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An undiagnosed breech

An undiagnosed breech

Despite many women opting for a CS when faced with a breech birth, Naomi Carlisle shares an experience that shows a healthy vaginal breech delivery is possible.

An undiagnosed breechAt term, a breech presentation is found in approximately 3-4% of all deliveries (RCOG, 2006). Breech presentations are often diagnosed antenatally but sometimes they are diagnosed in established labour. There are often conflicting views on whether a vaginal birth or a CS is the best way to manage a breech presentation. ‘The term breech trial’ (Hannah et al, 2000) found that a CS birth is less hazardous than a vaginal birth for uncomplicated term breech presentation. The trial has been described as substantially influencing current practice and policies (Steen and Kingdon, 2008). However, some argue that the study is extremely flawed and, therefore, its recommendations should be withdrawn (Glezerman, 2006). Outlined as follows is the story of a woman I looked after while on my delivery suite placement. 
 
The woman arrived at the delivery suite in labour with her second child. It was around 5am. She was at 39 weeks and considered low-risk. Her first child had been a spontaneous vaginal delivery with no problems. Our initial vaginal examination found her cervix to be 8cm dilated, with the presenting part at -2 above the ischial spines. Because of the high presenting part, determining position (such as via the fontanels) was difficult. On abdominal palpation the baby appeared to be in a cephalic presentation. 
 
The woman was using Entonox for pain relief and soon began to feel the urge to push. The midwife I was working alongside undertook another vaginal examination, which found her cervix to be 9cm. The midwife then tried to determine the baby’s position, before suddenly shouting at me to get help. She had felt a ‘hole’.
 
I ran down the corridor to tell the doctor that there was a query face or breech presentation in our room. Together, we fetched the scanner and went back to the delivery room. A scan determined that the baby was in the breech position. 
 
Due to the woman being multigravida and her cervix 9cm dilated, a quick discussion took place on her options. The doctor explained that she could have a vaginal breech delivery or a CS. It was interesting hearing the doctor explaining all the positives of a CS and all the negatives of a vaginal breech delivery. However, the woman was certain that she wanted a vaginal delivery. The atmosphere in the room was urgent and fraught with fear. This was exacerbated by the fact that the number of vaginal breeches is low as many women with breech presentations decide to have a CS (Johnson and Taylor, 2011). 
 
It was decided that we should go to theatre for the delivery so that we were in the correct environment in case anything should go wrong. The doctor advised an epidural, in case an instrumental or CS was needed, and ‘to prevent early pushing’. However, there is no evidence that epidural analgesia is essential (RCOG, 2006). A midwife then advised her against an epidural, as it would affect her ability to push, hence increasing her chances of an instrumental or operative delivery. Women who have an epidural for pain relief in labour are at an increased risk of having an instrumental delivery (Anim-Somuah, Smyth and Jones, 2011). The woman decided against an epidural, although she must have found it extremely confusing to receive conflicting advice. 
 
Soon we were in theatre. It seemed as though all the available staff were there, ready to watch a vaginal breech. The woman was lying on the theatre table in lithotomy with her husband beside her. It is recommended that the woman is in lithotomy or the dorsal position, as practitioners have the most experience of delivering breeches in these positions (RCOG, 2006). However, some argue that ‘all fours’ position is more effective as it allows gravity to assist with the birth (RCM, 2011).
 
While the woman seemed in control, her husband seemed nervous being in theatre. Another vaginal examination confirmed full dilation and the woman commenced pushing. Immediately there was a sudden gush of meconium, and then we could see a bit of the baby’s bottom. More of the bottom became visible, before finally it all wriggled out. Quickly the legs followed. The bottom almost went up in the air by itself to release the legs, before coming back down again. Then the back came out, shuffling itself side to side, followed by the shoulders and arms. The baby hung from the vulva, her head still inside. Then, after about 10 seconds, the head followed. It was amazing! It took under a minute from the bottom becoming visible to the head delivering. The room burst into applause. A baby girl had been born!
 
It was a completely ‘hands-off’ delivery (mainly because the midwife in charge kept batting the doctors hands away whenever he was about to pounce). It has been said that the practice for normal spontaneous breech births should be to keep hands off and allow the breech to deliver spontaneously (Stables and Rankin, 2010). 
 
I left the shift feeling elated. The woman was pleased that she had delivered vaginally and was overjoyed with her healthy daughter. As I was a vaginal breech myself, I found it interesting to see what my mum went through with me. I understand that many potential difficulties and complications can arise from a vaginal breech delivery, hence some practioners may be wary of them. However, it taught me that managed correctly, a woman with an undiagnosed breech can have a hands-off vaginal delivery with good outcomes for both mother and baby. 
 
Naomi Carlisle
 
Student midwife, King’s College London 
 
 
References
 
Anim-Somuah M, Smyth RM, Jones L. (2011) Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev 4: CD000331.
 
Glezerman M. (2006) Five years to the term breech trial: the rise and fall of a randomised controlled trial. American Journal Obstetrics and Gynecology 194(1): 20-5.
 
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, Term Breech Trial Collaborative. (2000) Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 356(9239): 1375-83.
 
Johnson R, Taylor W. (2010) Skills for midwifery practice (third edition). Churchill Livingstone Elsevier: Edinburgh.
 
RCM. (2011) Normal breech birth. See: www.rcmnormalbirth.org.uk/ stories/do-as-you-would-be-done-by/normal-breech-birth/ (accessed 9 October 2012).
 
RCOG. (2006) The management of breech presentation: Guideline No. 20B. RCOG: London. See: www.rcog.org.uk/files/rcog-corp/GtG%20no%2020b%20Breech%20presentation.pdf (accessed 9 October 2012).
 
Stables D, Rankin J. (2010) Physiology in childbearing (third edition). Elsevier: Edinburgh.
 
Steen M, Kingdon C. (2008) Vaginal or caesarean delivery? How research has turned breech birth around. Evidence Based Midwifery 6(3): 95-9.