Heads Up! Breech Conference

Jane Evans: Physiological Breech Birth

November 9, 2012

Jane Evans's presentation was a shortened version of her "A Day At the Breech" workshops. I was able to film her presentation, but not the accompanying slides or videos. Jane also gave a shorter presentation about the cardinal movements of the breech baby on day 2.

UK midwife Jane Evans began by outlining the prenatal discussions and informed consent process she goes through with her clients. She wants everyone to make the right decision for that baby and that woman at that time. Today's presentation is about the full-term, normal sized baby; it doesn't apply to premature babies.

She has noticed that breech babies more often have a battledore insertion of the placenta. When you're thinking about ECV and VBB, there's so much we still don't know.

Aims of this session:

• Feel confident that many women are able to give birth to their babies, even if it's in an unusual position
• Have a clear understanding of the mechanisms and the path through the pelvis that the breech presenting baby takes

If you can keep the normal mechanisms in your mind, you'll be able to pick up on the small, subtle differences.

Causes of breech presentation (3-4% of term babies will be breech)

• Gestational causes
• Fetal causes. About 6% of head-first babies have some sort of anomaly; 10% of breech do. There might be some neurological difference that predisposed a baby to breech.
• Maternal causes: placental location, fibroid, etc.

Physiological breech birth

• Spontaneous onset of labor at or around term (37th-42nd week). No induction or augmentation.
• Labor progresses well; contractions come oftener, last longer, get stronger. In the view of the woman, they come too often, last too long, and are too strong!
• The presenting part descends in the birth canal, accompanied by effacement and dilation of the cervix. As long as this is happening, at whatever speed, the outlook for a VBB looks good. Labor typically takes 6-8 hours for a primip breech-shorter than typical for a head-down baby. A stop-start labor is less likely to end in a VBB. She tries to observe without putting her hands inside the woman.
• During 2nd stage, the baby descends in the birth canal and is born by the expulsive efforts of the mother and baby, without traction from the attending practitioner.

Descent into the pelvis
The most common, most optimal position for breech baby prenatally is RSA. Frank breech most common for primips. Complete breech is more common for multips. As labor starts, the baby descends RSA through the widest part of the pelvic inlet. In a good-sized baby, if the bottom goes through spontaneously, the head should come through. The baby's bottom drops into the pelvis and is guided by the pelvic floor muscles to rotate to RS Lateral. This is what you see when the baby is rumping. You might see lots of meconium; don't be surprised or alarmed. The mom will often drop her bottom down to the floor and help drop the baby down. Usually you see the anterior buttock first, then the posterior buttock. Don't wipe any maternal feces away; it causes the woman to clench up. You don't want that to happen, especially in a breech labor.

Rumping and birthing the legs
Carefully observe the baby's color and tone, although it's not always reliable. At or soon after rumping, the baby will rotate back to RSA. At this point, the shoulders are coming into the widest diameter of the pelvic brim. When the baby is out to the knee pits, the baby extends its pelvis (arches its back / extends its pelvis backwards) around the maternal symphysis pubis. That's what makes the knees look like they're inside out. This movement helps release the legs. The baby's head naturally tilts back as it goes past the maternal sacral prominence. The legs will look like they're going on forever!

She's observed that knee presentations tend to come down posterior, rather than anterior.
She pointed out the Rhombus of Michaelis (more info on its role here), which is easy to see when a woman is upright. If a woman is sitting, it presses the sacrum inward. Anatomically, it makes a breech birth more difficult.
She's cut one 1 episiotomy for a head-down baby and 2 for breech in the past 30 years.

Birthing the arms
Once the legs are out, the baby should be direct SA. The baby continues to rotate. It does its own Løvset maneuver and rotates from SA to Sacrum Lateral. By doing that movement through the pelvic floor, that does its own Løvset and brings out the first arm. The second arm usually slides out. As the shoulders are coming out, the head comes into the pelvis. The occiput has rotated and is coming onto the left side.

Flexing and birthing the head
The baby comes into the pelvis and down and restitutes. The baby does a stomach scrunch and lifts its arms and legs, serving to flex its chin to its chest. This puts the baby's head nicely into the pelvis and rolls the occiput on the internal aspect of mother's symphysis pubis. Women report a "funny" or "peculiar" feeling and have to move, dropping forwards. This rotates the sacrum around the baby's head and out of the way. At this point, it's only the perineal skin ring holding the baby in, if they haven't already fallen out completely.
3 cardinal things to watch for: color of baby, tone of baby, color of cord (don't touch, but observe closely).

Choices for women in pregnancy with a breech presentation:

• To try to turn the baby or not? Are we pushing women too strongly to have ECV's? NO matter how much we think we know, please try not to force women into it. • Positional aids: how to help babies to turn such as lying tilted, knee-chest (this is the only position that's been well studied)
• Complimentary therapies that may encourage the baby to turn
• ECV

Choices for women on how their baby will be born

• Breech birth. Don't be overly dogmatic about H&K; women should choose what positions feel right at the time.
• Breech delivery/extraction
• Cesarean Section
• Elective prior to labor
• At start of labor (common practice in Frankfurt clinic)
• During labor when help is needed (Women need to know that a CS at full dilation is more dangerous than pre-labor)

1/3 of all breeches are still undiagnosed, which comprises 1% of all births. All of us practitioners ought to know how to safely birth a breech baby.

Skills required for Practitioners

• Knowledge
• Share experiences
• 2nd practitioner acceptable to woman
• Remind yourself of mechanisms
• Practice with doll & pelvis or torso
• Competent resuscitation skills & appropriate equipment (more often need to do inflation breaths; rare to require more)
• Ability to drink tea intelligently (watch, but don't interfere. Keep fear and panic out of the room).

If you see anything unusual, put a flag up in your head.

Q: What do you do during the pushing stage?
A: No Valsalva maneuver. Wait until the woman is ready to push. Don't encourage early pushing; don't delay inevitable pushing.

Q: What about epidurals?
A: Epidurals are outside her scope of normal and cause a breech birth to fall into obstetrics rather than midwifery. Epidurals interfere with the intricacies of the cardinal movements and pelvic floor maneuvers. That's why she prefers land births for breeches, since the water pressure interferes with the mechanisms.

Q: What about babies who come down on the left side rather than right?
A: Let them do their own rotations. However, you are more likely to need to help an arm out. It doesn't matter which one you help out first, as long as you get one out.

Q: Average length of labor?
A: No answer-it depends on mother and baby. As long as there's good progress.

Q: What about posterior breeches?
A: Jane and Anke Reitter both agree that the H&K position is key to helping posterior babies rotate appropriately without intervening. This is a very difficult, dangerous scenario when a woman is on her back.

Jane Evans concluded with two quotes:
"The art of waiting on is a difficult one, and not many obstetricians have either the courage or the patience to sit idly by whilst the breech delivers spontaneously." Plentl AA, Stone RE, Obstet Gynecol Survey 8.3 (1953): 313.
"Caesarean section cannot be the response to suboptimal care for vaginal breech birth." Benna Waites, author of Breech Birth. 

If you don't feel experienced enough with breech birth, don't push yourself.
For more information, see:

• Jane Evans. Understanding physiological breech birth. MIDIRS 2.3 (Feb 2012).
• Jane Evans. The final piece of the breech birth jigsaw? MIDIRS 3.3 (Mar 2012).

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