Mary Cronk
(For the benefit of those who were unable to attend the Nottingham meeting, an edited version of Mary's text is given here. At the meeting each slide had its own explanatory note or title, but the text alone gives a good flavour of the skills involved in attending a breech birth.)
This talk, and accompanying slides, is about pregnancies where the baby presents by the breech and what we as midwives can do when the diagnosis is made: "It's a breech!"
We need first of all to ask ourselves, why is this baby presenting this way? It could simply be due to prematurity - many babies present by the breech until 30 weeks or so, and if labour starts before then, we have a breech baby. There is some evidence that very premature babies do better if delivered abdominally. Though there is always the 28 week baby who arrives on the labour ward with the buttocks at the vulva. These babies sometimes don't do too well, and this, of course, is one of the factors which skews the morbidity figures for vaginal breech delivery.
If the pregnancy is at term we need to ask, "Is there any reason for this breech presentation?" Placenta praevia? These don't always bleed antenatally. If the woman has chosen not to have a routine ultrasonic scan, in my opinion this is a situation where selective ultrasound scanning should be strongly advised, as it can be very helpful in excluding placenta praevia or other objects in the pelvis. I have seen fibroids and ovarian cysts being the cause of breech presentation, and we also need to keep in mind the possibility of a bi-cornuate uterus. This does not necessarily exclude a vaginal birth, it depends on the degree, but it is something to check. Has this baby a problem? The fetal anomalies such as hydrocephaly, which can lead to breech presentation, also need to be excluded.
But let us consider the 'normal' woman, at term, with her baby in the breech position, which shows no inclination to turn. I believe that this baby can be born easily and spontaneously, if the labour proceeds spontaneously and easily. Just like a cephalic presentation, if labour progresses and all is well, the woman supported and cared for, the baby will be born. However, there is one major difference. Where in a cephalic presentation, the labour is incoordinate, or lacks progress, augmentation is occasionally justified. I do not believe there is any place for induction or augmentation in a breech labour. If labour does not progress, this woman's body is telling us something, and we should listen. There is no emergency, there is no rush, this labour just isn't progressing, and this baby should be delivered abdominally.
I do not believe there is any place for either trying to push breech babies through pelves with oxytocic drugs, or pulling them through with actively managed breech extractions. I feel that these procedures have contributed to giving vaginal breech delivery poor outcomes and such a bad name. In my experience, if the labour does not progress well spontaneously, the baby needs to be delivered by Caesarean operation.
But what I want to discuss is not the necessary and proper use of surgery to deliver babies, but what many consider unnecessary surgery electively performed simply because of breech presentation. Performed because while we have good surgeons who can do a good CS, they, and we, have forgotten that many breeches can safely be born vaginally. Many midwives have lost, or never been enabled to learn, the skills necessary to assist a woman to give birth when the diagnosis has been made - IT'S A BREECH!
I actually consider breech presentation to be a normal presentation, though not the usual presentation. A normal labour and a spontaneous birth are not to be excluded just because the presenting part is the breech. I emphasise that I am NOT saying that all breeches can or should be born vaginally.
I have attended many breech births. In my experience, if the labour progresses well and spontaneously (and by that I mean spontaneous onset at or around term, contractions which come oftener, last longer and get stronger, a cervix that effaces and dilates, and a presenting part that descends through the pelvis), this baby will be born.
The slides which I use in this presentation were made from photographs taken during the birth of a baby who was born earlier this year. I would have preferred this labour to have taken place in hospital, but for a variety of reasons that did not happen so Bill was born at home. Most of the breech births I attend are at home, but I don't believe that home is always the right place. I actually don't see why women should have to stay at home in order to be able to labour and give birth in peace. But that can be the subject of another talk.
The photographs show the woman in the hands and knees position. I find that this is the best position for mother, baby and midwife. I am aware that some practitioners ask the mother to stand in an upright position for the second stage and the birth of the breech. I am concerned that the placenta may separate too quickly if the woman is upright. It seems to me that if the woman is upright, there may be some traction on the cord/placenta due to gravity just after the birth and in the absence of a contraction. While I do not have any evidence to support this theory, I feel that until I have evidence to refute it, I should not encourage women to give birth to breeches in the upright position. It also seems that women will bend forward and assume the all fours position if not directed by us. We need research to help us in this area. There is also some evidence that with the woman standing, the birth can be too swift and the placenta can separate too quickly. Assisted too much by gravity it can arrive almost on top of the baby's head. So I prefer the all fours position.
Many of the old textbooks showed the lithotomy position for breech births, and recommended lifting the baby up by the heels, over the mother's pubis. Turning the photographs upside down it is obvious that the same manoeuvre happens by gravity with the hands and knees position.
While many breech babies will be born with satisfactory Apgar scores (and this one had an Apgar of about 10.5), some in my experience are slow to breathe spontaneously. They are pink, the heart rate is good, but they often only score 1 on reflexes, 1 on muscle tone and are not breathing spontaneously. It is important to have a bag and mask at hand, or in the hospital situation to have the resuscitaire ready. In my experience, a minute or so with the bag and mask is all that is necessary, and respiration ensues. It is important to have discussed this with the parents beforehand, so that they know that the baby may need help "to get going".
If labour does not progress spontaneously , there is no hurry, no panic. This baby is usually fine, the labour is just going nowhere fast and needs help. The woman and baby are in good condition, transfer when the woman is ready. In the hospital situation, consult when the woman is ready and strongly advise that she have the baby by Caesarean operation.
Don't push a breech through the pelvis with oxtytocic drugs. No inductions, no augmentations
Don't pull a breech baby down through the pelvis - No breech extractions.
Breech babies should birth by propulsion NOT traction. If it isn't coming down - Caesarean operation.
If labour isn't progressing - Caesarean operation
Keep your hands off a breech that is birthing spontaneously - sit on them if necessary!
Be ready to bag and mask.