From MIDWIFERY MATTERS, Issue No. 78, Autumn 1998
Lynda Cantillon
I looked after Elizabeth all the way through her antenatal period. This was her third baby, the first two (Lily 5yrs and Tanya 4yrs) had been delivered at home in Switzerland. They had both been straightforward, uneventful pregnancies with no postnatal problems.
Elizabeth struck me as a quietly confident, instinctive woman from the outset; full of practical common sense, particularly about her family's health. She explained how difficult it had been, going through the process of obtaining home births in her home country. This reinforced my assessment of Elizabeth's inner strength and beliefs. On meeting her husband David, and getting to know the couple over the antenatal period it was very obvious that they shared the same philosophy of birth. Had this not been the case I would have felt a lot more anxious about forthcoming events.
Around the 30th week the baby was lying in the breech position. No one expected it to remain so, however, by 36 weeks there was no change and so we began the process of encouraging the baby to turn, and meeting with doctors to discuss birth options. Everything to date had been normal. The 36 week scan showed the position to be a fully extended breech and not engaged. At my suggestion Elizabeth was keen to try acupuncture and also cranial osteopathy, aware that the baby's extended position gave it less chance of turning. She tried several other tactics, including massaging her abdomen when in the bath and swimming on a regular basis. Nothing would turn this baby. We discussed the birth with both her consultants and with the Supervisor of Midwives. The risks attached to vaginal breech delivery, especially at home, were more than highlighted. These were not news to her - we had discussed them at length beforehand.
Elizabeth went home to think and talk with David while we all waited for their decision. No surprise really - she wanted to remain at home. David supported her decision without question and I had reassured her that I would support her whatever she decided.
I must admit that at this stage, I personally did not feel well supported. From colleagues there was far too much of: "You poor soul", "I'm sure you'll be glad when it's all over!"; even "I pray for you".
There was plenty of well-meaning sympathy but not support. Maybe I'm paranoid, but I did feel that the Supervisor thought that I had been a little lenient in allowing Elizabeth the freedom to make her own decision; I hadn't clamped down hard enough on the 'risks'. Phrases such as 'unbiased information', 'non-judgmental', 'parent's advocate' and 'informed choice' kept flashing through my mind - where was all of that? In the face of obstetric risk, do these principles evaporate and become inconsequential?
At around 37 weeks, one of the local GPs volunteered to assist at the delivery - at the last minute, his wife was to be involved as second midwife as she works with my team - and this was the one real supportive gesture made. Talking about management tactics to an independent midwife who had delivered breech babies gave me added confidence. But it was the parents themselves who made me feel positive.. If I had felt any doubts about their reasons and rationale for going ahead with home delivery then my attitude might have been very different.
I read the books on breech presentation, I dreamt about it, any spare moment I had my mind slipped back to breech delivery, so much so that I feel I could almost have done it in my sleep! The weeks went by 37, 38, 39, 40... I remained on-call throughout this time.
At term plus five days. Elizabeth went into labour. She phoned me at 10 am to say that contractions were very irregular, her membranes were still intact and she would page me when she felt she was progressing. Around 3 pm she called to say that contractions were strong and more regular - she was coping and about to get into the bath.
When I arrived about half an hour later, Elizabeth was in the bath and we both agreed it would be a good idea to check dilatation. She remained in the bath, her cervix was 3-4 cm dilated and the membranes were bulging. I contacted the GP and second midwife to inform them that labour had started, although Elizabeth and David did not want anyone else present until necessary. I also let my Supervisor of Midwives know the situation. One hour later Elizabeth's behaviour indicated that she was fully dilated and she had urges to push, a vaginal examination confirmed full dilatation. She got out of the water, still coping extremely well, breathing through strong contractions. I encouraged her to get into the knee/chest position while I phoned and asked my backup to come. This took only minutes.
We had discussed positions beforehand and Elizabeth found it comfortable kneeling with one leg up while leaning over on to David's lap. Pushing became instinctive. The membranes were expelled with a few pushes forming the shape of a balloon which burst gently and was all caught in the birth stool tray (very neat!) and this was followed instantaneously by the buttocks. I had to bite back the urge to say "It's a girl!".
As I watched, the extended legs slowly opened towards me and without any help released themselves. Elizabeth was pushing well and coping as I talked her through what was happening. Gradually the navel emerged showing the cord to be pulsating and free. Eventually the armpits followed with arms extended. I placed finger and thumb on each hip and sacrum and performed Lovset's manoeuvre; releasing both arms. Again I left the body to hang, a strange sight, as the baby at this stage performed slight body movements in this suspended position.
Aiming to flex and slow down the delivery of the head, I suggested that Elizabeth go on to all fours (forward flexion of the pelvis can assist flexion of the head). Unfortunately this terminated the contractions altogether, so she got back into her previous position. As contractions re-established I delivered the head using the Mauriceau-Smellie-Veit method. The head eased out very gently and the baby was born in excellent condition. Elizabeth turned on one knee and took hold of her baby. It was all over.
I couldn't believe how simple it had been - I hardly did anything. Elizabeth was amazing and so was David. He had remained so quiet, yet reassuring throughout. The whole labour and delivery had been very calm and Lily and Tanya who were downstairs watching television had not even noticed their sister Harriet's arrival into the world.
I had not even noticed that mv backup hadn't arrived. Caught in rush hour traffic, they missed the birth - but it was lovely to see them all the same. Harriet breastfed almost immediately. The placenta took about one and a half hours to deliver itself. Blood loss was minimal and Elizabeth's perineum was intact.
In retrospect, when in the company of the parents and involved in the actual birth I felt no anxiety - I suppose I was too preoccupied to waste time on what might happen. In my own mind I had gone over the negative aspects well in advance and had the scenario been different, I was mentally prepared.
When a couple like this have knowledge of all the facts and make what is obviously an informed decision, having rationalised both the information given and their personal feelings and beliefs towards the birth of their child, I feel it is only right that we as midwives respect this and detach our own personal viewpoints and emotions from the case. We are only the advocates, not the judge.
Speaking from the midwife's point of view, once the decision is made by the parents, the midwife needs constructive support. 'Support' is all too easily confused with 'reassurance'; unless support takes the form of balanced practical advice, with questions answered honestly and fairly, it is of little value and can be detrimental. With hindsight, I would have benefited from an "ad hoc" workshop, learning from speakers who have practical experience of normal breech deliveries.
One midwife afterwards commented "you were very lucky!" But surely that could be said after every delivery. Nature always has the upper hand - go along with nature and you need less luck! For me this proved to be a learning experience from start to finish, and one which I found extremely rewarding, especially as all goals were achieved: The safe delivery of a healthy baby with the parents informed and in control throughout; no unnecessary interventions; maximum privacy; and home delivery.
Lynda Cantillon
Breech Birth - discussions from our UK Midwifery email group
Assisted Birth - not Assisted Delivery by Debby Gould
Midwifery Skills needed for Breech Birth by Mary Cronk
Commentary on the Term Breech Trial, by Maggie Banks, midwife and author of "Breech Birth Woman-Wise".
AH updated 16 September 1999