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Becoming a Breech Expert (BABE®) Course

AMaRE Australia

5th Edition

2015

BABE Course: AMaRE Australia (2015)2

BABE Course: AMaRE Australia (2015) 1

Becoming a Breech Expert (BABE®) Course Manual

Advanced Maternity & Reproductive Education (AMaRE) Australia

5th Edition 2015

The BABE® course was developed by a group of obstetricians, midwives and consumers as part of the AMaRE Australia suite of education programs.

The BABE course is administered by AMaRE Australia which is a not‐for‐profit organisation. AMaRE Australia is run by a seven‐person Board who are all volunteers. The members of the instructor Faculty are also all volunteers. The Board and the Faculty have assisted in the development of this course.

The BABE course can be claimed for Continuing Professional Development points (RACGP has approved 40 Category 1 points, RANZCOG has approved 8 C points) or you can claim at least 8 MidPLUS points with ACM (plus time for pre‐reading).

Completion of the BABE course does not license participants to practice beyond the scope defined by their relevant registration boards and professional bodies.

Disclaimer

The Board and Faculty of AMaRE Australia have made considerable efforts to ensure that the content of the course is accurate and up to date. Users of the information presented in the course are strongly recommended to consult independent sources and local resources, for confirmation. The Board and Faculty accept no responsibility for any inaccuracies, information perceived as misleading, or the outcomes of using any management strategies that are presented in the course.

Contributors to the 1st Edition of the BABE Course Manual

Name (in alphabetical order)

Discipline

Jyai Allen Consumer and Midwife Andrew Bisits Obstetrician Helen Cooke Warwick Giles

Midwife Obstetrician

Caroline Homer Midwife Mandy Hunter Midwife Henry Murray Obstetrician


Karol Petrovska Consumer Anne Sneddon Obstetrician Rhonda Tombros Consumer

AMaRE Australia/ALSO Asia Pacific Board Anne Sneddon, James Lie, Helen Cooke, Andrew Bisits, Kevin Stanton, Teoni McHale, Caroline Homer

Contact details AMaRE Australia c/o Mayhem Corporation Pty Ltd ABN: 86 092 862 229 Address: Level 1, 4 ‐ 6 Park Lane, Caringbah NSW 2229 Phone: (02) 9531 5655 Fax: (02) 8209 4949

Recommended citation AMaRE Australia (2015) Becoming a Breech Expert (BABE) Course Manual. 5th Edition. AMaRE Australia, Sydney.

Acknowledgements Some of the teaching materials used in the BABE course were taken with permission from the Hands off the Breech Conference and Workshop held in Sydney in December 2012. This was organized by Professor Sally Tracy and her team at the Midwifery and Women's Health Research Unit, University of Sydney and Dr Andrew Bisits from the Royal Hospital for Women in Sydney in conjunction with Women's Hospitals Australasia (WHA).

We thank Karin Ecker who filmed the entire proceedings of the conference and workshop. In the BABE course, we have used sections from these films with permission and sincere thanks.


Table of Contents

BABE Course Program _______________________________________________________ 6

Chapter 1: Breech presentation and breech birth – the evidence _____________________ 7

Objectives ______________________________________________________________________ 7

Epidemiology ___________________________________________________________________ 7

Causes of breech presentation _____________________________________________________ 9

The evidence about vaginal breech birth _____________________________________________ 9

Changes in practice and outcomes since the TBT ___________________________________________ 10

Studies supporting the safety of vaginal breech birth ________________________________________ 11

National and international guidelines ______________________________________________ 13

Australia ___________________________________________________________________________ 13

United Kingdom _____________________________________________________________________ 14

United States ________________________________________________________________________ 15

Canada _____________________________________________________________________________ 15

Providing women with the evidence _______________________________________________ 15

Summary _____________________________________________________________________ 16

Chapter 2: Breech presentation and breech birth _________________________________ 18

Objectives _____________________________________________________________________ 18

Definitions ____________________________________________________________________ 18

The fetal head and the maternal pelvis _____________________________________________ 19

Diagnosing a malpresentation ____________________________________________________ 19

Antenatal care of women with a breech presentation _________________________________ 20

Postural options for women with a breech presentation _____________________________________ 20

Moxibuston _________________________________________________________________________ 20

The Webster Technique _______________________________________________________________ 21

External Cephalic Version (ECV) _________________________________________________________ 21

Labour and birth _______________________________________________________________ 21

Positions for birth ____________________________________________________________________ 22

The mechanism of the birth ____________________________________________________________ 22

When is assistance required? ___________________________________________________________ 24

Forceps ____________________________________________________________________________ 25

Rare difficult situations in a breech birth __________________________________________________ 26

Principles in an unexpected vaginal breech birth ____________________________________________ 27

After the birth _________________________________________________________________ 27


Summary _____________________________________________________________________ 27

Chapter 3: Critique of the Term Breech Trial _____________________________________ 29

Objectives _____________________________________________________________________ 29

Introduction ___________________________________________________________________ 29

Issues with the Term Breech Trial __________________________________________________ 29

Critiques of the Term Breech Trial _________________________________________________ 30

Follow‐up data _________________________________________________________________ 32

Useful learning points from the TBT ________________________________________________ 32

Conclusion ____________________________________________________________________ 33

Chapter 4: External Cephalic Version for Breech Presentation ______________________ 34

Objectives _____________________________________________________________________ 34

Introduction ___________________________________________________________________ 34

Timing of ECV __________________________________________________________________ 34

Factors associated with successful ECV _____________________________________________ 35

Complications _________________________________________________________________ 35

Contraindications to ECV _________________________________________________________ 36

Procedure for External Cephalic Version ____________________________________________ 36

Recommendations ______________________________________________________________ 38

Chapter 5: Care of the woman planning vaginal breech birth _______________________ 39

Objectives _____________________________________________________________________ 39

Physiological differences between cephalic and breech presentation ____________________ 39

Criteria for making vaginal birth possible: ___________________________________________ 40

Induction of labour _____________________________________________________________ 41

Augmentation of labour _________________________________________________________ 41

Care in the first stage of labour ___________________________________________________ 42

Fetal monitoring _____________________________________________________________________ 42

Managing pain in labour _______________________________________________________________ 43

Care in the second stage of labour _________________________________________________ 43

Positions for second stage _____________________________________________________________ 44

Positions for birth ____________________________________________________________________ 44

Episiotomy __________________________________________________________________________ 44

Fetal monitoring in the second stage _____________________________________________________ 44

Summary _____________________________________________________________________ 45


Chapter 6: Women’s views and experiences _____________________________________ 46

Matilda’s birth _________________________________________________________________ 46

Vaginal Breech Birth: From Doubt to Decision _______________________________________ 52

Elsa’s birth: Caesarean after trial of labour __________________________________________ 56

Vaginal breech birth: Driving interstate to access supportive public maternity care _________ 63

The importance of ‘having a go’ ‐ A caesarean after labour _____________________________ 69

Chapter 7: Setting up a breech service _________________________________________ 74

Objectives _____________________________________________________________________ 74

Introduction ___________________________________________________________________ 74

Maternity carers _____________________________________________________________________ 74

Planned elective vaginal breech birth ______________________________________________ 75

The Breech Score ____________________________________________________________________ 77

Discussing vaginal breech birth _________________________________________________________ 78

Training for obstetricians and midwives ____________________________________________ 78

Review and audit _______________________________________________________________ 79

Summary _____________________________________________________________________ 79

Resources for women and clinicians ___________________________________________ 80

References _______________________________________________________________ 84

Slides used in the BABE Course _______________________________________________ 87


BABE Course Program

TIME LECTURES/WORKSTATIONS ALLOTTED TIME

8:00 – 8:10 Welcome – aim of course, confidentiality, copyright 15 minutes

8:10 – 8:30 Breech presentation in many settings today (video)

15 minutes

8:30 – 9:00 Lecture 1: Communicating the evidence

30 minutes

9:00 – 9:20 Lecture 2: External cephalic version

20 minutes

9.20‐10.00 Lecture 3: Mechanics of vaginal breech birth

40 minutes

10.00 – 10.20 MORNING TEA 20 minutes

10.20 – 11.00 Lecture 4: The reality of breech birth

40 minutes

11.00‐11.20 Lecture 5: Consumer perspectives

20 minutes

11.20 – 12.10 Lecture 6: Dealing with the unexpected

45 minutes

12.10 – 12.55 LUNCH 45 minutes

12.55 ‐ 1.25 Lecture 7: Setting up the birth space

30 minutes

1.25 – 2.20 WORKSTATIONS 1 Normal breech Complicated breech Counselling women

55 minutes Red Group Blue Group Yellow Group

2.20 – 2.25 Changeover

2.25 – 3.20 WORKSTATIONS 2 Normal breech Complicated breech Counselling women

55 minutes Blue Group Yellow Group Red Group

3.20 – 3.40 AFTERNOON TEA 20 minutes

3.40 ‐ 4:35 WORKSTATIONS 3 Normal breech Complicated breech Counselling women

55 minutes Yellow Group Red Group Blue Group

4:35‐4:55 Lecture 8: Requirements for a safe vaginal breech service

20 minutes

4:55‐5.00 Finish


Chapter 1: Breech presentation and breech birth – the evidence

Chapter written by Andrew Bisits, Caroline Homer and Rhonda Tombros

Objectives

At the end of this chapter participants will be able to understand the:

epidemiology of breech birth

the causes of breech presentation

evidence and debate about the evidence

international guidelines in relation to breech birth

Epidemiology

In a breech presentation, the fetal breech or buttocks present in the birth canal with the head lying

in the uterine fundus. Breech presentations may be classified as:

Frank breech: hips flexed and legs extended over the anterior surface of the body ‐ occurring

in 45‐50% of breeches.

Complete breech: hips and legs flexed ‐ occurring in 10 to 15% of breeches.

Footling breech: one or both hips and knees extended with one or both feet presenting ‐

occurring in 35‐45% of babies in a breech presentation.

In Australia in 2012 (the most recent data available), the predominant presentation at birth was

vertex (95.8%). Breech presentation, the presentation occurred for 3.4% of women. Of the 11,557

women with a breech presentation, 92.2% were singleton pregnancies and 7.8% were multiple

pregnancies where the first baby born had a breech presentation [1].

Currently, in Australia and New Zealand, most women with a breech presentation give birth by

caesarean section. Of babies with breech presentations at birth in 2012, 87.0% were born by

caesarean section. This ranged from 77.1% in Tasmania to 88.6% in South Australia and the

Australian Capital Territory. The remaining babies were born vaginally [1] (Table 1).


Table 1: Babies with breech presentations, by method of birth and state and territory, 2012 [1]

Mode of birth

NSW Vic(a) Qld WA SA Tas(b) ACT(c) NT Total

Number Vaginal(d) 513 467 362 181 110 36 32 21 1,722 CS 3,166 3,076 2,604 1,354 854 121 248 132 11,555 Total 3,681 3,543 2,966 1,535 964 157 280 153 13.279 Percent Vaginal(d) 13.9 13.2 12.2 11.8 11.4 22.9 11.4 13.7 13.0 CS 86.0 86.8 87.8 88.2 88.6 77.1 86.6 86.3 87.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 (a) Data provided by Vic are provisional. (b) For Tas, presentations via caesarean births were not reported by hospitals still using the paper-based form, so care must be taken when interpreting these data. Presentations via caesarean births will be included in the paper-based form from 1 January 2013. (c) In 2012, 14.2% of women who gave birth in the ACT were non-ACT residents. Therefore care must be taken when comparing percentages between jurisdictions. (d) Includes instrumental vaginal births.

In 2012, of singleton babies born at term with breech presentations, most were born by CS. Of

singleton babies born at term with breech presentations, 95.4% were born by caesarean section.

Over three‐quarters of all term singleton breech births were delivered by caesarean section without

labour (77.9%) [1] (Table 2).

Table 2: Singleton term babies with breech presentations, by method of birth and state and territory, 2012 [1]

Mode of birth NSW Vic(a) Qld WA SA Tas(b) ACT(c) NT Total NumberVaginal(d) 113 98 95 25 23 5 8 7 374CS 2,361 2,001 1,662 903 571 85 158 83 7,824

Labour 408 333 344 159 122 14 36 19 1,435

No labour 1,953 1,668 1,318 744 449 71 122 64 6,389

Total 2,474 2,099 1,757 928 594 90 166 90 8,198 PercentVaginal(d) 4.6 4.7 5.4 2.7 3.9 5.6 4.8 7.8 4.6CS 95.4 95.3 94.6 97.3 96.1 94.4 95.2 92.2 95.4

Labour 16.5 15.9 19.6 17.1 20.5 15.6 21.7 21.1 17.5

No labour 78.9 79.5 75.0 81.6 80.2 75.6 78.9 71.1 77.9

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

(a) Data provided by Vic are provisional. (b) For Tas, presentations via caesarean births were not reported by hospitals still using the paper-based form, so care must be taken when interpreting these data. Presentations via caesarean births will be included in the paper-based form from 1 January 2013. (c) In 2012, 14.2% of women who gave birth in the ACT were non-ACT residents. Therefore care must be taken when comparing percentages between jurisdictions. (d) Includes instrumental vaginal births.

Prematurity is commonly associated with a breech. As the baby approaches term, the incidence of

breech drops to three to four percent (Table 3).


Table 3: Fetal presentation at various gestational ages

Gestation (weeks) Percent breech

21 to 24 33

25 to 28 28

29 to 32 14

33 to 36 9

37 to 40 3

Modified from Scheer and Nubar [2]

Causes of breech presentation

One of the main factors for breech presentation is prematurity as discussed above. Other

predisposing factors include women with high parity and relaxation of the uterine and abdominal

wall, uterine anomalies, pelvic tumours, polyhydramnios, oligohydramnios, macrosomia, multiple

pregnancy, placenta praevia, absolute cephalopelvic disproportion; and previous breech. Various

fetal anomalies including hydrocephalus, anencephaly and Down Syndrome are also associated with

a higher incidence of breech presentation. Breech babies, preterm and term, have double the

incidence of anomalies compared to cephalic presentations at term. Because of these associations a

formal ultrasound with a fetal anatomical survey is indicated whenever a breech presentation is

diagnosed in the mid‐third trimester or later. Often, no cause is found.

The evidence about vaginal breech birth

The optimal mode of birth for breech infants has been the subject of much controversy. In the

1990s, vaginal breech birth numbers were steadily declining; then with the results of the

international Term Breech Trial in 2000 vaginal breech births plummeted in favour of elective or

semi elective caesareans [3, 4].

In 1996, the Term Breech Trial was commenced. This was a randomised controlled trial comparing

planned elective caesarean delivery to planned vaginal birth for selected breech presentations:

greater than 37 weeks, frank or complete breech, and less than 4000 grams estimated fetal weight.

This trial was undertaken in 121 centres over 39 months. It was terminated early, in April 2000, after

preliminary data analysis showed a significant reduction in perinatal mortality and morbidity, and no

increase in serious maternal complications, in the elective caesarean group [3]. The findings of the

trial showed that there was:

5% of babies with significant adverse events

increased perinatal mortality (with 3 deaths)

no difference in maternal morbidity

no subgroup analysis could point to a “safe “ set of circumstances.

Since that time there has been extensive criticism about the external validity of the trial [5‐7]. A

detailed critique of this trial; is included in a subsequent chapter in this BABE course manual.


Changes in practice and outcomes since the TBT

Following the TBT, practice in many countries dramatically changed [8]. For example in The

Netherlands within two months of publication of the trial, the overall caesarean rate for infants born

at term in the breech presentation increased from 50% to 80% and remained stable for the next 2

years. An observational study undertaken from 1998‐2002, showed that for infants < 4000gms this

was associated with a significant decrease of perinatal mortality from 0.35% to 0.18%, a decrease of

the incidence of a 5‐minute Apgar score <7 from 2.4% to 1.1% and a decrease of birth trauma from

0.29% to 0.08% [9]. In Australia, there was a similar change in practice with trainee obstetricians

reporting decreased opportunities to learn vaginal breech birth [10] and significantly less

obstetricians (73% prior to the TBT to 20% afterwards) routinely offering vaginal breech birth for

women with uncomplicated singleton breech pregnancies [4].

These changes were also driven by other observational studies. Again in Holland, a retrospective

observation study used routinely collected data from 1995‐1999, compared neonatal outcome of

infants born in breech presentation in relation to the different modes of delivery (i.e. planned

caesarean section, emergency caesarean section and vaginal birth) after controlling for parity,

duration of gestation and birthweight [11]. The analysis showed an association between vaginal

birth and emergency caesarean section and an increase in low Apgar score, birth trauma and

perinatal mortality compared with planned caesarean section. However, data on longer term

morbidity outcomes were not presented.

Interestingly, despite these findings, two later papers from Holland raised concerns about the

maternal mortality rate and increased long‐term risks including perinatal deaths and maternal life‐

threatening risks such as uterine rupture in subsequent pregnancies[8, 12, 13]. The Dutch paper

from 2007 concluded that “Elective cesarean section does not guarantee the improved outcome of

the child, but may increase risks for the mother, compared to vaginal delivery” [12].

More recently, another study from The Netherlands has shown decreased perinatal mortality and

morbidity over a 8 year period [14]. This study used data from the Dutch national perinatal registry

from 1999‐2007 to examine the effect of practice changes post the Term Breech Trial. The

population based study showed that, overall perinatal mortality decreased [1.3 vs. 0.7; odds ratio

0.51 (95% confidence interval 0.28–0.93)], whereas it remained stable in the planned vaginal birth

group [1.7 vs. 1.6; odds ratio 0.96 (95% confidence interval 0.52–1.76)]. The study calculated that

the number of cesareans done to prevent one perinatal death was 338.

This study has received some online criticism [15, 16]. The study did not provide details on the

circumstances surrounding the perinatal mortality and morbidity including the management of the

labour and the reasons for the deaths. This means that it is not possible to determine whether more

careful management in labour could have impacted on the outcomes. The paper recognises that up

to 40% of women in The Netherlands will choose a vaginal breech but does not provide any guidance

to clinicians and services on how these women should be cared for other than suggesting a CS. In

addition, unexpected or unplanned vaginal breech birth will still occur and resorting to a policy of CS

will mean an even further dilution of skills. The study does acknowledge that the risk of a previous


CS in a future pregnancy carries risks in itself stating “the relative safety of an elective cesarean

should be weighed against the consequences of a scarred uterus in future pregnancies”.

Studies supporting the safety of vaginal breech birth

Several other observational studies have attested to the safety of vaginal breech birth so long as

strict criteria are adhered to [17‐19].

Goffinet et al [17] undertook an observational prospective study with an intent‐to‐treat analysis to

compare planned caesarean section with planned vaginal birth for women with a breech

presentation at term. The principal outcome measure was a composite variable which was similar to

that used in the Term Breech Trial. The study included more than 8000 women who had a singleton

breech presentation at term in 138 French and 36 Belgian maternity units.

In this study, which is known as PREMODA (PREsentation et MODe d’Accouchement: presentation

and mode of delivery) [17], caesarean section was planned for 69% and vaginal birth for 31% of

women. Of the women with planned vaginal birth, 71% gave birth as planned.

The principal outcome measure was defined as fetal or neonatal mortality at less than 28 days of age

before discharge (excluding lethal congenital anomalies) or 1 or more of the following: birth trauma,

including subdural hematoma, intracerebral or intraventricular haemorrhage, spinal‐cord injury,

basal skull fracture, peripheral‐nerve injury present at discharge, or clinically significant genital

injury; seizures occurring at less than 24 hours of age; 5‐minute Apgar score of less than 4,

intubation and ventilation for at least 24 hours, tube feeding for at least 4 days, or admission to the

neonatal intensive care unit for longer than 4 days.

The rate of the combined neonatal outcome measure was low in the overall population (1.59%; 95%

CI 1.33‐1.89) and did not differ between the groups (unadjusted OR =1.10, 95% CI 0.75‐1.61), even

after controlling for confounding variables (adjusted OR = 1.40, 95% CI 0.89‐2.23).

The authors concluded that in maternity units or countries where planned vaginal birth is a

widespread practice and has careful policies about practice and care before and during labour, there

was no significant excess risk associated with planned vaginal birth compared with planned

caesarean section for women with a singleton baby in a breech presentation at term.[17]

A secondary analysis of the PREMODA data was undertaken to identify factors associated with

adverse perinatal outcomes among term breech babies with planned vaginal birth [20]. Among the

2502 women analyzed in the secondary analysis, 71% gave birth vaginally. In the analysis, the risk of

adverse perinatal outcomes was not associated with any factors related to pregnancy, labour or

birth. There was a lower risk of adverse outcomes associated with giving birth in the higher level

hospital and in one with more than 1500 births per year.

Prior to the release of the TBT, a clinical follow‐up study was performed between 1984 and 1992 of

all term singleton breech presentations in Norway [19]. Each woman included for vaginal breech

birth had a matched control in the vertex position. The study used a strict protocol to guide which

women were considered suitable for a vaginal breech birth. Vaginal delivery increased from 45% to


57% (p = 0.01), and caesarean section for failure of vaginal delivery declined from 21% to 6% (p <

0.01). None, however, died or had Iong‐term sequelae because of a complicated or failed vaginal

breech birth. The authors concluded that women with a breech presentation can be offered vaginal

birth if properly managed.

A systematic review of vaginal breech birth outcomes was conducted by a Norwegian group [21].

The study was performed in a systematic manner in accordance with international criteria for health

technology assessments and studies were graded according to preset criteria. In conclusion, vaginal

delivery for term breech presentation was found to be advisable in suitable cases after careful

selection, given the facilities for fetal electronic monitoring, experienced obstetric staff, facilities for

emergency caesarean section and a good neonatal service.

Another observation study from Europe (Finland) showed that the only difference for a carefully

selected group of breech babies versus a comparable group of babies in the vertex presentation

were lower Apgar scores for the breech babies. However, by the age of 7 years, the babies born by

vaginal breech were similar in terms of general health and readiness for school compared with the

similar group of babies born head first. The conclusion was that if women were carefully selected

and appropriately cared for during labour, vaginal birth for term breech is as safe as for term vertex

babies [22].

Smaller prospective observation studies have also shown that the outcome for babies from vaginal

breech births and of those from elective caesarean section were comparable in terms of cord blood

pH, base excess, Apgar score, fetal trauma, and transfer to neonatal intensive care unit. This study

again concluded that vaginal breech birth is a safe option in a stand‐by system of senior obstetricians

with controlled decision‐making before labour [23]. Another Finnish study showed that selective

vaginal breech births may be safely undertaken in units having a tradition of vaginal breech birth

[24].

Closer to home, an Australian study undertaken at a single site in New South Wales compared the

short‐term neonatal and maternal morbidity for infants with a singleton breech presentation born

after 37 weeks, according to planned mode of birth over an 11‐year period [25]. Two hundred and

forty‐three of 766 (31.7%) eligible women elected for planned vaginal breech birth with an overall

success rate (achieving a vaginal birth) of 58%. Morbidity rates were low and were similar to

international studies. However, there was a non‐significant trend towards higher rates of short‐term

serious neonatal and maternal morbidity in the planned vaginal birth group (1.6 vs 0.4%, P = 0.08

and 8.2 vs 4.8%, P = 0.06, respectively).

The common theme from most of the prospective and retrospective observational studies is that

vaginal breech birth is a good option to present to carefully selected women in systems that provide

expertise and high level of care. Guidelines from professional groups can assist in determining this

careful selection. A number of these are described in the next section.


National and international guidelines

Statements and guidelines from four prominent colleges of Obstetricians and Gynaecologists are

reviewed in this chapter: the Royal Australian and New Zealand College of Obstetricians and

Gynaecologists [26]; the Society of Obstetricians and Gynaecologists in Canada [27]; the British Royal

College of Obstetricians and Gynaecologists [28], and the American College of Obstetricians and

Gynaecologists [29]. Each of the colleges base their guidelines/statements on the physiology of

breech birth, the results of the Term Breech Trial (TBT), the PREMODA study (with the exception of

the ACOG) and other cohort or observational studies. They all acknowledge the importance of the

experience and clinical judgment of the health care providers and sound selection criteria for labour

and vaginal birth.

Australia

The Position Statement from RANZCOG acknowledges that many women with breech presentation

at term will choose to have a CS. They do state that the care of women should be individualized and

provide a list of factors that may favour women planning a vaginal breech birth [26]. This is

reproduced in the Figure below.

Figure 1: Factors that may favour a planned vaginal birth (RANZCOG) [26]

1. Reduced fetal risk from planned vaginal birth:

Continuous fetal heart monitoring in labour is required.

Immediate availability of caesarean facilities if necessary.

Availability of a suitably experienced obstetrician.

Presumed favourable fetal circumstances, e.g. small or average size, no placental

insufficiency, frank breech, appropriate gestational age, documented head flexion.

Favourable maternal circumstances, e.g. adequate pelvis, maternal co‐operation with

pushing, multiparity.

2. Increased risk from planned caesarean section:

In particular, this would include women planning a large family where a scar on the uterus

may have particular serious morbidity in association with placenta praevia accreta in

subsequent pregnancies.

3. Strong particular maternal preference for vaginal delivery:

Counselling the woman about the risks and benefits of planned vaginal breech birth should

be undertaken wherever possible.

Management of the Breech Presentation that is first diagnosed in Labour

Although far from desirable, even in the presence of optimal antenatal care, there will still be

pregnancies where the breech presentation is first diagnosed in labour. In determining the preferred

mode of birth in this circumstance, the accoucheur should consider all of the above factors and in


addition:

1. Whether caesarean section can be effected prior to spontaneous vaginal birth without the need

for undue haste that might further endanger mother or child.

2. Fetal well‐being as determined by cardiotocography.

3. Increased maternal risks of emergency caesarean section in this circumstance:

Anaesthetic considerations such as the woman who has not been fasting

Potential technical difficulties delivering the baby at caesarean section if the breech is very

low in the pelvis.

4. Increased fetal risks of vaginal breech delivery in this circumstance:

Including the possibility of undiagnosed congenital abnormalities or undiagnosed

hyperextension of the fetal head.

United Kingdom

In the United Kingdom, the RCOG’s guidelines have a series of recommendations in relation to the

planned mode of birth for women with a breech presentation at term.

Figure 2: Recommendations in relation to planned mode of birth (RCOG) [28]

Women should be informed of the benefits and risks, both for the current and for future

pregnancies, of planned caesarean section versus planned vaginal delivery for breech

presentation at term.

Women should be informed that planned caesarean section carries a reduced perinatal

mortality and early neonatal morbidity for babies with a breech presentation at term

compared with planned vaginal birth.

Women should be informed that there is no evidence that the long term health of babies

with a breech presentation delivered at term is influenced by how the baby is born.

Women should be advised that planned caesarean section for breech presentation carries a

small increase in serious immediate complications for them compared with planned vaginal

birth.

Women should be advised that planned caesarean section for breech presentation does not

carry any additional risk to long‐term health outside pregnancy.

Women should be advised that the long‐term effects of planned caesarean section for term

breech presentation on future pregnancy outcomes for them and their babies is uncertain.

Women should be assessed carefully before selection for vaginal breech birth.

Routine radiological pelvimetry is not necessary.

Diagnosis of breech presentation for the first time during labour should not be a


contraindication for vaginal breech birth.

United States

The American College of Obstetricians and Gynecologists made a number of recommendations in

2006 [29]. They stated that:

the decision regarding the mode of delivery should depend on the experience of the health

care provider.

caesarean section will be the preferred mode of birth for most physicians because of the

diminishing expertise in vaginal breech delivery

obstetricians should offer and perform external cephalic version whenever possible

planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital‐

specific protocol guidelines for both eligibility and labour management.

The ACOG go on to state that in those instances in which breech vaginal births are pursued, great

caution should be exercised, and detailed patient informed consent should be documented. Before

embarking on a plan for a vaginal breech birth, women should be informed that the risk of perinatal

or neonatal mortality or short‐term serious neonatal morbidity may be higher than if a CS is planned.

Canada

The guidelines from the Society of Obstetricians and Gynaecologists in Canada about the safe

conduct of vaginal breech birth [27] highlight certain contraindications for vaginal breech birth.

These apply to the unexpected breech birth as well as the planned vaginal breech. These include:

inadequate pelvis (very uncommon) based on the woman’s height and build or reduced

measurements on pelvimetry

estimated fetal weight on ultrasound 4.0kg or greater

severe prematurity ‐ defined variously

intrauterine growth restriction or evidence of placental insufficiency

footling breech at the onset of labour

hyperextension of the fetal head: birth can be difficult, and labour can result in neurological

injuries with a hyperextended head. an X‐ray of the abdomen may be necessary to

determine the attitude of the fetal head

fetal anomalies such as hydrocephalus

slow progress in labour, first or second stage

lack of a clinician with the experience, skill and confidence necessary for vaginal birth.

Providing women with the evidence

It is important the woman who have a breech presentation towards the end of their pregnancy are

provided with the evidence in a straight‐forward and non‐judgmental manner. Women’s consent for

a CS for a breech presentation is not fully informed if women are only told of the conclusions of the

Term Breech Trial. Women should also be told that the Term Breech Trial has been criticised in


terms of its methodology (including vaginal breech birth in conditions which many experienced

obstetricians would consider too risky) [7]; its conclusions (attributing neonatal harm to mode of

birth rather than to inappropriate management); and, the way it has been applied to obstetric policy

[30]

Women need to be informed that other studies have shown that, for carefully selected women, the

outcomes for women with appropriately managed vaginal breech births are usually as good as those

of elective CS [31]. Accurate information about the risks of VBB in absolute (rather than relative)

terms should be provided. For instance, even in the term breech trial ‘the risk in a multigravid

patient of a normally‐formed singleton breech presentation dying as a result of vaginal delivery was

zero’ [32]. The importance of a skilled provider needs to be explained to women as vaginal breech

birth is likely to be less risky in the presence of an experienced care‐provider.

A policy of elective CS for all women with a breech presentation late in pregnancy does not take into

account the long term obstetric implications of CS for the mother or the sociological and

psychological aspects of childbirth for women. These factors are extremely important to many

women but they are often underplayed with a focus on short‐term risk‐analysis alone.

The risks of CS for mother and baby appear to be poorly understood by women. Anecdotally, it

appears that many women see a CS as risk‐free. In particular, the implications for future

reproductive health should not be underplayed, including the increased risks of uterine rupture and

placental attachment abnormalities, particularly in the case of multiple CS. These 'down‐stream'

effects of routine CS for breech have not yet been properly analysed [31, 33]. Failing to offer women

any other option but CS may lead to an increase in unattended births and any resultant poor

maternal or neonatal outcomes [33].

If the hospital in which the woman is booked or attends or labour and birth, or her provider, are

unable to support vaginal breech birth, the woman should be advised as to where she can have a

second opinion and access to a vaginal breech service if she chooses this option.

Finally, women who present with an undiagnosed breech in labour face additional challenges in

terms of ensuring they have clinician with the necessary expertise and also obtaining the relevant

information in a time of stress. Despite the woman being in labour, 'emergency' caesarean sections

in these circumstances often take some time to organise, so that time could be spent providing

information and support to the woman and enabling her to make informed choices.

Summary

In summary, decision‐making about the mode of birth for women with a breech presentation at

term can be complex. Many factors must be taken into account, including the best conclusions from

the medical literature, community and national standards, the specifics of each individual case, the

woman's wishes and the skill of the clinician.

In order to optimise women’s opportunity to choose and have a vaginal breech birth, it is necessary

to reduce and balance the associated risks with labour and birth. This can be challenging given that it

is difficult to isolate and study the individual factors to provide the evidence to support or refute


them. However there are evidence‐based and well established clinical guidelines and college

statements available to guide practice.


Chapter 2: Breech presentation and breech birth

Chapter written by Andrew Bisits and Caroline Homer

Adapted with permission from ALSO Asia Pacific 2013 Manual

Objectives

At the end of this chapter participants will be able to:

define breech birth and understand the different positions

understand the principles around diagnosis of a breech presentation

discuss the antenatal care of a woman with a breech presentation

discuss the labour and birth care of a woman with a breech presentation

Definitions

Definitions are an important start in a discussion about women with a breech presentation.

Lie refers to the relationship of the long axis of the fetus to that of the mother, specified as

longitudinal, transverse, or oblique. Presentation refers to the portion of the fetus that is foremost

or "presenting" in the birth canal. The fetus may present by its vertex, breech, face, brow, or

shoulder. Position refers to a reference point on the presenting part and how it relates to the

maternal pelvis. For example, the reference point on the vertex is the occiput and in a breech it is

the sacrum.

Table 4: Incidence of malpresentations and malpositions at term [34, 35]

Malpresentation Incidence Percent

Occipito‐posterior 1 in 10 – 20 5 ‐ 10

Breech 1 in 25 – 33 3 ‐ 4

Transverse lie or shoulder presentation 1 in 322 – 420 0.3 ‐ 0.23

Face 1 in 500 – 1200 0.2 ‐ 0.08

Compound presentation 1 in 700 – 2235 0.14 ‐ 0.047

Brow 1 in 4470 0.02


The fetal head and the maternal pelvis

Most fetal malpresentations (posterior, breech, face, brow) are clinically significant because the fetal

head is not round but rather ovoid or egg‐shaped. The smallest of the important fetal diameters is

the sub‐occipito‐bregmatic; the largest is the occipito‐mental. The difference between them is three

centimetres, or about 24 percent. When the head is fully flexed the sub‐occipito‐bregmatic (9.5cm)

presents at the pelvic brim. When the head is in full extension (or deflexion) the occipito‐mental or

largest diameter presents.

Women are more likely to be able to achieve a vaginal birth, and theoretically it will be easier, if a

smaller diameter presents. Therefore, the attitude of the fetal head (flexion versus extension) is of

paramount importance. A degree of fetal extension of the head occurs with occipito‐posterior

presentations, face and brow presentations, and some breeches.

Diagnosing a malpresentation

There are three principal methods of determining fetal lie, presentation and position. These are

abdominal palpation, vaginal examination and imaging. Ultrasound is the preferred imaging method.

An ultrasound conducted in the Birth Suite or Labour Ward is widely utilised in many large and small

hospitals to diagnose a breech presentation when a woman is in labour. In situations where there is

no ultrasound, an X‐Ray can be used if there is uncertainty about the presentation.

The diagnosis of breech presentation can often be made by abdominal palpation and vaginal

examination. On Leopold's manoeuvres, the firm, ballotable, rounded head is felt in the fundus.

On vaginal examination either small parts or the breech itself may be detected. If small parts are

palpated it is essential to distinguish between a hand and a foot. The breech itself is smooth and

rounded and may feel remarkably like the fetal head. Most maternity providers have had the

experience of "missing a breech" on vaginal examination. The key is to seek fontanelles and sutures

with the examining finger, which always signify a vertex. In a breech presentation the anus and

ischial tuberosities form a straight line, whereas the mouth and malar prominences form a triangle.

Additionally, the skin of the fetal buttock is smooth. An alert examiner can distinguish it from the

hairy feel of the scalp. This subtle sign may raise an examiner's index of suspicion and, thus, the need

to perform a more definitive examination. If the examiner's finger encounters an orifice then the

finger can be gently inserted into the orifice. If it is the mouth, (signifying a face presentation) the

fetus may suck on the finger, whereas, if it is the anus (signifying a breech) the finger may be coated

with meconium.

The clinical diagnosis of a breech presentation can be inaccurate therefore ultrasound should be

used liberally where there are doubts about the presentation of a baby antenatally at term or, in

labour [36].


Antenatal care of women with a breech presentation

There are four elements to the antenatal care and management of women with a breech

presentation. First, a cause must be sought for the breech presentation. Most of the causes of

breech presentation that can be identified are detectable by ultrasound. Secondly, the woman may

attempt certain exercises to turn the breech. Thirdly, external cephalic version should be

encouraged if there are no contra indications. Fourthly, failing successful version, a decision must be

reached regarding the most favourable mode of birth.

Postural options for women with a breech presentation

Various exercises and positions have been tried in an attempt to turn a breech baby. No difference

in outcome has been noted in a review of trials in which women were randomised to a postural

management group or a control group [37, 38]. There was however, an increase in maternal

satisfaction with no increase in adverse outcomes. This may be the important component for the

woman and is not to be underestimated.

The exercises themselves are simple. One version is for the woman to assume a knee‐chest position

for 15 minutes three times a day, for five days. Another is for the woman to assume a deep

Trendelenburg position by elevating her hips nine to twelve inches while lying supine, for ten

minutes once or twice a day. Pelvic rocking while in either of these positions is often recommended.

While efficacy cannot be proven, these exercises seem to do no harm and there are no

contraindications to doing them. More information on postural management can be found on the

Spinning Babies website which summarises non‐medical turning techniques and includes links to

other relevant websites (http://www.spinningbabies.com/).

There are also anecdotal reports of other strategies that may persuade the baby to change position

including music played at pelvis, lights at pelvis or cold peas/ice. None of these have been tested

using a trial or other form of research however some women report that sometimes their babies

have moved. When women come to a clinician with these reports it is important to explain that they

are without formal evidence but to explain that some women may find them useful,

Moxibuston

Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) to the

acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has

been proposed as a way of correcting breech presentation. A Cochrane Review [39] on this topic

found that moxibustion did not reduce the number of non‐cephalic presentations at birth compared

with no treatment. However, there is some evidence to suggest that moxibustion may reduce the

need for oxytocin augmentation. When combined with acupuncture, moxibustion may result in

fewer births by caesarean section; and when combined with postural management techniques may

reduce the number of non‐cephalic presentations at birth. However, there is a need for more

research to determine safety and effectiveness [39].


The Webster Technique

The Webster Technique is another strategy that some women may ask about or try. This involves a

specific chiropractic manipulation of the woman’s pelvis aimed at relaxing the uterus and

surrounding ligaments. There is no evidence to support the safety, efficacy or effectiveness of this

technique.

External Cephalic Version (ECV)

External cephalic version for turning a breech has become an accepted component of the antenatal

management of women with a breech presentation. The Cochrane Review [40, 41], and ACOG

Practice Bulletin [42] both support ECV for breech presentations. RANZCOG also states that all

women with breech presentation in late pregnancy should be offered the option of ECV [26]. This

procedure is low tech and low cost and can lower caesarean section rates. The risk of an adverse

event occurring as a result of ECV is small. Therefore, women near term with breech presentations,

and who meet selection criteria, should be offered an ECV. A detailed description of ECV is provided

in another chapter in this manual.

Women do not always find that an ECV is a positive experience. Women have varied emotions and

responses associated with the ECV, including a perceived inevitability of a caesarean section for

breech and consequences of an unsuccessful ECV. Strategies to assist women to deal with conflicts

from an unsuccessful ECV need to be implemented [43].

It may be useful to explore the woman’s source of information and her specific concerns. “Dr

Google” is increasingly a source of information and some information may present specific concerns

for the woman.

Some women will choose not to have an ECV because of past experiences or due to not wanting to

be in the position of having to deal with an unsuccessful version. This needs to be acknowledged and

women respected if that make the decision not to have an ECV.

Labour and birth

There are fundamental differences between cephalic and breech births. With a cephalic or vertex

presentation, the largest part of the fetus, the head, births first. Moulding of the cranium can occur

over several hours. With a breech birth, first the breech, then the shoulders, then the head are born,

each larger and less compressible than the previous part. Moulding of the head does not have time

to occur because the fetal head is in the pelvis only for a few minutes and because it enters the

pelvis with the base of the skull leading which, unlike the vertex, cannot mould. The greatest

challenge in a vaginal breech birth is that the last part of the fetus to be born may also be the largest

part and it might not fit through the pelvis. This is the commonest expressed concern by mothers

and maternity care providers. Language around this can contribute to the maternal anxiety and is

one of the skills in providing accurate but non‐threatening information. It should be noted that the

bitrochanteric diameter and biparietal diameters are similar at term, so that the spontaneous

delivery of the breech will predict the safe birth of the flexed head.


Labour with a breech is not very different from labour with a vertex and should be enabled to

continue as long as progressive cervical dilatation and descent occur and as long as there is no fetal

or maternal compromise. A frank breech will distend the perineum and dilate the introitus in a

manner similar to a vertex. Episiotomy may be required although many clinicians believe that an

intact pelvic floor assists the normal mechanism of the breech birth more. An episiotomy does not

create more room in the bony pelvis but it may enable the clinician to perform various

manipulations more easily including emergency procedures such as Piper forceps application. An

episiotomy is very difficult to perform once the whole body is born. Many breech experts are of the

view that episiotomy is rarely needed in an upright breech birth – much less so than for a head‐first

baby as the perineum does not experience as much trauma during the birth [44, 45].

The physiological mechanisms of breech birth work best in a calm environment. The physiological

mechanisms are described in the next section. Some of the descriptions and diagrams are with a

woman in the supine position – this is just to demonstrate the mechanisms. However, the BABE

course recommends that women planning a vaginal breech birth give birth in an upright or 4 point

kneel position. The next series of diagrams provide a more upright view [45].

Positions for birth

Women will adopt the position that they find most comfortable and effective for the birth of their

baby. This applies particularly to a woman having a breech birth. The possibilities for a breech birth

depend on the woman’s natural preferences at the time. It is important that the doctor/midwife are

familiar and comfortable with attending women in different positions.

Many maternity carers feel most oriented with the woman in position in lithotomy. However,

women often report that this position is less comfortable and make it harder to push effectively.

Semi lithotomy, with the woman’s buttocks over the end of the bed, may be the most common

position in the case of an unexpected breech or when maternity carers feel less confident with

attending woman in different positions.

The following positions can also be considered where birth in the semi‐lithotomy position is

unsuccessful or when the woman would prefer not to be in this position:

birth stool, semi squat, fully upright – these positions do have the advantage of gravity and

assisting expulsive efforts. On the birth stool it is possible to conduct all the manoeuvres

hands and knees position may be favored by some women and many midwives. It allows the

sacrum to move a little and open the pelvis further. Access to difficult arms is made easier in

this position.

Maternity carers need to rehearse these variations so that in an emergency situation maximum

cooperation with the woman can happen. These positions are not just to be considered where birth

is unsuccessful but when labour or descent is slower than expected.

The mechanism of the birth

Usually the baby commences in a left or right sacrum anterior position.


With effective uterine contractions the body compacts and descends while the cervix dilates.

At full dilatation and with further contractions the hips will do an internal rotation so that

they are now in the AP plane of the pelvis.1

With effective pushing the body undergoes a lateral flexion so that the anterior hip passes

below the symphysis pubis.

With further lateral flexion the posterior hip delivers over the perineum. At this point the

baby springs out as a result of the bodily compaction during labour.

The body then rotates externally so that the back is uppermost.

1Thank you to Professor Jeremy Oats for the use of these diagrams


The body descends with the continued expulsive efforts of the woman (often the woman

will wish to keep pushing despite the absence of contractions).

The shoulders will rotate in an alternating wiggling fashion so that one shoulder will present

under the symphysis then with a further rotation the other shoulder will follow suit. The

arms will “fall out” in succession.

By this stage the head will be flexed enough into the pelvis so that it can be gently delivered

with the Mauriceau Smellie Veit (MSV) manoeuvre.

The accoucheur must keep his or her hands off the breech. Allow the legs to deliver themselves,

avoid flicking them out. Hands on the breech are only necessary to stop the back from rotating to

the posterior position, manage arms that are in the wrong position or control the birth of the head

(to avoid rapid decompression of the head).

Diagrams in the MIDIRS Essential article that will be distributed at the BABE course illustrate breech

birth from a more upright position [45].

When is assistance required?

In 10‐20% of breech births, some assistance will be necessary because the arms are either extended

or behind the neck (nuchal arms). Both problems manifest as a failure of the body to descend much

further than the umbilicus despite adequate maternal effort and suprapubic pressure between

contractions. In order to deal with this problem, do a vaginal examination to determine whether the

arms are extended or nuchal.


In the case of extended arms:

first, attempt to sweep the arms down by flexing the elbow and bringing the arm out

second, attempt the Lovset manoeuvre, which is, hold the baby’s pelvic girdle and rotate the

fetal back from one anterior oblique to the other anterior oblique. If there is any major

resistance to this, immediately stop so as to avoid any trauma to the cervical spine

third, reach under the baby’s body in the hollow of the pelvis to access and release the

baby’s arms

In the case of nuchal arms:

first, attempt to sweep the arms down by flexing the elbow and bringing the arm out

second, attempt Lovset manoeuvre as above with the first rotation being in the direction

that the nuchal arm is pointing. Again if there is any major resistance to this stop so as to

avoid trauma to the cervical spine

third, reach under the baby’s body in the hollow of the pelvis to access and release the

baby’s arms

If the head is extended ‐ this is most likely to occur where it has been necessary to release the arms

as described above. In order to deal with this:

Mauriceau Smellie Veit (MSV) manoeuvre means resting the baby’s body on your dominant

hand. Flex the baby’s head with the ring and index finger on the malar eminences. The

middle finger of the non‐dominant hand exerts pressure on the occiput to further aid flexion

an assistant applies substantial suprapubic pressure with a closed fist directed towards the

hollow of the sacrum

If there is further difficulty then forceps can be applied to the head.

These manoeuvres and others that have been used in the case of delays will be explained and

demonstrated in the workstations during the BABE course.

Forceps

Piper, Neville Barnes, Simpson and Haigh Fergusson forceps can all be used to deliver the after‐

coming head. Forceps are indicated when the MSV manoeuvre fails. Although there are no strict

guidelines, clinicians should consider forceps if two or three minutes have passed without progress

during the MSV manoeuvre. It is prudent to have the forceps readily available for any vaginal breech

birth.

To apply forceps, the baby is gently held up and to the clinician's left. The left forcep (blade) is

always applied first. It is held in the clinician's left hand and is applied to the left side of the mother's

pelvis (but to the right side of the fetus). The right hand is placed in the vagina alongside the fetal

head to protect the vaginal sidewalls. The left forcep is insinuated between the right hand and the

fetal head following the cephalic curve of the blade along the cheek. Once inserted the handle may

be allowed to dangle or is supported by an assistant.


The right forcep is then inserted in a similar fashion, by holding the handle with the right hand and

sliding the forcep into the vagina alongside the head, protecting the sidewall with the left hand. The

forceps should then be locked. When the right forcep is applied over the left forcep the lock will

articulate normally. The handles are usually separated slightly away from the lock and should not be

squeezed together.

With the application complete, birth of the head commences. The clinician applies a small amount of

traction to the forceps. The primary motion of the forceps is to raise the handles in a large arc

starting about horizontal and ending at or past vertical. This arc flexes the head through the pelvis

with exactly the same geometry as the MSV manoeuvre but with greatly increased leverage due to

the length of the forceps. None of the flexing manoeuvres of the MSV manoeuvre are required when

forceps are used. The baby may be laid on the shanks of the forceps during the birth.

The principal difficulty in applying forceps is a result of the condition that indicates their use: that is

failure of the MSV manoeuvre implies a tight fit of head to pelvis. There may be insufficient room to

place a hand alongside the head. In this situation the blade must be applied ‘blind’ with risk of injury

to mother and baby. Once the forceps are on, birth can be accomplished in almost every case.

Rare difficult situations in a breech birth

If the baby has rotated so that the abdomen is upper‐most under the symphysis (sacrum posterior)

and the shoulders have delivered the following steps should be applied:

Lift the baby’s legs up while an assistant applies suprapubic pressure. This will succeed if the baby’s

head has already entered the pelvis and the chin is not caught on the symphysis. As with Lovset’s

manoeuvre, if there is any major resistance, do not persist.

The accoucheur should have an assistant hold the baby’s pelvic girdle, while they place a hand in the

woman’s vagina and reach for the right cheek. The accoucheur and the assistant should then exert a

clock‐wise rotation simultaneously in the same direction. Once the baby’s head has turned 900 the

accoucheur should insert their left hand to undertake the MSV manoeuvre for the head to flex and

rotate to the occiput anterior position.

Entrapment of the after‐coming head by the cervix is another serious complication of breech birth.

This situation occurs primarily in premature and footling breeches in which the body has slipped

through an incompletely dilated cervix. The head, being the largest part, becomes entrapped by the

cervix. The problem is most severe in a nulliparous woman whose cervix has never been fully dilated.

Resolution without excessive traction will first involve an attempt to push the cervix back over the

head along with firm suprapubic pressure but then may require cutting the cervix, a procedure

known as Dührssen's incisions. Ring forceps are placed in pairs, parallel to each other at 2:00, 10:00

and, if possible, 6 o’clock, extending three to four centimetres into the cervix. A radial incision is

made between the ring forceps of each pair. This procedure is recommended only in the most

extreme life‐threatening circumstances. Following the birth, the cervix needs to be repaired

immediately to minimize haemorrhage.


Hydrocephalus may present as a breech birth with an entrapped head. The appearance of a

meningomyelocele or spina bifida may herald the hydrocephalus, occurring in about a third of such

cases. Although antenatal diagnosis will call for highly individualised management, and probable

caesarean section, the unexpected diagnosis at the time of a breech birth presents a significant

dilemma and expert consultation needs to occur.

Principles in an unexpected vaginal breech birth

The response to the undiagnosed or unexpected breech when the woman is already pushing and the

presenting part on view needs to address:

keeping the room calm, explain the situation to the woman, call for help

ensuring the woman is having good contractions (maximum calm in the room favours good

contractions), have a syntocinon infusion drawn up in the event that contractions subside

keeping your hands off the breech (remember if the bitrochanteric diameter delivers

spontaneously then the flexed head will follow) but knowing when to intervene if progress is

too slow

ensuring that the baby’s back stays underneath the symphysis

watching for steady progress from the birth of the breech to the scapulae over a three

minute period

allowing the shoulders to deliver spontaneously. If there are delays, then deal with nuchal or

extended arms as described above

after the birth of the shoulders, doing everything to encourage flexion of the head i.e. good

expulsive efforts, strong contractions (in the absence of these it will be suprapubic pressure,

MSV maneuver). It is recommended to have forceps ready in the event of difficulties with

the birth of the head.

After the birth

As after all births, it is very important that clinicians, especially those who counseled the woman

prior to birth and those who attended the birth, have a discussion with the woman about the birth.

This is regardless of whether she ultimately had a vaginal birth or caesarean section. Clinicians will

learn from women about the process of counselling and information sharing, the care during labour

and birth and the decision‐making process if they ask women how it was for them.

This opportunity to talk should be with both the doctor and midwife and should occur in the early

days after the birth with an opportunity for further discussions later. This discussion should be

recorded in the medical record [46].

Summary

This chapter has defined breech birth and the different positions that the baby may be in prior to

labour. The diagnosis of a breech presentation was outlined and the options for care in the antenatal

period. Understanding the physiological mechanisms of breech is critical to supporting vaginal birth.

These have been presented as well as strategies for dealing with complex breech births. Finally,


talking with women after the birth is a powerful means to learn more about what works for women

experiencing a breech presentation at term.


Chapter 3: Critique of the Term Breech Trial

Chapter written by Henry Murray

Objectives


articulate some of the main concerns with the Term Breech Trial (TBT)

understand the major impacts of the TBT on practice

put the context of the trial into perspective when discussing vaginal breech with women

Introduction

The Term Breech Trial (TBT) was published over 10 years ago [3]. A brief overview of the trial and its

findings have been presented in Chapter 1 of this manual. Despite many expressing caution in

accepting the initial outcomes, and data from the 2 year follow up of the babies showing no

difference in outcome with respect to death or neurodevelopmental delay in the babies [47],

caesarean section (CS) for women with a breech presentation has continued unabated [8]. This

chapter explains the concerns around the term breech trial and provides an overview of the

strengths and weaknesses of the trial. An earlier version of this chapter was published in the O&G

Journal of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Issues with the Term Breech Trial

Why the caution in accepting the TBT findings? Some who were approached to take part in the trial

were clearly concerned that the trial was asking participants to undertake practices that were at the

least unusual, and at best not at all part of the routine approach to vaginal breech birth in Australia

or New Zealand. The issues were

1. Although the vaginal breech birth was to be ‘planned’, consent to enter the trial could be

obtained in labour leaving little or no time for fetal assessment or maternal counselling.

2. Electronic monitoring in labour was optional even though the labour and birth was deemed

by many as high risk.

3. The vaginal birth rate for the breech delivery group was to be more than 50% even though

that rate was achieved in only a very few selected specialist breech units in the developed

world [7].

4. Oxytocin augmentation was to be utilised for delay in labour which many clinicians would

caution against using as delay is suggestive of problems.


5. Included were women who had previous caesarean sections and a fetal weight of < 2.5kg

even though this weight is associated with growth restriction at term and are more likely to

have poorer neonatal outcomes.

6. Fetal weight and attitude of the head, considered important as entry criteria, could be

assessed clinically if no ultrasound was available.

7. The person responsible for the birth could be in the range of 20 years experience to

someone who thought themselves experienced and who had their head of department

agree regardless of whether or not they had been observed as being competent.

8. The enrolment of women was to be ad hoc rather than consecutive, meaning that units

could deliver those they knew would give birth successfully vaginally, and randomise only

the group in whom a vaginal birth outcome was uncertain.

9. Women were randomised rather than maternity units. Therefore, maternity units did not

contribute equal numbers of women with caesarean and vaginal births as there was no

blocking of the units by mode of birth. That meant that some units with staff highly

competent in vaginal breech births could be made to deliver all the trial babies by caesarean

section.

10. Maternity units were included that could not undertake an emergency caesarean section for

up to 1 hour, or provide oxygen to a baby for up to 10 minutes after birth, and/or intubate a

baby for up to 30 minutes.

Clearly there were those that recognised that this trial would not answer the question as to

whether:‐ a woman with a breech presentation at term in Australia or New Zealand, who a) has a

complete prelabour fetal and maternal assessment; b) has counselling; c) can have continuous CTG

monitoring in labour in a unit that can undertake an immediate caesarean section and has neonatal

resuscitation facilities; and, d) can be attended by a fully competent obstetrician and midwife, is

better giving birth vaginally or by caesarean section?

The Term Breech Trial (TBT) group tried to counter the issues of units with lower standard facilities

by separating off those with a perinatal mortality rate (PNMR) of less than 20 per 1000 from those

with a PNMR of more than 20 per 1000. A PNMR of less than 10 per 1000 is now common in units in

the developed world and such units differ markedly in their ability to mount a rapid caesarean

section and neonatal resuscitation when compared to those with a PNMR of more than 10 per 1000

[6, 48, 49]. This division of units is not likely to have been helpful.

Critiques of the Term Breech Trial

Given the trial as published, and the subsequent published data, the question remains ‐ are we still

justified in saying that the term breech trial indicates a superiority of caesarean section over vaginal

birth? Numerous publications have critiqued the TBT [6‐8, 48, 49], and space constraints allows only

a summary of the issues in the section below.

The 121 centres entered 2088 women into the trial over 39 months. This amounts to 5 births

per centre per year. This opens the trial to selection bias.


Despite being a planned breech trial, only 21.5% of women underwent an external cephalic

version. This very low percentage strongly questions the adequacy of counselling in the trial

[49].

Competence of the inclusion process: Despite the TBT inclusion criteria of singleton, non‐

footling breech with flexed attitude, weighing less than 4.0kg, 2 intra‐uterine deaths, 2 sets

of twins and a baby who was anencephalic and another with spina bifida baby were

enrolled. In addition 5.8% of fetuses in the vaginal birth group were over 4.0kg at birth and

in 4.1% the type of breech was unknown.

Of those women enrolled in the trial, 40% entered with no ultrasound assessment of fetal

weight or attitude of the head.

Of the 13 deaths attributed to the vaginal birth group, 2 were ‘most likely’ to have died

before randomisation, 2 died after discharge (1 SIDS and 1 gastroenteritis), 2 died because

of respiratory difficulties after birth (possibly due to inadequate resuscitation facilities), 1

most likely had a congenital anomaly, and 3 had an abnormal CTG but did not receive a

caesarean section in a timely manner. Only 3 babies died after a ‘difficult delivery’. In his

own analysis of the original data Glezerman [6] assumed that up to 5 deaths in the vaginal

birth group could be attributed in some part to mode of delivery, as against 2 in the

caesarean section group. This made the mode of birth PNMR 5/1038 vs 2/1038, p = 0.45,

that is, a non‐significant difference.

Despite the undertaking that only a qualified person would attend the birth, 6.7% of the

vaginal breech births were delivered by people with little or no expertise as opposed to 2.7%

in the caesarean section group. Over 30% of the morbidity/mortality in the vaginal birth

group was from this 6.7% of births. Kierse’s paper [49] provides a complete reanalysis of

morbidity data and is recommended reading.

The morbidity data is inconsistent. Fourteen babies in the caesarean section group were said

to suffer severe morbidity but 16 went to the neonatal intensive care unit (NICU), but of

more concern, 8 of 39 babies who had severe morbidity in the vaginal birth group

apparently never went to the NICU.

A skull fracture was sustained by a baby during a caesarean section, another baby death in

the caesarean section arm occurred after the woman was allowed to labour and give birth

vaginally after augmentation with oxytocin, and a further 27% of woman in the caesarean

section group gave birth vaginally after labour was augmented with oxytocin. These

incidents and violations of protocol question the abilities and commitment of trial

participants.

Of the 69 cases of mortality and morbidity in the original trial, Glezerman [6] could find only

16 that could be attributed to mode of birth from the published data. The vaginal birth vs

caesarean section morbidity rates were calculated as 11/1038 vs 5/1038, p = 0.2, which is

not significantly different.

Outcome data for the neonates was only short term. Long term morbidity was not assessed

in the original TBT paper.


Despite all the flaws the authors of the trial indicated that perinatal mortality, neonatal mortality or

serious neonatal morbidity was significantly lower in the planned caesarean section group versus

the planned vaginal delivery group:‐ RR 0.33 (95% CI 0.19‐0.56) p < 0.0001 (1).

Follow‐up data

In 2004, data from the 2 year follow up of infants [47], a paper that many the world over have

chosen to either dismiss or ignore [8], was published. A total of 923 of 1159 children (79.6%) from 85

centres were followed to 2 years of age. The risk of death or neurodevelopmental delay was no

different for the planned caesarean section group than for the planned vaginal birth groups (14

children [3.1%] vs 13 children [2.8%]; relative risk, 1.09; 95% CI, 0.52‐ 2.30; P = .85; risk difference,

+0.3%; 95% CI, ‐1.9%, +2.4%) (2). These outcomes suggest that the markers of severe morbidity used

in the trial were not useful.

Further data published has looked at various risk factors in the vaginal birth group. Neonatal

morbidity is more likely with the use of oxytocin augmentation, prolonged second stage, and birth

weight less than 2.8kg, and less likely with an experienced clinician [50]. Such findings agree with

breech delivery guidance from the United Kingdoms’ Royal College of Obstetricians and

Gynaecologists (RCOG) [28]. The lowest absolute risk for the woman is through birth with a

prelabour caesarean section, however , maternal morbidity increases after labour has commenced

OR 3.33; 95% confidence intervals [CI] 1.75‐6.33, p < 0.001 (10). Caesarean section for women with a

breech presentation may also result in maternal mortality [48].

For those that were subjected to pressure because they dared to question the TBT, these final

outcomes are of little comfort. Breech birth does carry a risk and should be carried out only after

careful consideration and counselling [17, 26, 28]. The art of vaginal breech birth has in some places

been lost and the BABE course is one avenue to attempt to rebuild these skills.

We have been told over the last 10 years that the randomised control trial is the only form of trial to

be undertaken, and for any other form of trial ‘.. we’d suggest you stop reading..’[48]. Others would

disagree with this to the extent that a trial is only as good as the relevance of the clinical question it

seeks to answer and the parameters it uses to measure outcome. Complex clinical issues like breech

do not lend themselves to controlled trials and inappropriate outcomes like neonatal hypotonia lead

to unjustified conclusions [7].

Useful learning points from the TBT

While there are numerous critiques of the TBT, there are also a number of useful learning points

from the trial. It is important to consider these findings as well.

The findings of the TBT demonstrated that birth trauma of the baby can occur with both vaginal

breech births and elective caesarean sections. This finding emphasises the need for similar

approaches in the birth of the baby. Even in a caesarean section, as much as possible, the

accoucheur should adopt a similar approach and not exert excessive traction on the baby’s body or

hyper‐extend the neck.


Another useful finding from the trial was that fewer complications occur when skilled experienced

practitioners attend the birth. This highlights the need to concentrate the provision of vaginal breech

services to ensure that practitioners develop expertise.

The trial showed that in 5% of vaginal breech births there will be problems with the position of the

head, arms, shoulder or body requiring extra manoeuvres to deal with the situation. Identification of

the delay due to the position of the arms is important. In the trial, babies born after a vaginal breech

birth tended to have lower Apgar scores and pH values however this did not translate into any

longer term harm for the babies. This is an important part of the discussion with woman who may be

planning or considering a vaginal breech birth.

Overall, it is important to remember that extra precautions are warranted to minimise problems

associated with a vaginal breech birth.

Conclusion

In summary, the TBT did not show any benefit for the fetus delivered by a planned caesarean

section, rather it showed that caesarean section increased maternal morbidity [47, 50]. Planned

vaginal birth therefore must become part of the skills and expertise of the thinking and competent

obstetrician. With regard to the trial itself, we should learn from the issues it raised. As a previous

Editor of the BJOG, Grant stated “The term breech trial is an example of a randomised trial that was

impeccable as regards its methodological design but questionable as regards its clinical design” [51].

A key reason planned vaginal birth must become part of the skills and expertise of the thinking and

competent obstetrician is that women are demanding them. Even with the term breech trial results,

there will always be women who will want a vaginal breech birth. It is the responsibility of the

maternity care sector to cater for these women as well as others who request a CS.


Chapter 4: External Cephalic Version for Breech Presentation

Written by Warwick Giles

Objectives


describe the purpose and timing of an external cephalic version (ECV)

understand the factors associated with a successful ECV

articulate the complications associated with ECV and the relative frequency

explain the contraindications to ECV

describe the procedure for ECV

Introduction

The background regarding the occurrence of breech presentation in late pregnancy has been

described in previous chapters. External cephalic version (ECV) for turning a breech has become an

accepted component of the antenatal management of women with a breech presentation. The

Cochrane Review [40, 41], and ACOG Practice Bulletin [42] both support ECV for breech

presentations. RANZCOG also states that all women with breech fetal presentation in late pregnancy

should be offered the option of ECV [26]. State‐wide policies also support ECV. For example, in NSW,

the Towards Normal Birth policy state that health services should provide or facilitate access to

external cephalic version [46].

The ECV procedure is low tech and low cost and can lower caesarean section rates. The risk of an

adverse event occurring as a result of ECV is small and the caesarean section rate is significantly

lower among women who have undergone successful version. Therefore, women near term with

breech presentations, and who meet selection criteria, should be offered an ECV.

A review of relevant literature reporting on ECV was obtained via MEDLINE regarding ECV.

Timing of ECV

It is important to consider the most appropriate time in which to offer an ECV. The early ECV

randomized controlled trial (at 34‐35 weeks) [52] demonstrated that in 1533 women recruited from

68 countries early ECV was associated with higher rates of success (51.4% vs. 42.1%), and a lower

presentation with breech at labour (41% vs. 49%) but there was no reduction in proportions of

caesarean sections. However the study suggests an increase in preterm birth. There is increasing


concern about late preterm birth and thus early ECV is not likely to be adopted in preference to ECV

at term [53].

ECV after 37 weeks has a significantly lower success rate. This gestational age appears to be optimal

for ECV as the success rate is still good, the reversion rate back to breech is low and, should

immediate birth be necessary, the fetus is sufficiently mature [41, 54].

There are also instances of ECV being successful in later pregnancy or even in early labour. The

decision to attempt ECV at these times needs to be made on an individual basis.

Factors associated with successful ECV

The factors associated with successful ECV that are intrinsic to the woman include parity, BMI, type

of breech and mobility of the breech. Borgos et al [55] have noted that the following were

associated with success; parity of 2 (3.74 times more successful, 95% CI 2.37‐5.90); a posterior

placenta (2.85 times more successful, 95% CI 1.87‐4.36) and abundant amniotic fluid (7.44 times

more successful, 95% CI 1.55‐35.65). In one study of more than 200 women undergoing ECV in Hong

Kong, only multiparity, non‐engagement of a fetal buttock, and thin maternal abdomen were

associated with successful ECV [56].

The main extrinsic factor associated with improved success of ECV is tocolysis. Although Nifedipine

[57] has been reported the evidence from the Cochrane Review of 25 studies [58] showed a clear

preference for beta‐stimulants for increasing the success of ECV (RR 1.38, 95%CI 1.03‐1.85) with a

decrease in the number of caesarean sections (RR 0.82, 95% CI 0.71‐0.94). Interestingly, when

combined with regional anaesthesia, there was higher success rate for ECV but no change in the

rates of cephalic presentation in labour, or in rates of caesarean sections. A number of trials have

suggested that the administration of spinal analgesia may increase the rate of successful ECV among

multiparous women at term with increased patient comfort [59].

Another factor associated with successful ECV is the skill of the operator [55]. Therefore, it is

appropriate to advise that each unit should have a medical officer(s) who can perform an ECV.

Alternatively women should be offered the opportunity to travel to a centre where it is offered [46].

A recent trial in Germany has examined the use of relaxation using a clinical hypnosis intervention as

a strategy to increase success rates [60]. Women who received a hypnosis intervention prior to ECV

(n=78), had a 41.6% success rate, whereas the control group (n=122), who had a standard approach

to an ECV, had a 27.3% success rate (p < 0.05). More research needs to be done to determine

whether such findings are replicable especially in settings with higher success rates using standard

approaches.

Complications

The rates of complications of ECV are very rare. Hofmeyer and Kulier [61] reporting on 44 studies of

7,377 women reported although there was a 5% rate of transient fetal bradycardia or decelerations

these were only pathological in 0.4% of cases. In this analysis, there were 0.1% abruptions, 1.5%


fetal haemorrhage, 0.5% maternal haemorrhage, 0.16% fetal mortality and a caesarean section rate

of 0.4%. There were no cases of cord entanglement or maternal death.

As clinicians it is important to be aware of the low rate of complications from ECV. Say et al [62]

reported that the key challenges facing women and their clinicians regarding ECV is the need to be

able to counter the differences between evidence‐based information about ECV and some

commonly held misbeliefs and fears in the community.

Contraindications to ECV

There are a number of contraindications to ECV. These include:

Multiple pregnancy

Utero‐placental insufficiency

Non‐reassuring FHR pattern

Uterine anomalies

Placenta praevia

Unexplained vaginal bleeding

There is one small, randomised study that examined ECV in women with previous caesarean section

with no cases of uterine rupture [41].Women with other risk factors (eg. gestational hypertension)

need an individualized decision.

Procedure for External Cephalic Version

This is a sample protocol that is similar to protocols in many hospitals.

Preparation

The room should be set up in a manner that helps to reduce stress and is warm and

welcoming.

The woman may be accompanied by a support person/people

The woman should be asked to empty her bladder

Confirm breech by ultrasound and rule out fetal anomalies

Perform CTG or BPP (biophysical profile)

Ensure the CTG is normal before continuing.

Explain the procedure and obtain consent from the woman

Caesarean delivery personnel and facilities available

Tocolysis (recommended for primagravidas; optional for multiparas)

Position: supine, slight left lateral tilt, Trendelenburg, knees slightly bent

Woman’s abdomen coated with ultrasound gel or baby powder?

Some women suggest that it is useful to be in a posture to help the baby move out of pelvis before

the procedure. It has been suggested that being in a ‘downward dog’ or breech tilt whilst waiting for

the team to arrive may be beneficial although there is no specific research to evaluate this strategy.


Procedure (for two clinicians)

Clinician #1 elevates breech from pelvis by placing a hand suprapubically beneath the breech

Clinician #1 pushes the breech into the iliac fossa

Clinician #2 flexes the head (for a forward roll), and rotates the baby into an oblique lie

Two thirds of the pressure should be applied to the breech and one third applied to the

head. Avoid excessive force. Use a massaging motion when possible rather than direct

steady pressure

Both clinicians should rotate the baby slowly around. Just enough pressure should be used

to move the fetus. Progress will occur in stages, or "cogwheel" fashion. The fetus will rotate

slightly, then resist, then rotate more. Allow the woman and her baby brief rest periods

when resistance is felt while still attempting to maintain the progress already achieved.

Monitoring may be by ultrasound or doppler, and should be performed every 30 seconds,

during rest periods

When the fetus is just past the transverse, it may rotate the rest of the way without effort,

as it accommodates to the shape of the uterus

The vertex may be guided gently over and into the pelvic inlet with suprapubic manipulation

and fundal pressure

Ultrasound to determine the position of the baby

Points to note

If the forward roll fails then try a backward flip, especially if the vertex and breech lie on the

same side of the maternal midline

Avoid strenuous efforts at turning the baby

If no success after 10‐15minutes discontinue the procedure

Stop the procedure if the woman feels sharp pain

Stop the procedure if bradycardia occurs. If it persists, revert the baby to its original breech

position. If the bradycardia still persists prepare for caesarean section

Post‐procedure

After successful version, monitor for 20 to 30 minutes or until a reassuring CTG pattern

occurs.

Recommend induction of labour if the ECV has been done for a breech unstable lie.

In Rh negative women recommend Anti‐D; may obtain Kleihauer test.

Document the procedure, the CTG pre and post procedure, the use of tocolysis and the

success.

Discuss with the woman the possibility of the baby turning back.

Consider “tubi grip” for the multiparous woman to increase the abdominal muscle support.

Ensure the woman has a follow‐up appointment with her care provider.


Recommendations

ECV should be discussed with women presenting with a breech presentation (without

contraindications to ECV) at term.

If ECV is to be performed it should be undertaken by a practitioner skilled in ECV, with

tocolysis and electronic fetal heart rate monitoring and access to CS if needed.

Even if not skilled in ECV all obstetric clinicians should be able to present the evidence‐based

information that is currently available.

Health services should ensure that there are training packages and networked support for

obstetric registrars to enable the development of skills and competence in ECV

Videos of ECVs

There are many videos on YouTube showing ECVs – some are very good and some are quite

challenging to watch. We suggest you have a look and spend some time critiquing the different

techniques and approaches. We will show some of these during the course but there are many

others. Here are just a few:

http://www.youtube.com/watch?v=6AM6wDwTjmc

http://www.youtube.com/watch?v=qT2jBxVoOQc

http://www.youtube.com/watch?v=fKaNZfUno50

http://www.youtube.com/watch?v=Wj3RMqoZnC8

http://www.youtube.com/watch?v=Z8aCNyT‐Nrk


Chapter 5: Care of the woman planning vaginal breech birth

Chapter written by Mandy Hunter and Anne Sneddon

Objectives


review physiological differences between vertex and breech presentation

discuss women’s progress in first stage of labour

review current guidelines on induction and augmentation of labour in women who have a

breech presentation

discuss the use of various options for women to manage pain in labour

review care of women in the 2nd stage of labour including positions

review guidelines for fetal heart rate monitoring in 1st and 2nd stage

Physiological differences between cephalic and breech presentation

The incidence of breech presentation depends on women’s gestation at the onset of labour; it is

quite common in earlier gestations, around 20% at 28 weeks and falls to approximately 3‐4% at term

[28]. As described in previous chapters, there are a number of known factors which may predispose

women to having a breech presentation, these commonly include: prematurity and abnormalities of

the baby, amniotic fluid volume, placental location or uterine abnormalities. Other common

contributing factors are more lax uterine muscles e.g. in a grand multiparous woman, which allow

more mobility of the baby (this is associated with more flexed or footling breech presentation) or a

more toned uterus e.g. primigravid woman’s uterus which may hinder a baby from turning from a

breech to vertex presentation.

In many situations, breech presentation can be considered a variation of normal particularly if there

is no contributing maternal or fetal pathophysiology, however it can also be an important sign of

underlying abnormality depending on contributing factors for the breech presentation. Ultrasound

examination may help to identify many of the known causes of the breech presentation and should

be recommended for all women with breech presentations in late pregnancy to help plan care.

There are three fundamental physiological differences between a breech and vertex presentation

which are important considerations when women are in labour:


breech presentations are associated with an increased risk of cord prolapse because of the

irregular nature of the presenting part of the breech compared to a head, particularly with a

footling breech

during the breech birth, the umbilical cord enters the pelvis before the head increasing the

likelihood of cord compression

the largest part of the fetus, the fetal skull enters the pelvis last in a breech presentation and

the fetal head has no time to mould during labour.

Criteria for making vaginal birth possible:

Towards the end of pregnancy, every woman with a breech presentation requires an individualized

assessment and discussion to assist her make the most appropriate decision regarding her mode of

birth. This is not always easy in a busy tertiary hospital however, systems need to be put in place to

ensure women can have time to hear the information and make an unhurried decision. Breech

clinics are being proposed in a number of maternity units as one strategy to ensure information can

be provided appropriately.

An ultrasound will provide valuable information to assist women in their decision making.

Ultrasound will show the type of breech presentation, estimated fetal size and weight, and attitude

of fetal head. The SOGC [27] recommend a caesarean section if this is not available. Carefully

selecting women who are most appropriate to have a vaginal breech birth is important. The

PREMODA study highlights that their results can only be extrapolated to centres that apply strict

criteria before and during labour [17].

Three of the professional obstetric and gynecology colleges (RANZCOG, RCOG, SOGC) [26‐28] have

developed guidelines or college statements regarding the recommended selection criteria to

support successful vaginal breech birth. The following table summarises their considerations in

relation to planned vaginal breech birth. The differences show how guidelines, even based on the

same evidence, can differ based on local needs and interpretations. It is also important to note that

these are guidelines, not mandated practices. Guidelines should assist the care of women but should

also be adapted for individualised care.

Table 1: Summary of considerations in relation to planned vaginal breech birth

Estimated fetal weight RANZCOG ‐ small or average size

RCOG – 2000 ‐ 3800g

SOGC – 2500 ‐ 4000g

Type of breech A woman with a frank or complete breech is favourable for a vaginal

breech birth. Footling and kneeling presentations are contraindications

to vaginal breech birth.

Experienced and skilled

clinician

Attendance of an experienced clinician for a vaginal breech labour and

birth is required.


Routine radiological

pelvimetry

Clinical assessment of pelvic adequacy based on obstetric history, height

and build and vaginal examination (where appropriate).

Routine radiological pelvimetry is not advocated as there is no evidence

that it is beneficial.

Access to caesarean

section

Ready access to caesarean section is required.

Other considerations There should be no evidence of placental insufficiency.

Previous caesarean section is not recommended for planned vaginal

breech birth by the RCOG although this is not uniform across the

colleges.

Any obstetric or medical complications likely to be associated with

mechanical difficulties at birth are not recommended (RCOG).

It is important to exclude evidence of hyperextension of the fetal head.

Induction of labour

There are varying expert opinions on whether or not woman can have an induction of labour with a

breech presentation. The reason for the induction of labour is of particular importance as the

presence of medical or obstetrical risk factors necessitating early birth may be an indication that

vaginal birth is not the preferred mode for the given situation. The RCOG [28] state that induction of

labour may be considered if individual circumstances are favourable while the SOGC [27] do not

recommend induction of labour with breech presentation. One of the common reasons for inducing

labour in women with breech presentation is the availability of an experienced obstetrician in the

absence of which the woman would otherwise have a caesarean section.

In the PREMODA study, of the 1825 women who had vaginal births, induction of labour was

undertaken in 163 (8.9%). The most common means of induction was oxytocin (71% of those

induced) followed by prostaglandins (29% of those induced). About three‐quarters (74.1%) of the

women who were not induced had their labours augmented. Only 13% of these were due to a lack

of progress in dilatation. It is not reported why the remaining women were augmented.

Unfortunately no conclusion regarding the outcomes for induction of labour for women with breech

presentations can be drawn from this study.

Augmentation of labour

There is conflicting expert opinion about whether or not a woman’s labour should be augmented if

she has a breech presentation. The important consideration is that good labour progress is the best

indicator of adequate fetal pelvic proportions and thus it is important to question why the labour is

not progressing and augmentation is being considered. Is the labour not progressing because of


something correctable, importantly is it something to do with the environment, is the woman

fearful, and is she sensing her clinician’s doubts and what sort of terminology is being used? Fear

and anxiety may impact on the progress of labour.

RCOG [28] do not recommend labour augmentation but state it may be justifiable in some

circumstances but is controversial. The SOGC [27] say it is acceptable, and 74% of women who had

spontaneous labour in the PREMODA study [17] had their labour augmented with oxytocin.

Artificial rupture of membranes should be used with caution and due to the risk of cord prolapse,

only when the breech is deeply engaged.

Care in the first stage of labour

Good progress in labour is said to be the best indicator of adequate fetal‐pelvic proportions [27, 28]

and poor progress may be a sign of fetal‐pelvic disproportion. Progress in labour is heavily reliant on

the woman having good contractions to aid compaction of the fetus which results from increased

flexion of the fetal limbs. Contractions are assisted by the release of endogenous oxytocin.

Increasingly over recent years a woman’s psyche has been considered to be an important element in

the progress in labour and deserves careful consideration for women with a breech presentation in

labour especially given the apprehension and fear surrounding the issue of vaginal breech birth.

Pleasant stimuli in the environment such as warmth, peacefulness and massage are all known

triggers for the brains release of oxytocin [63] and women who are calm and connected are more

likely to release oxytocin [64‐66]. Fear can have serious detrimental effects on women’s perceived

capacity to give birth vaginally, there is a significant link between fear of childbirth and caesarean

section [67], and maternity care providers have been identified as a cause of fear and fundamental

to helping reduce it. Maintaining a calm environment therefore is important.

The SOGC guideline states that in first stage of labour clinical judgment and experience is important,

labour should be progressive and advise a CS if there is no progress for 2 hours despite adequate

contractions. RCOG, SOGC and RANZCOG [26‐28] do not define progress in the first stage of labour.

Fetal monitoring

A high level of diligence and care is required in relation to fetal monitoring. Continuous fetal heart

monitoring is recommended in labour [26, 28]. This can be achieved using telemetry so that the

woman is not restricted to being supine or in bed.

At the moment, fetal blood sampling from the buttocks during labour is not advised as there is little

data to show that the values would be the same as for a vertex presentation. One small study of

fetal blood sampling from the buttocks showed that acid base values were accurately obtained from

this site [68]. However, given the concerns above and the small sample size of the study, the use of

fetal blood sampling during labour is not currently recommended.


Managing pain in labour

Women who choose vaginal breech birth are often highly motivated to labour physiologically and

should be provided continuous support in a calm environment preferably by known carers. In

general, women who have access to midwifery continuity of care are less likely to require

pharmacological analgesia for labour and birth [69]. While these studies are not specifically related

to women with a breech presentation, it is likely that there will be similar benefits.

There may be pressure in some hospitals to encourage the use of epidural analgesia for women with

breech presentation in labour. The possible reasons include that the analgesia is in situ if the woman

requires an urgent caesarean section or needs to have forceps for the after‐coming head or a breech

extraction. Similar arguments about urgency could be made for women with cephalic presentations.

Epidural analgesia is very effective at relieving pain but has significant disadvantages that are

important to consider. Epidurals are associated with decreased mobility, decreased gravity, less

ability to bear down, longer length of second stage and increased association with the need for

augmentation [70]. The disadvantages are particularly relevant to women with a breech

presentation in labour. The pain of labour is intense and tension, anxiety and fear make it worse.

Concentrating on creating an environment and building relationships can be more conducive to

vaginal birth than pharmacological methods of pain relief. SOGC [27] state that maternal

cooperation is essential and heavy sedation and epidural analgesia should be avoided to maximise

expulsive efforts and the RCOG [28] also recommend that epidural analgesia should not be routinely

advised. Some guidelines and clinicians in Australia would disagree with these recommendations and

require women to have epidural anaesthesia. Again, this needs to be considered in the light of

women’s requests and the benefits in maintaining an active labour.

Care in the second stage of labour

Ongoing progress in second stage and effective maternal pushing are particularly important for two

reasons with breech presentation. Cord compression is more common in 2nd stage than with vertex

presentation and the fetal skull does not have time to mould. The fetal head circumference and BPD

of a normally grown baby at term are comparable to the bitrocanteric diameter with most babies. If

the bitrochanteric diameter is born, the fetal head should follow, however it will not have time to

mould if it is a tight fit. Ultrasound prior to labour can reassure that there is not a head shape or

dimension that may be of concern.

Most women will have a strong urge to push when the breech meets the pelvic floor and descends

further to the perineum. Until women feel this urge to push, passive descent should be encouraged.

Passive second stage without active pushing allows the breech to descend well into the pelvis and

may last up to 90 minutes [24].

In the PREMODA study [17], only 0.2% of women were in active second stage of labour for longer

than 60 minutes and secondary analysis of the data associated adverse perinatal outcome with an

active phase of second stage lasting more than 60 minutes. Consequently SOGC [27] recommend a

caesarean section if the birth is not imminent after 60 minutes of active pushing. The RCOG [28]


recommend that a caesarean section is considered if there is a delay in the descent of the breech at

any stage in the second stage of labour.

Positions for second stage

The aim of second stage continues to be on compaction and descent of the fetus. Current evidence

for women with a cephalic presentation associates upright positions in second stage with increasing

pelvic diameters, enhancing gravity, improving bearing down efficiency, fewer reports of severe

pain, shorter length of second stage and less abnormal fetal heart rate patterns [71]. An upright

position in the second stage of labour has the potential to improve outcomes for women having a

vaginal breech birth although there is very little specific evidence available as yet.

Some practitioners may not be comfortable to recommend alternative positions to lithotomy [28].

Ultimately, there is a balance that needs to be met with the woman’s wishes and the level of

experience and fear level of the practitioner. The position the woman feels most comfortable has to

be a high priority.

Positions for birth

There are no studies that show an advantage of position in relation to outcomes. These are unlikely

to be done due to the numbers needed. There does need to be a conversation with the woman

around her expectations of her birth position and the availability of carers that are experienced with

variable birth positions.

A birthing stool is often very helpful and it allows the woman to maintain effective pushing while

providing the opportunity for her to see the baby as it is born. There is some concern that this

position places pressure on the perineum with a possible increase in perineal damage, however

there is little data available to support this in breech births. The birth stool does certainly provide a

good gravitational effect on the contractions and the descent of the baby to the perineum.

Adopting a hands‐on‐knees position for the birth may also be advantageous for viewing the decent

of the baby. This position allows the baby to hang under the effect of gravity and may have

advantages over the lithotomy position of increasing the diameters of the pelvis. This position

enables the accoucheur to see the position of the arms.

Episiotomy

An intact pelvic floor will provide for the ongoing flexion of the descending breech. A selective

approach to episiotomy should be used.

Fetal monitoring in the second stage

There is some uncertainty about the level of fetal monitoring required during labour although a high

level of vigilance is required. RANZCOG [26] recommend continuous electronic monitoring in labour

but do add that it can be interrupted for short periods of up to 15 minutes if all is normal. RCOG [28]

state that continuous monitoring should be offered to all women with a breech presentation, and

the SOGC [27] state that it is preferable to monitor continuously in first stage of labour but


mandatory in second stage. Modern telemetry does allow women to labour with more freedom of

mobility and even in the bath and shower and is preferable to traditional continuous monitoring

techniques because of the importance of being able to be upright and mobile to aid progress in

labour.

Summary

The care of women with a planned vaginal breech birth requires careful attention to progress. The

use of gravity and the achievement of strong uterine contractions are the key to achieving success.

Appropriate counselling is required prior to making the decision regarding the mode of birth is

essential for all women considering or choosing a vaginal breech birth.


Chapter 6: Women’s views and experiences

In this chapter we present the stories of three women. This is not to say that these are the only

stories or the only outcomes but they are examples of women’s experiences. It is essential when

working with women who have a breech presentation at term, that an individualised approach is

taken. The most important place to start is to listen to the woman and acknowledge her views and

wishes and then work from that point. There are more stories on the Breech Birth in Australia and

New Zealand website http://www.breechbirth.net/

Matilda’s birth

Written by Rhonda Tombros

I loved being pregnant. I felt that it suited me and I felt very healthy – better than I had been in

years. I knew that I was growing a lovely little baby girl and we decided early on to call her Matilda,

which means 'strength in battle'.

We first learned that Matilda was breech when I was 32 weeks pregnant, in the context of

interviewing an independent midwife about the possibility of a home birth. I was disappointed that

the hospital I was planning to give birth in (a tertiary hospital in Melbourne) did not have a family

birthing unit. Having recently arrived from London, I naively thought that all modern hospitals had

this sort of facility. Unless a problem arose, I wanted a low intervention, non‐medicalised birth. I was

not planning to use pain relief. After all, I was pregnant, not sick. In my view, I did not need to be in a

hospital to birth my baby.

Before the midwife left, she examined me and commented that our baby was breech. My husband

and I then spent the weekend deliberating but couldn't commit to the home birth. At the time we

couldn't identify why because logically all the factors pointed in favour but possibly we knew deep

down that the home birth would not happen. Or possibly we hadn't been in Australia long enough

for our house to be 'home'.

As I was not working, I had read a lot about birth and was aware that vaginal breech birth (VBB) was

possible, albeit not the path generally recommended by obstetricians. I set about reading more and

more – in fact, all the books I could find on the subject in the Women's Health Information Centre at

the hospital as well as information on the internet. I read the policies of the various professional

bodies of obstetricians in Australia, Canada, the United Kingdom and the USA. I read the various

medical studies which led to policies of elective caesarean section for breech in most of the


developed world. I also read numerous birth stories of VBBs and saw several videos online as well as

Karin Ecker's movie, A Breech in the System. I was convinced that the risks were overstated (when

viewed in absolute terms) and became convinced that in well‐controlled circumstances VBB would

be the best option for us overall. I wanted to attempt a VBB even if Matilda did not turn.

Throughout this period, I felt conflicted because part of me wanted Matilda to turn to suit the

medical establishment and remove the 'high risk' label from my pregnancy. That part of me wanted

an 'ordinary' birth with a midwife and no doctors, at the public hospital. Another part of me felt that

my baby had grown in her own particular way and that I should accept her as she was. I felt that she

was being unduly criticised for not conforming. I told her that I loved her just the way she was. I

would even go so far as to say that I felt proud of her for standing out against the norm. That part of

me was willing to give birth to her bottom first and was not particularly worried about it – if my body

grew her that way then my body could surely birth her that way.

At 36 weeks it was confirmed by an obstetrician that Matilda was breech. I was offered an attempt

at External Cephalic Version (ECV). Again, a conflict arose: why should Matilda turn if she was

healthy where she was? Why should I let the doctors interfere with her naturally assumed position?

My husband and I decided that although we both had misgivings, it was the best thing to do, as it

could remove the 'issue' and the risks were low. Nevertheless, it felt wrong to agree to the ECV for

the sake of the hospital's birth policy.

I underwent the ECV without the usual uterine‐relaxant drugs as I didn't want the drugs in my

system. I am glad I did it this way but the procedure was extremely uncomfortable and felt 'wrong'.

The doctors tried twice to turn the baby, both times unsuccessfully. My husband later told me that

he considered asking them to stop in the middle as it was so stressful to watch. I was having the

same thought but was focusing on 'zoning out' using breathing techniques – apparently I looked like

I was sleeping! If I have another breech baby I will not undergo ECV.

The next step was a meeting with the Registrar, at which I made clear that I wanted to give birth

vaginally. I knew that, other than being a first pregnancy, all of the 'factors' in favour of VBB pointed

in my direction (frank breech, baby not too big, position of placenta, etc). The Registrar said that she

would support my decision but that I would need to discuss it with the Consultant. When we met the

Consultant it was clear that she had already discussed my case with the head of birth suite (known

to be supportive of VBB). She told me that she would be willing to support my vaginal birth but the

problem was that she could not be on‐call for me. She told me that there were only three doctors at

the hospital who were comfortable with VBB and if I turned up in labour and a different doctor was

present, they may take a different approach. I did feel that the Consultant was 'on my side' with the

vaginal birth but was constrained by the public system and the views of her colleagues.

I now wish I had asked what would happen if I turned up in labour and refused a caesarean. I know

that they cannot force you to undergo surgery. If the doctors present were uncomfortable or

inexperienced with VBB, would they have an obligation to call in one of the doctors who could help

me?


On the other hand, I knew that I would not necessarily be in a position to stand up for myself once in

labour and I worried that an unsupportive medical team might have a detrimental effect on my

labour. Also, the risks of VBB increase if the birth is 'assisted' by insufficiently experienced people

(although one might respond that I was wanting to birth my baby myself and was not requesting an

'assisted delivery'). However, I did not ask my question. This is probably because I was so shocked

that the doctor proposed to induce me at 39 weeks so that my labour coincided with her 24 hour

shift. After a few exchanged shocked looks with my husband, for reasons I do not understand, I

signed the consent form.

Over the next few days we both had increasing doubts about the proposed induction. I had read a

lot about the dangers of unnecessary inductions and had formed the view (which has since been

reinforced by the numerous induction birth stories I have heard recently) that an induction is a

recipe for a caesar. It would be highly medicalised. I would be on a drip and would probably need an

epidural to withstand the pain. I wanted a spontaneous labour, not an induced labour. I wanted my

baby to be born when she was ready and when my body was ready to give birth to her. I wanted the

healthy pain of labour not the unhealthy pain of artificial contractions. And there was no medical

reason for induction. So, we decided against it.

That left me with two options: turn up to the hospital in labour and hope for the best or find a

private obstetrician who would support my decision to attempt a VBB and be on call for me. I did

also consider reverting to the home birth. However, I talked to a highly experienced independent

midwife, who recommended I approach a particular private obstetrician, which pointed against this

as an option. As my husband was no longer in favour of home birth, I dropped the point. I was at this

stage in favour of showing up to the public hospital. I felt, and I still do, that the public hospital ought

to be able to cater for my situation. My husband was uneasy about this approach – he felt that I

would end up being pressured into an 'emergency' caesar and regretting it afterwards.

My husband asked around his medical colleagues and came up with a list of three possibilities. One

was unavailable as he was going on holiday and we couldn't get hold of the second. The third was

recommended by a friend who had gone to him for two attempted VBACs. He is generally known in

Melbourne for supporting vaginal birth. My husband called the obstetrician (against my wishes as I

still wanted to birth at the public hospital) and he agreed to meet me (at 38 weeks). Once I had

'cooled off', we agreed that we would meet the obstetrician and if I got a 'good vibe' from him, then

we'd transfer to his care and if not, we'd stay with the public hospital but not go for the induction. I

would find a way to accept that whatever would be would be and hope for a supportive team on the

day.

As it turned out, I thought the obstetrician was fabulous. He has a reputation for having a 'rough

bedside manner' but I found him extremely caring and I liked his sense of humour. He is straight‐

talking but that is a good thing in my view. He answered all my (many) questions sincerely. I believe

that he is truly dedicated to his profession and was extremely supportive of my wish for a 'natural as

possible' birth, within the constraints placed. The constraints were: I would give birth at a private

hospital (I hated that idea), I would give birth in a semi‐reclining position on a bed (ugggghhh!!!!), I

would have continuous electronic monitoring after I was 5cm dilated and I would 'probably need' an


episiotomy. The obstetrician advised against epidural (tick!) and induction in the case of breech

babies. His time lines for dilatation were wider than most – assuming everything else was going well.

We disagreed on one point – he wanted to break my waters after 5cm dilation if they didn't break

spontaneously. His reason was that this would speed up the labour. I saw it as an unnecessary

intervention which could add a risk of infection. We agreed to 'wait and see' on the day – thankfully

the question didn't arise. I also made it clear that I did not want the episiotomy unless absolutely

necessary – it should not be treated as automatic.

My husband and I decided that my best bet of a VBB would be to transfer care to the private

obsetrician, who claims to have a 75% 'success rate', which we thought was significantly higher than

my chances of a VBB at the public hospital. We had to borrow in the region of $10,000 as we were

uninsured but what price do you put on the integrity of your reproductive organs?

At just under 41 weeks I started having Braxton‐Hicks contractions at regular 3‐4 minute intervals

over a couple of days and they were starting to get pretty uncomfortable. I knew I wasn't in labour

but eventually we called the hospital. The midwife agreed that I probably wasn't in labour as I wasn't

feeling any pain but that it was possible to have a painless labour (although rare) and suggested

coming in for a 'check‐up'. Big mistake.

We arrived at the hospital and it all started to go wrong. The contractions stopped. The midwife we

were allocated was patronising and quickly suggested I might have to 'adjust my expectations'. I told

her that I wanted no pain relief but nevertheless she offered me pain killers, despite the fact that I

had told her that I wasn't even feeling pain. She even tried to tell me that I really was in pain but was

just being stoic! After 2 hours or so, with no vagina examination (VE) and no more contractions, I

was told that I would be spending the night and offered sleeping pills. What?! At that point, my

husband and I agreed to 'escape'. So (after the midwife sought 'permission' from the obstetrician),

we went home. Phew! I think that this episode probably delayed my labour from starting as it took

me time to regain confidence to go back to the hospital.

When it did happen, three days later, it happened pretty fast. Contractions started at about 11pm at

night, we arrived at the hospital at about 12.45am and Matilda was born at 6.23 in the morning. I

wanted to avoid arriving at the hospital too early and had been advised to try and rest through the

initial stages of labour and then to get 'active'. I tried to lie down and breathe through the

contractions in bed but they were too strong. I tried leaning over the kitchen bench but that wasn't

much better. So I woke my husband, whose view was to take me straight into hospital. We were

greeted by a lovely midwife, who said that she used to run a home birth team in England (where

home birth is supported by the National Health Service). I think my husband must have briefed her

outside the door as she seemed familiar with my views and ideas.

I was standing and walking around for about an hour. Then my waters broke spontaneously (what a

shock that was!) and after that it all moved pretty fast. Soon my lower back couldn't support me so I

ended up lying on my side on the bed. Actually, I found this to be pretty comfortable, although I

wonder whether warm water on the back might have done the trick and enabled me to stay active.

The midwife gave me my first VE at around 2am and didn't tell me at the time but later said I had


been 4‐5cm dilated. At our insistence, she called the obstetrician, who arrived at about 3am. He did

a second VE and said I was 8cm dilated and fully effaced but not to push. I then started feeling my

contractions 'convert' to what felt like spasms of some sort (the baby moving down the birth canal –

obvious now but it wasn't at the time). I was not actively pushing but I could feel my uterus pushing

for me. I tried to relax through it using breathing. My husband felt sure the baby was 'on its way' and

called the midwife, who confirmed that she could see the baby's buttocks and called the doctor. I

had no pain relief and nobody offered it, which was what I wanted, but OMG it hurt!

The birth itself wasn't at all how I imagined: no breathing the baby out and letting my body do its job

at its own pace. Up until I was told to turn onto my back, I had been feeling the baby moving by itself

– I never actually pushed as such, I just breathed. Once I was on my back, I lost the sensation of the

contractions and the movement of the baby. At that point it became an externally managed process

rather than an internally guided one. It was all push push push. Although I was happy enough at the

time, I have since wondered whether the managed pushing was responsible for the need for an

episiotomy. Maybe if we had taken it all more slowly this could have been avoided? I now have

chronic pain from the scar and I suspect that if I had experienced a physiological breech birth in an

upright position, then it may not have been necessary.

Once the obstetrician cut me, Matilda's body came out on the next contraction, he then flicked out

the legs and arms (that sure felt weird!) and with some very closely managed pushing the head came

out soon after. For that part of the birth he told me when to push, how much, when to stop, to hold

it there, push a bit harder, a bit less, etc. I'm told he swung the body of the baby up to the ceiling as

the head came out but I had my eyes closed for the entire process. I had a physiological third stage

but (against my preferences) it was necessary to cut the cord before the placenta had birthed as

Matilda needed a spot of oxygen.

After the birth, I remember lying on the bed gazing at my husband in amazement and shock about

the whole experience. It was very surreal. Although nothing at all went wrong during the birth and at

no point did I feel at risk or unsafe or unsupported, I would describe it as traumatic, both physically

and psychologically. There was something primitive and animal about it. My husband was also pretty

shocked by the experience.

Reflecting back, I have some regrets for not having been strong enough to walk into the public

hospital in labour and birth my baby. Although moving to the private system guaranteed me 'the

opportunity' of a vaginal birth, I resent the fact that this is seen as something I should be grateful for.

In my mind there was never any question that I could birth my baby and it is insulting that I should

need an 'opportunity' to be provided to me, let alone to pay for it. On the other hand, given that the

risks of VBB decrease with the presence of a skilled birth‐attendant, and given the importance of

feeling supported during the birth, overall it was the best decision in the circumstances.

I am glad that Matilda chose my husband and me for her parents and I am proud of my little breech

baby for challenging the system by coming out bottom first. She is now two years old and continues

to be strong‐willed. I wonder whether that is a 'breech thing'?


Since Matilda's birth, I have formed a support group for Australian and New Zealand women with

breech babies (whether they are born vaginally, abdominally or yet to be born). We have a website

where we share links to information related to breech presentation as well as our birth stories:

www.breechbirth.net. You can also find us on Facebook under Breech Birth Australia and New

Zealand. We have become the Australian chapter of the Coalition for Breech Birth, which is an

international organisation that supports women and their families as they prepare for the birth of

their breech babies and campaigns for the renormalization of VBB: www.breechbirth.ca.


Vaginal Breech Birth: From Doubt to Decision

Written by Karol Petrovska

First published in Midwifery Matters – The newsletter of the Australian College of Midwives – NSW

Branch

As I saw our baby’s bottom appear between my legs in the mirror I threw my head back and

screamed her into the world. The last 3 weeks of this pregnancy with a breech baby had been

especially stressful, but the little voice inside my head that had said it would all be fine was right all

along.

The irony was not lost on me. Just over 2 years ago, as policy officer for Maternity Services at the

Department of Health, I had been involved in developing the Towards Normal Birth policy to

decrease the caesarean section rate in the state. Facilitating more vaginal breech births is one of the

strategies in the policy, as is increased access to external cephalic version (ECV). I didn’t have any

clinical experience in the maternity field (my background is in occupational therapy and journalism)

but the strategies seemed quite logical to me. I hadn’t banked on one day having to actually use

them.

I finished work on the policy just as I commenced maternity leave for our first child. By that time I

was so familiar with the policy content that I felt quite passionately about it. I went on to have a

water birth after a five hour labour ‐ a little girl. I had done it! I had lived the Towards Normal Birth

dream!

I hadn’t really. 2 years later would come the real test ‐ I was pregnant again.

I was anxious during both of my pregnancies. I am genetically predisposed to being a worry wart.

Being pregnant in my job, however, caused me even more anxiety. Although I knew mortality and

morbidity rates in Australia were very low, I was often present when clinicians would discuss the

very few adverse events that occurred in the health system. Coroner’s reports and stillbirth

information were the hardest to deal with. As a result, I had a bit of a skewed perspective and would

often find myself fearing the worst and was a walking example of a little bit of knowledge being a

dangerous thing. It led to some ridiculous behaviour, self diagnosis of the worst kind. This is

probably on the increase in the age of ‘Dr Google’, but this was my job and not something I could

turn off when it all got to be too much. Headache? Oh no! I have pre eclampsia! (it turned out to be

caffeine withdrawal). Swollen glands? I can’t decide whether I have toxoplasmosis or

cytomegalovirus!

At 35 weeks, our midwife was concerned about the baby’s position ‐ was that a bottom or a head? A

quick ultrasound found the baby was in a frank breech position.

I went home in a daze. I cancelled a planned dinner with friends ‐ I needed time to process it all.

After an uneventful first labour and birth, I had been unwise in assuming this pregnancy would


progress the same way but was suddenly faced with the possibility of having a caesarean section.

One of these friends I had planned to have dinner with happened to be a midwife. Following my

dinner cancellation, she had promptly emailed a friend and colleague of mine who happens to be a

midwife. The midwifery grapevine was on fire and a mere half an hour later my colleague was

phoning me.

It was all sorted, she said. She had just phoned an obstetrician well known for his skills in breech

birth and he was happy to see me about having a vaginal breech birth. She gave me his personal

mobile number and told me he was waiting to hear from me.

I wasn’t even close to being ready to think about that.

We set about trying everything to get the baby to turn. I spent hours with my bum in the air, I swam,

I spent evenings smoking my toes with moxa sticks. Nothing worked.

We tried an ECV, and despite the obstetrician admirable efforts, it was unsuccessful. Next option, as

outlined in the Towards Normal Birth policy, was a vaginal breech birth. A few weeks prior, a

midwife I knew through work casually said that I should contact an obstetrician with skills in breech

birth after I had told her that the baby hadn’t turned. My reaction at the time was a wide eyed, head

shaking NO! Are you crazy? That was scary territory, one for the risk takers. Wasn’t it?

To my great shame, I see now that I had fallen for the hysteria that exists around breech births ‐ I

should have known better. I hadn’t explored breech birth in detail at work. Ask me to provide

evidence in defence of homebirth, no problem! Breech births occasionally rate a mention, but

homebirth usually steals the limelight. I knew about the Term Breech Trial and the criticisms of the

study, and I knew this contributed to an unfortunate decline in obstetricians who were skilled in

facilitating breech births. That was the extent of my knowledge. Breech birth had a kind of mythical

quality to me, to be honest. One thing kept nagging at me though ‐ those fabulous clinicians who

developed the strategies for inclusion in the normal birth policy would not have included vaginal

breech birth unless it was a legitimate, evidence based option. I kept coming back to that each time

and my mind began to open up to the prospect of birthing this baby naturally.

My midwife colleague had encouraged us to watch some videos to help with our decision. I imagined

clinicians pulling and tugging a baby out of its mother and braced myself for some disturbing vision.

What I saw was something very natural ‐ a mother pushing her baby out gradually, not a hand was

laid on the baby. As the video ended I turned to my husband and said, “What’s all the fuss about?”

I called the obstetrician skilled in breech birth, who happened to work in a hospital just over 30

minutes from our home and, to my surprise, he was happy to see us the next day. I knew of his

reputation as the go‐to‐guy for breech birth. He was an incredibly relaxed person, the perfect

antidote to my highly anxious approach to, well, everything. I had so many questions, but my biggest

worry was that by trying for a vaginal breech birth I was prioritising the way I birthed our child over

the baby’s welfare. Is that what I was doing? One thing I did know ‐ I owed it to myself and the baby

to get informed. If there was a chance I could birth normally, I wanted to know more about it.


During our first meeting, the obstetrician simply said that given my first labour was so

straightforward, I was a “prime candidate”. I had never loved my child‐bearing hips more than in

that moment. Aside from the size of my pelvis, there were a number of criteria that had to be met,

but basically the risks to the baby for breech birth are almost the same as a caesarean provided

there is a clinician present who is skilled in breech birth. I was assured that at the first sign of fetal

distress, an emergency caesarean section would be performed and I was at peace with that.

The risks for the baby had been established, but this was about me too. I had been around midwives

long enough to know that my own wishes to try for a normal birth were also important. Now that we

were well informed, no hysteria or misinformation, the decision was easy to make ‐ we would give it

a try for both the baby and myself. We transferred care to the hospital where our new obstetrician

was based.

Despite our calmly made decision, the remainder of the pregnancy was not without angst. I trusted

the clinicians and the evidence but it was an effort to manage my anxiety. Now I actually had

something REAL to worry about. Cord prolapse hit Number 1 with a bullet on my anxiety hit parade,

closely followed by the fact that in order to get to the new hospital we had to tackle the dreaded M5

motorway ‐ a nightmare in peak hour. Another concern was the change in carers so late in the

pregnancy. The evidence screams continuity of carers! My beautifully cultivated relationships with

my midwives at the birth centre I had originally booked into hit the pause button.

It’s a testament to the talent and skill of our new obstetrician and the new midwives assigned to me

that the transition was surprisingly seamless. I saw them a handful of times before I went into

labour, and yet the trust I felt being in their care was as if I had been with them from the start.

The due date came and went. The day after, we made an appointment for a sweep of my

membranes. I think I would have wept if the midwife had told me otherwise but she announced I

was 3 cm dilated and she could stretch me to 5cm. My waters were bulging and she thought the

baby would arrive in 6‐12 hours! Our obstetrician dropped by and they both suggested we stay in

the vicinity of the hospital as sweeps tend to “bring things on”.

The contractions started on our way back to the car. I laboured through a meal of fish and chips and

we then decided to go to a movie but about half way through I began to have trouble keeping quiet.

We left for the hospital as I didn’t think my fellow cinema goers would appreciate the sound of the

movie being drowned out by a woman in labour‐and the contractions were 3 minutes apart, so it

was time.

I was examined when I arrived‐I was 6‐7cm dilated, hooray! It wasn’t long before I got to 10cm. By

the time I sat on the birthing stool, there was no room for worry, there was no room for anything in

me but the primal urge to push. Did I mention there was a cast of thousands in the room?

Apparently, this was quite a clinical event (I had happily agreed to this, of course).

A couple of pushes yielded nothing, except perhaps a few cracks in the walls from my screams. The

obstetrician assured me the baby’s bottom had stayed down after the last push ‐ it was coming. A

mirror was held between my legs, and that was the perfect visual feedback for me to try again.


Another push, and there in the mirror I saw a tiny bottom. As the obstetrician called for me to push

again and again, I felt the baby’s limbs spring from my body. I looked in the mirror at the last push

and saw her head leave my body. Physically, the birth felt no different to that of my first daughter.

There was a slight perineal tear, similar to what I experienced with the birth of our first child.

It took a brief moment for her to pulse to life in the outside world, and the vision of her turning pink

and writhing in the obstetrician’s hands is something I have replayed in my mind many times since.

I feel extremely lucky that we had the opportunity to make an informed choice about how our child

came into the world ‐ it led to the chance to birth her naturally. Wouldn’t it be great if all women

with breech babies had this opportunity, whatever their final decision may be? The voice in my head

had been saying it from the start ‐ whatever the outcome, however our baby came into the world,

all would be well if I just tried my best. In the end, that’s all any mother can ask of herself.


Elsa’s birth: Caesarean after trial of labour

Written by Rachel Muntz

At the age of 36 I became pregnant with our first child after six months of trying to conceive. I had

moderate morning sickness in the first trimester and some more in the third trimester. I worried

about almost everything during pregnancy, but after starting childbirth classes at the hospital my

rising sense of anxiety turned into a couple of panic attacks. I was overtaken by my fears of the birth,

of being a bad mother, and of the enormous changes I would have to face. I sought help: I talked to

my partner, saw a psychologist, and hired a doula – one of the best decisions of my life, as it turned

out. She helped me to erase Hollywood images of childbirth from my mind and replace them with a

notion of childbirth as a privilege, a sacred event, something to be enjoyed. I began believing in

myself and my body’s abilities, believing that my baby was safe inside me and that I would be a great

mum.

Finding out about the breech

We had been receiving antenatal care at the smaller of the two public hospitals in our city. At the 20‐

week ultrasound it was found that the placenta was lying low and that another ultrasound at 34

weeks would be necessary to check that it had moved clear of the cervix. At 34 weeks the ultrasound

showed that the placenta had moved out of the way but that the baby was in the breech position.

The doctor we saw explained that the vast majority of breech babies in Australia were delivered by

elective caesarean and that there was a severe lack of clinical skills in vaginal breech birth. He (and

all other care providers we talked to) cited the findings of the controversial Term Breech Trial.

I remember crying in that appointment – feeling like the likelihood of a natural birth was slipping

away due to blanket policies that didn’t assess my case on its merits ‐ everything else with my

pregnancy was normal and I felt that a vaginal breech birth could very well be achieved. We asked

about a trial of labour before a caesarean but this doctor didn’t agree that it was best to wait for

spontaneous labour and then to have a caesarean. This was contrary to what I had been told by our

doula. More importantly, it went against my gut instinct. (I understood later that this advice was

related to the staffing limitations at the hospital where, if required during the night, staff would have

to be called in from home to perform surgery. The doctor believed that in such a case mistakes were

more likely to happen so he thought a scheduled elective caesarean was much safer than an

unscheduled one that had to be done in a hurry).

Attempts to turn the baby

After the initial shock of finding out the baby was breech and the realisation that the path ahead

may involve some argy‐bargy with care providers, I began to get serious about turning the baby,

trying some folk remedies that some people believe encourage the baby to turn head‐down. I did

handstands at the pool, swam, put ginger paste on my little toes before bed, tried moxibustion

sticks, played music and shone a torch at the bottom of my tummy, tried to talk and think the baby


around, inverted myself on a tilted ironing board propped up at one end on the sofa. Once or twice I

convinced myself that the baby had moved but at the 36‐week check‐up we learned that she hadn’t.

We consented to an external cephalic version (ECV) later that week. I was given ventolin

intravenously to relax the uterus. It immediately made my heart race. I started sweating and then I

retched for a few minutes (nothing came up because I had to fast for eight hours before). The

manipulation was pretty painful ‐ like getting a Chinese burn on your belly at the same time as

trigger point massage. I noticed that it upset my partner to see me in such pain. Two doctors each

had a try but the baby didn't move an inch. This didn't surprise me as I felt like my uterus was rock‐

hard throughout.

Going with the breech

I remember feeling a bit disheartened after the ECV, but also having a feeling that my baby was

doing what she knew was best for her. I began to accept that I would most likely be having a breech

baby and stopped hoping so fervently that she would turn. Our doula gave me a book on breech

birth by Maggie Banks and I watched the Karin Ecker movie of her footling breech birth A Breech in

the System. These resources and others showed me that breech birth is a variation on normal, that it

is not abnormal and that I was not alone in wanting to try for a vaginal breech birth. I joined the

Breech Birth Australia Facebook group – an online community of people who’ve had breech babies

or have an interest in breech birth (e.g. midwives). These women especially were a great comfort as

the mind games with the healthcare system really began.

After the ECV attempt we met with another obstetrician (we got whoever was on duty that day).

That doctor was very pro‐caesarean for breech births, saying that he concurred with the Term

Breech Trial’s conclusions that caesarean was safer than vaginal breech birth. He was honest about

his and most of his colleagues’ lack of experience with vaginal breech birth, saying that he didn’t

want to practice on us. It was clear that if we stayed at that hospital I had little choice but to consent

to an elective caesarean the next week at 39 weeks. It all felt wrong – like a decision made out of

fear.

Changing hospitals

At home I shot off emails to doctors at the larger hospital in our city and to a doctor interstate who

specialises in breech births and advocates for them if the conditions are right. I considered paying

for a private obstetrician in another interstate city who also specialises in breech births. Luckily a

drastic late dash interstate was not required. We got an appointment at the other hospital in our

city. We saw an older doctor with a kindly manner who would have been practising long before the

Term Breech Trial all but halted vaginal breech births in Australia. He was objective in setting out the

risks and benefits of both vaginal birth and surgical birth for breech babies. He assessed our case on

its merits, agreeing that there were no other contra‐indications for vaginal birth. He also agreed that

there were benefits for both me and the baby of a trial of labour before a caesarean. Most

importantly he respected our right to choose which option to take. He made me feel empowered to

make the right decision. A senior midwife also spent a good amount of time with us reviewing our


birth preferences document. I came out of the hospital with a big smile on my face and a huge sense

of relief. It was a simple decision to transfer hospitals. I could put all the negativity from the other

hospital behind me and focus on getting back to envisaging a positive birth for my baby. Still, it was

not an easy decision. Ultimately, it came down to a combination of gut instinct and a confidence

that, having no contra‐indications, I was a good candidate for a vaginal breech birth.

So we waited for labour to commence. We waited about two weeks. A couple of times during those

two weeks I second‐guessed myself. Was I choosing vaginal breech birth for the right reasons? Was

it truly about what was best for the baby or had I been brainwashed by reading too many stories

about orgasmic vaginal birth? Was I putting our doula’s image of feeling like a goddess during labour

ahead of the health of my baby? My gut instinct told me that the right decision for us was to go into

spontaneous labour and give a vaginal breech birth a go. My partner and I took on board the medical

advice we had received, however, and agreed that if it didn’t go like clockwork we would consent to

a caesarean.

Pre‐labour and labour

On the evening of Friday 2 March at bedtime I began having regular light contractions. They

continued throughout the night. Laying on my side made them stronger so I got on my hands and

knees and waved my butt in the air for thirty seconds about every six minutes. I was amazed that I

could sleep between contractions. I kept my excitement in check ‐ I knew this was only pre‐labour.

At about 3am I noticed some blood when I went to the toilet. My partner rang the hospital, as we

were a little unsure about when to go in – we’d been told not to stay at home too long because of

the breech position. Thankfully the midwives didn’t see any reason to come in and told us to stay at

home. This was just as well because by morning the contractions eased.

We spoke to our doula in the morning. She told us to get plenty of rest that day as contractions

might start again at night. I slept for quite a few hours that day. In the evening my partner went out

to a football game and I did a bit of vacuuming. Sure enough, after dinner the contractions began

again. This time they were a bit stronger. Gradually the contractions got stronger – I found a

standing position with my nose and hands against the wall worked well. At 1am I felt my waters

break. I was relieved that the fluid was clear. I got a towel to stand on near the wall in case there

was a big gush, but the fluid continued to leak lightly into the pad I’d put on to keep an eye on the

colour. I noticed by this time that the contractions were getting closer together as well. I woke up

my partner. We called the hospital. They advised that it was time to come in. We called the midwife

who was on‐call for us, and the doula. They would both meet us at the hospital. I spent most of the

time in the car with my eyes shut and breathed and moaned through about 4 or 5 contractions on

the way there.

At the hospital

We arrived at the hospital at about 2.30am. The doula had prepared the labour room wonderfully.

The lights were dim, the aromatherapy scents were lovely (although upon entering the room was

the only time I was conscious of them). It was really cosy and such a comfort to see her there,


smiling at me. The only thing I remember annoying me in the room was the ticking clock above the

bed. But I was quickly able to tune it out once I established my rhythm. We met the midwife who I

instantly felt comfortable with. They put the fetal monitors around my belly. We had consented to

this as a precaution because of the breech situation, although looking back the baby never did get

distressed so they weren’t really necessary. Luckily the monitors were cordless and waterproof ‐ I

don’t recall them being a distraction. Then the doctor on duty asked if she could examine me. I lay

on the bed and parted my knees. She gently felt inside me. Although I had told the midwife

previously that I didn’t want to know how dilated I was, the doctor told me anyway. I preferred not

to know because I wanted to get back in my trance and not think about anything to do with time and

numbers. As it turned out, it was good news though – I was already at 5cm and the cervix was quite

thin.

After a little while I found a pattern – between contractions I sat on a big soft chair with my eyes

shut, possibly taking microsleeps, and during contractions I stood up and leaned over the bed with

my forearms resting on pillows stacked on the bed. During the contractions I shifted my weight from

foot to foot, like a cat kneading on a soft cushion. The doula placed a soft mat under my feet so they

wouldn’t get sore. At one point I had a nice hot shower as a bit of a break and then I got back into it.

I used hotpacks and massage for pain relief and didn’t even think about drugs except to a few times

when I observed that, as I had hoped, I hadn’t needed to ask for any.

At 6am the doctor examined me. Again, she told me my dilation. Anyway, I was 8cm so it was good

news again – I was progressing at 1cm per hour, bang on expectation. During the next period I

remember feeling that I was nearly there, that soon I would be in transition. The contractions were

getting stronger and I had a slight urge to poo (associated with wanting to push) but nothing I

couldn’t hold back. I took this as a good sign.

Failure to progress

At 8am the doctor examined me again. I had no idea that two hours had elapsed since the last

examination. It felt like 30 minutes to me. The doctor told me my dilation but this time it was not

great news ‐ I was still at 8cm. This was disheartening but I felt like I had lots of energy left and that I

could keep going fairly easily. The doctor said she would give me another two hours. I lost my

rhythm a little during this time and decided to have a shower to refresh and reset myself for the last

2cm.

While I was in the shower I could hear people talking in the labour room. I knew something was up

but decided to ignore it and stay in the shower a little longer. When I’d had enough of the shower

and turned the water off my partner came in. I think it was him who relayed the extra information

that the doctor hadn’t told me before – the baby was not descending. The specialist on duty had

been consulted and had advised a caesarean before the baby became distressed due to ‘failure to

progress’. As soon as the c‐word (caesarean) was in the room I felt the game was up. The faces of my

partner and the doula, more than their words, told me that they believed the caesarean was

justified. I didn’t question the advice. In retrospect I wonder whether I should have but by then I had

already come so far out of my labour trance that I felt it would be too big an ask to re‐establish


myself into the zone I needed to be in to get to 10cm. It was as if my cervix began closing as soon as I

heard the word ‘caesarean’. Indeed, my contractions became less intense and less frequent from

that time on. I consented to the caesarean. I cried briefly with disappointment as my partner hugged

me.

I summoned all the concentration I had to read and sign a consent form (I had to read it aloud to

myself and follow the words with my finger like a child learning to read). The lights were flicked on

and my partner and the doula hurriedly packed up their bags. A trolley arrived and I was wheeled

down to theatre. In just a short time my contractions had weakened significantly – I was able to talk

through part of them and they became spaced out. Although I was sad that I was going to have to

have surgery, I was also excited – I now knew that within about half an hour I would meet our baby.

The caesarean

When I got to theatre several staff introduced themselves. I remember telling them I was a little

scared and asking that everyone be respectful of the occasion – I had visions of surgeons discussing

cricket scores as they sliced me open. I needn’t have worried though – everyone was very caring and

extremely professional. Nurses and the anaesthetist explained what would happen with the spinal

block and asked me questions about allergies and past operations. They gave me a pillow over which

to curl my body and told me to stay very still. I held a nurse’s hands. I had to wait for a mild

contraction to finish and then they gave me a local anaesthetic in the lower back and inserted the

spinal block. It didn’t take very long for my whole lower body to go almost completely numb.

They moved me so I was lying down and put the cloth screen up. My partner and the doula came in.

I was very grateful that they let the doula come in as they often don’t allow doulas into the theatre.

This meant that the doula could stay with me and my partner could go with the baby if anything

went wrong with either me or the baby. There was a bit of description by various people about what

was going on the other side of the screen and pretty soon I felt some rummaging around inside me. I

felt some weight lift out of me and then the rummaging stopped. There were comments about her

being out and I could see people on my side of the screen smiling as they looked over the screen.

They lifted our baby girl over the screen and I saw her for the first time for a few seconds. I started

crying with happiness – she looked complete and healthy! They quickly took her off to do her Agpar

scores. I heard her crying and I knew she was breathing fine then. My partner cut the cord. They

waited for the cord to stop pulsing before cutting it which is better for the baby. The doula told us

later that this was the first time she had seen this happen at a caesarean – she was thrilled, telling

me later I had made local history. Within a few minutes the baby was placed on my chest. I was just

so amazed that she was real – pink and kicking, not the grainy black‐and‐white static image from our

fridge door anymore. She looked perfect.

About this time I started feeling I couldn’t breathe. I started coughing and had to ask for the baby to

be taken off my chest so I could breathe a bit better. My partner held her while I was given an

oxygen mask and some type of anti‐asthma drug to help me breathe. The operating doctor told me

later that because I was coughing she put in a few extra stitches to make sure the suture would hold.

I started to shake quite a lot too ‐ a common side‐effect of the drugs. The doula held my hand as all


this happened. Apparently it takes about 25 minutes to stitch up the incision but it seemed quicker

than that to me. Before I knew it we were in the recovery room and the baby found my breast just

the way they showed us in the childbirth education classes. She took in a few drops of colostrum. I

was still shaking quite a lot and they wrapped lots of blankets around me. Everyone commented on

what a beautiful baby she was with her full head of hair and chubby cheeks.

Recovery and the first few days

After a brief time in the recovery room we were taken to the maternity ward. I was taking tablets for

the pain but they weren’t very effective. Someone came to examine me and when they touched the

wound, the area went into a spasm. I screamed with pain – it was like a contraction and felt like the

stitches were being ripped out. Before long a whole team of people surrounded my bed, trying to

figure out what was going on. I was afraid that I was bleeding internally and that was what was

causing the pain. After a few more contractions, through which I screamed my lungs out, they

figured out that the syntocinon I was on was causing contractions. This is a drug they give to stop

internal bleeding but it is also the drug they give to stimulate contractions in labour. (Note: this is my

recollection but subsequent conversations indicate it is unlikely that I would have had intravenous

syntocinon at this stage, so I could be mistaken.) They also gave me intravenous pain relief where I

could control the dose with a click of a button. It took quite a while for the pain to recede but the

intravenous pain relief was much more effective than the tablets. I had to have one of those oxygen

tubes in my nose the whole time too.

It wasn’t easy recovering from the caesarean. On the second day they took the catheter out and I

went back onto tablets for pain relief. Getting out of bed for the first time was very difficult. My

partner helped me inch off the bed and into the bathroom. It took at least half an hour for me to

walk a couple of metres. It was very painful but great to have a shower. My partner helped me do it

all. I don’t know what I would have done without him. After a few trips to the bathroom with some

help I was able to go by myself – dignity almost restored. It was still difficult getting in and out of bed

though.

During this period Elsa was deemed to have some jaundice. To treat this they put her under bright

UV lights for about 48 hours. She had to wear a little blindfold that kept coming off and she had to

be naked except for a nappy. It made me a little bit sad to see her like that and I was unsure that it

was necessary. Jaundice makes babies very sleepy so we had to wake her up for feeds and keep her

awake during feeds. My partner used an ice cube on her skin sometimes to do this. We also tickled

her. That time in the hospital was precious. I was in a shared room for the first night and then we got

a room to ourselves for the next three nights. My partner stayed the third and fourth nights on a

mattress on the floor. I remember being euphoric for most of that time, marvelling at the brilliance

of my body’s hormones and being utterly absorbed by Elsa.

Froggy legs

Elsa’s breech position gave her ‘froggy legs’. On our last day in hospital her hips were checked by a

neonatologist and no problems were detected. Her legs gradually straightened out over the next few


weeks. At six weeks she had the hip ultrasound recommended for all breech babies and was given

the all‐clear.

One month on

When Elsa was three weeks old our wonderful doula came to visit. It was lovely to see her again. She

made childbirth something to look forward to, not something to be feared. And I now look back on

the labour as something magical and enjoyable. We talked about the birth and discussed the one

thing that had been playing on my mind since the birth – should I have asked for more time when

the caesarean was first discussed? Did I give up on a vaginal breech birth too easily? The doula put

my mind at ease, confirming that she thought the caesarean had been justified – although we don’t

know what it was, there must have been some reason why the baby had not descended down

enough by 8cms’ dilation. I felt a sense of closure upon hearing this. Elsa’s birth was the best birth it

could have been. Now we’re setting about being the best family we can be.

Thanks to Breech Birth Australia and New Zealand for helping BABE Australia access some of these

stories. There are more stories on their website: http://www.breechbirth.net/birth‐stories.html


Vaginal breech birth: Driving interstate to access supportive public maternity care

Written by Jyai Allen

First published in Birth Matters – The Journal of Maternity Coalition. Reprinted with permission.

Normal pregnancy

I am a happy, healthy woman and as a midwife I knew I wanted a homebirth. At 5 weeks pregnant I

contacted a highly experienced and esteemed midwife who agreed to attend me. I booked in at my

local tertiary hospital as back‐up in the event of transfer in labour, and also to have easy access to

blood tests and ultrasound should I require it. The first trimester was punctuated by lethargy and

nausea. This passed as I moved into the second trimester which was filled with energy and joy. I

found myself moving into my body with yoga and swimming; even meditation and relaxation

became easier as I enjoyed the effects of the endorphins. The third trimester was focused squarely

on the position of the baby who was happily transverse and then frank breech.

Complementary methods to turn a breech

I tried visualisation, artwork, talking to the baby, upside down tilting, crawling off couches,

acupuncture and moxibustion, Webster chiropractic technique, cranio‐sacral therapy, and emotional

freedom technique. When we got desperate we used a combination of these all at once: hanging

upside down, while getting moxibustion from my partner, while both visualising the baby turning,

while tapping on my tummy (wish we got that on video!). When all these complementary methods

had failed, I had an experience of deeply surrendering and connecting to the baby. I ‘let go’ about

the breech position, and felt absolutely confident in my ability to give birth to a breech baby. The

next morning I saw the midwife at 36 weeks and the baby had turned over night to head down.

Preparation for homebirth

Suddenly I felt I could focus on preparation for homebirth, so I gathered together a list of everything

I might need or desire and began to decorate the lounge room with lights, birthing images, birthing

artwork, and set up the birth pool surrounded by colourful cushions and infused with the scent of

geranium oil. I had a Blessingway (baby shower) with female friends and family where we threaded a

birthing necklace and painted prayer flags for labour with one word blessings like ‘open’, ‘breathe’,

‘strength’, ‘let go’.

At the 39 week home visit the baby was again found to be breech. Both private midwives said they

lacked confidence in supporting a breech birth at home. I imagine this was particularly the case in

the current political climate where homebirth midwives were being targeted (and potentially de‐

registered) for attending ‘high risk’ homebirth. I felt abandoned, scared and angry.


External cephalic version (ECV)

The next day I made an appointment at the antenatal clinic of my local tertiary hospital where I was

booked. The baby was confirmed frank breech, not fixed in the pelvis. I agreed to have an ECV that

day which is I understand is about 70% effective. Despite several attempts by an experienced

practitioner the baby’s bottom just would not shift. The midwife in charge brought me an article

about breech birth in Australia and encouraged me to make contact through their Facebook group. I

came home and sobbed at the prospect of having a caesarean section. I couldn’t face the idea of

more frantic alternative therapies and felt that breech birth was the right way for me and my baby

as s/he was so clearly showing me. I made contact with the group and received ongoing support

from other women who had walked the same road. (This group has now developed a website

www.breechbirth.net which has inspiring breech birth stories and links to relevant research

including critiques of the Term Breech Trial.)

Birth plan

I made a plan to set up support for a “calm, upright, vaginal breech birth” at my local hospital with

the assistance of an experienced consultant and confident birth suite midwives. I met with the public

consultant who was happy to take me on (and be on call for my birth) as long as I agreed to have

pelvimetry (so he could feel more comfortable) and didn’t “want anything weird.” I had pelvimetry

the following day, not realising until I was in the room that I was subjecting my baby to x‐ray, but I

felt powerless to say no and went ahead, talking to the baby as we went and feeling very guilty.

I wrote a birth plan which included that the birth would be upright (squat, stand, birth stool) and

that there would be no manoeuvres to deliver the baby without a clinical indication. I sent this plan

to the consultant and the midwives who had agreed to be on‐call in birth suite. The consultant

phoned me almost immediately to say that he had an issue with both those preferences. He

explained that he gets “girls to get into a comfortable position in stirrups” and does “a gentle forceps

to the after‐coming head”. When I clarified that he used forceps, even when the birth was

progressing spontaneously, he said something to the effect of “that’s how I’ve been doing breech

deliveries since the seventies – I know what you want but I’m not the doctor to provide it for you.” I

got off the phone and again sobbed, yet another plan torn to shreds, now 2 days before my due

date.

Driving interstate to give birth

In the back of my mind I remembered a public consultant who I had worked with briefly as a

midwifery student, and who specialised in supporting upright breech birth. He agreed to take me on

and within a few hours we were packed and on the road to Sydney. The next afternoon we had an

appointment with the obstetrician and two midwifery group practice midwives (one who was a

colleague I knew well). He outlined his parameters for safe breech birth and we discussed and

negotiated my birth plan. I felt respected, heard, safe and supported – deep exhale!


Away from home and overdue

We initially stayed in Coogee, then Bondi, and then as the baby really went overdue we ended up in

an apartment in Clovelly overlooking the sea. Each day we walked along the cliff top path, swam in

the ocean, and spent time together connecting in preparation for the journey of birth and

parenthood.

At 40 weeks plus 10 days my clear waters broke on the apartment floor. I went to the hospital the

next morning for a routine ultrasound for postdates that the consultant had requested (all normal

except for no fluid!), a swab from GBS (negative) and a routine CTG (normal). I agreed to come in

daily for assessment but wanted to wait at least 96 hours before induction of labour, unless there

was a reason individual to me and my baby. Each afternoon I had acupuncture, did nipple

stimulation, had plenty of orgasms, walked sideways and ran up and down stairs, and massaged

clary sage on my belly. Each morning I awoke still pregnant; it was very frustrating.

Reduced fetal movements

At 40 weeks plus 13 days I woke around dawn surprised and irritated that I had not gone into labour.

I sat quietly on the balcony taking in the dawn and talking to the baby about his upcoming birth. I

had a feeling today was the day. When my partner woke we went for a walk along the coast line to

Bronte beach. I had not felt any baby movements all morning and started to feel panic rising. Once

at the café I felt a few very mild movements and was only partially reassured. I was keen to get

checked out by the midwife.

Induction or caesarean

We arrived at the hospital mid‐morning. The doctor expressed concerns about the baby’s well‐being,

including the increasing risk of stillbirth, which resonated with my own concerns that morning about

lack of baby movements. He gave three options: elective caesarean, induction that day, induction

the following day at 42 weeks. If we agreed to induction, he gave me a parameter of just four hours

to go into labour with the use of Syntocinon. I really did not want Syntocinon because of the

increased risks of an intervention‐filled birth and the interference with the hormones of love,

bonding and attachment for both me and the baby. My partner and I took some time together to

discuss the options and we phoned our own midwife to seek her advice. She didn’t push me in any

direction but said induction was a reasonable option at this stage. More importantly she said if we

decided to have an induction, then I needed to commit to it 100% in my mind, to forget about the

clock, and go inwards into the space of labour.

Preparing myself for induction

We returned home to pack the apartment (as we were due to check out the following morning), had

a rushed lunch and quickly made a chocolate ganache and mixed berry birthday cake.

On the way back to the hospital I told my partner it was now quite likely that I would have a

caesarean. If that happened and I was unable to have skin‐to‐skin with the baby then I wanted her to

do so, and to protect the baby against any routine interventions (like weights, measures, Vitamin K)


until I had breastfed him/her. I cried as I was talking this through; but it felt like surrendering to the

prospect of caesarean enabled me to let go of any fear of caesarean and focus on having the normal

birth I wanted. My partner and I had both learnt and practised Hypnobirthing techniques (breathing,

relaxation, positive visualisation) to use in labour. Our plan was to begin these techniques as soon as

the induction commenced, to move into the right space physiologically and mentally, rather than

staying in the everyday mind of conversation waiting for labour to start.

When we arrived the midwives had decorated the birth suite beautifully and my partner finished the

space with my birthing prayer flags, my personal drawings of positive breech birth, some chill‐out

music and aromatherapy.

Starting the induction

My cervix was 1cm dilated and stretchy, but the baby’s bottom was still fairly high in the pelvis

(station minus two). At 15.30 the Syntocinon drip started. I put on my headphones and listened to

positive affirmations while my partner gave me a light touch endorphin massage. I felt myself drift

into deep relaxation. I had agreed to CTG (fetal heart monitoring) for 15 minutes every hour rather

than continuously which enabled me freedom of movement. I could feel contractions starting to

come regularly, the sensation in my lower belly was quite pleasurable as I visualised the cervix

opening with each contraction.

Establishing in labour

By 18.00 I was having contractions every three minutes, lasting 50‐60 seconds, but was totally

relaxed and using long slow breathes with each (as practised during pregnancy). This confused the

midwife who could palpate and see on the CTG that the contractions were regular but my behaviour

did not match up.

At 20.30 the midwife told us to go for a walk to ‘get things going’ as she still didn’t believe I was in

good labour. We walked to the other end of the birthing floor. I stopped every few minutes to hang

off my partner during a contraction. Suddenly I felt a gush of pink fluid and a sensation of heaviness

as the baby dropped deeply into my pelvis. We made our way (waddling) quickly back to birth suite. I

remember saying to my partner that now this was starting to feel intense. We put on world music to

dance to as I felt the need to rock, swing and sway my body with each contraction. Soon the power

of the contractions brought me to my knees (literally) and I burst into tears “it’s too much, I can’t do

it.”

Transition

It was now 22.00 and I was eight centimetres dilated. I had made awesome progress! This was a

turning point in the labour. I stripped off all my clothes including my birthing necklace and started

making intense sounds as I moved my body exactly as I felt I needed to move. The contractions were

now one on top of the other (too close together because of the Syntocinon), and very intense. As

soon as I leaned forward to rest on a bean bag, another would come and I would throw the bean bag

out of the way. I felt at this point in the labour that I understood why women ask for epidural. I


asked myself what I would do if I felt this during my homebirth; would I transfer to hospital for an

epidural? No, I would just get through it, and this knowledge helped me through without drugs. It

was not painful but it was overwhelming and intense during transition.

About 23.00 I vomited copiously all the snacks and raspberry leaf tea I’d been drinking, it felt like

such a strong release and relief. At this point the midwife whispered to me “that’s the last of your

cervix gone” and she was right.

Pushing

Soon after that I felt the anal sensations of second stage as the baby began to really descend and

stretch me. I also had pain above my pubic bone which was a full bladder so I went to sit on the

toilet for a few contractions, which only intensified the pressure. I remember thinking I could ask the

doctor for local anaesthetic and an episiotomy to take this sensation away! And as soon as I’d

thought it, I could let it go again and carry on, just knowing I had an ‘out’ if I needed one (no matter

how ridiculous it was). I felt claustrophobic in the bathroom, so returned to the darkened main room

and sat on the birth stool.

Birthing the breech

The lights were very dim and the midwife and the doctor both knelt on either side of me while my

partner sat behind me. Everyone was respectfully quiet. I worked with my breath and my body with

each contraction and felt the baby descend gradually and start to stretch the perineum. I had no

idea where I was up to; when the midwife invited me to look in the mirror I could see the baby’s

whole bottom had been born. This gave me the impetus to keep going. Next I felt the baby’s legs

(which had been extended along the body) flick out and the shoulders corkscrew out and one arm

release. The doctor gently released the other arm which remained above the baby’s head. I was

instructed to “push” to give birth to the baby’s head, but that push felt totally ineffective and

‘wrong’ and nothing happened. The doctor did a simple manoeuvre to flex the head and the baby

was born immediately onto the mat in front of me at 00.07 (after 6 hours of labour). When I

debriefed the birth with an experienced midwife who had given birth to her own vaginal breech, she

said that the instruction should be ‘release or open’ to let the baby’s head be born as there is no

longer anything inside the uterus / abdomen to push out – the head is in the vagina ‐ hence ‘pushing’

is and feels ineffective at this point. This made total sense of my experience.

Bonding immediately after birth

The doctor milked the cord to deliver as much fetal blood as possible to the baby, before cutting it

and giving me Syntocinon by injection to manage the moderate haemorrhage that had begun (which

is not uncommon following an induced labour). The baby came up to me skin‐to‐skin and as I talked

to him and blew on his little face he transformed from blue to pink within seconds. It was magic. He

was so alert that he breastfed instinctively, attaching himself, and having a leisurely breastfeed for

about 2 hours on and off. I had only sustained labial grazes, which I believe is in part to perineal

preparation from 35 weeks.


Postnatal reflection

After the midwives left, we ate birthday cake and adored him while he slept. I was too high to sleep!

We left birth suite about 10 hours after he was born. The drive home took three long days, staying in

motels, and breastfeeding frequently by the side of the road. It was exhausting and so far from the

restful, intimate baby moon we had planned. Was it worth it? Absolutely! But it reflects so poorly on

our maternity services that many obstetricians don’t feel confident or competent to assist with a

vaginal breech birth; more specifically to stay ‘hands‐off’ unless hands or instruments are warranted.

I hope this workshop signals a turn in the tide towards not only supporting vaginal breech birth but

normalising it so that it becomes a legitimate and accessible option for women in Australia.


The importance of ‘having a go’ ‐ A caesarean after labour

Written by Jacqui Lachmann

Being pregnant for the first time was good. I was really happy to be pregnant and took care of myself

well. Through my local hospital, I chose the “Centering Pregnancy group model of care and I really

looked forward to all the appointments, it was really nice to meet all the other girls. I felt really

positive about the whole pregnancy.

I guess as a first pregnancy, it’s pretty much all you think about and it’s all you want to talk about. So

it was really nice to be part of a group of girls that were going through the same thing at the same

time and have the midwives take you through various issues and things that we’re supposed to find

out about and learn about.

I was around thirty weeks pregnant when I found out my baby was breech. I went to the hospital for

my visit and the midwife came and felt my tummy and she said, “Yep. There’s the head up there and

that’s the bottom. A doctor came in to confirm it and he put the ultrasound on and there was a

head up the top. It didn’t surprise me because I was breech and my sister was breech.

My mum had two breech babies and I think that had just always been in the back of my mind. I

didn’t think it was going to happen to me but, it didn’t surprise me. The doctor said, “Oh, don’t

worry. There’s plenty of time to turn. Such‐and‐such a percentage of babies are still breech at this

stage”. So I didn’t really worry about it, at that point. Then a few weeks later, all of a sudden they’re

giving me a brochure on ECV and saying that I’ll need to go to the hospital to talk about making an

appointment for a caesarean. It was just a shock to me because I thought that there was still plenty

of time to turn. One of the midwives in the Centering Group was pro natural breech birth. So even

though the local hospital was putting in motion these things for a caesarean birth and that was their

policy, it was good to have a little bit of information from that midwife that there were other

options.

What I had been told about breech from my mum was that it was a danger to the mother’s and

baby’s life to be born naturally breech. That it was basically impossible. That because the head

comes out last and the umbilical cord is compressed….that that’s a real, life threat to the baby. And

that if it wasn’t for caesarean operations that I might not be here. That’s from my parents. Growing

up ‐ not as a pregnant woman, but just growing up. That’s the story I got and that’s obviously what

they were given.

So even though this midwife had talked about an obstetrician who was supportive of natural breech

birth, it’s not something I wanted to explore. Because as far as I knew, that was really dangerous. I

felt scared. Disappointed and worried. I felt that way for a long time until we’d decided that we were

going to try for a natural birth. It was horrible. I was a mess for ages.

And so, I felt that if my baby stayed breech, then it would be a caesarean. And that was it. And I

wasn’t happy. I’d been educating myself on labour, and birth, and breastfeeding. We’d been to an


Australian Breastfeeding Association workshop. I dragged my husband along too. And I knew how

important it was to have that skin‐to‐skin contact to facilitate breastfeeding after birth. I knew that

the local hospital policy was, after a caesarean, the baby would be wrapped, put on your chest for

maybe ten minutes or something and then taken out of the operating theatre while I was stitched up

and while I went to recovery for however many hours that would take. So I was really upset that all

that was going to happen.

I went to the local hospital to see the doctor to talk about the options….which there wasn’t any. I

had a low‐lying placenta and a doctor decided that I was not a candidate for ECV. That was actually a

relief because I was really not comfortable with it. I wanted to know if I could go into labour and

then come in for a caesarean because I knew the benefits of letting a baby go full term and come

when it’s ready. And she said, “No”. I couldn’t do that. And she told me that there was a real danger

of cord prolapse and of head entrapment. So, that was really scary to hear that from her. I was in

tears in the appointment. I felt like there just were no options for me whatsoever. I look back on it

and I think she’s horrible because she wasn’t educated and obstetricians should know this stuff.

After that appointment I was still looking down the line of caesarean and of being separated after

the birth and everything. I went to a coffee morning of the local Australian Breastfeeding Association

and the group leader was a midwife at the closest tertiary hospital. She told me about an

obstetrician that did breech births and suggested I call. So I called this doctor on a Friday afternoon

and he told me to come at nine o’clock on Monday. So I went. I was in the waiting room and he was

late. And I was just sitting there, I was so uncomfortable. I was like, “This isn’t the hospital I’m meant

to be in, I don’t know this place. I’m in a weird suburb”. I almost got up and walked out. I just didn’t

feel comfortable being there at all. But I stayed and he was great. He took the time to answer all my

questions. It was so relieving to hear him say that my body is well capable of giving birth. That

nothing was wrong with me, which is what I had been feeling. Even though I’d had this very healthy

pregnancy I thought “something is obviously wrong because I can’t give birth to my baby because it

has to be cut out of me”.

I guess the main thing I wanted from him, was to have that option of going in to labour and coming

in for a caesarean because I was still really scared about giving birth to a breech baby. He said, yes, it

was an option. But he looked at my scans and he said that he would be willing to give a cautious go

at an ECV as well. So that became back on the table as an option. And he said, “You’re a perfect

candidate for a vaginal breech birth”. So, I went out of that and suddenly everything had opened up

again and it felt really good, to have all those options. He said “Just call me and tell me if you want to

do an ECV or not”. There was no pressure there whatsoever. We had a go at the ECV and it didn’t

work. We were in one of the Birth Centre rooms. My husband and I were like, “There’s a double

bed” and “There’s a spa” and I was just lying on this double bed having the ECV done. It was so, nice.

Afterwards the doctor came and sat down on the chair and we just had a bit of chat. He answered a

few more questions and he said that, “The important thing to remember is that we would not try

anything that’s unsafe.” I trusted him.

The doctor emailed some more information and some links to the Canadian Society of Obstetricians.

We read a lot of breech information and looked up the numbers and the risks and everything like


that and decided that it was worth giving it a try. It was actually something that was safe, or at least

as safe as caesarean. That was one of my first questions to the obstetrician, “What’s safest for me

and the baby? Is it caesarean or natural breech?” And he said, “The difference is negligible”. So that

was huge for us once that actually sunk in. And it did take a while to sink in. Like, it was a long

process of coming around to finally deciding that we did want to try for a natural birth. It felt so

good to finally come to that decision— “We’re back in the game”. “Back in the range of normal

again”. To have a go.

The document the doctor sent through was clearly something that he sort of just made small

modifications to, for each woman, I guess what was missing was getting that sort of information a

lot earlier. I guess it must have been pretty good information to have it given to me at thirty‐seven,

thirty‐eight weeks of pregnancy and be able to process it quickly enough to then decide to try for a

natural birth. It was hard to process it that quickly. It would be much better if you knew before you

have even got a breech baby that breech is really normal. That if you have a breech baby that that’s

OK so that you don’t have to process anything and re‐change your whole way of thinking.

I looked on the internet for information, particularly for birth stories, for successful birth stories. It

was mostly pretty positive. I had the confidence in the information from the Canadian website, as a

reputable source and I had confidence in the doctor and his numbers that he’d had and his

experience and that his numbers were far better than what the Term Breech Trial showed and that

sort of thing. So, I think if I had come across anything, negative it wouldn’t have been from such a

reputable source so I wouldn’t have given it so much credibility.

I kept my immediate family informed the whole way through. My mother knew how much research

we were doing and she knew that we were making informed decisions. And, I could tell that she felt

a little bit reserved about it. She was a little bit worried about it. And, early on when we found out

that it was breech, I was pretty open with telling people about it because I was still expecting the

baby to turn. Later on, once we had decided to try for a natural birth, I couldn’t tell anyone that

that’s what we were going try because I was worried that so many people would have the same

opinion that I did before, about how dangerous it was and I didn’t want those perceptions put on to

me. As much as we felt we’d made an informed decision, there was still that sort of insecurity about

it. And, I also felt that, because we were choosing a path that was not the status quo that the

responsibility for anything going wrong would rest with me. Because we had made that decision, to

try for a natural birth so if it went bad, that would be my fault. Whereas if we’d had a caesarean and

it went bad, well, that wouldn’t be our fault because that’s the way you do it.

As time wore on, we just thought, “Wow! Isn’t it so good that we’re going to be able to go into

labour naturally.” We were actually booked in for the caesarean at the local hospital and that date

passed and then we went post‐dates and we were waiting and waiting. And I didn’t feel impatient at

all actually. I was just enjoying being pregnant. Finally it got to the point where the doctor said that

we should make an appointment to break my waters. Which would have been 12 days after my due

date. The night before we were going to have that done, I woke up at midnight and my waters

broke. Once my waters actually broke, I was like, “Yes. It’s on” On the way in to the hospital, I

started having some contractions. So I was really excited about that. They were very mild ones and


they were probably four minutes apart. I laboured like that for many hours. At some point the

doctor decided that, it would be good to try and move things along a little bit with a bit of

syntocinon.

So they started a low dose of it and that made everything much more painful. I’d been using a TENS

machine. That was good. And, after a while of being on the syntocinon, I felt like I couldn’t cope with

the pain anymore. I had some morphine which made things much easier.

Time marched on and I was progressing very slowly. We had talked about time frames beforehand.

They stopped the syntocinon and the doctor brought up c‐section and I said that I would go with

whatever he recommended but, that I felt like, since I’d had the morphine I could cope for a bit

longer. He said he would give me another hour. And that was a really hard hour. The contractions

were really hurting. It was longer than an hour before he came back and I was looking at the clock,

waiting for him. He came back and I think I might have been seven or eight centimetres and the

decision was made to go to c‐section. You know the spinal block was absolute bliss.

And then she was born and she was perfect. The midwife that I had at the end was really nice. I told

her it was really important to us that we have skin to skin contact and that I wasn’t separated from

the baby. She facilitated that to happen in the operating theatre. It was really good that my baby

stayed on my chest the whole time I was being stitched up. The doctor that was assisting the

operation was asking the other one all these questions about breech birth, like, “But what about

head entrapment?” or “What about this and that?” It was really weird. And I thought, “Oh, well. At

least someone’s getting educated”.

But I don’t know. I still think that I just had not, mentally, quite come to terms with the fact that it

was OK to give birth to a breech baby. And I feel like that was what didn’t allow me to dilate fully. I

spoke to the doctor about it a few days later and told him that I felt like I just wasn’t mentally

committed enough. He said, “Oh, no. You were just as committed as anyone possibly could be to

your labour” which made me feel a lot better. But I still feel like it was a block in me, mentally, that

stopped it from happening. And I feel like if I’d had longer to come to terms with it, or if it was just

thought of as a normal thing to do, then I wouldn’t have had that block.

When I think back about it I feel like we made the best decisions we could with the information that

we had in the time that we had. I feel really positive that we tried a natural birth and I feel proud of

it. I’ve done so much more reading on breech birth now. I wish I could’ve just trusted my body more.

I was really happy to do the whole labour in hospital because I felt like that was the safest. But now

I’d I think it would be nicer to labour at home for a while before going into hospital. And I’d probably

be a bit more assertive with what I wanted in the hospital. But, overwhelmingly, it was positive.

And, I’m not really that disappointed that it ended in caesarean. But I am a little bit worried for the

future ‘cause I do want to have natural birth next time, whether it’s breech or not. And having a

caesarean, I know that’s there’s lots of obstetricians that are pro‐VBAC but it just seems like that’s

another little thing to overcome and they might try to put time limits on labour. I guess it’s just going

to make it that little bit harder to have a natural birth next time.


I would tell other women that breech is a variation of normal. That it’s totally normal and their

bodies can give birth naturally to breech babies and that there’s plenty of evidence that it’s safe.

And, that there are practitioners that will support it. And that they should inform themselves, arm

themselves with the information. Know the facts themselves and then it doesn’t matter what other

uninformed people say to them. They’ll have the right information.

In the beginning I didn’t want to have a natural breech birth because I thought it was really

dangerous. I think, to make a decision to end up with trying for natural breech birth, to go against

the status quo, it’s a really hard thing to do. It was hard to navigate the breech decision because

what I wanted at the end of birth was the optimal result. I wanted a shot at the best result possible.

And having a caesarean was not going to give us a shot at the best result possible because there are

compromises in having a caesarean.

The other thing that the experience has also given— it’s really taken away my trust in the medical

system because as much as our doctor in the end was just amazing, and I’m so grateful that we had

his care, what about that other doctor that just told me scary things? I’ve read story after story of

the same thing happening to other women where they’re just basically being told that their bodies

don’t work. And, it’s all based on a study that’s been shown to be wrong. Why is our system still

doing this? For me it extrapolates to other things like of, “How can I trust this doctor on this matter?

I don’t know if they’re giving me advice based on evidence or based on, myth.” So it’s good to always

question things but I just don’t really trust the system anymore.


Chapter 7: Setting up a breech service

Written by Anne Sneddon

Objectives


identify which women are the best candidates for a successful vaginal breech birth

discuss the tools that can be used to assess suitability

articulate the elements of a sustainable breech service

understand the training needs of doctors and midwives in relation to vaginal breech birth

explain the auditing requirements for a vaginal breech service

Introduction

The primary prerequisite to establish a breech service is engaging the maternity care providers.

Identifying key leaders of clinical practice, both midwifery and obstetric, ensures that a service will

be sustainable. Ideally the engagement of a core group of midwives and obstetricians who are

available to provide an acute and planned service on a sustainable 24 hour basis is a key component

to being able to support women in this birth choice.

Maternity carers

All maternity care people should be able to support women in a calm manner. Fear and panic in a

birth room is not conducive to supporting a woman to have a physiological labour and birth.

Midwives should be able to support a woman in her wishes in occupying the birth space. For

example, increasing use of telemetry may make labouring in water a real possibility for women with

a breech presentation. Midwives and obstetricians should aim to increase their comfort in

supporting women in a number of positions as this is likely to be able to increase the choice for

women, enable them to feel safe in the environment and then optimize the birth outcomes.

All maternity carers should be skilled at being able to communicate about breech births in both the

emergency and planned situations. Being able to have a conversation that clearly outlines the

differences in outcomes and complications between breech and cephalic births is a skill that requires

development and training. Being able to explain clearly complex concepts in a calm non‐alarming

manner but ensuring the woman and her family are aware of the choices is one of balance and

requires skill and practice.


Obstetricians need to be able to philosophically support women who choose a vaginal breech birth

and this is not a choice that all can make. They also need to be able to support a woman to give birth

in a number of positions. There may be a role in some maternity units for those who are trained only

in the lithotomy method to continue to do this but it would be beneficial for them to expand their

skills with others who may be more confident attending women in alternate birth positions.

Having an on call “breech roster” for those who are happy to be able to support women may be an

option. It is not useful to the woman or obstetrician to be involved in a breech birth if the comfort

level of the obstetrician is not conducive to a calm environment. This may need to be part of the

antenatal conversation with women who plan a vaginal breech about what happens in a particular

maternity unit during and after hours, who is on call, who is available and the presence of training

registrars at the birth.

Planned elective vaginal breech birth

A breech service should encourage women with a breech presentation in the first instance with an

opportunity to undergo an external cephalic version (ECV). This is discussed elsewhere in the

manual.

Where a woman chooses not to have an ECV or if the ECV is unsuccessful, those women who are

interested in a vaginal breech birth, should be offered a discussion around breech birth. A proforma

is attached to this manual that enables women and their families to be able to be informed of the

differences between vaginal birth with a cephalic presentation and a breech presentation.

The conversation about vaginal breech birth may take around 60 minutes and is best undertaken out

of an otherwise busy antenatal clinic. One option is to give the woman and her partner the

information and allow them to go away and consider the options available. Making a decision at this

time is often difficult due to the volume of information given.

The decisions may also change with time. What seemed a very favourable choice may change as the

gestation advances, the baby grows, the liquor diminishes and if the woman’s cervix remains

unfavourable. Using a scale as a guide as demonstrated in the proforma allows time for the woman

and her carers to be able to come to terms with altered expectations.

A formal ultrasound should be performed if not already done before the ECV attempt. This will

ensure that the information about the baby can be discussed in the initial talk. Type of breech, head

circumference and biparietal diameter, estimated fetal weight, flexion of head and that there are no

uterine or fetal reasons why a breech birth should not be attempted.

In summary the following should be discussed:

Discussion of the literature and evidence, why some of the literature may be applicable to the unit in which a breech service is established and why some of it may not be.

Discussion around personal motivation and maternal effort required, especially in second stage, will ensure that the woman is aware of the need to do this unassisted.

Analgesia, and anaesthesia the advantages and disadvantages.


The maternity unit’s philosophy and availability of experienced obstetricians and midwives.

Reasons for an intrapartum caesarean section including increased rates due to the inability to do a lactate level and inability to assist birth with instruments unlike a cephalic baby.

Lower 1 minute Apgar scores are often normal for breech babies. The presence of a neonatal doctor is often suggested to ensure that the delay sometimes seen in breech presentation to adaption to the outside world does not result in any compromise for the baby. Their presence does not mean that they will need to intervene.

Neonatal review of the hips as the incidence of congenital hip dysplasia is increased in breech presentation regardless of mode of birth.

It is important to explain to women about the maternity unit’s breech service. This includes who is

involved, variations in practice and the limitations of the breech service. It may be that all

practitioners are comfortable with a woman in a hands‐and‐knees position or on a birth stool,

however, for a sustainable service this may not be possible. It is important to explain to the woman

that if a practitioner is not able to feel safe in complicated breeches that optimising the confidence

of both the woman and her practitioners may involve some compromise.

It is essential that there is clear documentation of the individualised conversation in the woman’s

clinical records.

Table 5: Factors to consider when discussing breech presentation with a woman

Type of breech Frank Complete Other

More difficult ECV Easier Variable

Likely more successful vaginal birth

Cord compression in labour Less likely More likely Most likely

Cord prolapse 0.5% 5% 15% or higher

Evidence available: why we need to have this conversation

Term breech trial: positive contribution to evidence, limitations:

Why it may or may not apply to the service or to this women

PREMODA study: positive contributions to evidence, limitations, why it may or may not be

applicable to the service

Making a breech birth possible

Experienced clinicians: how the service works at this hospital

Creating a birth space

Engaged woman and support group

Induction of labour limitations


Monitoring of baby including inability to perform lactate sampling in cases of non reassuring

heart rate and the need for intrapartum caesarean section.

Analgesia and anaesthetic

o Epidural advantages and disadvantage

Management of labour dystocia

o Limitations to augmentation and relation to increased intrapartum caesarean

section

Management of second stage

o Maternal effort only

o Maximising maternal effort: positions including birth stool, 4 point kneel, standing

Birth positions: birth stool, hands‐and‐knees, standing, lithotomy including advantages and

disadvantages for women and maternity care providers

Perineal management: women’s choice, reasons that an episiotomy may be necessary.

Management of birth of the head through the pelvis including slow controlled passage and

indications for intervention.

Neonatal presence

o Delay in adaption common (ie decreased Apgar score)

The Breech Score

The Breech Score has been proposed as a guide to assist in determining which women are most

likely to be successful in achieving a vaginal breech birth. This score was developed in the 1960s and

1970s [59, 72] and has been used by some clinicians to provide a guide for recommending vaginal

breech birth. It is important to note that the score in itself does not have a high sensitivity or

specificity. It should only be used as a guide of considerations. A “favourable score” does not

guarantee a vaginal birth, and an unfavourable score does not preclude a vaginal birth. Some of the

information will be known at the time of the initial consultation, whilst some will need to be

determined at the onset of labour.

Parity is important and may alter the scoring. For example a woman who has previously given birth

to babies who are more than 4.5kgs may well be more favourable to birth a baby with an estimated

fetal weight of 4kgs. Head circumference is a more important measure than biparietal diameter as

the breech head is more likely to be doliocephalic (that is, the head is longer than would be expected

relative to the width of the head). Gestational age is likely to be related to the other growth

parameters and placental function. Cervical diameter is an arbitrary guide. However, the woman

who has laboured for a number of hours at home and presents in established labour with a cervix

that is undilated, with a presenting part higher may not be as successful as the woman who presents

3cms with minimal contractions. Some women will find this information reassuring and be able to

place realistic expectations around the woman’s likely success of the vaginal birth.


Table 6: Breech score

0 1 2

Type of breech Other Complete Frank

Parity Nulliparae Primipara Multipara

EFW (kgs) <2.5 and >4.0 3.8‐4.0 2.5‐3.8

HC (cm) >36 >35 Up to 35

Gestational age

(completed weeks)>41+ 40+ <40

Cervical dilation at on

arrival to birth suite

(cm)

0‐1 1‐2 >3

Source: Z‐A Score (Zatuchni‐Andros Breech Score) [59] modified by Anne Sneddon

Discussing vaginal breech birth

The manner in which the information is relayed to the woman must be inclusive of her choices.

Alarmist language …for example “the head will get stuck” should be avoided. A conversation that is

calm, encouraging and positive but realistically explains the differences between a cephalic birth and

a breech birth will ensure the best choice is made by the woman and her family.

Some women will not be suitable for a vaginal breech birth for a multitude of reasons related to

maternal, fetal or combination of reasons. These women may still wish to experience some labour,

“allow the baby to choose its birthday”, or wait until a particular gestation before electing to have a

caesarean section. The “all or nothing approach” may for some women be too confronting. The

conversation should explore any limitations that a woman may self‐impose, for example, a trial of

labour up to 40 weeks, or even waiting for onset of labour but limitations around how long the

labour will be, may provide some women with options that allow her to feel more comfortable. A

woman and her family should be able to choose a variety of options around her birth.

The emphasis on optimising the success of a vaginal breech birth should be around the minimisation

of interventions. The most likely successes will come with spontaneous onset of labour, active

labour, conducive environment with confident support people and maternity care providers,

minimal analgesia, active second stage and a birth position that works best for the progress of

labour.

Training for obstetricians and midwives

Currently there is concern that many obstetric registrars and midwives will not have sufficient skills

and confidence to offer vaginal breech birth. An established breech service can provide the support

and confidence to be able to experience a mentoring system of training in vaginal breech birth. In


addition skills based training courses, such as BABE, which aims to increase knowledge and skills in a

practical hands on way will provide avenues for those that are keen to provide the opportunity to

support women with a baby presenting in the breech position.

Review and audit

Over the past decade, the term breech trial has had far reaching effect and impact on the decreasing

number of women who are offered or select to plan a vaginal breech birth. Today, there are an

increasing number of units that offer services that support women to have a vaginal breech birth.

The monitoring of the outcomes of these services is important to provide information than describe

appropriate management against measures and definable outcomes.

There are a number of relevant data items that are worthy of collection on an ongoing basis as part

of service audit and review. Below are a list of recommended data items that can form the

beginning of your data collection for audit and review. These might include:

Parity, gestation at birth, type of breech presentation at ECV and/or birth

Number of women with a breech presentation at 34 ‐ 36 weeks

Number of women offered access to ECV

Number of women who select ECV

Was ECV successful?

Success rates of ECV, with or without tocolysis

Number of women with an undiagnosed breech presentation presenting in labour at term

and the antenatal care received prior to presentation.

Selected mode of birth – vaginal/caesarean section

Achieved mode of birth ‐ vaginal/caesarean section

Augmentation in labour

Maternal position for vaginal birth

Length of first stage

Length of second stage

Neonatal outcomes – Apgar Score/Level of resuscitation/Admit SCN or NICU/ Reason for

admission/ Length of stay in nursery

Neonatal cord gas measurements

Maternal complications

Longer term outcomes.

Summary

Establishing a vaginal breech service is gathering interest and enthusiasm in many units. It is

important to consider the number of women who will undergo vaginal breech birth, the skills and

training needs of the staff, the processes in which to support women and the space required. The

auditing of outcomes is essential to ensure that the service is meeting its aims and being

implemented in a safe manner.


Resources for women and clinicians

In this section are a number of resources that might be useful to recommend to women or for clinicians to access themselves. The BABE team has checked these links and they were correct at the time of writing. The Board and Faculty of AMaRE Australia have made considerable efforts to ensure that these resources are accurate and up to date however we cannot vouch for them all, especially over time.

Users of the information presented here are strongly recommended to consult independent sources and local resources, for confirmation. The Board and Faculty accept no responsibility for any inaccuracies, information perceived as misleading, or the outcomes of using any of these resources.

GUIDELINES AND PROTOCOLS

Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)

Management of Breech Presentation at Term (2001, reviewed 2013)

http://www.ranzcog.edu.au/component/docman/doc_view/945‐c‐obs‐11‐management‐of‐term‐

breech‐presentation‐.html

Society of Obstetricians and Gynaecologists of Canada (SOGC)

Vaginal Delivery of Breech Presentation (No. 226, June 2009)

http://www.sogc.org/guidelines/documents/gui226CPG0906.pdf

Royal College of Obstetricians and Gynaecologists (RCOG)

The Management of Breech Presentation (2006)

http://www.rcog.org.uk/files/rcog‐corp/GtG%20no%2020b%20Breech%20presentation.pdf

External Cephalic Version (2006, reviewed 2010)

http://www.rcog.org.uk/files/rcog‐corp/uploaded‐files/GT20aExternalCephalicVersion.pdf

New Zealand Guidelines Group:

Care of Women with Breech Presentation of Previous Caesarean Section (2004)

http://www.health.govt.nz/publication/care‐women‐breech‐presentation‐or‐previous‐caesarean‐

birth

American College of Obstetricians and Gynecologists (ACOG)

Mode of Term Singleton Breech Delivery: Opinion 340 (2006, reaffirmed 2012):

http://www.acog.org/~/media/Committee%20Opinions/Committee%20on%20Obstetric%20Practice

/co340.pdf?dmc=1&ts=20130414T0500435203


BOOKS AND ARTICLES ON PHYSIOLOGICAL BREECH BIRTH

Benna Waites, Breech Birth (2003; Free Association Books Ltd) (224 pages)

http://www.fishpond.com.au/Books/Breech‐Birth‐Benna‐Waites/9781853435638

A book on breech birth for parents, obstetricians, midwives and all who come into contact with

women carrying breech babies. This book addresses the whole experience of breech from causes to

turning techniques to the options for birth.

Maggie Banks, Breech Birth Woman Wise (3rd ed 2003; Birthspirit Ltd) (109 pages)

http://www.birthspirit.co.nz/

Detailed descriptions on how to manage a breech birth, with clear photographs and researched

background information written by a midwife with extensive experience in managing breech birth.

Jane Evans Understanding physiological breech birth (2012) Essentially MIDIRS 3(2) 17:

http://www.midirs.org/wp‐content/uploads/2012/09/Essentially‐MIDIRS‐Feb‐2012.pdf

Jane Evans The Final Piece of the Breech Birth Jigsaw (2012) Essentially MIDIRS 3(3) 46:

http://www.midirs.org/2012/03/01/essentially‐midirs‐vol‐3‐no‐3‐march‐2012/

Ina May Gaskin The Undervalued Art of Vaginal Breech Birth

http://www.inamay.com/article/undervalued‐art‐vaginal‐breech‐birth‐skill‐every‐birth‐attendant‐

should‐learn

NETWORKS AND CAMPAIGNS

International Caesarean Awareness Network:

http://www.motherandchildhealth.com/Prenatal/breech.html

Royal College of Midwives Campaign for Normal Birth:

http://www.rcmnormalbirth.org.uk/stories/do‐as‐you‐would‐be‐done‐by/normal‐breech‐birth/

Upright and Empowered ‐ The BirthRite Experience (includes a segment on breech births):

http://www.birthrite.com.au/


CONSUMER‐FOCUSED MATERIAL

Breech Birth Australia and New Zealand: Links to a wide range of breech‐related resources

http://www.breechbirth.net/

Decision making brochure for women:

http://www.breechbirth.net/uploads/1/2/7/8/12786795/infosheets_decisionmaking_breech_1.pdf

Karin Ecker, (film) A Breech in the System

http://www.abreechinthesystem.com

Spinning Babies: Summarises non‐medical turning techniques and includes links to other relevant

websites.

http://www.spinningbabies.com/

Jane Evans Breech Birth: What are my options? (2005, AIMS): A British midwife experienced in

assisting women to give birth to their breech babies has written this informative and empowering

book to inform women about the choices they have and help them decide what is right for them.

http://www.aims.org.uk

Royal College of Obstetricians and Gynaecologists

A Breech Baby at the End of Pregnancy:

http://www.rcog.org.uk/files/rcog‐

corp/A%20Breech%20Baby%20at%20the%20end%20of%20Pregnancy.pdf

Turning a Breech Baby in the Womb:

http://www.rcog.org.uk/files/rcog‐

corp/Turning%20A%20Breech%20Baby%20In%20the%20Womb%20(External%20Cephalic%20Versio

n).pdf

Andrea Robertson If your baby is Breech


https://www.birthinternational.com/articles/midwifery/37‐if‐your‐baby‐is‐breech

Pregnancy, Birth and Beyond: A collection of articles and resources related to breech birth by

midwife Jane Palmer

http://www.pregnancy.com.au/birth‐choices/breech‐birth/index.shtml

Women's Health: This site strives to improve the availability of accurate health information for

women.

http://www.womens‐health.co.uk/breech.asp

American Congress of Obstetricians and Gynaecologists FAQ 079: If your Baby is Breech

http://www.acog.org/~/media/For%20Patients/faq079.pdf?dmc=1&ts=20130414T0500022625


References

1. Hilder, L., et al., Australia’s mothers and babies 2012 (Perinatal statistics series no. 30. Cat. no. PER 69). 2014, Canberra: AIHW.

2. Scheer, K. and J. Nubar, Variation of fetal presentation with gestational age Am J Obstet Gynecol 1976. 125: p. 269‐270.

3. Hannah, M.E., et al., Planned caesarean section at term versus planned vaginal birth for breech presentation at term: a randomised controlled multicentred trial. Term Breech Trial Collaborative Group. Lancet, 2000. 356(9239): p. 1375‐1383.

4. Phipps, H., et al., The management of breech pregnancies in Australia and New Zealand. Aus NZ J Obstet Gynaecol, 2003. 43: p. 294‐7.

5. Hauth, J. and F. Cunningham, Vaginal breech delivery is still justified. Obsterics & Gynecology, 2002. 99: p. 1115‐6.

6. Glezerman, M., Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol, 2006. 194: p. 20‐5.

7. Kotaska, A., Inappropriate use of randomized trials to evaluate complex phenomena: case study of vaginal breech delivery. BMJ 2004. 329: p. 1039‐42.

8. Daviss, B., K. Johnson, and A. Lalonde, Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions. J Obstet Gynaecol Can, 2010. 32(3): p. 217‐224.

9. Rietberg, C., P. Elferink‐Stinkens, and G. Visser, The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants. BJOG: An International Journal of Obstetrics & Gynaecology, 2005. 112: p. 205‐209.

10. Chinnock, M. and S. Robson, Obstetric Trainees’ Experience in Vaginal Breech Delivery: Implications for Future Practice. Obstetrics & Gynecology, 2007. 110 (4): p. 900‐903.

11. Rietberg, C., et al., Term breech presentation in The Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33,824 infants. BJOG, 2003. 110: p. 604‐609.

12. Schutte, J., et al., Maternal deaths after elective caesarean section for breech presentation in the Netherlands. Acta Obstet Gynecol Scand, 2007. 86: p. 240‐3.

13. Verhoeven, A., J. de Leeuw, and H. Bruinse, Breech presentation at term: Elective caesarean section is the wrong choice as a standard treatment because of too high risks for the mother and her future children [article in Dutch]. B. NedTijdschr Geneeskd, 2005. 149: p. 2207‐10.

14. Vlemmix, F., et al., Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population‐based cohort study. Acta Obstetricia et Gynecologica Scandinavica, 2014. 93(9): p. 888‐896.

15. Dr Stu. The Problem With Research By Press Release: Another Attack On Breech Delivery. 2014 [cited 2014 18 August]; Available from: http://www.birthinginstincts.com/blog/the‐problem‐with‐research‐by‐press‐release‐another‐attack‐on‐breech‐delivery.

16. Walker, S. Can we eliminate all risk for breech babies? 2014 [cited 2014 18 August]; Available from: http://breechmidwife.wordpress.com/2014/08/14/can‐we‐eliminate‐all‐risk‐for‐breech‐babies/.

17. Goffinet, F., et al., Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006. 194: p. 1002‐11.

18. Giuliani, A., et al., Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol, 2002. 187: p. 1694‐8.

19. Albrechtsen, S., et al., Evaluation of a protocol for selecting fetuses in breech presentation for vaginal delivery or cesarean section. Am J Obstet Gynecol, 1997. 177(3): p. 586‐92.

20. Azria, E., et al., Factors associated with adverse perinatal outcomes for term breech fetuses with planned vaginal delivery. Am J Obstet Gynecol 2012. 285: p. e1‐9.

21. Haheim, L., et al., Breech birthat term: Vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team. Acta Obstet Gynecol Scand 2004. 83: p. 126‐130.

22. Ulander, V.‐M., et al., Are health expectations of term breech infants unrealistically high? . Acta Obstet Gynecol Scand 2003. 83: p. 182–189.


23. Maier, B., et al., Fetal outcome for infants in breech by method of delivery: Experiences with a stand‐by service system of senior obstetricians and women’s choices of mode of delivery. Journal of Perinatal Medicine, 2011. 39: p. 385–390.

24. Uotila, J., R. Tuimala, and P. Kirkinen, Good perinatal outcome in selective vaginal breech delivery at term. Acta Obstet Gynecol Scand, 2005. 84: p. 578‐583.

25. Borbolla Foster, A., et al., Lessons to be learnt in managing the breech presentation at term: An 11‐year single‐centre retrospective study. Australian and New Zealand Journal of Obstetrics and Gynaecology, 2014. 54: p. 333‐9.

26. RANZCOG. Management of breech presentation at term (C‐Obs 11) 2013 [cited 2013 21 September]; Available from: http://www.ranzcog.edu.au/womens‐health/statements‐a‐guidelines/college‐statements/433‐management‐of‐term‐breech‐presentation‐c‐obs‐11.html.

27. Kotaska, A., S. Menticoglou, and R. Gagnon, Vaginal Delivery of Breech Presentation: SOGC Clinical Practice Guideline. J Obstet Gynaecol Can, 2009. 31(6): p. 557‐566.

28. RCOG. The Management of Breech Presentation. 2006 [cited 2013 7 April]; Available from: http://www.rcog.org.uk/files/rcog‐corp/GtG%20no%2020b%20Breech%20presentation.pdf.

29. ACOG. Mode of Term Singleton Breech Delivery. 2006 [cited 2013 7 April]; Available from: http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/Mode%20of%20Term%20Singleton%20Breech%20Delivery.aspx.

30. Glezerman, M., Five years to the term breech trial: The rise and fall of a randomized controlled trial. American Journal of Obstetrics and Gynecology, 2006. 194: p. 20‐5.

31. Deans, C. and Z. Penn, ' The case for and against vaginal breech delivery. The Obstetrician & Gynaecologist, 2008. 10: p. 139‐144.

32. Turner, M., The Term Breech Trial: Are the clinical guidelines justified by the evidence? Journal of Obstetrics and Gynaecology 2006. 26(6): p. 491‐94.

33. Kotaska, A., Routine Cesarean Section for Breech: The Unmeasured Cost. Birth 2011. 38(2): p. 162‐64. 34. Cunningham, F., et al., Williams Obstetrics (Chapter 24: Breech Presenattion and Delivery). 23rd ed.

2010, New York: McGraw Hill Medical. 35. Gibbs, R., et al., Danforth's Obstetrics and Gynecology. 10th ed. 2008, Philadelphia: Lippincott

Williams & Wilkins. 36. Nassar, N., et al., Diagnostic accuracy of clinical examination for detection of non‐cephalic

presentation in late pregnancy: cross sectional analytic study. Bmj, 2006. 333(7568): p. 578‐80. 37. Hofmeyr, G. and R. Kulier, Cephalic version by postural management for breech presentation (Asessed

as up‐to‐date: 21 FEB 2011). Cochrane Database of Systematic Reviews 2000. CD000051. DOI: 10.1002/14651858.CD000051. (Issue 3).

38. Smith, C., et al., Knee‐chest postural management for breech at term: A randomized controlled trial. Birth 1999. 26(2): p. 71‐75.

39. Coyle, M., C. Smith, and B. Peat, Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews, 2012. 5(CD003928): p. DOI: 10.1002/14651858.CD003928.pub3.

40. Cluver, C., et al., Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database of Systematic Reviews, 2012. Art. No.: CD000184. DOI: 10.1002/14651858.CD000184.pub3( Issue 1).

41. Hofmeyr, G. and R. Kulier, External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews, 1996. Art. No.: CD000083. DOI: 10.1002/14651858.CD000083(Issue 1).

42. American College of Obstetricians and Gynecologists, External cephalic version. ACOG Practice Bulletin No. 13. 2000, reaffirmed 2009. 95(2): p. 1‐7.

43. Menakaya, U. and A. Trivedi, Qualitative assessment of women’s experiences with ECV. Women and Birth, 2012. 26 p. e41‐e44.

44. Evans, J., Essentially MIDIRS. The Final Piece of the Breech Birth Jigsaw, 2012. 3(3): p. 46. 45. Evans, J., Understanding physiological breech birth. Essentially MIDIRS, 2012. 3(2): p. 17. 46. NSW Health, Towards Normal Birth in NSW. 2010, Sydney: NSW Department of Health. 47. Whyte, H., et al., Outcomes of children at 2 years after planned cesarean birth versus planned vaginal

birth for breech presentation at term: The international randomized Term Breech Trial. Am J Obstet Gynecol 2004. 191: p. 864‐871.


48. Lawson, G., The Term Breech Trial Ten Years On: Primum Non Nocere? Birth, 2012. 39 (1): p. 3‐9. 49. Keirse, M., Evidence‐based childbirth only for breech babies? Birth, 2002. 29(1): p. 55‐9. 50. Su, M. and et al, Planned caesarean section decreases the risk of adverse perinatal outcome due to

both labour and delivery complications in the term breech trial. BJOG, 2004. 111: p. 1065. 51. Grant, J., Obstetric conundrums. BJOG, 2002. 109: p. 968. 52. Hutton et al, The early external cephalic version (ECV) 2 trial: An international multicentre randomised

controlled trial of timing of ECV for breech pregnancies. BJOG, 2011. 118: p. 564‐77. 53. Moster et al, Long‐term medical and social consequences of preterm birth. N Eng J Med, 2008. 359: p.

262‐73. 54. Hutton, E. and A. Reitsma, A comprehensive review of the research literature on external cepahlic

version (ECV). Canadian Journal of Midwifery Research and Practice, 2008. 7(1): p. 4‐16. 55. Bogner et al, Single‐institute experience, management, success rate and outcome after external

cephalic version. Int J Gynecol Obstet, 2012. 116: p. 134‐137. 56. Cho, L., et al., Predictors of successful outcomes after external cephalic version in singleton term

breech pregnancies: a nine‐year historical cohort study. Hong Kong Med J, 2012. 18: p. 11‐9. 57. Azlin et al, Tocolysis in term breech external cephalic version. Int J Gynecol Obstet, 2005. 88: p. 5‐8. 58. Cluver et al, Interventions for helping to turn term breech babies to head first presentation when using

external cephalic version. Cochrane Database Syst Rev, 2012. 1: p. CD000184. 59. Zwarnstein, M. and M. Bryant, Interventions to promote collaboration between nurses and doctors

(Cochrane Review), in Cochrane Library. 2000, Update Software: Oxford. 60. Reinhard, J., et al., Clinical hypnosis before external cephalic version. The American Journal of Clinical

Hypnosis, 2012. 55(2): p. 184‐92. 61. Hofmeyr, G.J. and R. Kulier, External cephalic version for breech presentation at term (Cochrane

Review). Cochrane Database of Systematic Reviews, 1996. Issue 1: p. Art. No.: CD000083. 62. Say et al, A qualitative interview study exploring pregnant women’s and health professional’s attitudes

to external cephalic version. BMC Pregnancy and Childbirth,, 2013. 13(4). 63. Moberg, K., The Oxytocin factor: Tapping the hormone of calm, love and healing. 2003, Cambridge: De

Capo Press. 64. Foureur, M., et al., The relationship between birth unit design and safe, satisfying birth: Developing a

hypothetical model. Midwifery, 2010. 26 p. 520‐525. 65. Foureur, M., The Importance of Undisturbed Labour and Birth: Guarding the Birth Territory, in Birth

Territory and Midwifery Guardianship, K. Fahy, M. Foureur, and C. Hastie, Editors. 2008, Elsevier: Oxford

66. Fahy, K., Theorising birth territory, in Birth Territory and Midwifery Guardianship: Theory for Practice, Education and Research, K. Fahy, Foureur, M., Hastie, C., Editor. 2008, Elsevier: Oxford. p. 11‐19.

67. NICE, Caesarean Section, ed. National Collaborating Centre for Women’s and Children’s Health. 2004, London: RCOG Press.

68. Brady, K., et al., Reliability of fetal buttock sampling in assessing the acid‐base balance of the breech fetus. Obstet Gynecol 1989. 74: p. 886‐8.

69. Hatem, M., et al., Midwife‐led versus other models of care for childbearing women. Cochrane Database of Systematic Rev, 2008. 4: p. CD004667.

70. Anim‐Somuah, M., R. Smyth, and Jones L, Epidural versus non‐epidural or no analgesia in labour. Cochrane Database Syst Rev, 2011. 12: p. CD000331.

71. Gupta, J., G. Hofmeyr, and M. Shehmar, Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, 2006. 5(CD002006): p. DOI: 10.1002/14651858.CD002006.pub3.

72. Zatuchni, G. and G. Andros, Prognostic index for vaginal delivery in breech presentation at term: Prospective study. Am J Obstet Gynecol, 1967. 98(6): p. 854‐7.


Slides used in the BABE Course

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1

Communicating the evidence

Thanks to Professor Alec Welsh (RHW) who provided an earlier version of these slides for adaptation

Remembering Wanda

• Wanda spoke to 4 clinicians

• Fearful

• Information

– In an age of information overload – she got limited information

– She could have been given more – but it can get very confusing

• She was facing family pressure

Objectives

• Understand the evidence about breech birth

• Discuss how this informs our communication with women with a breech presentation late in pregnancy

• Making use of the evidence in communicating with women

– We will practise this later today

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2

The Term Breech Trial ‐ TBT

Hannah, M. E., et al. (2000) Lancet356(9239): 1375‐1383.

[email protected]‐Legal Issues and the current state of vaginal breech birth:

4th Annual Obstetric Malpractice Conference (21‐22 June 2012)

Why the TBT was needed

• Until the late 1950s vaginal birth was mode of choice

• Studies in the 1950s and 1960s

– Showed 3‐4x increase in perinatal mortality compared with CS

• Balanced by CS risks

• By 1980s CS rate about 80%

• No conclusive evidence: 2 RCTs in early 1980s

– Increased fetal risk with VD

– Small numbers and still maternal risk

• Small retrospective studies contradictory



Why the TBT was needed

• RCT became the answer to medical questions, no

matter how complex

– Breech was an opportunity to test the RCT and evidence‐

based paradigm

• Medicolegal anxiety esp in USA provoked a

justification for CS, reducing medicolegal risk



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Construction of the TBT

• Singleton live fetus in a frank or complete breech at term (≥37 weeks)

• Planned vaginal breech – not unplanned

• Exclusion if >4kg; hyperextension; fetal anomaly; contraindication such as placenta praevia

• 2083 women across 121 centres in 26 countries with varied perinatal mortality rates

• Vaginal breech birth performed by ‘experienced clinicians’ as judged by self and supervisor



Outcomes and analysis of the TBT

• Primary outcomes

– perinatal mortality; neonatal mortality; or one of a number of measures of serious morbidity

• Secondary outcomes

– maternal mortality or serious morbidity during first 6 weeks postpartum

• Sample size calculated as 2800

– to find a reduction in risk of perinatal or neonatal mortality or serious morbidity from 0.8% with VB to 0.1% with CS

• Second interim analysis at 1600 recommended ceasing; another 488 meanwhile recruited => 2088



Results of the TBT

• 2088 women

– entry and outcome data for 99.8% women

• Planned CS

– 90.4% gave birth by CS

• Planned VB

– 56.7% gave birth vaginally



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Results of the TBT

• Perinatal mortality, neonatal mortality or serious

neonatal morbidity significantly lower for planned

CS vs VB (1.6% vs 5.0%)

– Relative Risk 0.33 (95% CI 0.19‐0.56)

• No differences for maternal mortality or serious

maternal morbidity (3.9% vs 3.2%).

– RR 1.24 (0.79‐1.95)



Results of the TBT

• After removing confounders still lower risk of complications with CS

• Policy of planned CS meant for every additional 14 CS performed one baby will avoid death or serious morbidity



Unprecedented impact

• Professional obstetrical associations recommended routine CS for breech (e.g. ACOG/RCOG)

• Denmark

– CS for breech went from 80% to 94%

• Netherlands

– over 2 months CS for breech went from 50% to 80%

• Canada

– VB offer dropped from 84% to 14%

• By 2003 more than 93% of TBT centres had abandoned vaginal birth for breech



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Impact within Australia

• Between 1991 and 2005 VB of singleton breech

babies in Australia dropped from 23% to 4%.

• NSW, 66% decline in VB for breech with steepest

decline 2000‐2001: corresponded to a halving of

the breech PNMR 6.2 to 3.1/1000.

• Feb 2001: RANZCOG statement that VB of

breech carries higher risk than planned CS

Phipps, H., et al. (2003). Aus NZ J Obstet Gynaecol43: 294‐297.

Outcomes for children at 2 years

• 923 of 1159 children (79.6%) from 85 centres followed to 2 years

– Risk of death or neurodevelopmental delay no different for CS than VB (14 (3.1%) vs 13 (2.8%); RR 1.09 (95% CI 0.52‐2.30)

• 6% absolute increase in risk of unspecified medical problems in children randomised to PCS

• Conclusion: Planned caesarean section not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years

Whyte, H., et al. (2004). Am J ObstetGynecol 191: 864‐871.

Outcomes for mothers at 2 years

• 917 of 1159 (79.1%) from 85 centres completed a structured maternal questionnaire

– No differences: breast feeding; relationships; pain; pregnancy; incontinence; depression; etc

– Planned CS associated with a higher risk of constipation

• Conclusion: Maternal outcomes at 2 years postpartum are similar after planned caesarean section and vaginal birth for the singleton breech fetus at term



Hannah, M et al. (2004). Am J ObstetGynecol. 191 (2): 917‐927

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TBT: A perfect statistical study(in an imperfect clinical world)

Multicentre

RandomisedControlled

Trial

Intention to Treat

Compound morbidity

Multioperator in a diverse range of environments

Reduces a complex clinical issue to a simple randomisation process

Statistically ‘ideal’ but relates poorly to actual management

Inability for any single morbidity to be significant plus varied relevance and [email protected]

Medico‐Legal Issues and the current state of vaginal breech birth: 4th Annual Obstetric Malpractice Conference (21‐22 June 2012)

The Flaws in TBT: The Deaths

• 3 deaths in planned CS group

1. 2300g respiratory issues post CS

2. 2850g myelomeningocoele ruptured during CS

3. 2550g stillborn after attempted difficult vaginal birth

• 13 deaths in planned VB1. Twin BW 1150g

2. 3650g cephalic presentation

3. 2000g Late neonatal death: Sent home well

4. 2500g discharged home well died after GIT infection

5. 2500 and 2700g neonatal deaths: Respiratory no issues with birth

6. 3 x FHR abnormalities: 2 loss of FH before CS

7. 3370g difficult birth led to CSOnly 4 deaths were difficult vaginal [email protected]

Medico‐Legal Issues and the current state of vaginal breech birth: 4th Annual Obstetric Malpractice Conference (21‐22 June 2012)

TBT: Serious Neonatal Morbidity

Issues of ‘Compound Morbidity’:

• 14 in CS, 39 in VB

• Hypotonia: 2 CS vs 18 VB.

– In 7 of 18 disappeared at 2 hours

• Abnormal level of consciousness in 13 of planned VB

• Of the 69 cases of composite perinatal morbidity and death on which all of the conclusions are based, only 16 cases could be related to the mode of delivery. Not statistically significant



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Other issues

• Included 2 sets of twins, 1 anencephaly and 2 stillbirths

• Babies >4000g over‐represented in VB group (5.8% vs3.1%)

• Huge variation in standard of care between centres

• Many VB didn’t have skilled accoucheur

– 18.5% obstetric trainees; 2.9% student midwife

– accounted for 32% of infants with significant morbidity

• More than half the data from countries with PNMR >20 per 1000

AJOG opinion – 5 years later

• “Repeated analysis of the data after 2 years reveals that the initial conclusions can no longer be maintained and that actually there was no difference in outcome between the 2 groups.

• “A comprehensive and unequivocal withdrawal of the TBT conclusions by the authors themselves is overdue.”

Glezerman, M. (2006). Am J Obstet Gynecol 194: 20‐25.Medico‐Legal Issues and the current state of vaginal breech birth:


How would you communicate all this information with Wanda?

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8

The end of vaginal breech?

• Impact of TBT in the Netherlands (2001‐2005):

– As a result of the increase of CS from 50‐80% modelling predicts

• 327 planned CS needed to save one extra child and even more child deaths due to cases of uterine rupture, praevia and increased SB rate before term with previous CS

• 4 maternal deaths as a result of elective CS for breech

• Future pregnancies ‐ 4 children with brain damage from uterine rupture

De Leeuw. The end of vaginal breech delivery. BJOG 2007 (letter) auMedico‐Legal Issues and the current state of vaginal breech birth:


The PREMODA Study

• Observational: all term singleton breeches in France and Belgium over one year– 2529 PVB; 5576 PCS

– TBT comparable composite variable

• Low rate of overall adverse outcome (1.6% vs 3.2% in TBT) with no difference between groups

• Why?– Unbroken tradition of VB in France and Belgium

– Better selection of women

– Higher standard of care

– More stringent management guidelines

Goffinet, F., et al. (2006). Am J Obstet Gynecol 194: 1002‐1011.

Other cohort studies

• Norway– strict protocol to guide suitability for a vaginal breech birth

• VB increased from 45% to 57%

• CS for failure of vaginal birth declined from 21% to 6%

• No deaths or Iong‐term sequelae due to complicated or failed vaginal breech birth

• Conclusion– women with a breech presentation can be offered vaginal birth if properly managed

Albrechtsen, S., et al. (1997) Am J ObstetGynecol 177(3): 586‐592.

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• Finland – only difference for a carefully selected group of breech babies versus a comparable group of babies in the vertex presentation were lower Apgar scores for the breech babies

– By 7 years, the babies born by VB were similar in terms of general health and readiness for school compared with the similar group of babies born head first.

– Concluded • if women were carefully selected and appropriately cared for during labour, vaginal birth for term breech is as safe as for term vertex babies

• Other examples in your Manual ….

Ulander, V.‐M., et al. (2003). Acta ObstetGynecol Scand 83: 182–189.

An Australian study

• Borbolla Foster et al, 2014 ‐ ANZJOG

• 11 year retrospective audit from Newcastle John Hunter Hospital

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2/21/2015

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How would you communicate all this information with Wanda?

We practise this later today

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The things that the TBT did teach us

• The role of planned, considered vaginal breech birth in settings with skilled providers and appropriate access to emergency CS

• The potential hazards of a breech birth

• Ways to ensure high standards prescribed by the PREMODA group as well as ensuring obstetricians and midwives are confident and competent in face of:– Low number of births

– Large distances between ‘breech’ units

– Potential resource implications

– Graduating trainees: 47% don’t feel confident and 89% don’t plan to offer it as specialists (Chinnock & Robson (2007). O&G 110 (4): 900‐903)

.(21‐22 June 2012)

Conclusion

• Breech vaginal birth was discarded too rapidly and fearfully after the TBT

• With that we lost one of the key paths to maintaining and developing an understanding of labour

• Breech vaginal birth can be offered as an option

• Safety can be maximised by common sense approaches to case selection, labour management, prepared for problems, practice with life like models, learning from each labour

• Care for women having a planned vaginal birth should be concentrated in willing enthusiastic centres

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1

External cephalic version

• Wanda is offered an ECV

– What information would she need before the ECV?

Objectives

• Describe the purpose and timing of an ECV

• Understand factors associated with success

• Describe the complications and relative frequency

• Explain the contraindications to ECV

• Show some examples of ECVs

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Purpose

• To reduce the incidence of breech at term– can lower caesarean section rates

• An accepted component of the antenatal care of women with a breech presentation

• Supported by– Cochrane Review – RANZCOG Position Statement– ACOG Practice Bulletin

• State‐wide policies also support ECV– Towards Normal Birth policy (NSW)

‘Success’ rates

• Turning rate ranges from 35 to 86%

– generally quoted in the order of 50%

• Recognise that not all women will choose an ECV

– Some might want to go straight to a vaginal birth

– Some women find the procedure painful

– Some women believe it is meant to be

Timing

• Early ECV (34‐36 weeks)

– higher rates of baby turning (51% vs 42%)

– lower rates of breech presentation at onset of labour (41% vs. 49%)

– No reduction in caesarean section rate

– possible increase in preterm birth

• ECV (+36 weeks)

– Associated with statistically significant and clinically meaningful reduction in non‐cephalic birth

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Contraindications

• Include:– Multiple pregnancy

– Utero‐placental insufficiency

– Non‐reassuring FHR pattern

– Significant uterine anomalies

– Placenta praevia

– Unexplained vaginal bleeding

• Relative contraindications– previous caesarean section

Factors associated with success

• Intrinsic to the woman– Parity

• multiparous higher success rate

– BMI / thin maternal abdomen • lower BMI higher success rate

– Type of breech

– Mobility of the breech• non‐engagement of a fetal buttock – higher success rate

– Posterior placenta

– Abundant amniotic fluid

Factors associated with success

• Extrinsic factors

– Tocolysis

– Skill of the operator

– Use of relaxation

– Regional anaesthesia

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Tips for success

• A relaxed and reassured woman

• A quiet room

• Trendellenburg

• Adequate elevation of the breech

• Gradual pressure

• Tocolysis

Complications

• Rates of complications of ECV are very rare

• Cochrane Review of 44 studies (n=7,377 women)

– 5% rate of transient fetal bradycardia or decelerations

• only pathological in 0.4% of cases

– 0.1% abruptions

– 1.5% fetal haemorrhage

– 0.5% maternal haemorrhage

– caesarean section rate of 0.4%.

– no cases of cord entanglement or maternal death

Issues to consider to increase safety

• CTG – before, during and after

• Fasting – not necessary

• Ultrasound – position of the back

• Availability of theatre

• How much do you try?

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Procedure

• Information

• Scan

• CTG

• Tocolysis

• Lifting of the breech

• Consider the amount of pressure

• Role of the second hand

A FEW EXAMPLES …

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An example we don’t suggest you copy …

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Summary

• ECV is a safe and effective option for women

• It can be uncomfortable for some women

• Rate of turning is around 50%

• The main extrinsic factor associated with improved success of ECV is tocolysis

• ECV should be offered, where appropriate as an option for achieving vaginal birth

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Mechanics of vaginal

breech birth

• Wanda asks

– How does the baby do it?

Objectives

• Consider the mechanics of the breech birth

• Understand the 3 delays

– The analogy with shoulder dystocia

• Be able to communicate this to Wanda

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Posterior Fontanelle

Occipitomentodiameter: 12.5cm

Suboccipitobregmaticdiameter: 9.5cm

Anterior Fontanelle

CoronalSuture

Fetal head diameters

Principles

The mechanism of breech birth works best in a calm environment

• Hands off/poised

• Keep the sacrum anterior

Mechanism of a breech vaginal birth … 1

• Bitrochanteric diameter engages LSA or RSA

• Baby compacts and descends while cervix dilates

• Once full dilatation occurs

– Bi‐trochanteric diameter rotates internally to AP

• Anterior hip born by lateral flexion of the trunk, head flexing at the same time

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The bi‐trochanteric diameter rotates internally to occupy the AP diameter

Thank you to Prof Jeremy Oats for use of the diagrams

Mechanism of a breech vaginal birth … 2

• Posterior hip born and body externally rotates

– back is now uppermost

• Further descent of the trunk

• Twisting and turning of the shoulders

– anterior shoulder born under symphysis, posterior follows

• Head is now flexed enough to soon follow

The anterior hip is born by lateral flexion of the trunk, head is flexing at the same time

Bi-trochanteric and biparietal diameters

are almost equal

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The posterior hip is born and then the body does an external rotation so the

back is now uppermost

Twisting and turning of the shoulders, anterior shoulder births under the

symphysis, posterior follows

By then the head is flexed enough to almost immediately follow the

shoulders

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Delays

• Birth of bi‐trochanteric diameter

– No descent after one hour of effective pushing, advise caesarean section

• Descent of body after birth of breech

– Most commonly due to extended or nuchal arms

• Birth of head

– Due to deflexed head

Delay in descent of body

• No descent of the body in 3 minutes after buttocks are born and the back has rotated uppermost

• Most commonly due to extended or nuchal arms

– Diagnosed by VE after clear delay despite contractions and or suprapubic pressure

• Management

– Reach underneath or over the baby, locate elbow, flex arm and bring down

– Lovset’s – pelvic girdle rotation

– Direct shoulder girdle rotation

Rotating the fetal pelvis

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Delay in birth of the head

• If nothing happened within 1 minute

• Assist the birth of head –Due to deflexed head–Response – Mauriceau manoeuvre, counter pressure on the occiput with the non dominant middle finger

– Suprapubic pressure–Role of Forceps

Mauriceau manoeuvre and suprapubic pressure

An example: The woman in the hands‐on‐knees position

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An example: The woman in the lithotomy position

Seldom necessary

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Summary

Hands off/Calm+++++

Remember the mechanics of the birth

Birthing position

Contractions/Suprapubic pressure

Baby’s back opposite to maternal back

Shoulders spontaneous, sweep, rotate (direct or indirect)

Flex head

Breech to birth of the head <4 mins

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The reality of breech birth

• Wanda asks:

– What if I go overdue

– What will happen in labour?

– Will I need monitoring?

– Is a breech labour longer or harder?

– Do I have to have an epidural?

Objectives

• Discuss some of the practice points related to breech including

– First stage

– Second stage

– Pain in labour

– Monitoring

– Induction/augmentation

• Watch a breech birth

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Vaginal breech

• Vaginal breech can be challenging

• Unique physiology

• Difficult to isolate and study what works best, need to be guided by best evidence:

– Sound selection criteria

– Intrapartum care

– Fetal monitoring

– Birth techniques

Remember the physiology …

• Process heavily reliant on contractions to aid compaction

– Compaction is a result of increased flexion of limbs

• Unlike cephalic presentation cord enters the pelvis before the head making cord compression common in 2nd stage

– adds to a degree of urgency about the process

Progress in first stage

• Labour needs to progress

• Contractions rely on release of oxytocin

• Need to keep a calm environment conducive to release of natural oxytocin

• One to one midwifery care essential

• Keep timeframes in your head

• Consider various methods of pain relief

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Fetal Monitoring – 1st stage

• CEFM should be offered to women with breech presentation

• Use telemetry

• Good practice point – can interrupt for short periods of up to 15 mins if all is normal

• Intermittent auscultation if not using CEFM

Epidural anaesthesia

• Need good maternal effort for pushing to maximise expulsive efforts

• Non pharmacological pain relief is associated with less intervention and women are more likely to stay focussed and in control

• Some centres encourage the use of epidurals– Most guidelines recommend avoiding routine epidural (RCOG, SOGC)

– If used – consider the role of a ‘light’ epidural (or PCEA) and switching off in 2nd stage

Can labour be induced?

• IOL may be considered if individual circumstances are favourable

• Consider if indication for induction conducive to safe vaginal breech birth

• A common reason is availability of experienced accoucher

• IOL rates– 9% in PREMODA

– 12% in Newcastle (Australia) series

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Can labour be augmented?

• Augmentation for labour dystocia may be considered – with caution

• If the labour isn't progressing consider why?– Consider the environment, our language, is she sensing our doubts, is she fearful?

– If delay – consider CS

• Are we being unreasonable with our parameters– Good progress in labour is the best indicator of adequate fetal‐pelvic proportions

• Avoid ARM unless deeply engaged

Second stage …

• Keep the room calm ….

• Women may have a urge to push before full dilatation – May also be fully dilated without urge to push

• Encourage passive descent – Passive stage of up to 60 minutes allows breech to descend well into pelvis

• Most women will have a strong urge to push when the breech meets the pelvic floor and descends further to the perineum

Fetal Monitoring – 2nd stage

• Descent of cord into the pelvis is associated with ↑incidence of cord compression

– Continuous fetal monitoring

– Consider fetal (scalp) clip if contact problems

• The role of fetal blood sampling is not established

• Low threshold of non‐reassuring trace

– CS if concerned

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Positions for 2nd Stage

• Keep the room calm ….

• Self‐directed, physiological pushing for most women

• The aim in 2nd stage continues to be on compaction and descent

• Encourage and support women to be upright or on hands and knees

• If delay in 2nd stage – consider CS

Episiotomy

• Selective approach

• May be needed if there is a delay

• Watch Finn’s birth ….

– Consider the decisions being made in this birth

• Would you do the same?

• Think about your hands

• Listen to the discussions

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A woman's perspective on vaginal breech birth

With thanks to Rhonda Tombros for assistance with the development of this original talk

Each woman’s story is different

• Each woman’s story is different

• Wanda’s story and experience will also be different

• There are stories in your manual to highlight women’s experiences

• Consider

– Whether to have an ECV

– How to give birth?

– Where to give birth?

– Who to give birth with?

• Important to discuss options with women

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Women’s stories

• Generally find out about the breech late in pregnancy

• Often attempt moxibustion, swimming and other postural techniques

• Often have a lot of anxiety deciding what to do and getting information

• Most centres offer an ECV

• If this does not work – what to do next?

Finding information

• Many women go looking for information

– Research on breech

• Term breech trial

• Critiques of the trial

• Other studies comparing planned CS with planned vaginal breech

– Other books and resources

– You‐tube videos

Sifting through the information

• Women want evidence to be used with them in mind as an individual

• Obstetricians and midwives should have the skills:– to determine which women are good ‘candidates’

– to support a woman in a vaginal breech birth if she chooses

• Evidence does not support an absolute policy of CS for all breech presentations

• Evidence supports trial of labour for ‘good candidates’ with experienced accoucheur

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Women want the best for their babies

• Women who choose to attempt a vaginal birth believe it to be the best for their baby

• A strong belief is that the baby was grown by the woman’s body and could be birthed by her body

• Many women do feel scared, isolated, lonely, stressed

• There is often very little emotional support and little support in their decision from others

Caesarean section …

• For many women

– Seems unnecessary

– Scared of surgery

– Denial of opportunity to give birth naturally

– Worried about difficulties bonding with baby

– Worried about effects of surgery on future

pregnancies

– Worried about caring for a newborn after surgery

Coming to a conclusion …

• Many women decide that:

– Misguided to compare risks – starting point is vaginal

birth, CS only if indicated

– Vaginal breech birth not too risky in absolute terms

– If indications arose during labour or birth that vaginal

birth problematic – it would be OK to have a CS

– No good reason not to attempt a vaginal birth

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The way forward

• Breech services– All tertiary hospitals

– Referral centres and training posts

• Balanced information

• One‐to‐one support with decision‐making

• ECV

• VBB supported by an experienced clinician

• Institutional support for obstetricians and midwives

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How to create a safe spacefor physiological breech birth

Original version by Jyai Allen, April 2013, for AMaREUpdated Kate Braye November 2014

• Wanda asks

– What will the room be like?

– What can I bring?

– How should I use the room?

– How many people will be there?

– Will it be private?

The birth environment

• Mammals share fundamental physiological processes during labour and birth

• Women in labour are “exquisitely sensitive to outside influences”

• Women ‘scan the room’ with their 5 senses:

– Do I feel safe to give birth here? Or frightened?

• The ideal birth environment enables women to feel private, safe and unobserved

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Endogenous oxytocin…

• Neuro‐hormone‐ has general behavioural and specific organ effects (uterine contractions)

• Orchestrates neuro‐hormonal process of labour, birth, attachment

• Analgesic: Lessens feelings of pain

• Anxiolytic: Lowers anxiety

• Enhances bonding with baby

Endogenous adrenaline…

• Is a stress hormone and inhibits oxytocin

• Sympathetic pathway of the autonomic nervous system is activated – flight, fight or freeze

– uterine inertia ‘lack of progress’

– blood vessel constriction, decreased uterine blood flow, decreased placental perfusion, decreased fetal oxygenation ‘fetal distress’

Women may perceive the birth environment as hostile when…

Sight: bright lights, metallic hospital equipment, sharp edges and right angled fittings/furniture, being observed Sound:complex language, machinery, pagers, loud voices, questionsSmell: hospital disinfectants, linenTaste: fish sandwiches!!Touch: cold, hard surfaces, air conditioningSupport: feeling disrespected, lack of privacy, unknown carers, others “chatting”

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Women may perceive the birth environment as

SAFE when…

Sight: eye‐to‐eye contact, view of nature, bound or unbound, rounded, soft edges, flickering candle lightSound: familiar music, pleasant soundsSmell: aromatherapy‐relaxing or stimulating, familiar pleasant smells such as own pillowTaste: sweet food or fluidsTouch: appropriate gentle touch, warmth, stroking, skin‐to‐skin, massage, warm water immersion, intimacySupport: feeling loved and respected, being in the company of known carers and companions

BUT REMEMBER what feels safe is individual to each woman…some women may be reassured by high‐tech

equipment, others frightened!

How to … help Wanda prepare

• Continuity of carer is optimal• facilitates trust; decreases preterm birth and many

interventions and need for exogenous analgesia

• Listen to the woman’s hopes for her birth • inspire confidence and affirm trust in her ability!

Suggest she practise relaxation techniques during pregnancy (e.g. mindfulness‐ in the ‘now’)

She may then access a state of relaxation

DESPITE a less than ideal environment

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How to … help Wanda prepare

• Visualisation‐ seeing the ‘job’ done!

• Help her ‘claim’ the space as her own – music

– her own clothing, sarong, shawls

– pillow

– food for sharing ‐ increases endogenous oxytocin

How to … set up a ‘safe’ space for breech birth

• BEFORE the woman arrives, change the space to make it feel more comfortable, for example:

– de‐centre the bed and raise it (chest height)

– place a shawl / sarong over the bed, beanbag

– place mats on the floor

– put on some of her music

– set up her images/symbols on a table

• Turn down the lights, run the bath

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How to … set up a ‘safe’ space for breech birth

• Set up the room to be warm, dim and quiet – Adjust air‐conditioning (should be warm enough for woman to be naked and comfortable)

– Dim lights, close curtains, use room dividers

– Keep door closed, use a sign to knock and wait

• Have supportive aids in the room (mat, bean bag)

• Have access to warm water (shower, bath)

• Cover or remove unnecessary technical equipment from room

How to … work ‘safely’ within the space

• Minimise talking / asking questions of the woman

• Take observations unobtrusively

• Minimise staff

• Keep an eye on the time

• Stay present – minimise walking in and out

• Stay calm – breech birth is normal

• Stay focussed – what we do and say affects the birth environment and therefore the woman, the baby and the birth

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Counselling the woman with a Breech

• Remember Wanda’s video

– How would you improve on the communication with her?

Objectives• Discuss some of major aspects of the information provided for women with a breech presentation

• Exploring the woman’s commitment to vaginal birth

• Develop the skills to explore women’s knowledge base, options and understandings of the risks associated with breech birth

• Learning the skills to communicate balanced, and non‐judgemental information in everyday language

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Explaining risk

• Probably one of the most difficult conversations as clinicians

• Balance of numbers, stats, not scaring but based on reality

• In context of woman’s perceptions and knowledge

www.nice.org.uk. Patient experience

Explaining risk

• Ensure the woman has access to high quality and reliable data

– Agreed information sheets, websites

– Discuss reasons for information variability on internet

• Give the woman regular and accurate information

Set up a Breech service

Shared decision making

• Do so in terms that enable consideration of own personal needs and preferences

• Give opportunity to discuss diagnosis, prognosis and treatment

• Openly discuss risks, benefits and consequences

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• Clarify what she hopes to achieve

• Offer the opportunity for further consultations

• Accept and acknowledge variable view about balance of risks, benefits and consequences

Personalise risk and benefits

• Use absolute risk rather than relative risk– Risk increases from 1:1000‐2:1000 rather than risk doubles

• Use natural frequencies– 10 in 100 rather than 10%

• Consistent use of data– 7 in 100 and 20 in 100 rather than 1:14 or 1:5

• Present risk over a defined period– Short medium and long term

Personalise risk and benefits

• Include positive and negative framing

– Treatment is successful 97 out of 100 times and unsuccessful in 3 out of 100

• Be aware that different terms such as rare and uncommon are interpreted in different ways.

– Use numerical if possible

• Be aware that the woman and her baby are unique.

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• Offer support when counselling options

• Ensure she is aware of all the options

• Check her understanding of the information gained

• Encourage her to clarify what is important to her and that the choices she is making are consistent with this.

• Give time to make a decision.

Framework for Discussion• Assessment of the breech

• Physical capacity to birth a breech

• Explore the woman’s thoughts and anticipations• Personal supports for the decision she is going to

make

• Why breech birth is different• Women’s motivation

• Positioning and activity in labour

• CEFM

Framework for Discussion• Discussion of Complications

• Higher risk of intrapartum CS• Advantages/Disadvantages

• Timing of the information

• Varies between women• Labour and birthing

• Analgesia• Position for birth• Labour support – others in the room

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Essentials for a safe service

• How can we make safe services for women like Wanda?

Objectives

• Recommend criteria for a safe breech service

– Criteria for safe ECV

– Criteria to offer a woman a safe vaginal breech birth

– Safety backups protocols, monitoring , access to caesarean section

– training needs of doctors and midwives in relation to vaginal breech birth

– Audit and quality improvement

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Criteria for safe ECV

• Policy

• Training and support

• Audit outcomes

• Clear direction before and after ECV

• Remember, not all women want an ECV

Criteria to offer Wanda a safe vaginal breech birth

• Healthy woman who is motivated for a vaginal breech

– Normal pregnancy

– Baby estimated weight 2.5‐4kg

– Frank or complete breech

– Spontaneous labour

• Capable, motivated, informed, enthusiastic and available caregivers

Elements of a safe service

• Institutional commitment, enthusiasm and confidence

• Guideline for breech at term – pathway

• Adequate skill set amongst midwives and obstetricians

• Institutional acceptance and support apparent to women and providers

• Adequate numbers of women to sustain the service

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More elements …

• Women who are well prepared

• On call obstetricians

– Opportunity for registrar and midwife training

• Midwives able to support women in the space

• Continuity of care and carer

– 1 to 1 midwifery care in labour

• Anaesthetic / theatre availability

Who else do you need?

• Consumers

• Neonatologist/paediatrician

• Operating theatre staff

• Anaesthetists

Setting up the service …• Enthusiasts initiate• Co‐opt willing contributors

– Midwives– Obstetricians

• Consider the numbers of women– Will there be enough women? Or too many?

• Seek advice from other centres• Develop a guideline• Training and mentoring for staff• Provide consistent information to women

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Learning about breech …

• Other opportunities

– Twins

– Caesarean sections

• Attending vaginal breech births

– Who catches the baby?

– Watching and learning

Training and support …

• Consider:

– External courses

– Having available mannequins

• In house training and mentoring

• Learning from women

– Reflect with each woman after the labour and birth

Audit and feedback …

• Suggested data– Number of women with a breech presentation at 34 ‐ 36 weeks– ECV – numbers, success, complications– Number of women with an undiagnosed breech presentation

presenting in labour at term and the antenatal care received prior to presentation.

– Planned mode of birth – Events in labour ‐ Augmentation in labour, delay in labour,

emergency CS– Events in birth ‐Maternal position, health of the baby, maternal

complications– Neonatal outcomes – Apgar Score, cord gases, admission to SCN

or NICU, length of stay in nursery– Longer term measures

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Supporting women …

• Resources

– Many listed in your manual

• Support networks

– Other women

• Breech clinic

– Women support one another

• Continuity of care

– Midwifery and obstetric

Keeping it going …

• Leader(s)

• Organisational commitment to training

• Ongoing review and research

• Keeping up the volume

• Breech becomes more than an emergency event

• Learning from women

Conclusion

• A breech service requires planning and enthusiasm

• Consider – Numbers of women

– The skills and training needs of the staff

– Processes in which to support women

– Space required

– Auditing of outcomes

• Would this be the place that Wanda is safe and feels safe to have her baby?

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• Remember Wanda

– Would she get better information from a BABE graduate?

– What will you take away from today to ensure the next ‘Wanda’ you see gets better information

The End ….

• Thank you

• Immediate evaluation

– Keen on feedback on the day and the manual

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