An assisted complete breech birth

The mother-to-be was a 35 year old G2P1, with a thirteen-year-old daughter born via a normal spontaneous vaginal birth with an epidural on the East Coast. Now in a new partner later in her life, medically trained herself, and wanting a home birth here on the West Coast, her baby was found to be newly breech at 35 weeks with her midwives. 

External cephalic version at 37 weeks with a different provider was unsuccessful, and the patient came to consult with our hospital-based prenatal practice to discuss her options. She had no pregnancy complications and despite her "geriatric" second pregnancy felt confident in her ability to have a vaginal breech birth and wanted to exercise her right to "refuse" the hospital-recommended cesarean if labor started spontaneously (or another version) when supported/attended by an open-minded provider (although her partner, a first-time Dad, was more nervous!). 

Having attended the Madison Breech Conference four months previously and having worked frequently with her midwives in the past, I was the only physician/provider locally known to have the interest and comfort in helping her have a physiologic birth similar (but not identical) to the one she had desired this time around! 

She entered labor spontaneously at exactly 40 weeks, first calling me, and then after 2 hours, presenting to the hospital at 2 p.m. contracting every 3 cm, dilated to 4-5 cm with bag of waters intact. Formal ultrasound confirmed complete breech presentation with head in flexion, normal amniotic fluid volume, and a fetal weight of 3900g, although the baby felt smaller clinically. 

Despite much hospital administrator and anesthesia provider anxiety about a patient laboring with a baby in breech presentation in a hospital without in-house anesthesia or operating room crew, the patient progressed rapidly in active labor, feeling the urge to push at 17:04 and was found to be 9 cm dilated with a bulging bag of water. 

We moved the patient to the PACU (for planned delivery in the Operating Room) and the pediatrician and OR team was summoned at the request of the hospital and nursing supervisors due to the "high risk" delivery. A few minutes later, the patient (in the upright, standing position) began uncontrollably pushing. Fetal heart tracing, monitored continuously, was reassuring. 

At 17:20, we moved her into the operating room, and the standing position was resumed. At 17:27, the bag of waters was seen extruding out of the vagina with feet and buttocks at +2 station, and amniotomy was performed. Baby's feet passed through the introitus at 17:29, the hips and buttocks at 17:31, and meconium was passed. 

Baby stayed right sacrum transverse and at 17:32, abdomen and trunk delivered but there was no further descent nor chest crease seen. The mother reached down instinctively to grab but was counseled to keep her "hands off the breech"! 

At 17:34, when the shoulders and arms had not rotated nor spontaneously delivered despite maternal expulsive efforts, squatting, and and another contraction, I grasped the baby by the hips to elevate him and attempt the posterior-anterior rotation, but the arms were still not visible. I was able to reach up behind the left (posterior) shoulder and sweep the extended arm anteriorly across his chest, and after this arm was freed, he rotated 45 degrees towards sacrum anterior. Then, the right (formerly anterior) arm was similarly swept across the infant's chest, and baby was fully rotated to sacrum anterior. Perineum was distended, and his mouth was visible. With a shoulder press, head delivered easily in full flexion with the time of birth 17:35, just three and a half hours after presentation. 

The baby was passed forward through the mother's legs, and was placed on the Operating Room table to be dried and stimulated. Although I was urged to cut the umbilical cord from hovering staff, I encouraged staff to leave him attached as per training I received at the breech conference, and had the mother walk over to the infant warmer, where he (limp and apneic), required oral suctioning and positive pressure ventilation for a few minutes (Apgars 1 & 8). He was vigorous and screaming by five minutes. 

We moved the mother and baby (skin-to-skin) back to the labor unit, and unfortunately she had a prolonged third stage of labor requiring manual removal of the placenta (but without hemorrhage), and there was a small first-degree vaginal outlet laceration repaired easily. The baby (who weighed 3776g, 8 lb 5 oz) nursed extremely well, the couplet was discharged on the date after delivery, and all was well at 6 weeks postpartum! 

While there was a lot of hospital scrutiny and an "incident report" made about my care after this birth, this mama was thrilled to have been "allowed" to have breech vaginal birth, as she's told me that she plans more children (via homebirth) in the near future, and a cesarean scar would have made her dreams less of a safe possibility. It was worth it.

Written by a physician who attended the 2019 Madison Breech Conference