician & Gynaecologist at Imperial College Healthcare Trust in London.  She worked in Yemen as an MSF Gynaecologist from March-July 2021.

The conflict meant that there was no publicly run maternity hospital in Taiz Houban, as it was not safe for civilians to cross the frontline.  Six years into this war (and no end in sight), Taiz Houban Mother and Child Hospital (MCH) is the largest maternity hospital in the region, and the largest MSF project in Yemen.  We deliver 400-500 babies per month, and we mainly treat women with risk factors in pregnancy or who develop intrapartum complications.  Breech presentation is one such risk factor.

In many high resource countries, breech presentation has become synonymous with Caesarean birth and most mothers opt for this, in spite of no evidence showing any difference in long-term outcome for babies. “Everybody says it is safer to have a Caesarean” is what many women tell me.  Thus in London my experience with vaginal breech birth is mostly in the pre-term or second twin scenario.  In my time in Yemen, however, I have delivered more vaginal breech babies than I had in my preceding 15-year career.

The average number of children a woman has is six.  Many women get married and start their reproductive journeys in their teenage years, and carry on for the next 20 years.  It is not unusual for women to have 12+ pregnancies.  The conflict has devastated Yemen’s public healthcare provision, and very few can afford private antenatal care. Even if they could, the war has meant that there is a real shortage of skilled providers even in the private sector.  There is no national screening programme.  Many women will labour at home.  Some labour with a private midwife and practices of private providers are unregulated.  It is not uncommon for women to receive oxytocin in the home setting, whilst in labour, to speed things up. 

The high fertility rate, lack of easy access to maternity hospitals with facilities for The high fertility rate, lack of easy access to maternity hospitals with facilities for emergency Caesarean, and unregulated practices occurring in the community make the risks of a Caesarean very high.  The risks are not so much in the index pregnancy, but in future pregnancies.  We have many women with previous Caesarean who attend with ruptured uteri after receiving oxytocin at home, or after labouring for some hours at home.  We also have women experiencing the complications of multiple Caesarean births – dense adhesions and surgical issues, but more terrifying is the complication of abnormal placentation from previous Caesarean birth.

We had one woman who we saw in our high-risk clinic with a low lying placenta, and a history of two previous Caesarean births.  She also had two previous vaginal births.  Only two of her four children were alive.  We brought her back to have a planned Caesarean the following day, and on entry, found that the placenta had invaded through the previous uterine scar (a complication called placenta accreta).  I delivered the baby and had to perform a hysterectomy.  She received six units of blood.  She is lucky to be alive.  If she had bled at home or gone into labour before finding a hospital to do her Caesarean, she would have died.

We saw another woman who was about 18 years old.  She had a 5-month old baby, and got pregnant immediately after her period returned about 2 months prior.  She turned out to have an ectopic pregnancy in her Caesarean section scar.  It was quite large, about 5cm by 5cm and she bled a lot during the treatment (I evacuated the pregnancy via the cervix).  I was seriously afraid she would need a hysterectomy. This is a serious consequence for a young woman in any culture, but my Yemeni colleagues tell me it can be particularly devastating here, where a woman’s status in her husband’s family can be dependent on her potential to have more children.  We were lucky this time and she will be back, pregnant, in the not too distant future I expect.

I had to explain the backdrop in Yemen for you to understand that here, Caesarean is not an inconsequential operation.  The risks to mothers of complications directly or indirectly related to a Caesarean birth are huge.  The relatively small benefit to the baby demonstrated by the Term Breech Trial (2000) do not justify a policy of elective Caesarean breech delivery in this context.  Thus, it is common and routine for us to induce women with breech presentation (for all the usual indications), and if a woman presents in labour with a breech baby, we manage them exactly as we would with a head down baby.  This includes giving oxytocin to augment labour if needed (especially in first-time mums).

The lack of regional anaesthetic would make an upright breech vaginal birth an ideal option for women, but the standard practice here is for women to deliver in lithotomy position.  Culturally, women in labour tend to lie flat on their beds, usually hooked up to an intravenous drip for some reason.  Believe me, every time I do a ward round I sound like a broken record, “Get her up and moving – tell her lying flat is not good for her baby!”  And at delivery, I get the women to try going on all fours position.  For the breech births, I have had most women (including primiparous women) delivering beautifully on all fours, where nothing more was needed than some verbal encouragement. I was really happy this week, however, when the skills I had learnt from physiological breech training helped with what could otherwise have been a tricky breech birth.  .

A mother came in fully dilated, with her second baby in the breech position.  Lots of women come to hospital fully dilated and this is not a good thing.  The conflict means that women sometimes have to wait until it is safe to travel, or they have trouble accessing transport, or issues like roadblocks and the closure of local services mean they just have really long journeys to get here.  Without any idea of what the fetal heart rate has been doing in the preceding hours, without any clue about what medication the woman may have received at home, what has her blood pressure been… I have seen it go wrong far too many times before.

This particular mother was immediately brought to the delivery room, and the midwife explained she had heard a deceleration.  We checked the fetal heart and there was definitely a bradycardia going on.  I immediately got her onto all fours position and got her to push.  The rump advanced to the perineum and I could see the abdomen emerging, and the legs shortly afterwards.  I didn’t see the “valley of the cord” as the baby was slightly misaligned so I corrected this with a little rotation.  I could hear the mantra “don’t tell the woman to ‘just breathe and wait for the next contraction’”, particularly with the concerns over the fetal heart.  So I went ahead and delivered the anterior arm and proceeded confidently with a shoulder press.  It worked like magic and the baby was born.  Baby started crying after a few minutes on the resuscitaire, and was good as gold by the time we cleaned mum up.  The best bit for me was presenting the gorgeous girl to her mother.  I told her, “jameel” which means “beautiful”.  It is one of the few Arabic words I know.  She kissed her hand and touched mine, and without words we shared a moment of connection.

Not all my breech stories are so successful.  We had another woman who had four children (all alive) who came in at term with a breech baby in spontaneous labour.  She laboured to full dilatation and was pushing for a long time, about two hours.  By the time I got involved, she was exhausted and asking for a Caesarean.  We persevered for another 30 minutes.  She had been in lithotomy, so we got her on the floor.  Squatting, kneeling, McRobert’s… we tried all positions possible.  The baby’s bum was visible without even parting the labia, but it was not budging.  We brought her into theatre and did a Caesarean.  On the operating table before starting, I noticed minimal urine in the catheter tubing and what was there was a deep blood-red.  Her abdomen was a crescent shape, and looked sunken in on one side.  She had the most obstructed labour I had ever seen.  The lower segment of her uterus was so distended it looked bruised, almost like a large purple mass.  The bladder was extremely oedematous.  The baby was not excessively big (3.4kg) but for some reason, the way his bum was fitting in the pelvis, it was malpositioned in some way and there was no way he was coming down.  The long second stage in a multiparous women, and all the other outward signs of obstructed labour should have been singing to me. 

I saw a similar woman the following day with an intrauterine fetal death at term.  We induced her and she was in second stage for about four hours.  We were not keen to do a Caesarean for a baby who had already died but in her case it was obstructed.  To avoid a ruptured uterus, a Caesarean was the right thing to do for the mum.

So, here’s a summary of what I have learnt about breech birth working alongside my very skilled Yemeni colleagues here in Taiz:

1. Upright position is fab, as is the lack of regional anaesthetic for a breech birth.  That Ferguson’s reflex is a really helpful thing to help the rump deliver.  The manoeuvres work a charm once the woman has gotten herself past that point of “no return”.  Up to that point, however, you can’t do anything to speed things up apart from verbal encouragement.
2. If the rump is not delivering, particularly in a multiparous woman, things are not going well and the breech might be malpositioned in some way.  Do not start oxytocin in this case (especially if she had been contracting well before).  Any sudden cessation of contractions is not a good sign and should prompt an assessment for rupture of the uterus.  I would recommend a Caesarean after about two hours of active pushing in second stage for multiparous women.
3. You can induce or augment a woman with a breech baby just like you can when the baby is cephalic.  The same rules apply – look for adequate progress, monitor as you would with a cephalic baby for fetal distress or hyperstimulation, and be wary of augmenting multiparous women who are in spontaneous labour (they are at risk of uterine rupture). 

I think that if healthcare professionals follow these simple rules, breech vaginal birth is just as safe as a cephalic vaginal birth in any setting. 

If you would like to make a contribution to MSF’s work in Yemen, please visit https://msf.org.uk/pain-motherhood-yemen-different-scale