Tuesday, February 12, 2013

Breech vaginal birth: Turn the picture up the other way

Today I am focusing on the subtle but significant difference between spontaneous breech birth, and managed breech delivery.

Recently I was in a major public hospital with a woman in labour, who was intending to give birth to her breech baby vaginally.  This was her first baby.  The fact that her baby was presenting as a complete breech (tailor sitting - legs crossed) had been discovered by a midwife during a routine antenatal check a couple of days earlier.  She was labouring well, and was probably close to fully dilated at around 06:00 hours, when the medical team entered the room to have a chat with her.

Dr #1 was accompanied by Dr #2.  They were both very new to their respective jobs - teaching hospitals have times, like this, when the new Registrars and Residents take up their positions.  Dr #1 did the talking; the younger #2 watched and listened.  They had been told that this woman wanted to give birth vaginally.  Dr #1 was very friendly, using old-fashioned familiar language such as 'dearie' and 'sweetie' that is not really acceptable in such circumstances, in today's world.

Dr #1 informed the woman that the hospital's advice at this point in time was a caesarean birth; that the hospital considered the risk of vaginal breech birth to the baby to be too great, and quickly listed off a bunch of horrible things that could happen to the baby if she did not have that caesarean.  There was no mention of risk to mother or baby from caesarean.  There was no scope for an informed decision or questions - the decision had been made.

I wish I had made a note of the items on that list.  I was surprised at the speed of delivery, and the inherent threat.  Babies being rushed to the nursery with cerebral palsy from hypoxia; with broken bones; with other brain damage ... and that the mother herself had a greater risk of a fourth degree tear!  That if she refused a caesarean she would be required to have an IV line in situ, and continuous electronic fetal monitoring, and be placed in lithotomy position with her legs in stirrups.  I don't think the mother heard or understood much of what was said to her in that brief exchange.

I stayed at the woman's side, and was not able to question or debate the doctor's pronouncements.  She finished her shift in the morning, before the baby was born.

The point that was clear to me was that this doctor was performing what she considered her 'duty of care', in the interests of wellbeing and safety of mother and baby.   She took the high moral ground, referring to the evidence (the 'Term Breech Trial' - Hannah et al, 2000) which was like the Pied Piper of Hamlin, leading all the breech mothers directly to the operating theatre.

I began this post saying that I wanted to explore the subtle but significant difference between spontaneous breech birth, and managed breech delivery.

The hospital in this little story, and probably all the other hospitals in Melbourne, would not acknowledge spontaneous breech birth as a realistic option; as indeed women who want spontaneous natural cephalic births, and spontaneous natural third stages can find themselves arguing against the experts.  The only way that most obstetricians know for vaginal breech birth is a managed breech delivery.   I have witnessed doctors performing the moves with great skill, and have seen babies come through managed breech deliveries well.

There is an excellent set of drawings, accompanied by brief comment and instruction, available online at the Women's Hospital Policy, Guideline and Procedure Manual: Breech - Management of (Publication date (08/10/2012)

This guideline describes vaginal breech delivery.  The drawings are all done with the woman's sacrum below the action.  Even Picture 1, which describes the position of the fetus at the beginning of labour, shows the woman's pelvis in a recumbent position.

Turn Picture 1 and Picture 2 a quarter turn to the Right, and the mother's spine will be upright, as indeed a woman in active first stage labour would usually be.

Pictures 3-8 need to be turned a full 180degrees.  The woman needs to be on all fours - hands or elbows, and knees, as the breech progresses and the baby's body becomes visible.  The body needs to hang, using gravity and the weight of the baby to bring the head into the pelvis and through the birth canal.  Picture 9a becomes irrelevant, and picture 9b is reversed.  Maneuvers to release the arms, and to flex the head, if needed, can be performed by the accoucheur. 

Here is a YouTube video of spontaneous breech birth demonstrating the 'all fours' position for the birth of the baby. 

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