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.

strength

Following on from the previous post about submission to the spontaneous natural processes of birth, it may appear that I am fence-sitting to now write about strength.

Yet in normal childbirth, strength is the other side of the submission/surrender coin.  There is probably no more emotionally challenging, physically demanding event that ordinary women face in life than the act of giving birth and nurturing a baby.

Readers who are mothers may recall the evenings, just prior to the births of your babies, when you have doubted your strength for the task ahead.  When you have gone to bed hoping the baby doesn't need to be born tonight: "I just don't have the strength!"

(Your midwife might also experience that!)  

Or, in labour, when you experience that overwhelming feeling of weariness.  "How will I have the energy to keep going?"

(Your midwife might recognise that as progress, moving into an altered state of consciousness, when your thinking mind is suppressed, and the more instinctive, hormonally driven activities of your body can be freed up.)


Readers who know the ancient Biblical stories may remember Gideon, who was told by an angel that he had been chosen by God for the (rather daunting) task, to "deliver Israel from the hand of Midian" (Judges 6:14).  Gideon argued that he was not suited for the task, that he came from the weakest clan in Israel, that his family were inconsequential, that he was the least significant person in his family ... .  In response to Gideon's obfuscation, God's angel said "Go in this might of yours and deliver Israel."  The power to achieve was there, even though Gideon continued to duck and dodge and try to avoid the job.

The strength to give birth is a deep inner strength that resides in a woman.  Not in her logical, calculating mind.  Not in her organised, planned day.  But it's within her body, wonderfully made.  And that strength can only be realised when we (the woman and the midwife) submit to the natural physiological processes, and refrain from interrupting these processes without a valid reason.

working in harmony with great natural processes

back-yard bounty

Tomatoes, peaches, figs - summer bounty from our little garden yesterday.  The tomatoes are eaten fresh, and if there are any extras I will blanch and freeze them for later use.  The figs are either eaten fresh, or find their way into Noel's delicious fig jam (which is handed out in small jars to family members and special friends).  The peaches have done well this year, despite the few that have gone to support the local possum population, and the visiting rosella family (see pic below), and the few grubs that find their way into the fruit because we don't spray.  For many years now we have enjoyed poached peaches from the freezer, year-round, as our main dessert fruit.

The natural processes I am referring to include the wind and rain and sun; the soil; and the little group of brown-feathered cleaners (otherwise known as chooks) who maintain a weed-free and regularly fertilised soil wherever they go, but who are quite indiscriminate about what they scratch up and eat.

I work in harmony with these natural processes by choosing places that are exposed to enough sunshine, by watering when there is not enough rain, by adding natural fertilisers and root growth promoters to the soil, and by putting up fences to keep the hens away from plants that they would otherwise destroy.  Some of these measures are even 'interventions', to use language familiar to midwifery.  The end result is a healthy, bountiful harvest.

Two rosellas in a peach tree

We haven't always had good outcomes.  When young plants are not watered, or supported, or given adequate nourishment, or protected from snails, or ...

Sometimes the fruit trees blossom during a rainy spell, and there aren't many bees to do the work of pollination, so not many fruit develop.


The other great natural (even back-yard) process that I seek to work in harmony with, and to intervene carefully into if and when appropriate, is (of course) childbearing. 

It's not enough to simply declare my trust in natural birth; to admire the function of the woman's body; the integration of physical, emotional and hormonal energies that work so marvelously most of the time. 

I, the midwife, function in a similar way to the gardener.  I must understand and respect all the forces, internal and external, that are at play.  I must take measures that will prevent harm from illness (eg pests) or poor nutrition (eg by rotating plants to different garden beds), or physical forces (eg the chookies). 

A midwife colleague challenged me recently when I described a situation when I accompanied a woman in labour to hospital.   After what I considered to be a reasonable period of time had passed, during which the physical progress of the baby into the birth canal was minimal, the woman agreed to a caesarean birth.  I agreed with this decision.

My colleague questioned me sincerely: was I not concerned that the act of going (from home) to hospital could have interfered sufficiently with the labour to CAUSE the obstruction of progress?  Could this woman have given birth 'naturally' if her physiology had not been interfered with?

My answer: No.

I know this because I was there.  This woman's body did all it could, under the natural physiological processes and rules, and it was time to move to Plan B.

The sobering thought, that we must not forget, is that even wonderful natural processes can lead to death and mayhem.  Recognising the points at which timely, and relatively small interventions, such as health promotion through improving diet and activity in pregnancy, or major interventions, such as the need for a caesarean birth, is the work of the midwife.  Just as the back-yard bounty is evidence of many months of careful work, the healthy newborn baby, at the breast of the strong and healthy woman, is evidence of a woman's strength and care of herself and her baby, as well as appropriate maternity care.

Bungee jumping on a short cord

Midwives who attend strong, healthy women for their births are used to seeing mothers give birth unassisted, unmedicated, and with an ecstatic and triumphant cry. We are used to seeing labour establish and progress in a purposeful way. We are used to the power of the birthing process, which takes the woman beyond any limit that she imagined she possessed.

Occasionally we are surprised, even confused.

Especially when the woman has other babies who have all followed the standard 'normal' journey. ... when labour seemed to be established in the morning, so the midwife and the birthing team were summoned. After the greetings, and a cup of tea, and some conversation, and another cup of tea, and talk about what we should do for dinner, and mother lies down because she's feeling tired ... and the fetal head is still floating high and mobile. This mother has given birth previously, and there is nothing apparent in the size or presentation of the baby. Her contractions appear strong when she stands up and walks, but they become weak and infrequent when she rests. 

I could name several women who fit this picture, the most recent last week.  When I looked at the placenta with the mother we commented on the short cord.

The image I have in these 'slow start' multiparous births is that the baby was bungee jumping – pressing down on the cervix when the contraction’s there and mothers upright, and floating away when mother lies down or is not contracting. 

The cord may be short because of entanglement, or simply short.  The distance from the baby's umbilicus to the point of insertion of the placenta on the uterine wall does not change.  The distance between the placenta and the cervix can be reduced by amniotic fluid release, by contractions, and by the mother's position. The critical 'tipping point' will be reached only when that fetal head can dilate the cervix and enter the birth canal.  Then, it's "coming, ready or not!"

This is an article from Midwifery Today 

The Cord and the Strength of Life 
I have observed babies being birthed with the placenta detached and following right behind them for over 20 years. Throughout that time I have kept mental notes, observing, recording, pondering.

Then one day, finally, it all added up. The explanation is a short umbilical cord, a phenomenon that requires us to allow time for the baby, the cord and the placenta to descend slowly through the birth canal, in the wisdom of nature, for a healthy and natural birth. My first encounter with a short cord began with a false labor. The mother thought this was the day. She called me, and I stayed with her until labor ceased several hours later. The mother and baby were fine. There was no good reason to intervene, despite the fact that she was multiparous with 4 cm dilation and the baby was not engaged. I warned her of possible cord prolapse and asked her to be aware of her baby’s activity. A couple of days later she called me again. The birth was very quick and the baby was born with shoulders and body entangled in a barely pulsing cord. The newborn had some blood on his bottom because the placenta had separated at the time of birth. He required stimulation and oxygen, but it was all resolved quickly and within the realm of the normal. I have watched vigilantly for short cords ever since.

Two weeks ago, some twenty years after I noticed it for the first time, it happened again. This time it was with a mother who had had three babies. The last two had been very fast. She had always had mild contractions before going into labor, but this time she had more. As she was multiparous, I initially did not think there was a problem. About ten days after her due date I thought she was going to have her baby. Her uterus looked so low that it was “by her knees.” But it did not happen. “Something is strange,” I thought while checking her. I sighed. The baby was floating, even though the uterus was very low. It seemed the baby ought to be engaged, but he was not. I then listened to the baby’s heart tones and found normal heart tones but with minimal decelerations. The heart tones were at 140 and descended to 126 or so in the middle of mild contractions. I listened to the heart tones every three days. The mother was noticing movement. We decided she should try to induce herself through nipple stimulation and an enema of medicinal plants. I gave her an exam in which I stimulated the opening of the cervix. The contractions began, and she dilated another centimeter easily. The heart tones remained within normal ranges.

... However, everything stopped after a few hours. The mother was already at 5 cm, but the cervix remained inflexible. Although the baby’s head was in a good position, he was not engaged, and therefore was not exerting pressure. After the second attempt I sat down to think. I concluded that we were dealing with a short cord. In any other situation a vaginal exam, some nipple stimulation and an enema would have produced labor.

But beyond the mother and me, the wisdom lies between the baby, the cord, the placenta and the uterus. You can confirm that you are dealing with a short umbilical cord by observing the abdomen. During contractions, and sometimes without them, the baby appears engaged, even though a vaginal exam reveals that she is floating. It is important to avoid interventions that force the mother’s body to enter the birth process before the placenta and uterus are ready. The fundus has to descend with the baby. This process takes time. Contractions that cease despite dilation of 2–5 cm in a mother with previous fast births and no other complications indicate the possible existence of a short cord. Observation without intervention is important in these cases. 

—  Marina Alzugaray Excerpted from “The Cord and the Strength of Life,” Midwifery Today, Issue 70

spontaneous birthing

There was no acceptable alternative; no short-cut or easy way.  The labour had established.
The young mother struggled with every surge of uterine activity.  "I can't do it!  I am too tired!", she cried in English, then lots more in another language.
If one of us had been able to step in as proxy; to labour and give birth, or even to do some of the work, and lessen her load, we would have.  Surely it's unfair that the woman has to do it all?

Each time I witness the massive effort that culminates in the unmedicated, unassisted birth of a baby - and particularly a first baby - I am in awe.   The journey that can have many unpredictable and unexpected turns in the path; many forks in the road.  At each decision point, only one way can be taken.  Is this the best way?

As midwife, I hear many voices.  The mother's body, the baby's body, my own mind, the voice of professional and scientific knowledge, and the words of others participating in the birthing journey.

When the mother's mind says "I can't do it! I'm too tired!" I can't just block my ears.

I ask, what does her body tell me?

There is power in these contractions, and I have seen progress over time.
There is strength in this young body.  Her pulse rate is steady and strong.
There is quietness in the moments of resting between contractions.
Is mother well?  At present, yes.

I know we can continue.

I ask, what does her baby's body tell me?

The baby's heart rate is strong and steady.
The contractions, although strong, do not bring any sign of distress in the baby.
The baby's station is progressing with time.
Is baby well?  At present, yes.

I know we can continue.

I ask, what does my own mind tell me?

It's the middle of the night, and my mind is also weary.
I hear the cries.  I know that she is sleep-deprived.
I seek to guide this girl who is being transformed into a mother through this rough terrain.

I will not interrupt or interfere with the amazing metamorphosis; the life-giving struggle that we are witnessing.

I ask, what does professional and scientific knowledge tell me?

Simply this: that there is no safer or more appropriate way for this baby to be brought into the world, than for the midwife to work in harmony with natural physiological processes in labour and birth.
That this woman's body is wonderfully made, that this baby's body is uniquely suited to this mother, and that the process of birth is so much more than delivery of a child from the womb to the outside world.
That the transitions which must take place shortly are best supported in strong, unmedicated birthing.

I know we can continue.

I ask, what do the others - the husband, the friend, the student - tell me?

We are working together, and I am responsible for so much.  These members of the team are looking to me for encouragement and strength.  They do not have the years of life experience that I have, and they are quietly learning to harmonise their actions with those of the labouring woman.

I know we can continue.



We moved to the birthing pool.  The pushing had been ineffective, and the voice "I can't do it, I'm too tired!" was becoming more persistent.

Then, as an expulsive urge was about to go, I saw some fine, thick black hair peep out between the labia, then disappear again.

"I can tell you what colour your baby's hair is" I said.  "Black."

We all laughed.  Babies from their people group all have black hair.


I don't know when the young mother realised that she actually could give birth, that she was giving birth.  But I know and hold onto the look of utter amazement and satisfaction as she took her child into her arms.