Breech: bottoms up
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In seeking safety parameters for home breech birth, the following guidelines developed from what I've learned from breech-experienced midwives and doctors.
Protocols, or guidelines for care, are designed to increase safety by reducing the trial and error approach by a lone individual. With protocols, we hope to avoid "wish-midwifery" ("I wish the birth was going to pick up and finish soon, I wish the baby was coming down," etc.) Sometimes a parent or provider decides to continue with a birth that is "outside" the protocols. This may be simply because the protocols can't apply to every single variation of normal birth. But the chance that risk is rising should be acknowledged with increased communication, coverage and/or transport.
I am not suggesting that this is enough information for a family or provider to make complete decisions about a breech birth. Let's be real. Yet, with more parents learning about breech birth on YouTube, a practical, hopefully balanced, approach may be helpful for decision making.
Personal Breech Birth Protocols
Breech Birth Protocols (Oct 2012)
Breech birth can be a lovely variation on a natural process. Labor may be less painful and shorter than with a head-down baby. Risk reduction through a holistic approach looks at individual comparison between home or hospital, and cesarean or vaginal birth with this mom (emotional preparedness, health, pelvis) and baby (presentation, health). Breech vaginal birth can be a conscious choice for parents.
Protocols protect our decisions when fatigue, emotion, birth plans, or inexperience might confuse issues. These breech protocols reflect, in my opinion, best practices for a home breech birth in my area:
- All mothers are assessed for pelvic alignment and myofascial issues. Repeated bodywork increases safety.
- All midwives agree to consultant's parameters and recommendations before, during and immediately after the birth.
- The baby’s head is normal size, and tucked (chin to chest, flexed) or neutral before labor, as noted by palpation (feeling the woman’s abdomen). The mother is informed for assessment by ultrasound or MRI.
- The baby is frank or complete. Footlings are referred. Footling vaginal birth; baby is of no more than average size and the mother continues body work to help her pelvis and womb be optimal for birth.
- Mother’s pelvis size is fine as determined by the previous vaginal birth of an average sized or larger baby, or, by pelvimetry which includes an internal exam of the pelvis. (An MRI is not universally recommended.)
- Safety increases when mothers are both relaxed and free to move during birth. This way, women can respond instinctively to labor and their baby. Helpers and providers behave and speak to nurture the calm.
- Labor begins spontaneously, without induction or augmentation, between 36-42 weeks at home, 34 and 43 in hospital with good fetal activity and growth. Mother doesn’t have hypertension; diabetes or diabetic symptoms. Metabolic stagnation or imbalance? Be more cautious.
- Labor progresses readily without a stall in active labor in the presence of strong contractions. A start and stop pattern in active labor without progress is means for transport. No breaking the water (AROM).
- The mother’s birthing position is physiological. Hands and knees (knee - elbow) is protective.
- The person catching keeps hands-off entirely unless the baby shows need of help to come out. No perineal massage and support, no wrapping the half-born baby in a cloth, no pushing on the mother to stop her sitting on her baby (mom will feel baby and stop herself). Episiotomy is not routine. No one can wipe the mother’s bottom during birth. All this to avoid the mother clenching. Quiet patience is key.
- Monitor appropriately. Fetascope is method of choice, Doppler only when fetascope can’t pick up heart tones. Touch cord only if cord is not visibly pulsing in assessment for emergency intervention.
- 2nd stage can last 4 hrs. After a latent phase early on, the pushing urge takes over and there is descent. If there is no progress after an hour of good pushing we transport for surgery. With slow descent, - the baby is coming down - pushing at home is given 3 hrs. If the hips aren’t then being born, rumping, meaning birth time isn’t imminent, we transport. No discussion. No debate. A cesarean is strongly protective of the baby in this case. [Very experienced midwives and physicians sometimes disagree with these time limits. Other experts follow them precisely. Its one thing to disagree, its another to know the parameters and signs of trouble when the time limits are exceeded.]
- Fundal pressure is preferable to pulling on the baby. No breech extraction.
- The attendant has experience and practices regular simulation of breech birth, knows the maneuvers; newborn resuscitation; delayed cord clamping; and knows techniques and maternal positions to open the pelvic inlet, midpelvis, and outlet. The attendent midwife or doctor practices breech drills with the mother's other midwife/doctor/nurse/midwife apprentice whenever possible.
About 20% of Jane Evan’s planned home breech births finish with cesarean surgery. This is the same percentage for Dr. Frank Louwen’s spontaneous breech births in his Frankfort hospital.
Transparency: Gail helped 18 families hoping for a breech home birth, either as primary, second, or consulting. Two periods of her practice are significant in terms of breech birth, before and after redefining "hands off" to mean no touching the baby unless the baby needs assistance, but hands off until later than the birth of the hips or umbilicus, even until the head is being, or has been born.
From 1983 to 1998, 7 home breech births, two 1sttime moms. Following the launch of Spinning Babies in 1999, 10-years passed before another singleton breech wouldn’t turn. In 2007, one twin breech needed help with head.
Since 2009 (learning that hands-off the breech means no hands on): In Pregnancy, transfer of care for postdates (one primary, one as consult); one induction turned C/S; the other, a hospital breech extraction with NICU and eventual full recovery. In Labor: 4 transports for lack of progress (3 C/S and one vaginal birth). 4 “hands off” home births (2 of which were VBACs); three frank breeches, one was a second twin. 1 incomplete breech needed help for trapped head. 1 needed fundal pressure for the birth of the head (flexion was fine).
In all, 12 of the 18 breech babies were born at home, one needed full resuscitation, none had injuries. Of these, 9 Frank breech; 2 complete breech, 1 incomplete breech. 1 got help freeing a knee braced at the perineum; 3 with extended arms; 4 with extended heads (3 were not hands-off in the new definition). Of 18 breeches, 13 did need some sort of intervention. This does seem a high rate, but only 4 were completely hands-off (until showing signs of needing help). Weight ranged from 6 lbs. 12 oz to 8 lbs, 11 oz. One 5-minute Apgar score was a 2 (out of 10), all others were 8s, 9s, and10's. There were no deaths or injuries. This does not include hospital breech births in which Gail attended and in a few cases provided hands-on help with the actual birth.
Gail is available to be a doula for vaginal breech birth families hiring an obstetrician supporting upright breech birth in the hospital when she is in town.
Gail offers consultations and collaborations for women planning home breech births with midwives. She can be present if she is in town, and everyone agrees to a physiological, completely "hands-off" breech birth approach.
The “hands-off” approach protects baby. “Helping” might startle or restrict the baby and increases risk of complications. Touching the mother might cause her to clench her muscles (Cronk and Evans). Let gravity be the midwife. As long as the cord is full and baby is in the optimal breech position (on the mother’s right to start and rotating to SA as the umbilicus is born) we expect success (Louwen). Hands and knees position is a traditional midwifery position for comfort and to reduce complications or to aid in resolving a complication in either head-down or breech births (Gaskin). This position, best described as "knee-elbow" (on elbows to protect the wrists) has now been well studied and documented and the results will appear shortly in a prestigious medical journal (Daviss and Johnson).
All parents must accept responsibility for their births. Midwives must be transparent with the limits of their experience (Hofer). Physiological breech home birth may not be safer than physiologic breech in the hospital (Daviss). Physiologic breech birth is seldom available in the hospital. Cesarean breech birth may be safer for the baby, especially when physiological breech birth is not practiced and/or there is not a person with gentle and abundant experience present. Vaginal birth is safer for the healthy childbearing woman.
Though breech birth isn’t supported by society, parents do have the right to choose a vaginal breech birth. Breech birth can happen at home.
Recent Breech Births
Only in October 2009, did I learn that “Hands Off the Breech” means absolutely No Touching until we reach for the baby who is dropping to the mattress/floor as the head is being born (Cronk, Evans, Louwen, Rietter). We touch wisely when the arms or head needs help, of course. Even a non-interventionist would pick up a child who falls in a busy street.
In 2010, I was asked to help at six breech births at home. (I'm not counting babies that flipped in pregnancy or planned hospital vaginal breech births).
In five of the six, strong contractions came, but did not bring the baby into the pelvis. We transported to a hospital for surgical birth. I think this number is high because all 5 of these births were in progress for a while before I was called in. If these hadn't already been complicated breeches, the midwives would have been catching and not calling me. If a baby doesn’t make the lateral flexion to engage the presenting part, there is time –and reason- to transport, no part of the baby is born yet, and no part of the baby is coming through the pelvis so a cesarean is a blessing for these babies in approximately 20% of breech labors.
Here is a powerful story from the mother, a homebirth midwife herself, who worked hard for a natural birth at home... I'll let her tell the story. Notice the clues of soft tissue traumas from a previous car accident and previous cesarean, as well as a previous posterior, not unusual history for a breech in a woman who's birthed before. Read Christine's story at Belly Baby Blog.
Another first-time mother had strong labor followed by a stall in contractions. After some hours it became apparent her labor was not going to pick up at home. Her water had been broke. She was also a first time mom, as were the other two transported moms. Our patient and breech-friendly doctor waited for active labor until the parents themselves asked for Pitocin augmentation and an epidural. When pushing began the epidural was turned off -and so was the Pit- the baby was born by a "no-touch" hands and knees position. The cord compressed at the end and the 1- and 5-minute Apgars were low but the ten-minute Apgar was good. Baby was alert and went to mom after brief Positive Pressure Ventilations (resuscitation). The baby didn't have to leave the room. Breastfeeding established slowly over the first couple of days with good weight gain by two weeks.
Only one of the six persistent breech babies in 2010 was born at home. This mother had had a cesarean for breech lie for her first birth and then birthed her nine-pound Occiput Posterior baby vaginally. Her third baby, her home breech baby, was just a bit under 7 pounds. Graciously, they let their video be posted on my blog. She just had her fourth baby at home and he was head down.
One surprise breech at home in 2011, excellent condition. Two home breeches in 2012; one baby needed significant help for the birth of the head but had excellent Apgars (9-10). The other 2012 baby's placenta came early and this baby needed full resuscitation, and is the only breech baby in this group with a low 5-minute Apgar. Early placental separation may be more common with breech position than head down fetal position due to increased uterine involution before the birth of the head ( based on my observations, and on listening to breech experts comments at the 2009 Breech Birth Coalition Conference and subsequent conversations). Both babies who needed help were also born in water and neither showed the breech flexion moves (bicycling / drawing the knees up).
So, hands-off, hands and knees birth might occasionally include complications. Traveling in England, I learned of two more "star-gazing" breeches that were unusually high inside the pelvis after the birth of the shoulders, just like the baby I helped in early 2012. One midwife helping one of these unusually high trapped heads so sadly did not know what to do to flex such a high head and the baby did not live. Please, midwives and doctors, even after many spontaneous breeches, know the details of bringing out the head and the details of the diameters of the pelvis so you know where the head diameter is in relationship to the pelvic diameters so you know how to rotate and flex appropriately for each level of the pelvis (station) in which you may find the head.
Hands and knees maternal position makes your work to rotate and flex the head much easier compared with a mother lying on her back. The pelvis itself has notably larger diameters when the mother is in this position and the sacrum is more mobile. Providers have more room to reach in to assist the baby should such help be necessary.
Hands and knees, or knee-elbow, position allows baby to rotate in harmony with the birth process. The back will rotate towards the mother's front and facilitate good flexion and avoid a posterior breech presentation for the birth of the chin. Even loving “help” might startle or restrict the rotation of the baby who is otherwise rotating and descending fine. The baby needs to rotate. Touch impedes normal rotation by the resistance, even though subtle, of the slight pressure hands make on the baby's rotating fascia (that important membrane awash in cerebral spinal fluid which wraps every muscles and organ and bone of the body)(Phillips). Touching the mother might also cause her to clench her sphincter muscles in response (Evans). Secondly, letting the baby hang in this position later extends the back, likely assisting the Perez’ reflex (Tully) for the shoulders to enter the brim and then the stepping reflex to flex the chin flex when the head is in the midpelvis (coming through the pelvic floor).
Waterbirth in hands and knees position may impede the work of gravity, lengthen second stage, and impede head flexion (based on Evans). Waterbirth in the standing position with one foot lifted to a submerged stool may improve outcomes. A rain barrel, not a birthing tub, is required for this arrangement (Enning).
So we let gravity be the midwife.
Reality check. There is not enough information here or anywhere on this website to extract enough information to guide parents or inexperienced baby catchers towards a safe breech birth. Nor do other's experience justify inexperience.
A little knowledge is a dangerous thing. Some midwives propose 15 or 30 breech births as a starting point, an entry level for breech competency; some doctors say 50 breech births is the number for competency. Some midwives feel that with their level of experience, whatever it is, they offer a better option than mandatory cesarean surgery. (I’m not sure that is always true.) Most of the time, things work out, but when they don't, don't let it be because the first 15 breeches you went to were easy and you didn't know something like that (whatever it was) could happen. Travel to get training. Work with local obstetricians so they can get training.
Some very important aspects of breech safety are not in the books!
We need each other and we need time together to discover just how much we do need each other. Work together for better, safer breech births whenever you can.
We have a moral responsibility to breech babies and their mothers to consider and support physiological breech birth when there seems to be an equal or nearly equal ratio of risk. We have to learn what is the actual risk to birth from the breech position, and also what is the risk to our chosen method of care, because those are often two different answers.
Only when we understand physiological birth and when our skills can deftly protect physiological breech birth will we know if breech vaginal birth is safe. Only when the statistics of harm due to cesarean surgery are commonly reported can we truly compare. Only knowing what is possible with physiological breech birth can we rank any favored breech method on the spectrum of safety with confidence and accuracy. Until the stats on knee-elbow and "hands off" breech protocols are published, the argument against vaginal breech birth is unsteady. And once the stats of providers such as Dr. Louwen's and Dr. Rietter's in Frankfort (knee-elbow "Hands Off" breech births) are published the argument against vaginal breech birth will be unfounded.