Sunday, March 16, 2014

breech

For several years now there has been a growing movement of consumer and professional opinion about the 'best' way to give birth to babies presenting breech. [See Breech Birth ANZ website]  This has come as a small pendulum swing away from the prevailing policy of elective caesarean for breech babies, which was quickly adopted after the Hannah et al (2000) paper on the Term Breech Trial, published in the Lancett.

Another historical grab, before I tell my breech story.

Please see the attached picture of the midwifery exam which I undertook in 1973.   Midwives then were required to have a basic understanding of breech presentations.   I don't want readers to imagine that the work of a midwife (or mother giving birth) was somehow ideal back then - in fact the medicalisation of childbirth, and the dominance of medical 'men' over the more subservient female nursing profession (which included midwifery) was entrenched, as can be seen in the previous post I wrote about this midwifery exam.
click to enlarge


I have always held that if for no other reason than the surprise breech, a midwife attending births needs to be competent in vaginal breech birth (vbb).   My involvement in workshops and education about vaginal breech births, and in the few vbbs I have attended, there has been an emphasis on having obstetricians who lead the cause of promoting vbb.  I have felt uncomfortable with this.  Obstetricians are surgeons.  Midwives need to claim breech births as being well within their scope of practice, as well as the identification of those for whom a vaginal birth is not likely to lead to good outcomes, and being able to refer to and collaborate with obstetricians.

Recently I have had the privilege of attending a birth at home, which turned out to be a surprise (undiagnosed) breech.  As the mother rested with her baby in her arms, she asked me to be sure to write a story about this birth.

Without identifying her, I am pleased to record the birth - through a midwife's eyes, with a midwife's knowledge and decision-making.  I don't consider myself an expert in breech or any other type of birth.  In fact, the only births that I take professional responsibility for are the ones that are very likely to proceed under the mother's and baby's own power, driven by an amazing natural physiological process.  My job is to work in harmony with those natural processes, and to protect, promote and support the natural processes, with the intention to intervene only if illness or complication arise in the birth and nurture of the baby.   In the case of breech births, the most critical period can be the birth of the baby's arms and head, and it is important that all midwives and doctors who take professional responsibility for birth are skilled in the decision making and simple manoeuvers. 

Working as I do, attending births privately usually in the home of the woman giving birth, I have a background knowledge of a mother before she tells me her labour has started.  In this case, I had been midwife for the birth of another child in this family, five years ago, also at home.  Reflections on the previous birth had also been tenderly preserved in my blog.

The first clear indication that this baby was presenting breech was the information that the waters had broken, and were "clear, with a bit of blood, and a black blob."  Labour was strong when I arrived.

I quickly set up my gear: the baby resuscitation box, and oxytocic, syringe and needle, and procedure gloves within reach; the oxygen cylinder connected up and ready if needed; a few clean bath towels to keep baby warm after the birth.   The 'nest' had been prepared - the couch draped with a waterproof cloth, so that the mother could kneel on the couch, facing away from me: an ideal upright position for a breech birth! (and a very reasonable position for an older midwife)

I saw more meconium, and asked the mother if I could examine her internally to confirm the presenting part.  The baby's bottom was 'at spines' - well on the way to being birthed.

I had a decision to make: I spoke simply to the mother and the father.  "The baby is coming, and it will be born bottom first."  I advised them that I did not expect any problems with the birth, but as an extra precaution I would like an ambulance to be called, in case we needed to transfer to hospital.

I would now like to describe each part of the birth as it proceeded.  Contractions were approximately every five minutes. 

As the baby's rump came on view a purple, swollen scrotum also appeared, and a stream of urine was passed from a swollen little penis.  I didn't mention these facts - the mother had work to do, and she would be able to discover her baby's gender in her own time.  From that moment it must have been 10-15 minutes until the birth was completed.  At some stage the 'first response' paramedic arrived, and I confirmed that the birth was going well.  He stood back.

  • Next contraction: a big push and one leg plopped out.
  • Next contraction: a slight rotation of the baby's bottom, and the second leg came down, and a little 'cycling' action of the legs (as though he said, "Thanks Mum, that feels better! Now, what should I do?")
  • Next contraction: the baby's body was born past the navel, then to the nipples, and a large, full blue and white umbilical cord was central.  The body hanging was unsupported - I had not touched him to this point (Hands off the breech!).  I was delighted to see the cord positioned beautifully in the little protected channel between the baby's two breasts that were squeezed together in the tightly stretched vaginal opening.  I gently checked the pulse - about 120, which is good.
  • Next contraction: first arm popped out, a little rotation, then second arm.  Baby's colour reasonable.
  • Next contraction: no progress.  I placed my thumb and fingers over the cord, close to its insertion.  Pulsing had slowed to about 80.  Time to get this little one out and breathing! 
  • With mother in the kneeling position, I placed my right hand in over the baby's chin, and a finger into his mouth.  The left hand went behind the baby 's head to flex it, and the head was born with minimal effort on my part.
  • Baby was initially pale as he lay on the birthing mat under his mother, with his cord intact, as mother turned to look at him, and ask how he was.  I dried him, checked the pulsing of the cord, blew on his face, and before the first minute was up, he had taken a gasp of air.  His colour began to improve.  A few more minutes before he was ready to cry, but all the time he was making the transition from womb to the outside world, there was no reason for me to interfere.
  • By 5 minutes, he was in his mother's arms, pink and strong. 
  • By the next day when I visited them, he had been breastfeeding strongly and effectively, and doing all the things newborn babies are expected to do. He weighed just over 4 kilograms.

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