“Practical insight into upright breech birth from birth videos: a structured analysis” is now available on-line! (Reitter, Halliday and Walker, 2020, Birth – https://doi.org/10.1111/birt.12480) This paper represents a few years of hard work by Anke Reitter, me and our Research Assistant, Alexandra Halliday. It contains insights into birth timings and the mechanisms as observed in upright breech birth videos. The Physiological Breech Birth Algorithm is also included.
We look forward to much debate and discussion! Please share with anyone concerned about safe vaginal breech birth.
Traduit par: Isabelle Brabant et Caroline Daelmans
Justifying to a seven-year-old Anubis why I’m going to Germany for my week off – and missing mothers’ day, helped crystallise objectives and motivation for this busman’s holiday* (*a form of recreation that involves doing the same thing that one does at work). “I’m going to see some babies be born bottom-first.” “Don’t you see that […]
“Health professionals attending upright breech births should be competent [to assist] rotation of the fetal back to anterior (when the mechanism has deviated from normal)” (p 5). 77% of the panel agreed that this is an important skill. This standard of competence combines two skills: 1) recognising deviation from normal mechanisms; and 2) assisting by restoring the mechanism to normal.
Recognising deviation from normal mechanisms
Within the past two weeks, two people have discussed with me concerns about an incorrect understanding of the correct position for the fetal back when a woman is in a hands/knees position. First, a Practice Development Midwife (PDM) says she advocates teaching breech in ‘only one way’ (eg. lithotomy) because people get confused. A midwife attending training advocated for hands/knees positioning, but when questioned about where the fetal back should be, replied, “The fetal back remains uppermost.” Similarly, a student I am mentoring in practice attended sessions on breech at university. Her lecturer suggested hands/knees may be a more advantageous positioning, but later she is told, even in hands/knees, “The fetal back remains uppermost.” The student had worked out that this couldn’t be correct and sought more information. Excellent critical thinking, Charlotte!
These are signs of a practice in transition, and the PDM and Charlotte are right to be concerned. Rotating the fetal back uppermost in a hand/knees position is a dangerous but not uncommon mistake. Even in textbooks, such as this German textbook for midwives (Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Göbel & Hildebrandt, 2007), the woman’s position is changed, but the professional is still following the rule of, “The fetal back remains uppermost.” (Just to reassure you, once the arms are born, they advocate rotating the fetal body 180° so that the head is born occiput-anterior.)
A physiology-based understanding of the normal mechanisms comes from closely observing spontaneous births which are not interrupted. In a spontaneous breech birth, the most common and most optimal (a.k.a. ‘normal’) rotation of the fetal back is to anterior after the sacrum is born, regardless of the position of the mother.
The simplest way for teaching this aspect of the mechanisms I learned from midwife Jenny Davidson. The baby should rotate “tum to bum.” In other words, the baby’s tummy (stomach/front torso) should be facing the mother’s bum (bottom/posterior), no matter what position the mother is in. If those teaching breech can adopt this language to describe mechanisms and positioning, fewer dangerous misunderstandings, and more flexible thinking mayoccur. Teaching breech as a set of rote manoeuvres leads to automatic behaviours, which are sometimes counter-productive. In my research, I am observing that the path to acquiring breech competence and expertise involves learning to problem-solve in complex, unique clinical situations, often un-learning ‘rules’ that one was taught in skills/drills — because the rules don’t always work (eg. ‘the fetal back remains uppermost’ does not apply in every situation). Experienced professionals replace inflexible rules with more flexible understandings and principles, over a period of time, and through much reflection with peers and mentors. Perhaps teaching should be about patterns and principles, rather than prescriptions?
2. Assisting rotation of the fetal back to anterior — restoring the mechanisms to normal
You should rarely have to do this, but if you do, this principle may be helpful: “Rotation, not traction.” You can assist rotation with your fingers on the bony prominences of the baby’s pelvic girdle, as for any breech manoeuvre. Consider as you do what is happening at the inlet of the pelvis – have the shoulders already engaged, or are they just beginning to enter the pelvic brim?
Safe facilitation of physiological breech births depends on the ability to determine when intervention will be beneficial, and when it is unnecessary and potentially harmful. A breech baby will normally rotate spontaneously, with the back to the anterior (“tum to bum”), as the shoulders engage in the transverse diameter of the pelvic inlet. Pulling or manipulating prior to this spontaneous rotation could cause problems. But if the rotation is to the posterior, it may be beneficial for attendants to intervene at this point rather than rotate an occiput-posterior head mid-pelvis. Or at least 77% of an experienced panel think so …
Gibes E & Hildebrandt S (2007) Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Thieme
Questions for reflection:
Watch the videos in this collection. Identify the normal mechanisms, beginning with descent of the sacrum transverse (to the mother’s side). As you are watching, identify which way you will expect the rotation to occur, anticipating the normal rotation. Did the baby rotate as you expected?
Imagine you are attending one of the births in the videos and quietly communicating with a colleague who has no previous breech experience, about what you are expecting to see, and what to document during the birth. What do you whisper to your colleague? Do this simultaneously with your colleague/fellow student as you both watch the video
January 2015 – See below for videos explaining the mechanisms of breech birth in different maternal positions
Yesterday, I was in snowy Salford – up north! Senior Lecturer and LME Elaine Uppal invited me with two goals: 1) to make sure her students thoroughly understood the mechanisms of breech birth in preparation for their vivas next week, and 2) to raise money for student electives abroad, particularly in Cambodia, where Elaine has a long-standing relationship with a midwifery twinning project.
After the study day, the students and I made two basic videos to assist their revision.
Breech births are few and far between, and there are very few ‘experts’ in the world to learn from, so staying updated is a real challenge. Especially if you do not live and work near others who are supporting breech births regularly.
Updating has two purposes: keeping up to date with current evidence and best practice; and reminding yourself how to use skills you use infrequently. Many breech babies, especially those whose mothers are active and upright (e.g. knees/elbows), can be born spontaneously. But those who cannot need calm, considered help in a timely manner. The same applies to external cephalic version – ECV. Both practices benefit from regular performance and knowledge sharing among those who are practicing.
Here are my suggestions on keeping your practice as safe and supportive as possible:
Attend study days. Many individuals offer study days to develop breech skills. Breech Birth Network days concentrate on lots of practical skills, but also have an emphasis on care pathway planning in the UK, aiming to encourage more Trusts to adopt an organised, committed approach to breech.
Share your work. If you are doing research or working with breech and would like to share your experiences, get in touch and present at one of the study days. I am not an expert, but an experienced and passionate believer in the idea that the more we share, the more we talk about it, the more normal it becomes. The best study days have a wide variety of speakers and reflect a wide community dedicated to developing and sharing skills.
Share your experiences. If you learned something at a breech birth you attended that might help us to make our practice safer, share it! Publish it if appropriate, but if you need to share anonymously to protect your client’s and your confidentiality, I can give you space on this blog. It is wonderful and encouraging to hear stories of triumphant breech births where the baby just fell out singing. But we need to hear the stories of doubt and sadness as well, and often these are the ones you learn the most from.
Create your own network. It’s been so valuable to me to have colleagues who I can phone up to debrief the breech births I’ve attended. I learn so much more by doing this. And so valuable to hear their stories, how they have approached certain complications, how they support women, their thoughts on what makes breech birth safe. Keep a record of these sessions and document them; they are part of your professional updating. Write an article about what you have learned together, so that others can respond to it. We need more voices talking about breech skills.
Organise your own study day. Bring the conversation to you. Empower those local to you to share their skills by asking them to present. Inspire your local community to think more about breech.
If you don’t have anyone local to ask questions or debrief with, my number is 07947819122 (in the UK) and I’m always happy to listen. I’m sure most of us are. Good luck!
Understanding the physiological process of a breech birth
The following pictures show the way a breech baby wiggles her way through a mother’s pelvis when mum is upright (e.g. kneeling or hands/knees), and the signs a breech birth attendant looks for to tell if this process needs help or not.
A breech baby may engage before labour, or may not engage until after her mother’s cervix is fully dilated.
Some midwives feel engagement with the back on one side or another may be ideal. (See Jane Evans‘s ideas on this, on Rixa Freeze’s blog.)
I am happy for the back to be on either side, and these pictures depict the birth of a baby whose legs are extended (frank breech), with her back on her mother’s left.
Descending LST, anterior buttock leading
The breech typically descends with the sacrum transverse, anterior buttock leading. On vaginal examination, this will feel asynclitic – the anal cleft is closest to the maternal sacrum. This is normal for breech.
Maternal movement assists this process in the same way it assists cephalic descent.
The buttocks will be born by lateral spinal flexion (wiggling the bum from side to side).
Anterior buttock rumping
The anterior (maternal front) buttock is born first, followed by the baby’s anus (usually squirting a thick glob of meconium) and the posterior buttock.
The sacrum will soon rotate to sacro-anterior (‘tum to bum’ – the baby’s rear should be in line with the mother’s front). If rotation is tending toward sacro-posterior, this may be an indication for intervention (to gently encourage sacro-anterior rotation).
Birth of the extended fetal legs
Baby’s legs seem to stretch forever, but will be born spontaneously as long as there is descent with each contraction. If one leg slips down before the other, this may indicate that full internal rotation has not occurred, and help with the arms may be needed.
“If it progresses, wait and see.” – Mary Cronk
Birth of the umbilicus
After baby’s legs flop down, you will have a clear view of the umbilicus and may even be able to see the baby’s heart rate from her chest. Do not touch the umbilicus, but observe: colour, tone, flexion/movement.
Reassuring sign: If you observe cleavage (the sternal crease) on the baby’s chest, you know the arms are in front and should be born with the next contraction or active maternal effort between contractions. If not, you need to help.
Indication for intervention: If full rotation has not occurred by the time the nipple line is visible, or progress stops for >90 seconds at any point, you will need to assist with the birth of the arms.
Rotation to drop the anterior arm below the pubic arch
In most breech births, the arms will be born spontaneously with the baby’s torso in a sacrum-anterior position (‘tum to bum’).
Occasionally, as the head engages, baby rotates slightly to release one arm below the pubic arch, then rotates the other direction to release the other arm.
Birth of the fetal arms
Baby should be ‘tum to bum’ following the birth of the arms, and the head should be aligned in the pelvis in an occipit-anterior position.
Unflexed head obstructed in pelvis
A well-flexed head will pass easily through the pelvis.
Commonly, women experience an urge to lower their bottoms to the surface on which they are kneeling (e.g. bed, floor mat, etc.) This maintains and promotes flexion in the baby’s body and should not be interrupted.
Flexed head passing through pelvis
Babies have often been observed doing a ‘tummy crunch,’ or full body flexion recoil, spontaneously pulling their knees up into a fetal position. This also promotes flexion and helps the head to be born.
Note: A compromised baby will not do this, and you will need to assist more, and sooner.
If progress arrests – no descent with maternal effort – help to flex the head is indicated, especially if baby’s tone and colour are not ideal.