Primip breech birth in South Sudan

By Kristine Lauria, CPM, of Médecins Sans Frontières. Kristine is currently working in a refugee camp in South Sudan, serving a population of around 100,000 people. Her clinic takes in all of the complex and/or complicated maternity cases: preterm, breech, multiples, high-risk pregnancies, etc. There is one general surgeon on call to do cesarean sections, otherwise Kristine and the other staff manage all of the births. 

Middle of the night breech, my favorite and this one was particularly beautiful. First time mom, 18 years old, came in complete and the staff called me. When I arrived, I had to bypass a big puddle of amniotic fluid and fresh meconium - the telltale sign of a breech about to be born. The mother was already on the table. I prefer upright physiological breech but the staff is so accustomed to putting everyone on the table to examine them, they don't think twice. 

I could see the baby had already descended and the mother looked like she really didn't want to go anywhere, so I just kept her there. I believe supine breech to be more challenging in general (not always) because of the pressure on the sacrum and how the baby maneuvers through. It often calls for more intervention than an upright breech. Because I am here to teach staff, it provides the opportunity to show them maneuvers I would not be able to otherwise. It is also good practice for me. Nevertheless, I made sure the table back was up high so she was almost in a squatting position.

I arrived in maternity at 2:12. I left by 2:47.

The mother pushed beautifully. If I had not known she was a primip, I would not have guessed by her demeanor. A foot and a butt cheek emerged at the same time with one push. And then on the next push, a foot and a testicle and then the next butt cheek. At this point it looked like the baby was in a crouching position, so feet and buttocks out to the hips, all facing transverse like the majority of complete breeches. When I see a complete like this that doesn't bring its legs down right away, I know the head will come easily because the diameter of all these things coming through the pelvis is quite wide. This told me everything I needed to know about how things would go.

On the next push, the baby then started to emerge, first to the umbilicus and then it spiraled beautifully into an anterior position. And then, as it came out past the umbilicus, it continued to rotate past anterior just a bit and released one shoulder, then the arm. Then it spiraled back to anterior and again just a little past to bring the other shoulder and arm down. It was like watching a ballet. It was all done as though it were in slow motion and it was just so graceful. I was in awe. After all these years, birth never fails to impress and amaze me.

The baby was born to the head and I could easily see the nape of the neck. I asked her to give a gentle push and the baby came right out into my hands. I never touched it until then.

The baby weighed 3.1kg. The perineum was intact. It was 1 minute and 30 seconds from bitrochanteric diameter to birth. The Apgar was 9/10.

For me, this marked my 500th breech birth. I have attended 18 breeches here since my arrival. Not all have been term but the ones that have been all had very good outcomes. All but 3 have been physiological breech, either hands and knees, squatting, kneeling or standing - always the mothers choice. Of those 18, I have had to do only a few maneuvers, including, Louwen, Løvset, modified Prague, shoulder press, and Ritgen. Also one breech extraction for a second twin that was transverse and would not rotate to either breech or vertex, and I used Burns-Marshall with that one as well.

When the mother is upright, I always prefer Ritgen to release the head if should press does not work. It is far less invasive than Mauriceau-Smellie-Veit (MSV), which I used frequently in the past and still do with supine breech because Ritgen is close to impossible when the mother is on her back. I have yet to have Ritgen not work for an upright breech. I have also used it a few times with shoulder dystocia.

If you want to learn more about the different maneuvers mentioned here, the very best resource on all things breech is Breech Without Borders. There you can find a wealth of videos, handouts, studies, lectures, as well as in depth courses for care providers, parents and doulas. Breech Without Borders have made it their mission to reteach breech and the impact has reached around the globe. breechwithoutborders.org/maneuvers/