Tag Archives: physiological breech

India and the breech

Missed our Facebook Live event with Fernandez Hospitals? Watch the recording here:

PMET student Arunarao Pusala receives her training certificate in Karimnagar

This month I am in Hyderabad, India, visiting Dr Evita Fernandez and UK Consultant Midwives Indie Kaur and Kate Stringer. Today at 5pm IST (that’s 11.30 GMT), we will be having a Facebook Live discussion on Breech Birth in India. This will be followed by hands-on workshops on the 12th and 19th in Hyderabad.

with Senior Midwives Theresa and Jyoti

The Fernandez Hospitals are at the forefront of compassionate maternity care on a large scale in India. The Stork Home facility has been beautifully designed and rivals some of the best midwifery units in the UK. But Dr Evita and her team of doctors and midwives are very ambitious. They want to revive vaginal breech skills so that women can confidently choose this option. How will this work in Hyderabad? Join us for a discussion.

Midwives and doulas support women together in the beautiful Stork Home facility in Hyderabad

From Arunarao: “My special thanks to dr Evita ,lndie mam Kate mam and Shawn mam for the opportunity to participate in BREECH BIRTH WORKSHOP at karimnagar.i am so panic about breech presentation and breech birth before I come to professional midwifery training, know iam very excited to assist the spontaneous and assisted breech birth,because now I came to know breech also has its own mechanism and always always we have to respect those mechanism and iam aware of the manoeuvres to apply whenever it’s needed.thank you all of you mam iam so blessed to have a teaching faculty like you.” Thank you Arunarao — you really got it!

Shawn

Mechanisms of upright breech birth

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. 

Engaging LSA

Engaging LSA

 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

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

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

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

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

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

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

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

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.

 

Want to learn more?

More on Mechanisms from this blog.

Excellent sources of information:

Evans, Jane. (2012). Understanding physiological breech birth. Essentially MIDIRS, 3(2), 17-21.

Evans, Jane. (2012). The final piece of the breech birth jigsaw? Essentially MIDIRS, 3(3), 46-49.

Frye, Anne. (2004). Holistic Midwifery, Volume II, Care of the Mother and Baby from the onset of Labour through the First Hours after Birth. Labrys Press. (available here)

Reitter A, Halliday A and Walker 2 (2020) Practical insight into upright breech birth from birth videos: a structured analysisBirth. doi.org/10.1111/birt.12480