Advice for primip breeches (including dropped feet)

Q&A with Kristine Lauria, CPM, of Médecins Sans Frontières. 

In response to a question about outcomes in breech births for primips with a dropped foot:

I have attended many primip breeches of all types. I have not noticed anything significant in terms of outcome other than the need for CS slightly more often, but again about the same as with a cephalic presentation. In some ways primip breeches are a little bit easier because the mother doesn't know what to expect from birth in general, so it doesn't feel any different to her because she doesn't know what it feels like to birth a cephalic baby. 

In terms of a dropped foot or feet, there's not really any difference that I have noted with a primip or a multip. Maybe just a little bit longer labor, again just like with a cephalic baby. I never am concerned about feet coming first at all. I know a lot of people are and it's very disconcerting for some providers to see a foot or feet dangling outside without further descent for sometimes quite a while. And that's just because the mother doesn't have an urge to push because the rest of the baby is not down far enough, most likely because the cervix hasn't dilated completely. So it is imperative that we are patient and wait. It's perfectly fine for those little feet to be sitting there for as long as they need to. As long as the labor continues and the fetal heart rate is good, there is no cause for concern. 

I had to explain to the midwives in the clinic where I work to not panic about that because, as I explained to them, the feet don't breathe! What are you worried about? It's fine! But I have to remind myself that they are not used to seeing things like that and just being patient. If you think by seeing the feet that you should be seeing the rest of the body following fairly soon after, this would be incorrect. It is not good to push the labor in any kind of way. Just be patient, otherwise that is where you're going to run into trouble. Because that's where we get a cervix that's not completely dilated and then things start getting trapped. It can be tricky if you're not used to it.

So generally a lot of the problems with the bad reputation that "footlings" have gotten are mostly because practitioners get frightened, try to push things or do the wrong thing, and then complicate the birth. That's where you get the bad outcomes.

Q: Are there any signs that would indicate the need for you to intervene, assuming the heart rate is fine? For example, the colour of the foot or something else?

Nope, just the fetal heart rate. In all likelihood the foot or feet are going to be some version of blue. Do not let this concern you. It's perfectly normal. The baby's feet will be bruised for a few days after birth. It's really totally fine. Sometimes their little bum is also bruised after birth if they present that way. A lot of the time you will see the baby even moving its little foot and that's a very good sign. But if it doesn't, that's not a bad sign. As long as the labor is continuing and the baby sounds fine, all is well. Sometimes at that point just before complete dilation and a descent of the baby and urge to push, there will be a little lull in contractions. It's fine to wait through this. And again as long as the baby's heart rate is fine, you can just wait until the contractions pick back up. This doesn't always happen, but it's not at all uncommon if it does. 

Q: So, you would intervene if baby's heart rate is altered, or loses muscular tone, right?

Yes, if the heart rate decreases and doesn't come back up, then you would likely want to intervene. But that's not likely to happen until the baby's starting to descend more. It certainly could happen if there is some cord compression somewhere, and in that case there may not be a lot you can do other than C-section if the baby's not ready to be born because the cervix isn't fully dilated yet. But I haven't really seen this happen. You won't notice any muscle tone loss until the baby's really descending. Then, if you don't see any tummy crunches or things like that, you may want to intervene depending on how quickly everything's happening to begin with.

Honestly, the women I've referred for C-section for breech have primarily been primips with complete presentations. I have seen the baby get wedged in the pelvis and just not descend any further. We wait and there just doesn't seem to ever be any kind of urge to push. I can feel the bum and the feet, legs and everything up there. But there is just some arrest somewhere. Fetal heart rate is fine, everything is good--it's just not happening. And sometimes at this point the contractions slow a little bit as well as if to say, this isn't going anywhere. So I guess what I'm trying to say is: sometimes the babies with the foot drop are doing themselves a little service. Because all those parts folded up wedged in there can be quite a lot to get through the pelvis sometimes. When I see feet or even just one foot, I know the baby will be coming eventually. I have not transferred anyone for a C-section when I've had feet presenting.