Breech Birth Update 11 May 2011

1. Breech Birth Update11 May 2011 Norfolk & Norwich University Hospital Facilitated by Shawn Walker, RM

2. Purposes of the Study Group Focus on planned vaginal breech birth as client�s choice, rather than unforeseen event Learning safety principles of planned breech birth as advanced midwifery skills rather than management of an obstetric emergency �The first thing to question, therefore, might be whether it is appropriate to teach breech as an obstetric emergency. Surely this is only likely to undermine midwifery ownership and entrench fears about managing breech physiologically?� (Scamell M, 2010)

3. Breech Birth Study Group �Midwives are expert professionals skilled in supporting and maximising normal birth and their skills need to be promoted and valued. The role of the midwife is integral to models of care, which promote normality. Maternity Services can enhance midwifery skills and autonomous practice by providing the appropriate practice settings� (RCM, 2007).

4. Breech Birth Study Group Sharing experiences to facilitate learning Jo�s story Everyone invited to share experience / facilitate discussion Has anyone had any recent experience with breech birth?

5. Review of Breech Mechanisms Frank (Extended) Breech in LSA position #1: Engagement Sacrum anterior oblique or directly anterior Main reference: Frye A, 2004

6. #2: Internal rotation to sacrum transverse Dilating the soft birth canal Shoulders and occiput also rotate to transverse Asynclitic (noticeable if a VE is done)

7. #3: Rumping of the breech By extension and lateroflexion of the spine Dilating the perineum

8. #4: Birth of the buttocks Anterior and then posterior buttock By lateral spinal flexion

9. #5: Internal/external rotation External rotation Sacrum anterior Internal rotation Shoulders transverse Occiput anterior

10. #6: Birth of the legs By extension of spine May occur at any point before or during the birth of the arms

11. #7: Internal/external rotation External rotation With upper torso Sacrum transverse Internal rotation To left or right Long shoulder axis AP Occiput transverse

12. #8: Birth of anterior arm and shoulder Lateral spinal flexion Head engages as the shoulders reach the outlet

13. #9: Internal/external rotation Begins before and completes after posterior arm is born to bring occiput anterior Slight movement to left or right as posterior arm is born � ... then shoulders rotate externally with the head to bring their long axis transverse Breech is now in line with head, sacrum anterior

14. #10: Birth of the head By flexion � enhanced by baby�s tone and movements (unflexed head)

15. Frank (extended) breech birth You can view the birth of a frank (extended) breech baby on Lisa Barrett�s blog, here: http://www.homebirth.net.au/2010/01/frank-breech-video.html And on this mother�s Daily Surrenders blog spot: http://dailysurrenders.blogspot.com/2010/09/breech-birth-of-annaka-faith.html

16. Scenario 1 Part I Amanda is a 30-year-old mother of 2. Her first baby was born 5 years ago and was a successful, planned vaginal breech birth in hospital. Her second baby was cephalic, and was born in water at home. Her community midwife has determined this baby to be a cephalic presentation, and Amanda has planned another home birth. You are called out to Amanda�s home birth at 3 am on morning, when she is 40 weeks pregnant. Upon arrival, you find Amanda on all fours, clearly in advanced labour. She is supported by her husband and a close female friend who has also been at her previous births. You turn around to begin getting your gear in order, when you hear Amanda enter the expulsive phase of her labour. You turn back around to see a tiny foot and leg emerging. What is your initial reaction?

17. Scenario 1 Points to consider: Remain calm � avoid stimulating reflex pelvic tightening Gently inform and reassure the mother The potential need for resuscitation The potential need for emergency services Documentation Remain calm and pay attention

18. Scenario 1 Part II You put your gloves on and sit down calmly behind Amanda. Her baby continues to descend and the posterior leg pops out. He (you can tell now) begins to rotate so that his stomach faces you, and then his arms sweep down across his chest, one and then the other. Descent then stops, with his head still high in the pelvis (you can see his chest but not his neck or chin). At this point there is what feels like a very long pause (you haven�t had time to get your watch out of your bag). His colour is good, the cord appears full, and he is occasionally making what looks like bicycling movements. But Amanda does not have an urge to push, and it feels like a LONG time since she�s had a contraction. What do you do?

19. Scenario 1 Points to consider: Evaluate the baby�s condition Tone & movement Heart rate (visible on chest) Colour Cord Any baby who is bicycling is in very good condition and you have time to wait and see Be aware of the effect of adrenalin on time perception Be prepared to catch and/or guide slow descent of head A more upright position involves tightening of the stomach muscles, which may stimulate a contraction

20. How and when to help Teaching aids for all fours breech birth are now available, linked from the Breech Birth Network website: http://www.breechbirth.org.uk/resources.html

21. Scenario 2 Part I Julia is a 39-year-old primip. She has known for several weeks that her baby is an extended breech. She has had an easy, healthy pregnancy, with no risk factors, and has had extra screening, such as an MRI, to determine if there is a problem with her or the baby. Nothing has been found. After trying ECV and every alternative trick under the sun, without luck, Julie has planned a vaginal breech birth. She feels frightened of coming into hospital because she has encountered a lot of resistance to her plans, and she appears to be in advanced labour when she arrives. You are assigned to be her midwife, due to your familiarity with the option she has chosen. What is your initial plan?

22. Scenario 2 Points to consider: Review birth plan Reassure her she does not have to defend herself Assess fetal condition ASAP Review mechanisms and manoeuvres Ideally involve the Registrar on-call Alert Co-ordinator to the need for a second midwife and (ideally) someone to document Alert Paediatric Team

23. Scenario 2 Part II Julia�s labour appears to have progressed very quickly, as far as you can judge, given that she has declined VE�s unless clinically indicated. She has chosen to be upright and active, leaning over a counter surface for most of her labour. In a couple of hours, it sounds as though she has begun pushing, and you bring her a mat and a small padded bench to lean over, because she has planned to give birth in an all fours position. There is steady progress as she pushes, and her baby emerges in a textbook fashion: anterior, then posterior buttock, rotation to sacrum anterior, buttocks swing back to allow release of the long legs, further descent to umbilicus. With the next contraction, the arms sweep down in front of the chest, and the face descends onto the perineum. At this point, you can see the baby�s chin (tucked to her chest), mouth, and the back of her neck. While you observe, the baby makes a brief leg movement, but you can see that instead of descending, the head appears to be deflexing, and the chin is lifting off the chest. Heart rate is good, above 100 bpm, and colour is good, but the cord appears deflated. What do you do?

24. Scenario 2 Points to consider: Assess condition of the baby Muslim prayer position may increase pelvic outlet diameter and draw perineum up over the bregma Only when chin/mouth and nape of neck are visible Mariceau-Cronk manoeuvre may be helpful Are you prepared to resuscitate? Are obstetrician and paediatrician available?

25. Understanding L�vset Interesting facts about the Lovset manoeuvre: Used to facilitate delivery of the fetal arms which have extended above the head Not routinely taught in North America (... are the results of the Term Breech Trial generalisable to the UK?) L�vset originally taught that horizontal traction should be applied to the first 90� rotation, followed by downward traction for the next 90�

26. Understanding L�vset

27. Understanding L�vset

28. Assisted delivery of the arms Consider this picture series, in which a doctor performs manoeuvres to free the baby�s arms while the mother is in a dorsal position: http://www.birthdiaries.com/diary/birth037/ You can view another example on this Breech Birth Skills page: http://www.youtube.com/watch?v=_UzvOwF9C78&feature=youtube_gdata

29. Spontaneous birth of the arms Now consider this picture series, and blog in which midwife Lisa Barrett describes how the baby assists itself through the mechanisms of breech birth when his mother is in an all fours position, essentially performing his own L�vset manoeuvre, without intervention: http://www.homebirth.net.au/2011/03/mechanism-of-breech.html

30. Scenario 3 Part I Rosie is a 25-year-old primip whose baby is a flexed breech by scan. She has tried ECV without success. She comes to you as her community midwife and says she is very upset because she really wants a �natural breech birth,� as she describes it, but her consultant says that she really should have a caesarean, and if not she should have an epidural and labour on her back so they can use forceps to deliver the head. What do you say?

31. Scenario 3 Points to consider: �You must act as an advocate for those in your care, helping them to access relevant health and social care, information and support� (NMC, 2008). �Woman-centred care also means that midwives encourage self-efficacy by providing a range of unbiased information which takes account of women�s beliefs and values. This includes a non-judgemental approach to understanding that some choices or decisions made by women may not fit into our framework of institutional guidance and protocols. Nevertheless, the midwife�s role remains that of being the woman�s advocate by enabling her to make decisions of her own� (RCM, 2008).

32. Scenario 3 Part II Rosie has phoned the Labour Ward to let you know she is coming in. You are the Labour Ward Co-ordinator. What is your strategy to support Rosie? Points to consider: Experience levels of staff Support for midwife

33. Scenario 3 Part III Rosie has arrived. She is T+3, contracting 1:4, waters intact. You are the midwife assigned to look after Rosie. What is your initial plan? Points to consider: Review birth plan Review mechanisms and manoeuvres Environment & support Fetal assessment and/or VE after waters release

34. Scenario 3 Part IV Rosie has laboured well. After five hours of labour, in which she used only Entonox, she has started pushing. You are monitoring the baby�s heartbeat intermittently because Rosie has declined CTG monitoring unless a problem is detected. After 30 minutes of pushing, you detect one episode of tachycardia (180-190 bpm). After the next contraction, the fetal heart is back within the normal range (150-160 bpm). But after the next contraction, it has become tachycardic again and is now over 190 bpm. What do you do?

35. Scenario 3 Points to consider: Problems can emerge very quickly in second stage Apply CTG with consent Inform Obstetric Registrar Is baby descending quickly? Is birth imminent? If not, prepare for caesarean section

36. Scenario 3 Part V After informing the Registrar of the tachycardia, you return to the room, and Rosie accepts your advice that a CTG is warranted. However, the anterior buttock is now visible at the introitus and you prepare for an imminent birth, with Rosie in the position she has chosen: all fours, on a mat, leaning into her husband�s lap as he sits on a chair beside the bed. Her baby girl is emerging according to the usual mechanisms, her legs are born extended, then descending to the umbilicus, then one arm sweeps down. Then there is a pause of about a minute and a half as the second arm is visible across the neck up to the elbow. During this pause, you note that the baby�s colour is pale, she is not making any self-flexion movements and appears flat. The cord appears full, but the fetal heart appears to be below 100 bpm. The second arm then sweeps down with the next contraction, but the head remains high. What do you do?

37. Scenario 3 Points to consider: Assess baby�s condition Include labour events (eg. tachycardia) Consider assisting posterior arm Ask mother to push, and/or Upright posture, suprapubic pressure (2nd midwife) and Mariceau-Cronk manoeuvre If unsuccessful, hand over to obstetric staff Prepare for resuscitation (paediatric team)

38. Maternal position � maternal choice? JGB Russell, a Consultant Radiologist, demonstrated that the average increase in the area of the outlet between supine and squatting positions is 28% � 1 cm in the transverse and 2 cm in the antero-posterior diameters (Russell, 1969). �Note that the femoral forces are similar whether the patient is squatting or kneeling so long as the thighs are abducted� (Russell, 1982). Variations: Squatting & kneeling Deep closed knees-chest Pulling on the knees when supine (McRoberts)

39. Maternal position � maternal choice? Both RCOG (2006) and PROMPT (2010) recommend advising women that supine or lithotomy is the preferred position for breech delivery. This recommendation is based upon: Greater practitioner familiarity with manoeuvres in lithotomy position Lack of research about upright breech birth = no proof that it does improve outcomes enough to justify a change in practice

40. Maternal position � maternal choice? Both RCOG (2006) and PROMPT (2010) suggest symphysiotomy for obstructed delivery of the aftercoming head. Symphysiotomy has been shown to increase the transverse diameter (primarily) by 1 cm (Menticoglou S, 1990, and Banks M, 2007). However ... A 2010 Cochrane Review found no high-quality clinical trials evaluating the effectiveness of symphysiotomy; all evidence is based upon observational studies.

41. Maternal position � maternal choice? Questions to consider: Can we justify restricting or not offering maternal choice with regards to position, when potential benefits have been demonstrated radiologically, and several very experienced practitioners advocate upright postures? ... ... while retaining the prerogative to cut episiotomies or unproven symphysiotomies on the basis of the same level of evidence?

42. Scenario 4 Hannah is a 29-year-old mother of one girl who was born very straightforwardly about 3 years ago, weighing 3.1 kg. She phoned earlier to say that her waters had broken (at 38 weeks) and there was �thick, black, gooey stuff.� You advised her to come in, and upon arrival on Labour Ward, you evaluate and discover the baby is breech. She is 3 cm dilated, all else is normal, and by palpation, you feel that the baby is probably about 3.3 kg. After a discussion with the Registrar, she is upset and tells you that she really doesn�t want a caesarean, but feels like she has no choice. What do you do?

43. Scenario 4 Points to consider: �Diagnosis of breech presentation for the first time in labour should not be a contraindication for vaginal breech birth� (RCOG, 2006). What information does she need to make a truly informed decision? Are there staff with experience available to give her a second opinion? Can you advocate for her to ensure she is offered a choice? Importance of not undermining each other as professionals

44. The Way Forward? Information for Women Consider a leaflet to inform women of their breech birth options Example: King�s College Hospital London, http://www.kch.nhs.uk/patients/general-information/leaflets/?assetdetesctl361495=12459&p=2 Anyone up for writing for Norfolk & Norwich, King�s Lynn NCT magazines? Any other ideas?

45. References & Further Reading Banks, M. (2007) Active breech birth: The point of least resistance. New Zealand College of Midwives Journal, 36, p. 6. Coppen R. (2005) Birthing Positions. London: Quay Books. Draycott T, Winter C, Crofts J and Barnfield S, eds. (2010) PROMPT: PRactical Obstetric MultiProfessional Training, Course Manual. London: RCOG Press. Frye A. (2004) Holistic Midwifery, Vol. II: Care of the mother and baby from the onset of labor through the first hours after birth. Portland: Labrys Press. Hofmyer GJ and Shweni PM. (2010) Symphysiotomy for feto-pelvic disproportion (Review). Cochrane Database of Systematic Reviews, 10. Oxford: John Wiley and Sons, Ltd. L�vset J. (1968) Vaginal Operative Delivery. Oslo: Scandinavian University Books. Menticoglou SM (1990). Symphysiotomy for the trapped and aftercoming parts of the breech: A review of the literature and a plea for its use. The Australia and New Zealand Journal of Obstetrics and Gynaecology, 30(1), pp. 1-9.

46. References & Further Reading Nursing and Midwifery Council. (2008) The code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC. Royal College of Midwives. (2004) Normal Childbirth, Position Statement No. 4. London: RCM. Royal College of Midwives. (2008) Woman-Centred Care, Position Statement. London: RCM. Royal College of Obstetricians and Gynaecologists. (2006) The Management of Breech Presentation, Green-top Guideline No. 20b. London: RCOG.� Russell JGB. (1969) Moulding of the pelvic outlet. J. Obstet. Gynaec. Brit. Cwlth. 76, pp. 817-820. Russell JGB. (1982) The rationale of primitive delivery positions. British Journal of Obstetrics and Gynaecology. 89, pp.712-715. Scamell M. (2010) Can all-fours breech birth ever be a reality within the NHS? The Practising Midwife, 13:7, pp. 29-30.

47. May 2011 Shawn Walker, RM shawn@norwichbirthgroup.co.uk Breech Birth Network www.breechbirth.org.uk Anne Frye�s books can be ordered from her website, http://www.midwiferybooks.com/