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Analysis

Study day report: A day at the breech

17 June, 2008

Study day report: A day at the breech

In her report of a study day entitled ‘A day at the breech’, Laura Abbott discusses how hearing from midwives’ theoretical and anecdotal experience has increased her confidence in her ability to help a woman birth her baby by the breech.
In her report of a study day entitled ‘A day at the breech’, Laura Abbott discusses how hearing from midwives’ theoretical and anecdotal experience has increased her confidence in her ability to help a woman birth her baby by the breech.

Midwives magazine: September 2005

 

When I was a student midwife, I struggled to learn the names and the  manoeuvres for women having a breech delivery. We played with our plastic pelvises and dolls, Loveset-ed and Mauriceau Smellie Viet-ed our way through. Before the Hannah trial (2000) that indicated better outcomes for breech babies born by planned caesarean section (CS) over planned vaginal birth, and subsequent policy on CS overnight for all breeches, I was lucky to witness a breech ‘extraction’ in the unit where I trained.

 

This helped me to understand the mechanisms involved, although I chose to stay at the ‘head end’ as the woman gave birth in a gallery of health professions, all eager to witness the unusual delivery. I clearly remember the woman draped in green, in lithotomy position, a generous episiotomy being performed by the doctor.

 

Would I have felt prepared for an unexpected breech at home after this? Would I have felt comfortable helping a woman birth her breech baby if that was what she chose to do? I don’t think I would. I witnessed my first breech ‘birth’ last year when I was called as second midwife to an unexpected breech. The woman, a multipara, birthed her baby beautifully and there were no complications. The baby boy was 4.2kg and needed some bagging with oxygen, but had excellent Apgars of six at one minute and ten at five minutes.

 

This breech birth went well – no manoeuvres were needed and the baby birthed himself with the mother’s strength and the calmness and confidence of the experienced primary midwife. But would I have been able to manage this situation by myself? Would I have been able to resist wanting to do anything other than sit on my hands? Would I have known what to do without causing harm should the baby have become stuck? I certainly would have felt more nervous, and although used to helping women birth at home, I would not have felt completely confident in my skills should the baby have become stuck.

 

I recently attended ‘A day at the breech’ with midwives Mary Cronk and Jane Evans who have a combined total of over 60 years of midwifery practice between them. Breech birth has really come alive for me as a result. We started the day looking at slides of a normal breech birth of a primigravida at 40-weeks’ gestation, with an informative commentary from Mary and Jane. We saw the baby ‘rumping’ (instead of crowning), moving through the mother’s pelvis and were asked to observe an array of signs indicating the baby’s wellbeing.

 

The most amazing slide showed mother and baby working together to birth the head – the woman on all fours with the midwife ready to catch the baby. The baby had excellent Apgars of eight and ten. Some of the women having their breech babies at home had made a choice to do this, but others were forced into this situation to have any chance of a vaginal breech birth. We did see slides of a breech birth in hospital facilitated by a forward-thinking head of midwifery.

 

We discussed women’s choices, looking at ways to help the baby turn to the cephalic position such as acupuncture and external cephalic version. We also learnt about when a woman may need to transfer to hospital and saw slides of a woman who did need to and had a CS. The baby had not descended at full dilatation and a gentle transfer ensued with mother and baby in excellent condition, but now needing the help of medical colleagues. What was most helpful for me was learning how and when to help and how to be hands-on. In the Confidential Enquiry into Stillbirths and Deaths in Infancy’s seventh annual report (2000), one of the resounding factors in breech baby deaths was inexperience of the attending professional, be it midwife, paramedic or obstetrician.

 

Many of the breech babies that died were unexpected with fast labours. We learnt, in a way that felt real, with slides of a baby needing help and the manoeuvres to assist the birth, when a baby may need help to come out and how to help without causing harm. I now feel more prepared in helping a woman birth a baby by the breech, be it unexpected or when the woman has made the choice to birth vaginally. I believe seeing the slides of breech births was one of the best ways of learning. Most importantly, I was learning from midwives who had experienced such births and were using their wealth of knowledge, both theoretical and anecdotal, for the benefit of others. I do hope our medical colleagues have the opportunity to learn from these midwives, especially as the latest studies (Kotaska, 2004;Whyte et al, 2004) negate much of the Hannah trial (2000).

 

We will always come across women who want to birth their baby by the breech and there will always be unexpected breeches. We need to be able to facilitate these births without doing harm. I therefore cannot recommend ‘A day at the breech’ highly enough.

 


References

 

Confidential Enquiry into Stillbirths and Deaths in Infancy. (2000). Seventh annual report. Maternal and Child Health Research Consortium: London. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. (2000) Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. The Lancet 356(9239): 1375-83. Kotaska A. (2004) Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery. British Medical Journal 329(7473): 1039-42. Whyte H et al. (2004) Outcomes of children at two years after planned caesarean section birth versus planned vaginal birth for breech presentation at term. The international randomised term breech trial. American Journal of Obstetrics and Gynecology 191(3): 864-71.

 

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