North of England Breech Conference II
March 31-April 1, 2017
Jane Evans: A day at the breech
March 31, 2017
Jane Evans has presented at several breech conferences around the world. I highly recommend reviewing at her presentations at those conferences: Mechanisms of Breech Birth (Amsterdam 2016), Physiological Breech Birth and Cardinal Movements of the Breech Baby (Washington, D.C. 2012).
She began today's lecture by mentioning the book Normalizing Complex or Challenging Childbirth. She wrote chapter 8 on breech birth.
Jane saw just one vaginal breech during her midwifery training and then went 10 years without seeing any breeches. Later she became an independent midwife (IM). She, Mary Cronk, and another midwife started meeting to discuss upright/kneeling breech births. They held their first Breech Study Day in the Grafton hotel showing slides of a VBB with a woman in a kneeling position. They kept studying breech with their group of IMs and began offering more Study Days around the country.
After the TBT shut everything down for vaginal breech birth, she and other independent midwives still felt very strongly that they must keep their skills alive because 1/3 of breech babies are undiagnosed until labor. Until you've had a surprise breech, you're not a midwife! It's easy to not really be able to feel a breech on internal examination. Jane Evans also has a personal connection to vaginal breech birth; her granddaughter was born breech and she was the midwife.
Goals for Study Day participants:
- Feel confident that many women are able to give birth to their babies, even though that baby is in an unusual position
- Have a clear understanding of the mechanisms and the path through the pelvis that the breech presenting baby takes. What is normal, what are the mechanisms.
- Feel confident about recognizing when/where to help
- Enjoy learning how amazing nature is. Feel able to confidently offer women a truly informed choice when a breech is discovered.
Jane then reviewed the causes of breech presentation, which include
- Gestational causes: (the shorter the length of gestation, the more often babies are breech)
- Fetal causes: 10% of breech babies have something wrong with them
- Maternal causes: ovarian cysts, uterine anomalies, pelvic fractures, etc
Definition of a breech birth (midwives' version):
- A breech birth follows the spontaneous onset of labor at or around term, i.e. 37th to 42nd week of gestation. No induction & no augmentation.
- Labor progresses well, gets stronger, and contractions come "much too often and far too long to the woman." (ie, a well progressing labor)
- The presenting part descends, and there is effacement & dilation of the cervix. As long as this is happening, at whatever speed, the outlook for a vaginal birth looks good. Some women might take a lot longer. A stop & start labor is a red flag that the birth might need help at some point. Slow, steady progress is ok.
- 2nd stage: the baby descends and is born on mother's efforts, without traction. The baby makes movements and is not a passive passenger.
Jane then explained why so many women adopt a kneeling or all-fours position for both breech or cephalic babies. If squatting is part of their normal everyday life, women will often squat during the birth. But if they are more used to chair sitting--which is common for many women today--squatting isn't as comfortable for their bodies. So upright kneeling tends to be a position of choice. When the women feels most comfortable, physiology will then work for her. We can't ignore physiology or neglect applying our knowledge of anatomy!
Jane then showed a series of slides and films of vaginal breech births as she summarized the cardinal movements of a breech baby. Some words of advice:
- Don't push a woman back up if she moves her bum towards the ground/bed-it's helping to open her pelvis.
- When the baby flexes laterally, their shoulders flex down-this puts the posterior shoulder to the posterior wall of the pelvic floor. The baby is spiraling out. While you're seeing the baby's bottom emerging, the shoulders are going into the brim of the pelvis.
- Don't flip out the legs. If you do, you're going to interfere with the baby's normal movements at this point (tilting its head back around the sacral prominence). The baby will arch its back really, really far back, and its legs seem to go on forever. Again, at this point, women will often drop down. Don't push them back up! When women drop down at this point, the uterus contracts and helps flex the baby and the baby's head more. A flexed baby is good!
- You don't really need to worry about cord compression until both arms are out; at that point, the head comes into the pelvis.
- When the baby does a "tummy scrunch" or "tummy tuck" after the torso and arms are born, that movement rotates the back of the baby's head on the internal symphysis pubis. When the baby does the tummy scrunch, the moms often need to move, and the baby usually drops out. (Rixa's note: several presenters emphasized that a tummy tuck is a normal, physiological part of an upright breech birth. Sometimes it happens really quickly; other times you can easily see the baby lifting its arms and legs and scrunching in its belly, as if it's doing a sit-up in the air. An inexperienced provider might see a baby doing a tummy tuck and think that the baby is seizing or otherwise in danger.)
Throughout this whole presentation, Jane kept referring to head-down babies being "reverse breech." This was an ongoing joke at the conference.
Here is an alphabet soup of the breech baby's cardinal movements: