By Joy Horner RM. RGN. Dip H.Ed.
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From breeches meaning trousers.
So breech presentation can be feet, knees or
bottom-first entry into the world.
25% at 28 weeks weeks
3-4% at term
We miss about 30% of breech presentations on
palpation.
So we need the skills to attend any woman
with a breech presenting baby.
Normal breech birth
“A breech presentation is normal, it is just not typical.
This is really important to remember: breech is not an
abnormality. And a normal labour and a spontaneous
birth are not excluded just because the presenting part
is breech (although not all breeches can or should be
born vaginally).
Even though many babies presenting by the breech can
and should be born normally, caesarean section is
currently the most common mode of delivery
(irrespective of clinical indicators). However, the fact
that caesarian section has become the accepted practice
for breech births does not mean that it is the only
acceptable option”.
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Cord prolapse
Head entrapment more with preterm births
Cord compression
Injury to brain or skull if sudden
decompression – more in pre term birth
Injury to skull/ spinal cord due to positioning
during delivery of the after coming head
Damage to internal organs
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Other contraindications to vaginal birth
(e.g. Placenta praevia, compromised fetal
condition).
clinically inadequate pelvis.
footling or kneeling breech presentation.
large baby (larger than 3800 g).
growth-restricted baby (smaller than
2000g).
hyperextended fetal neck in labour.
lack of presence of a clinician trained in
vaginal breech delivery.
previous caesarean section. (RCOG, 2006)
Spontaneous onset anytime after about the 37th week.
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No augmentation if labour is slow or there is poor progress - caesarean
section.
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Mother encouraged to assume positions of choice during the first stage.
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Fetal heart listened to frequently with a Pinard stethoscope or a hand held
Doppler Sonic aid.
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Food and drink encouraged, but remembering that women in strong
progressing labour rarely want to eat.
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Membranes not ruptured artificially.
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Vaginal examinations restricted to avoid accidental rupturing of the
membranes.
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If, and when spontaneous rupture occurs conduct a vaginal examination as
soon as possible.
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Second stage by maternal propulsion and spontaneous expulsive efforts
guided by the attendant if judged appropriate.
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Mother encouraged to be in an all-fours position.
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No routine episiotomy.
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Third stage without chemical or mechanical assistance, usually managed
according to woman's wishes.
(Cronk 1988)
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Since the Term Breech Trial (TBT. Also known as the Hannah trial) in 2000
caesarean section has been commonly recommended for women carrying a
breech presenting baby. It appeared to indicate caesarean birth was safer
for babies.
A follow up study 4 years later found that at 2 years of age there were
almost identical risks of death or neurodevelopmental delay in children.
PREMODA study 2006 Goffinet et al produced a study 4 times larger than
the term breech trial. It showed no difference in perinatal mortality or
serious neonatal morbidity between planned trial of labour and planned
caesarean groups.
If a breech presentation is diagnosed in pregnancy in the UK, ECV is
offered. If baby does not turn then caesarean, or trial of vaginal breech
“delivery” are given as options. Some women do not wish their birth to be
controlled and trust the power of their own body to be able to give birth.
Some breeches are undiagnosed until labour.
Unfortunately, since the publication of the flawed Term Breech Trial,
midwives and doctors have had less chance to attend spontaneous breech
births, so clinical skills have been lost. Those midwives who’ve been
practicing for many years before the TBT have learnt the skills to assist
women birth their breech presenting babies. Such a midwife is my mentor,
Mary Cronk.
The Term Breech Trial set out to test the safety of two
treatments: ‘caesarean section’ and ‘vaginal breech birth.’
The researchers in the Term Breech Trial used the word
‘vaginal breech birth’ but the concept that they have of
what that phrase is very different to the concept that
midwives and some obstetricians, particularly Northern
European ones, hold for the same phrase.
The safety of spontaneous vaginal breech birth was not
tested by the Term Breech Trial and therefore, the results
of the trial cannot be applied to women having
spontaneous vaginal breech births attended by skilled and
experienced maternity care providers. (Fahey, Katherine
2011)
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Unbiased information sharing
Time to discuss options.
Explain and offer ECV
Place of breech birth needs access to theatres
Skilled staff availability?
Maternal choice not coersion.
MATERNAL
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Abnormality of uterus,
septum/fibroids.
Oligo/polyhydramnios
Placenta previa.
Family history
Primip/strong
abdominal muscles.
FETAL
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Prematurity.
Multiple pregnancy.
Hydrocephalus, spina
bifeda.
Brittle bones, downs
syndrome.
Tight/short cord.
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60-70% of term breeches
Risk of cord prolapse
0.5% (cephalic 0.4%)
Cord can get compressed
between legs an
abdomen.
More common in
primips with strong
muscles (Frye 2004)
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10% of all breeches
Cord prolapse risk 4-6%
(Frye 2004).
A recent observational
study of non-frank breech
presentations found a
high rate of cord prolapse
(5.6%) but no increase in
abnormal labour nor
impaired perinatal
outcome. (RCOG).
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29% of all breeches with 1020% being footlings. Kneeling
rarest at 5% of term breeches.
More common with pre term
birth.
Baby has more manoeuvring
ability as body not splinted by
legs.
Risk of cord prolapse 15-18%
if footling, more commonly in
pre-term or small babies.
Less risk of cord compression if
cord prolapse.
Early rupture of membranes
more likely.(Frye 2004).
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ECV
Moxabustion
Accupuncture
Breech tilt positions
rebozo
Hypnosis
Handstands in pool
Cold on fundus
Shining light/playing music near symphysis
pubis.
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It’s important women choose their own birthing position to best birth
their babies. Most women naturally adopt a kneeling or on all fours
position. Maybe to feel grounded.
“The 28 percent increase in the pelvic outlet – 1cm in the
transverse diameter and 2cm in the anterior-posterior diameter
of active birthing is greater than that which is normally
achieved by symphysiotomy, which, primarily, increases the
transverse diameters by 1cm.” (Banks, 2007)
“I find that this is the best position for mother, baby and
midwife. Gravity is doing what many of the old textbooks tell
the operator to do; lifting the baby up by the heels, over the
mothers pubis when she is in the lithotomy position, on hands
and knees it happens by gravity.” (Cronk 2012)
Less need for manoeuvres as illustrated by Frank Louwen’s
work. Therefore less potential to harm the breech baby.
Other upright positions?
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Ve’s?
Continual or intermittant monitoring?
Palpation/descent of presenting part
Observing pattern of labour
Maternal observations
Documentation
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Monitor fetal heart frequently
Monitor descent of presenting part. Progress
with every contraction.
If no progress prepare to assist.
Observe colour and tone of baby and fullness
of cord.
Document times of presenting part visible,
rumping, legs, arms and head born.
Document any manouvers needed and
resussitation.
Birth Joy Ltd 2007 ©
Birth Joy Ltd 2007 ©
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Breech babies often suffer a short period of
cord compression during the second stage and
have lower Apgar scores.
Be prepared to resuscitate with cord intact if
possible.
Explain to parents what is happening and why.
WOMAN A
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Primip
Age 27
Healthy BMI
Born breech herself
Baby extended breech
Failed ECV
Planned homebirth
WOMAN B
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Primip
Age 25
Healthy BMI
Baby extended breech
No ECV
Planned homebirth
WOMAN A
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Spontaneous onset at
term
SROM
1st stage good progress
No pain relief
Intermittent
monitoring, no
decelerations.
2nd stage fast after
presenting part visible.
WOMAN B
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Spontaneous onset at term
SROM
1st stage good progress
No pain relief
Intermittent monitoring,
no decelerations
2nd stage slow progress
after presenting part
visible.
WOMAN A
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No pushing
Footling presentation
Proceeded rapidly
No manouvers needed
Asked to push for head
Stargazer.
5 rescue breaths
apgars
WOMAN B
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Spontaneous pushing
Baby birthed bottom and
legs slowly
Cord compressed between
legs and body.
Arms delivered lovesetts
Head deflexed, caught on
sacral promontory, unable
to reach for mauricaeucronk.
Other manoeuvres
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The Mauriceau-Smellie-Veit
manoeuvre should be
considered, if necessary,
displacing the head upwards
and rotating to the oblique
diameter to facilitate
engagement.
Easily performed on all fours
Suprapubic pressure by an
assistant can be used to assist
flexion of the head (mother in
supine position)
WOMAN AND BABY A
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2nd degree tear.
Bloodloss.
Feeding problems.
Baby eventually fully
breastfed.
No residual problems
WOMAN AND BABY B
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Episiotomy.
Baby transferred for
cooling.
Home fully breastfed
day 10.
No residual problems.
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At this point there is
compression of the umbilical
cord between head and
maternal pelvis.
Head usually in flexed position
and flexes more as baby lifts it’s
legs if in good condition.
Monitor colour and tone of
baby and fullness of cord, and
be ready to control speed of
birth of head.
Perform manoeuvres
immediately - if baby in poor
condition.
Birth Joy Ltd 2010 ©
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If baby in good condition, good tone, full cord heart rate >100
progress should resume with baby’s leg flexion to flex head.
If baby in poor condition, colour pale, heart rate <100, limp
DO NOT REMAIN HANDS OFF!
Attempt to flex head with mother on all fours (Mauricaeu
Cronk manouver, ask mother to push
Being upright tightens abdominal muscles and aids flexion.
Frye 2004
Lay mother down to manually flex head with suprapubic
pressure. (RCOG 2006)
Lift torso and rotate to bring head into the transverse diameter
if stuck at the brim (explained to me by Gail Tully 2012)
Positions which open the pelvis may be useful eg. Supported
squat.
DO NOT APPLY TRACTION.
Shawn Walker breech birth network
In the seventh Annual Report of the Confidential Enquiry into Stillbirth and Deaths in Infancy,
the most avoidable factor in causing breech stillbirths and death among breech babies was
suboptimal care in labour. In cases where the cardiotocograph was available for review, there
was clinical evidence of hypoxia in all but one case before delivery and delays in staff response to
fetal compromise occurred in nearly 75% of cases. These delays ranged from 30 minutes to 10
hours.
Consultants were informed in only 50% of these cases before delivery. Clinical inexperience at
the time of delivery exacerbated the risk for an already hypoxic baby in some cases. Trauma
was the sole cause of death in only one case. Any woman who gives birth vaginally with
breech presentation should be cared for by an attendant with suitable experience. Good
communication between practitioners is important.
In recent years in the UK, there has been a reduced number of vaginal breech deliveries managed
by an increased number of trainees. Alternative methods of training need to be introduced
(such as videos, models and scenario teaching). Simulation training has been shown to
improve performance in the management of a simulated vaginal breech delivery (CNST
criterion 5.2.1). A video-recorded teaching aid on vaginal breech delivery and symphysiotomy is
available in the World Health Organization Reproductive Health Library (available from
rhl@who.int; www.rhlibrary.com). (RCOG Guideline No. 20b)
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The most important thing to remember in spontaneous
breech birth is that the labour should progress well and
baby’s condition should be monitored frequently.
Skilled, calm confident birth attendants are needed.
The midwife (and doctor if present) should practice
watchful, hands-off waiting, unless help is clearly
required.
This may be due to slow progress (eg. no advance with
the next contraction), or poor tone in the baby, which
prevents him from helping himself to be born, indicating
the need to achieve a swift delivery.
Hands off the breech does not mean fail to help if help is
needed!
“Remember women’s bodies don’t go wrong. Sometimes
some labours need some help” Mary Cronk 2012
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Don't push a breech through the pelvis with oxytocic
drugs. No inductions, no augmentations
Don't pull a breech baby down through the pelvis - No
breech extractions.
Consider whether vaginal examination is necessary.
If labour isn't progressing in the first stage consider the
need for Caesarean section.
Keep your hands off a breech that is birthing
spontaneously - sit on them if necessary!
Breech babies should birth by maternal effort NOT
traction. If any delay in the second stage consider
manoeuvres to facilitate delivery, or caesarean.
Be ready to resuscitate baby if needed.
Practice breech mechanisms so you can help if needed.
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Volunteering to support women planning
vaginal breech birth.
Teaching other midwives and doulas how to
support women in breech birth choices.
Write articles about normal breech birth.
Join the Breech Birth Network at
www.breechbirth.org.uk
Possible NHS breech clinics offering women
informed choice, scans and ECV.
ACOG 2010. Mode of Term Singleton Breech Delivery ACOG committee opinion Number
340, July 2006 Reaffirmed 2010 (Replaces No. 265, December 2001).
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Banks M, 2001 Breech birth beyond the term breech trial www.birthspirit.co.nz
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Cronk M, 1998. Hands off the breech. Practicing Midwife 1 (6), 13-15.
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Evans J, 2005. Breech Birth – What are my options? AIMS Press.
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Evans J, February 2012. Understanding physiological breech birth. Essentially MIDIRS,
Volume 3, Number 2.
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Evans J, March 2012. The Last Piece in the Breech Birth Jigsaw? Essentially MIDIRS,
Volume 3, Number 3.
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Fahey. K Do the findings of the Term Breech Trial apply to spontaneous breech birth?
Women and Birth Volume 24, Issue 1 , Pages 1-2, March 2011.
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Frye A, 2004. Holistic Midwifery, Vol. II: Care of the mother and baby from the onset of labor
through the first hours after birth. Portland: Labrys Press.
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Hannah ME, HannahWJ 2000 planned caesarean section versus planned vaginal birth for
breech presentation at term: a randomised multicentre trial. Lancet, 356 (9239):1375-1383.
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Kotaska A, et al, 2009. Vaginal delivery of breech presentation. SOGC Clinical Practice
Guideline No. 226. J Obstet Gynaecol Can 31(6), 557–66.
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Royal College of Obstetricians and Gynaecologists, 2006. The Management of Breech
Presentation, Green-top Guideline No. 20b. London: RCOG. Volume 15 number 3 march 2012.
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Walker S 2012. Breech birth: an unusual Normal. The practicing midwife, volume 15, number
3.
On line resources
http://www.aims.org.uk/Journal/Vol10No3/handOffbreech.htm accessed 09/10/12
http://www.breechbirth.org.uk/ accessed 3/11/12
http://www.jpaget.nhs.uk/section.php?id=22331 accessed 01/10/12
http://www.rcmnormalbirth.org.uk/stories/do-as-you-would-be-done-by/normal-breech-birth
accessed 09/10/12
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