In June, I spent a week in the Netherlands working with a committed group of lecturers. The midwifery universities of the Netherlands share a common curriculum, and following our meeting last year, they agreed to incorporate physiological breech birth into their training programme. My visit was to support the midwifery lecturers to implement the new skills into standard midwifery training.
While in Amsterdam, I collaborated with Midwifery Lecturer Bahar Goodharzi of Academie Verloskunde Amsterdam Gröningen (AVAG) to create a short series of films demonstrating the rotational arm manoeuvre we teach in Breech Birth Network study days. We agreed that this is a tricky manoeuvre to learn and teach, but it is incredibly effective in practice so worth the effort of learning. I’ve collected our short demonstrations in the film below, along with information about how to recognise that this manoeuvre is required.
Note: If you have difficulty rotating the baby initially, you may have to elevate the baby slightly to a higher station, so that the shoulder girdle rises above the pelvic inlet. It can then rotate to engage in the transverse diameter.
Thank you to Emma Spillane of St George’s Hospital in London, who has helped to refine the way we teach this manoeuvre following her own experiences of successfully using it in practice.
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
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”
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 may be observed as a slight rotation, in which the pubic fetal arm is released under the pubic arch. If an observable external rotation has occured, 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
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:
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 ‘flat hands‘ or ‘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.
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
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
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.
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.
Posterior arm born, anterior arm high, shoulders in A-P diameter – help is required!
In July, Gerhard Bogner of Salzburg presented data at a Breech Birth Network study day. Although the series is small, the data indicate that when the mother is in all fours position to birth a breech baby, approximately 70% of those births will occur completely spontaneously, eg. without the need to perform assisting manoeuvres at all. Use of upright positioning also reduced the rate of maternal perineal damage from 58.5% to 14.6%, which is actually better than cephalic births!
The reduced need for manoeuvres potentially reduces iatrogenic damage to babies associated with interference at the time of birth, such as birth injuries and inhaled meconium. That’s great for that 70%, but what about the other 30%? The babies born with upright positioning in Bogner’s study had a slightly higher rate of low cord blood gases, indicating hypoxia, although no consequences for the infants or differences in 5 minute Apgar scores were observed.
If a woman is birthing her baby in an upright position, how do we assist the birth confidently and safely when delay is identified? How do upright manoeuvres differ from those performed when the woman is supine? To address a growing need for more practical training in upright breech birth, City University are offering Physiological Breech Birth Workshops in London and taster days around the country. The next one is on 2nd of December at the Whittington in Central London. Lots of hands-on training with a small group of doctors and midwives committed to extending breech skills. We also post conferences and workshops provided by others when we can.
Several people have been in touch to ask about the How and When to Help handout. I disabled the link because it is constantly being updated! Please feel free to download this one and use it in your practice area. But keep in mind understanding in this area is constantly expanding, and this is just one midwife’s current approach. I’m working on research to understand others’ approaches as well, but it will be some time until this is finished.
Look out for two articles appearing this month. In The Practising Midwife, I present a summary of current evidence related to ECV (external cephalic version), with some excellent photos provided by Dr Helen Simpson and Midwife Emma Williams of South Tees Foundation Hospital. In Essentially MIDIRS, Mariamni Plested and I talk about issues in providing innovative care for higher risk birth choices.
Finally, shameless plug: Today (30/9/14) is the last day to vote for my, um, remarkable cousin Jake in the NRS National Model Search. Read all about him here, and then click on the link at the bottom of the article to VOTE FOR JAKE!
Favourite quote from the article: “The funny thing is, some bulls are just like big dogs. They come up to you, put their butt in your face and say, ‘Scratch my butt.’ But as soon as they get that flank rope on them, it’s like, ‘Game on. I’ve got something to do now.'”
Awww. Gotta love a bit of passion, of finding your niche and loving it … We love you, Jake! (Just what every 18 year old boy always wanted, a plug on a breech birth information site. We clearly share a common love of butts.)
Update:He won! Go Jake!
Bogner, G., Strobl, M., Schausberger, C., Fischer, T., et al. (2014) Breech delivery in the all fours position: a prospective observational comparative study with classic assistance. Journal of perinatal medicine. [Online] Available from: doi:10.1515/jpm-2014-0048
‘Into the Breech’ Workshops in Perth and Melbourne, December 2013
Anke Reitter, Danielle Freeth, Rhonda Tombros, Andrew Bisits
This month has seen a small series of Australian workshops, hoping to increase confidence among those already working to modernise breech birth in Australia. The ‘Into the Breech’ conferences were instigated by Dr Rhonda Tombros, an academic lawyer with an interest in human rights and the mother of a breech born baby, and organised by Barbara Glare. The conferences coincided with a six month research fellowship visit by Dr Anke Reitter (FRCOG) of the Frankfurt team, whose MRI research will soon be published, concerning changes in pelvic diameters with maternal position changes.
The Perth workshop, on 3 December, was held in the Perth Zoo and was opened by midwife Danielle Freeth, also the mother of two breech babies. As for obstetricians, it was quality rather than quantity on this occasion. One of the participants, Dr Liza Fower, Head of Obs and Gynea at the Armadale Hospital, gained significant experience facilitating breech birth in South Africa and has been able to continue to offer support. She also contributed to one of our practical workshops with some useful tips.
Anke Reitter frisking Andrew Bisits .. while demonstrating how to release stuck nuchal arms.
Dr Andrew Bisits (FRANZCOG) presented in Perth, on pathways for women and complications. Bisits is one of the Directors of the ALSO (Advanced Life Support in Obstetrics) course in Australia, which will be updated to include emergency manoeuvres when a woman is in an upright position. He and his team, including Midwifery Professor Caroline Homer, have launched an intensive course for professionals in Australia, the BABE (Become a Breech Expert) course. I am very much hoping to bring this course to the UK at some point in the future, and in the meantime will be ensuring that the information presented at the Breech Birth Network study days is in line with the systematic approach they are developing.
Melbourne attracted more consultant obstetricians, GP obstetricians and a lively group of midwives. Many conversations occurred during the break, suggesting a critical mass in this location, likely to move on with a more organised and collaborative approach to supporting women with breech presenting babies. This may require more working together across traditional boundaries if women are to have adequate support for viable choices, especially as breech services are reintroduced among teams with minimal recent experience.
Dr Rhonda Tombros
A highlight of both days was Dr Rhonda Tombros’ presentation on the legal aspects of informed consent and negligence focusing specifically on issues around breech birth. We all hope she writes this up for publication in the near future.
Although I present at these conferences (in this case, on the evidence base and ‘normal for breech’), I find them invaluable to developing my own practice. The two messages I found most interesting with this visit concerned timings and episiotomy.
Timings: Bisits and Reitter gave increased focus to achieving a prompt delivery, suggesting that 3 minutes from the birth of the umbilicus to the birth of the aftercoming head is ideal. “Three minutes is ideal, you are probably okay with five, but after that most babies will experience some sort of compromise.” This aspect has not been previously emphasised at the conferences I have attended, but the intense dialogue which has developed between midwives and obstetricians supporting breech has revealed differences. It seems that timings are almost taken for granted in obstetric training for breech, whereas midwives have a much higher tolerance for a ‘wait and see’ approach, emphasising the ‘hands off the breech’ philosophy. In reviewing the anecdotal experiences where breech is being reintroduced, the current consensus among our small collective of professionals is that, while a ‘wait and see’ approach will often result in a spontaneous resolution, it will also more often result in a severely compromised baby when that spontaneous resolution does not occur. Therefore, following the birth of the umbilicus, if the birth does not continue to progress promptly or you are not confident of the condition of the baby, intervening to facilitate the birth is recommended, using the systematic approach we are advocating:
Try to sweep down the arms in front of the face
If not possible, rotate in the direction of the nuchal arm (modified Lovesets)
Ensure the head is aligned with the body and the mother’s birth canal
Deliver the head using classic or modern techniques to achieve flexion
The skill of an experienced practitioner is in holding back from intervening when the birth is progressing normally, balanced with effective intervention when it is not, and developing this judgement is a key aspect of breech training days.
Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare
Episiotomy: In Melbourse, Consultant Midwive Michelle Underwood presented data from the Westmead Clinic which she runs with Dr Andrew Pesce in Sydney. While all of their statistics were fascinating – especially demonstrating a reduction in CS for breech from 90% to 63% in the first year of the clinic – I was intrigued by their stats on perineal damage. It seems that, compared to all births, the breech births have the highest rate of episiotomy AND the highest rate of intact perineum. This suggests to me that the majority of perineal damage from vaginal breech births may be iatrogenic, which is not surprising given that cutting a timely episiotomy is an over-emphasised part of some obstetric training for breech (Deering et al 2006), as is the use of forceps.
But is it necessary, or helpful (in most cases)? In his own practise, Bisits avoids episiotomy because he feels the perineum has an active role in encouraging breech babies to remain well flexed throughout the birth. Reitter also discussed her own personal stats – three (3) episiotomies cut in the last 10 years, a period which has included management of over 300 breech births and countless cephalic complications. The episiotomy rate in her unit in Frankfurt is exceptionally low overall. Change was accomplished when the Lead Obstetrician (Prof Frank Louwen) insisted that episiotomies would not be cut unless absolutely necessary, and that each episiotomy would need to be justified personally to him. That’s what leadership can do.