Breech Basics Handouts Breech Basics With Gail Tully, CPM Review upright vaginal breech birth, view video footage, and explore what "Hands off the Breech" may mean to your practice. When to be hands-off and when to be hands-on. Could a new approach to protecting the breech cardinal movements mean a coming revolution in vaginal breech birth? Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144 Breech Basics Handouts For a Surprise Vaginal Breech Time—is there enough time to get to the hospital? Should EMT be called? Record conversation about informed consent, parent choice in place of birth. Does the Midwife have the support she needs, such as an assistant skilled in resuscitation? Is the family favorable for home breech by support attributes? Planning ahead for a vaginal breech birth at home: The physical attributes of the mother and child are not the only things to consider in planning to stay at home for a breech birth. We include social and emotional attributes. These are added to the screening assessment: Social and Emotional Considerations for birthing a breech presenting baby at home Favorable attributes Unfavorable attributes Point of Faith Preparation for breech, internal "locus of control" Discussion, informed consent Physiological breech approach (knee-elbow, hands off) Has watched a video Ultrasound or MPJ, a reassuring effect for long labors Time for couple to discuss, alone, breech home birth Support in immediate & extended family Lack of strong Point of Faith Not prepared for breech No time for informed consent Surprise breech More than a little anxiety in mother Anxiety in father Hostility in family or community Midwife not comfortable, not experienced; Hands on Gail Tully, CPM with guidance by Janet Hofer, Traditional Midwife (late). The Safest approach to vaginal breech birth, besides ongoing assessment, is honest, open communication. Neither the parents nor the midwife should have an ideological basis for this choice. That means, we don't attempt a vaginal birth because "natural birth is better" or Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144 Breech Basics Handouts including risk of injury or death of the baby and the mother. While honoring the mother -and father's- intuition, we take a very practical approach. To flip, Balance 1st w/FLInversion Then pick one of these: Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144 Breech Basics Handouts Breech Birth Protocols Breech birth can be a lovely variation on a natural process. Dilation may be less painful and, for some, faster than the typical head-down presentation. Mothers know the importance of being both relaxed and active during a breech birth. So, rather than drugged, women can respond instinctively to labor and their baby. Risk reduction is a holistic approach. Breech vaginal birth can be a very conscious choice. Protocols protect our decisions when fatigue, emotion, birth plans, or inexperience might confuse issues. These breech protocols reflect, in my opinion, the best practice for a homebirth in my area: * All mothers are assessed for pelvic alignment and myofascial issues. Repeated bodywork increases safety. * Labor begins spontaneously, without induction or augmentation, between 36-42 weeks. Mother doesn't have hypertension; diabetes or diabetic symptoms. Metabolic stagnation or imbalance? Be more cautious. * 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) or by ultrasound, or MRI. * The baby is frank; or, if complete or footling is of no more than average size and the mother is having body work to help her pelvis and womb be symmetrical for birth. Myofascial release is good for all mothers. * 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 may be useful for some mothers.) * Labor progresses readily without a stall in active labor. Absence of start-and-stop pattern in presence of strong contractions. No breaking the water (AROM). Vaginal exams are avoided; possibly one done early to assess Primip, VBAC, or transport. * The mother's physiological birthing position; When the presenting part is visible mother moves to Hands and Knees (knee - elbow) which protects flexion and rotation to sacrum anterior. After midwives have resolved several stuck breech babies, they will be safer at resolving obstruction in other maternal positions. Clear the area in front of mother after hips are born. * The person catching keeps hands off unless the arms or head need help to come out. No perineal massage or support, no pushing on/touching the mother to stop her sitting on her baby (mom will feel baby and stop herself). Episiotomy is not routine. No wiping the mother's bottom during birth. No towel around baby. All this avoids a mother clenching. Quiet patience is key. Positive words tell mother of signs of progress or that you are about to intervene to help baby. * 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, meaning birth time isn't imminent, we transport. No discussion. No extraction. No debate. A cesarean is strongly protective of the baby in this case. * The attendant has experience and practices regular simulation of breech birth, hopefully with each birth team; knows the maneuvers; newborn resuscitation; delayed cord clamping; and how to flex the head and open the pelvic outlet. About 20% of Jane Evan's planned home breech births finish with cesarean surgery. About 20% of Dr. Louwen's planned spontaneous breech births finish with cesarean in his Frankfort University hospital. 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. Let gravity be the midwife. All parents must accept responsibility for their births. Midwives must be transparent with the limits of their experience. Physiological breech home birth may not be safer than physiologic breech in hospital. Physiologic breech birth is seldom available in 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. Though breech home birth isn't supported by society, parents do have the right to choose. Breech birth can happen at home. Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144 Breech Basics Handouts Quotes from the Breech Conference Coalition for Breech Birth Ottawa, Ontario, Canada October 15-16, 2009 and Pre-conference, A day at the Breech, October 14, 2009 Jane Evans, Midwife (UK, Independent) 30 years as a midwife, and independent of the British medical system since 1991. Wrote Breech Birth, What are my options? She quotes Mary Cronk, her previous midwifery partner as saying that labor progress is when "contractions are close, long and strong, and they get closer and closer, longer and longer, and stronger and stronger and from the Mum's view, they are too close, too long and too strong. " (It's cuter with an English accent.) "The optimal position for the breech is frank and on the right hand side." "Don't say 'Push,' say, 'Allow your body.'" "The baby magically rotates to the Left Sacrum Transverse to allow shoulders to come into the pelvic brim." "When you see the "Valley of the Cord" (crease in chest) you know the arms will come spontaneously afterwards." "If you have somebody ferreting about, feeling where the cervix is, you tend to clench up a bit don't you?" "Whatever you do, you're interfering and you're likely to have to help out later." "Upright breech is a much more sensible position." "Cord prolapse.. why are we in such a frath about it?" When the head flexes the occiput rolls on the anterior surface of the symphysis and "Women convert religions; Women go from the Christian prayer position to a Muslim prayer position." Dr. Robert Gagnon, co-author on Canada's breech guidelines and a prominent research physician. The guidelines do not discuss home breech, mind you but I think he said, "I think there is a place for home breech delivery outside of all health systems." I quickly cleaned my ears after that but I think he really said that! "Nothing has a risk of zero." "For me, having an experienced midwife like Jane Evans would be great in our center." "Effective maternal pushing is essential and should be encouraged.. and now I think pushing on all fours is the best." Betty-Anne Daviss, midwife, Ottawa, Ontario, Canada "She can't get through her labor if she doesn't have hope." "Midwives have to take back breech skills. ..the mothers have never been deskilled." "We're not on the fringe, we're on the frontier." Robin Guy, Founder of CBB, mother of breech baby, cesarean against her will "I'd always wondered what would have happened if I'd started sooner." Dr. Andre Lalonde, Society of Obstetrics Gynecological of Canada "Young people today are risk-adverse." "The future of vaginal breech birth is training... every 2-years, retrain." Dr. Frank Louwen, OB, Frankfort University Hospital, Frankfort, Germany, "With hands and knees - no NICU." "If woman on her back, and baby is posterior, then you have to move baby; if hands and knees, then baby does it themselves!" "If you touch a child, complications are rising." "The umbilical cord is never the reason not to have vaginal breech." "If baby shows you the complete front, then arms will come down." "Footling (position) is not decided by sonogram, but when the rupture of membranes and pushing starts." "Prolonged 2nd stage is the main risk factor. With regular good contractions for 4 hours - we deliver immediately. This is explained at 36 weeks." "You can not pull the baby out. That is not allowed and that is very important. No discussion." "Don't break the water. ... that's the best situation you can have for breech delivery." "When you see the presentation, then the woman turns to the knee elbow position." Tells that 5 years after the Guttenberg bible was printed, the first western book printing, another German book was printed. Author Henckel, title: We Have to Talk about the footling in breech. Louwen maneuver - Head inside and shoulders are out. Now to help head out, push on shoulders with thumbs. Push directly to symphysis, not up or down, away from yourself. 2015: "Pelvimetry, as currently performed, adds little value to the effective management of breech presentation at term. -Bisits Andrew BISITS, Medical Co Director of Maternity Royal Hospital for Women, Randwick, NSW, Australia Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144 Breech Basics Handouts Spontaneous Breech Birth What you see at the perineum tells a story of what is going on inside at at the brim of the pelvis. This baby did not follow the classic rotations as described by Jane Evans. Baby started out RSP. Baby rotated at brim and pelvic floor until back was coming down from the left. Rotation to Left was before this baby was in view. 1. We see anterior bun first. 2. We see baby rotate to sacrum anterior as buttocks emerges 3. We see continuation of rotation as legs swing out. 4. We see from the angle of the legs that the shoulders are coming into the brim in oblique. 5. The baby's left shoulder comes into the pelvis first, we see the hips aim towards mother's left leg as this happens. 6. The baby's right shoulder comes into the pelvis second, we see the hips come back to the center. 7. The legs release spontaneously. 8. The baby's left arm came first, then the right. Which is to say, the baby's To help the rest of the head out the mother spontaneously moves her chest to bed/floor If you need to help, help the mother put her chest, not to her elbows, but touching chest to bed. Turn baby's face under tailbone to "OA." Flex head Apply Fundal pressure (Kristeller's). Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com Breech Basics Handouts Breech Chart Supplement Mother's Name (In addition to regular labor flow charting.) Baby's Name Baby's size Date: / / Time/Date Event Time that the breech was discovered Beginning of labor *cm. dil. station Time of urge to push * dilation rechecked? Y N cm. dil station *The presence of this dilation question doesn't not assume an exam was done. Pushing becomes active pushing Appearance of breech at: Sacrum is SA LSA RSA SP LSP RSP LST RST Type of breech: frank complete single footling double footling knee(s) Remember, don't touch the baby or the perineum or push the mother up Mother' position Hips both out at: Sacrum is SA LSA RSA SP LSP RSP LST RST Remember, don't touch the baby. Baby's position after both hips out Umbilicus appeared Appears to be pulsing? Y N Cord full or flat? Cord touched? Y N Rate If cord is white, and fetal position SAuse fundal pressure. If ST, initiate partial extraction by rotating chest to bring down the arms. Reassess tone and cord. First appeared at Arms born spontaneously_ Assisted R w rotation, & manually? Assisted L w rot., & manually Post. Arm was L R? Time of Posterior arm , and Anterior Arm R L "Double Chin," or nape of neck visible? Y N Head manually flexed? Y N If yes, what technique? Airway made? Yes No, no need or if other reason, why?: Mother's position is same,__Mother changed now to Maneuvers for birth of head were: Spontaneous, no need for maneuvers Frank Louwen's nudge in subclavical space, towards pubic arch Y N Cheek bones brought down, occiput up (Mauriceau-Cronk) Y N Reposition chin from oblique diameter to center on the perineum in AP diameter Other: Birth of head Fast decompression? Y N Cord clamped at, or placenta delivered before cord clamped at Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144 Breech Basics Handouts Apgar__1min__5 mins__10 mins Transport for baby? Y N Time: Resuscitation__cord resusc. _mouth to mouth_delee _PPV _02__homeopathy__other: See regular immediate postpartum chart for details. Prepared by GailTully, CPM gail@spiniiingbabies.com www.SpinningBabies.com When Provider Will Touch or Not Touch Baby During Birth Process Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144 Breech Basics Handouts Normal, Hands Off Watch closely Intervention Hands-On Cesarean Recommended Inlet RST/RSP/RSA LSA/LST Hips can't enter inlet, Active labor stall Midpelvi s Baby's spine remains to the Transverse diameter (thigh) >=4 hour 2nd stage Outlet LST7 LSA to SA (OA) RST Once arms are born you Must flex Normal, Hands Off Watch closely Intervention Hands-On Alternative method Inlet RST/RSP/RSA LSA/LSTI Not coming? Avoid total breech extraction, except 2nd Twin. Do not do AROM. Go to Cesarean. 2nd twin may be extract'd Rotating off the brim at the inlet or stuck on the inlet. Which is it? The anterior arm is stuck on the brim so the provider carefully holds chest (not abdomen) to rotate the baby so that the face will end up facing mother's perineum (OA, essentially now). Shoulders in oblique indicate baby is rotating shoulders free of the inlet, then baby is SA Baby's spine remains along mother's thigh in the transverse diameter. This baby is stuck and needs provider to rotate anterior arm off the brim. Pics by Louwen. Normal, arms will come next Rarely baby faces mother's back in "SA" when arms are stuck... these elbows are are against the sacrum Note, we are now seeing mother's anterior view. Comments If tone is low, use fundal pressure now Rotate arms before birth is possible 180 then 90 degrees, or bring posterior arm out and then SA Unusual complication, compound arms over head Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144 Breech Basics Handouts Outlet "From 'Christian Prayer pose' to 'Muslim'" for head (Mary Cronk). Is baby vigorous? Is tone good? Cord If baby is limp, turn face to perineum (OA), flex chin and do fundal pressure. Shadow under perineum, No flaring of anus, do Nudge Is head at the outlet? It must be OA to be at the outlet, not oblique! Flex head to see chin (On back? See nape of the neck before lifting face out.) Bibliography for Breech Topics 2015 Books and Video Breech Birth. Benna Waites Free Association Books, Great Britain, 224 pp. 2003 Breech Birth? What are my options? Jane Evans, AIMS 2008 Breech Birth Woman Wise, Maggie Banks, Birthspirit Books, 1998 Breech Birth. Video. The Farm Midwifery Service. Ina May Gaskin The Female Pelvis, Blandine Calais-Germain. Eastland Press 2003 Holistic Midwifery, Vol. II. Anne Frye. Labrys Press, (503) 255-3378. www midwiferybooks com 2004 Homeopathy for Midwives, Barbara Geraghty, Churchill Livingstone, 2002 Articles and Position Papers 1. 2006 ACOG Guidelines on breech birth, American College of Obstetrics and Gynecology, US 2. 2009 SOGC Guidelines on breech birth, Society Obstetrics Gyneocology, Canada 3. Connie Banack, Turning a Breech Baby! CLD CPD CCCE, Mother Care, 2003. http://www.mnthpr-rarp.ra/ rpprh htmďtilt 4. Bisits, A. The Value of Imagining Pelvimetry in the management of the breech presentation at term. Aust N Z J Obstet Gynaecol. VOL 55. Issue 1 P. 99-100. 2015 5. Breech Birth Benna Waites London: Free Association Books, $29.95, 224 pages 2003 6. Breech Birth Can Be Safe, But Is it Worth the Effort? Andrew Kotaska, MD, FRCSC J Obstet Gynaecol ;31(6):553-554 Canada 2009 7. Breech Birth; What are my options? by Jane Evans for AIMS UK 2005 8. "Breech, Posterior and a Deflexed Head! An active birth solution? Maggie Banks, Midwifery Today, Autumn 2009 9. Breech Wise. Maggie Banks Birthspirit Books, 1998 10. CPM2000 Betty-Anne Daviss, Ken Johnson, et al. British Medical Journal 2005 11. The Female Pelvis, Blandine Calais-Germain. Eastland Press 2003 12. "Five years to the term breech trial: The rise and fall of a randomized controlled trial" Marek Glezerman, MD Glezerman "original term breech trial recommendations should be withdrawn." Am Jour of Ob and Gyn 194, 20-5 (2006) 13. Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions. Betty-Anne Daviss, Kenneth C. Johnson, André B. Lalonde. March J Obstet Gynaecol Can 2010;32(3);217-224 14. Hofmeyer, et al. External cephalic version for breech presentation at term. Cochrane Database Sy st Rev Vol. 4, 2015 15. Holistic Midwifery, Volume 2, Anne Frye, 2007 16. Homer, C. et al. (Bisits) Womens' experiences of planning a vaginal breech birth in Australia, BMC Pregnancy Childbirth Vol. 15, No. 1 2015 17. "Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery" Andrew Kotaska, MD BMJ (2004) 18. "Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium." Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, Breart G; PREMODA Study Group. Am J Obstet Gynecol. 194(4):1002-11. Apr 2006 19. Joined-up Knowing. "The final piece of the breech birth jigsaw?" Jane Evans. Essentially MIDIRS March 2012 Volume 3 Number 3, pp 46-49. 20. Maternal deaths after elective cesarean section for breech presentation in the Netherlands. Joke M. Schutte et al. Acta Ohsfefricia et Gynecologica Scandinavica Vol. 86, No. 2, Pages 240-243 2007 21. Maternal thyroid function during gestation is related to breech presentation at term. Kuppens SM et al. Clin Endocrinology (Oxf) Volume 72, Issue 6, June, 2010, pp 820-824 22. Moxibustion for Bringing Babies Around to the Head-First Position Vas J, Aranda JM, Nishishinya B, et al. Correction of non-vertex pres w moxibustion: A systematic review + meta-analysis. American Journal of Ob and Gyn 2009;201(3), 241-59. Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144 Breech Basics Handouts 23. "Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial." Mary Hannah et al, for the Term Breech Trial Collaborative Group. The Lancet Vol. 356 October 21, 2000 Powell, R. "Informed Consent to Breech Birth: the Midwifery Relationship." (2014) 24. Understanding Physiological Breech Birth. Jane Evans. Essentially MIDIRS Feb 2012 Volume 3 Number 2, pp 17-21. Gail Tully, CPM www.SpinningBabies.com gail@SpinningBabies.com 612-817-3144