Heads Up! Breech Conference
November 9-11, 2012
Core Skills for Attending Breech Births (panel)
November 10, 2012
- Dr. Michael Hall
- Ina May Gaskin
- Jane Evans
- Betty-Anne Daviss
- Gail Tully (moderator)
He's been getting a little more support for what he's doing recently, although many doctors are glad he's doing it and not them! He's got into "trouble" for not only breech, but delayed cord clamping. He's done breeches for 30 years; he never quit doing them, so they all started funneling to him when everyone else stopped doing them. He gets super motivated women coming to him for breech from all over the Rockies; interestingly, most of his own patients really just want the C-section.
1st core skill: Hands Off
Leave your hands off and don't try to pull the baby out. We have this natural instinct to want to help the baby. But we're there to help the mother birth the baby, not to deliver the baby. I've seen more damage done by pulling than I've ever seen by maternal pushing. It's the same for shoulder dystocia; let the mother do the work and get that baby out.
2nd core skill: Encourage Maternal Pushing
Sometimes you have to encourage the mother to push once the baby is halfway out (unless the cord is beating really well). He gets much better results encouraging mothers to push than having them gently breathe the baby out; this is where your clinical skills of watching and knowing the mother's and baby's signs are important. Each mother is individual and every situation is different.
3rd core skill: Freeing Nuchal Arms
If the baby does not rotate to anterior as the body is emerging, you already know there's probably going to be some difficulties. You need to know how to reduce the arms. When the mother is on her back, you have to do this much more often than when she's on H&K. He's become converted to the all-fours position in the last 3 years since he learned about it at the last breech conference.
4th core skill: Stay Calm
You have to have a calm touch with the breech. Don't panic, don't pull side-to-side, don't flail. You need to keep the baby in line. Don't stretch the baby's head laterally one way or the other. Let the mother do the work. You can apply some pressure inside the perineum to make a bit more room. You can also help open up the pelvis with having the mother rock her back if she's on H&K, or doing by McRoberts if she's on her back. You want a breech birth to be smooth. It's an art to get the right touch.
5th core skill: Freeing a Stuck Head
Remember not to pull! Pipers forceps don't pull the baby out; they open the vagina so the baby's head can emerge. He does "finger forceps: with the mother on her back: put 2 fingers in deeply until you hit the leveators, then pull deeply and down. This opens more room in the pelvis. That's worked really well for him so he can avoid an episiotomy. He has only used Pipers forceps 4 times in the last 30 years.
Ina May Gaskin:
She had a difficult case with trapped arms a year ago. She did rotations similar to those in Dr. Louwen's illustration (see session on breech research) to the baby to help free the arms.
Her breech skills have evolved since Spiritual Midwifery; they do a lot more upright and all-fours births now.
Think on your feet
If you have an Amish woman in a long dress with really relaxed abdominal muscles, the typical techniques might not work!
Handle the breech carefully
Move as carefully as you can with a breech, especially when there's a baby with stuck arms or a stuck head.
Help the woman believe she can get that baby out
If you can do this, she can do amazing things.
Your heart will be pounding like bad, and you have to act like you're at a delicious picnic, as if you have all the time in the world. Somehow, you have to project a cool, calm demeanor. She tends to ask favors of the mother, rather than bark out demands. Take deep breaths. Nurses, first responders, midwives-they all need to do this.
Keep in mind Sphincter Law
If you have women with excessively shy sphincters-if, for example, they can't pee at work or when anyone else is around-keep this in mind and make a note in your charts.
She doesn't like for the cord to fall down with footlings, so she doesn't mind if women lie down to slow things a bit. It's a lot harder to tell dilation with a footling. She had one Sacrum Posterior footling that emerged nicely to the buttocks, then rotated to SA after rumping. She didn't want the baby to remain SP and would have done something to turn it had it not rotated on its own (and most will).
Freeing a deflexed head
Have the baby hang off the end of the delivery table to flex the head (woman on her back). Suprapubic pressure using a fist; this is done by an assistant.
In this room, we have mixed experiences. We first need to really understand what's normal before we can understand and identify abnormal situations. She wants to cover the core skills for assisting at a breech and for giving the woman the confidence to birth her baby.
#1: Be aware of how the baby ought to be coming down
Don't panic if it's not doing everything according to the textbook; just use watchful waiting. If the baby doesn't continue to come down and needs some help, you need to know what to do. When do we know to step in? If the baby doesn't do the rotation to SA as the bottom emerges, you know that something is stopping it-nuchal arms, etc.
#3: Careful Observation
Look carefully at the woman's condition. Observe the red line, the Rhombus of Michaelus, a sacrum moving upward and out of the way.
#4. Keep everything absolutely calm
This includes the woman; allow her to relax and encourage her to feel safe.
#5: Nuchal arms & trapped heads
As the baby is coming down, if you see a vertical crease in the middle of the chest, you know that both arms are forward. A crease = good. Keep your hands off the woman as well as off the breech so you don't interrupt what's happening.
If you see a perineum that's very empty after the arms are out, you know the head is extended. You've probably already raised flags in your mind before this point. If she's on all-fours and has an extended head, do Frank's nudge on the clavicles to bring the chin to the chest (Jane does a modified version of this where she places her thumbs on the subclavicular space and her other fingers wrapped around the back of the baby's shoulders. When you press, this scrunches the shoulders forward.) Then do MSV if needed.
#6: Carefully observe color of baby, tone of baby, & what the cord is doing.
#7: Work things out with a doll and pelvis so you're intimately familiar with the mechanisms of breech.
Betty-Anne began with a few notes from practices at the Frankfurt unit. They do some inductions with Prepidil; Dr. Louwen never uses oxytocin unless woman is already at 8 centimeters. They do a lot of fundal pressure in Germany; their feeling is that pushing from above is better than pulling from below. Betty-Anne has done it occasionally in selected breech cases-for example, to keep a scrotum that's coming in and out from becoming more bruised. But you want to see at least the bottom, if not more of the baby, before doing fundal pressure.
When you have a a baby out to umbilicus and doesn't rotate to SA, the arm is often caught up on the pelvis. Maybe the baby has come down too quickly. (Normal, optimum position to see at rumping is RSA; when you see LSA, it's more problematic). You help the baby do a 180 degree turn clockwise (unless of course the baby won't rotate that way). After you've helped rotate the body 180 clockwise and then 90 back, reach a finger in and gently turn the chin to bring the head back in line.
In Frankfurt, they think it's better to push on the shoulders than on the clavicles to avoid fractures. This helps bend the sternocleidomastoid muscle.
Anke Reitter came up to clarify Frank's nudge & Louwen's maneuver:
With Frank's nudge, you never pull the shoulders down, but guide the baby backwards toward the pubic bone. Don't fear using Frank's nudge. The pressure is continuous, not pulsed. You might have to apply pressure for more than a few seconds. The delivery of the head is not a continuous movement. You'll feel no movement during the nudge, then suddenly you'll feel a bobbing movement as you continue to press.
It does matter which direction you turn the baby; it matters where the arm is. If the arm is in front of the head, you simply release the arm and sweep it out. If the arm is behind the head, you'll need to turn the baby, but do it in the right direction. If you're not successful after turning in one direction, you can try the other direction.
Jane Evans commented that she has shrugged the shoulders physically forward (quite gently, with no downward traction). This releases the muscles across the back and also releases the thoracic spine.
Gail Tully added a few more skills:
Be skilled with resuscitation.
Keep the cord intact.