Midwife talks OB through a vaginal breech birth

I'm a midwife in PA just starting out in my career (attending births for 5 years), and I want to share a really cool experience I recently had with a client.

Prenatally, my client "Mary" (pseudonym) was by-the-books perfect. Mom and baby both checked out great. At the onset of labor at 39.5, we discovered baby was in a breech presentation. We have the freedom to support families through breech births here, but I'm not experienced enough to feel comfortable with a breech primip at home without the support of a more experienced midwife. I have done breech training with BWB (back in 2021 with David in Western PA) and also did some simulator training with Elizabeth Beachy, who is semi local to me. However, I haven't had the pleasure of attending a breech birth in person.

Labor began with SROM shortly after 11pm, and I arrived at the Mary's home around 4am when contractions were about 2-3 minutes apart, lasting nearly 1 minute. I think it's important to mention that FHT were in normal range the entire time I was with the family, however, shortly before we headed to the hospital, FHTs were now in the 170s. By the time we reached the hospital around 7:15 am and got checked into a room, she was complete, +2, and feeling the urge to bear down. Much to my surprise, the OB declared that Mary was "too far along for a cesarean", so we'd be attempting a vaginal breech birth.

The following is a portion of the birth story I wrote for the Mary and her partner to remember this momentous occasion, and she eagerly gave her blessing to share!

~~~

The moments following were a flurry. "We're going to set up the birth tray. Get the warmer in here," the doctor nervously said. I quickly briefed Mary on vaginal breech birth, and how birthing upright is the safest way to deliver the breech. I prepared her for the likelihood that her baby would be whisked to the warmer for some breathing support which is common following breech deliveries. In the home setting, we have the luxury nearly 100% of the time of helping baby transition with or near mom. But, logistically, the hospital can't (won't?) accommodate that. She understood. She was ready to meet her baby.

Setting the scene. Mary is on her back. I am sitting at the foot of her bed to her right. The OB is standing over my left shoulder. "Dr, what are the hospital policies on upright breech?" My subtle way of determining whether or not this provider is trained in safe, physiologic, upright breech. 

"I don't know what that is," she confusedly retorted. 

"Oh, ok… I was just asking if there are any policies guiding how clients 'may' labor while birthing a breech baby," I explained.

"We don't have a breech policy. We don't do breech."

Well then. "Mary, what do you think about raising the headboard, facing it while squatting, and leaning on it for support? Is that ok with you, Dr?" 

"Yes," they both replied. "That is fine." This was a very effective and powerful pushing position for her. Immediately, her strong and well-coordinated pushes produced fullness in her perineum. 

"Mary," I exclaimed, "those pushes are working, I can see your baby moving down!" 

"Can you really?" 

"Yes, I can!"

Pushing in this position continued for 20 to 30 minutes. Even without feeling internally during pushing to assess effectiveness of pushes, I could visibly see that these pushes were effective. Only, the OB was growing increasingly more uneasy. This was taking too long for her, despite the fact that it is completely normal and even expected for first time laboring women to push for hours, as long as progress is being made and both mom and baby are stable. "Mary, I'm comfortable trying 1 or 2 more positions to see if you can make progress," said the OB, "but if I'm not seeing progress, I'll have to recommend a cesarean."

That's odd, 40 minutes ago she said that my client had progressed too far to safely perform a cesarean. And here, 40 minutes later, visualizing the presenting breech while pushing with effective contractions, now she hasn't progressed too far for a cesarean? I must have missed something.

"What do you think about pushing on your right side?" asked the OB. While resting before pushing began, FHTs did return to normal ranges which was encouraging. However, as baby descended, tachycardia returned. Ok, baby is telling us she's ready to meet her mom. 

"Yeah, that sounds ok," Mary replies.

After 1 or 2 effective pushes on her side, the OB is dissatisfied and would like to try another position. I do have to give her so much credit for that. Most OB's scoff at the benefits of maternal movement and repositioning in labor. "Could Mary squat on the bed for more powerful pushes?" I asked. The OB agreed to my request, and Mary was making great progress, though still not enough to please the hospital staff. Up to this point, I am witnessing nervous, whispered exchanges between the OB and charge nurse from my official spot right between the two of them at Mary's perineum.

Front and center. Only, to the left. Front and left.

"Ok, Mary, let's try one more position," the OB said. "You're going to sit with your back against the inclined headrest and use your hands to pull your knees to your chest. I like the visualization of this position." That's what asking for consent sounds like, right? Mary agreed. Ironically, in physiologic breech birth, you can't visually assess anything you need to from the mother's anterior. And with her first push in that position, her baby's presenting part briefly descended past her tissues. "YES, Mary, YES!! Keep doing that! These are amazing pushes! You're going to meet your baby so soon!" In between contractions, the baby no longer retreated . And instead stayed in place. It's finally happening. It's actually happening. This breech baby will be born vaginally.

Through all of these position changes, in between contractions, I'm engaging in whispered conversations with the OB. "Have you heard of Breech Without Borders?" 

"No," she replies. 

"Oh, it's this great organization I've trained with that teaches safe, upright, physiologic, breech birth. Even hospital providers are taking these courses despite working in hospitals that ban breech birth. Even when you don't allow vaginal breech deliveries, occasionally they happen. And this organization is empowering providers to feel safe and confident in the rare chance that vaginal breech happens," I explained to her. "Makes sense."

Shortly after: "How many breech births have you seen," I ask. 

"Not many, usually only in twin births with the second baby." How interesting, the bulk of her breech experience is with vaginal twin births which occur a fraction as many times as vaginal breech with a singleton…. Her to me: "Do you do breech births?" 

"Oh no, I don't deliver breech births born to primips. And the only time I would catch a breech at home would be if it was a surprise, precipitous breech birth. And I'd call for transfer as soon as I confirmed a breech presentation. The political climate doesn't allow families much freedom in this regard." The "correct" answer to provide to an OB. 

"Yes," she nods.

The OB is stressed. Rightfully so. Baby's FHTs are telling us she is ready to be born, changing from tachycardia to bradycardia with each contraction. Her hands are shaking. She is stretching the tight perineal tissues that have never stretched so much before with her fingers. Doing something with her hands feels better than doing nothing. I get it. Something to control. Physiologic birth is unfamiliar to her. Physiologic breech, a foreign concept. A death sentence for a baby. A lawsuit for an OB. Baby descends more and more. End of contraction.

Mary pushed through about 3 or 4 contractions in this position when finally the widest diameter of baby's presenting part emerged. Baby was rumping. Go time. I could feel the fear radiating from the OB. Her hands were shaking. Her words not sounding confident, her voice shaking too.. Hands off the breech. Hands off the breech. She doesn't know this. It's not the time to tell her. Rumping. Baby descends in the complete breech position, legs not yet released from the perineum.

While Mary pushed in this slightly inclined McRoberts position, I asked "How about we get her upright and kneeling, have her lean on the headboard, and use gravity to help this baby descend. When you can see the nipple line, you can do maneuvers if needed." "Yes," she says, "let's do it." Yes?... Yes! Perfect, I can see what I need to now. Mary is upright, her back to the doctor, baby's front to the doctor as well.

More descent. Slowly more. And more yet, until finally, one leg releases and then the other. Baby partway rotating from SR to SA.

The OB's fear was making me uneasy. Shortly before rumping, while the OB continued to mention a recommendation for cesarean, I was prepared to encourage Mary to consent to the surgical birth. Because a scared provider is not a safe provider. And while a surgical birth is not what she, her partner, or I wished for, it was looking as though it would be the safest birth, and at the end of the day, safety is the highest priority. My clients want to return home with a healthy baby in arms.

Like one magnet to another, the hands of the OB shot out and grabbed onto the torso of this baby that was now born to just above her umbilicus. "Mary," I called in delight, "your baby's cord is thick and pulsing and beautiful." Baby had rotated from the right sacral position to sacral anterior. Exactly by the books. There is some creasing at the sternum. Baby's arms are properly positioned. "Your baby is well." 

At this point in an upright breach, the provider would be watching closely for tummy crunches that indicate vitality as further descent happens; however, with so much stimulation from the hands of the OB, it was challenging to note if there were any tummy crunches. Now I am scared. Oh no, we never pull on babies. What do I do? How do I advocate for this family? It was there that my rational brain left my body, and my instinctual, midwife brain (that struggles to keep my mouth quiet) entered the room.

Slow descent. More pulling. "How about some fundal pressure? That can help baby descend to the nipple line." The cord is thick and pulsing. 

"Yes, DO IT," the OB says. What?? Me? I look to the charge nurse on my left. The nurse attempts fundal pressure. It's not working. She isn't looking for the fundus in the right place. "Remember, the baby is halfway born so the fundus is located closer to the pelvis."

She tries again. Yes. It's working. Baby is descending more. The nipple line is visible with chest cleavage, still indicating arms are positioned ideally. One arm is released and then the other. The doctor has her hands inside Mary. "Do you feel chin flexion?," I ask the OB. 

"Yes," she says, "I have chin flexion." She is preparing to extract the head, terrified. The moment she has been dreading. But everything is fine. By the books, even. Only, she doesn't know that, despite my encouragement. 

"The perineum is not full. You could try a shoulder press to fill the perineum and release baby's head," I suggest. 

"What is that?" 

I hold my hand out in front of baby, demonstrating how and where to position her hand so that pushing the front of baby toward the direction that Mary is facing will achieve perineal fullness and allow this baby to be fully born. "I don't know how to do that," she says in a panic. 

"Here, like this," I calmly say as I demonstrate again. She holds her hand out, making an 'L' with her thumb and fingers, ready to catch baby's head by her chin in the crook of her hand as she presses firmly on the baby's chest.

The shoulder press worked. Once again, a full perineum.

The head is born. Baby is fully born. I just coached an obstetrician through the vaginal, upright, (mostly) physiologic breech birth of a 7lb 14oz baby girl who was born after roughly 1 hour of pushing.

~~~

It was a pretty incredible experience. What are the chances that the first vaginal breech birth I attend is at a hospital that doesn't "allow" VBB. And even slimmer are the chances that I'm able to competently walk an obstetrician through a breech birth only having education and not first hand experience.

I am so grateful for the OB on call that day. She was so brave. And I'm really proud of myself for communicating with the staff in a way that left space for collaboration. I totally recognize that I was overstepping by making recommendations to her and don't make a habit of that. But in this situation, I think it helped everyone have a great experience. And my hope is that maybe there will be 1 person, just 1 (out of the literal 15 in the room) who witnessed that birth who will go on to learn more about safe breech and supporting families through this variation of normal autonomously. And maybe that will be the impetus that brings more light to this very important aspect of birth!

Also, I hope the OB and rest of the crew there recognize that safe homebirth professionals are competent and that collaboration only helps everyone involved.

It was really cool getting to debrief with Elizabeth afterwards and thank her profusely for her instruction just weeks prior to this birth. I share this to thank you all for what you do and the training you provide. It really does make a difference, and it's impacting families everywhere. If it weren't for you, I wouldn't have had the foundation to support my clients in that capacity.