WE ARE SO APPRECIATED TO YOU,JANE!!!
Seminář den s koncem pánevním podzim 2017
Lektorka paní Jane Evans /Anglie/
Porodní dům u Čápa Zuzana Štromerová - organizátorka, tlumočnice
Fotografka, zapisovatelka- Milena Dvořáková
Zuzana zorganizovala seminář k výuce porodu koncem pánevním s lektorkou paní Jane Evans.
Měníme zaběhnuté postupy- takže tento seminář byl o tom, jak vést porod koncem pánevním na všech čtyřech - ne na zádech.
Tento typ porodu vedou ve Zlíně - též se vyučili na semináři, který organizovala Zuzana před pár lety a mají asi 200 porodů koncem pánevním porozených vaginální cestou.
Porod hlavičkou se může náhle změnit v konec pánevní a je potřeba být jako komunintní porodní asistentka nachystána.
Trénink znalostí a trénink praktický - pořád dokola.
Učit se od nejlepších a na to má Zuzana dobrý postřeh.
Děkuji, děkuji, děkuji.....
K úspěšnému a zdravému porodu koncem pánevním a zdravému dítěti je potřeba motivovaná maminka, přípravená po všech směrech.
Dále lékař - gynekolog, který ženu podpoří.
Také porodní asistentka - která ženu podpoří a pomůže ji zvlášt v závěru těhotenství správnými radami, co udělat pro zdravý porod a je u ní v začátku porodu.
Vědomá porodní asistentka, která je sama podpořena znalostmi, třeba z tohoto semináře.
Na semináři se prodával malý model dítěte a pánve - aby si mechanismus porodu koncem pánevním v poloze na všech čtyřech mohla každá účastnice prakticky vyzkoušet.
Měly jsme samozřejmě i velký model pánve a miminka.
Seminář byl empatický, jasný, poučný.
A jednoho dne přijde .....praktický den s KP, vezmete si přiručku, kterou jsme každá obdržely a víte jak postupovat.
Porodnice, kde jsou spolupracující porodníci jsou a tak společně se Vám to povede.
Jako fyziologický porod koncem pánevním můžeme označit takový porod, který:
- Se rozběhne samovolně přibližně mezi 37. a 42. týdnem těhotenství. NENÍ indukován, ani NENÍ urychlován.
- Porod postupuje dobře díky kontrakcím, které přicházejí stále častěji, trvají stále déle, stále zesilují. Z pohledu ženy trvají příliš dlouho a jsou přespříliš silné.
- Výhled na úspěšný přirozený, fyziologický porod KP je dobrý, jestliže naléhající část sestupuje porodními cestami za současného zkracování hrdla děložního a otevírání branky, bez ohledu na rychlost, jakou porodní proces probíhá.
- Během druhé doby porodní sestupuje dítě porodními cestami a rodí se jen za pomoci tlačení a pohybů matky a pohybů dítěte, bez popotahování asistujícího zdravotníka.
Následující článek v angličitně vysvětluje celý proces mechanismu porodu koncem pánevním.
Focus
Understanding
physiological
breech birth S ince the release of the Term Breech Trial (Hannah 2000) many women, midwives and obstetricians have been concerned about the increase in caesarean section operations for breech presenting babies, and the apparent lack of choice as the skills required to safely assist a breech birth are lost. The follow-up to the Term Breech Trail (Hannah 2004, Whyte 2004) acknowledged that the trial ended before any conclusive evidence was found and yet, still, the original research paper is used, in many units in the UK, as a reason to advise women to have a planned lower segment caesarean section (LSCS) if their baby is in a breech presentation at 38 weeks’ gestation. The skill of the birth attendant has been shown to be the most breech birth could be ‘normal’; an experience that is now hard to
Jane Evans
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important factor in the outcomes of vaginal breech birth (Maternal
and Child Health Consortium 2000, Hannah et al 2000, Robinson
2000/01). As well as planned breech births there will always be
undiagnosed breech presentations that deserve knowledgeable
practitioners to facilitate safe birth in all circumstances.
I have attended many breech births during my midwifery career, particularly during the 20 years I have practiced as an independent midwife, and have observed the spontaneous movements made by the woman and the baby that facilitate a successful vaginal breech birth when they are not sedated and are free to move around during labour. I was taught by older, more experienced midwives to observe and not interfere unless help was required, and that a
replicate within the UK’s National Health Service (NHS). With my
colleagues I have studied many sets of photographs, and the
occasional video of a breech birth, and have again observed the
spontaneous movements made by both women and babies.
Whilst working with a doll and pelvis, and being aware of the
anatomy and physiology of the pelvis and pelvic floor, it became
clear that these movements, as the baby travelled through the
pelvis, facilitated spontaneous birth. With further research I found
that many of these movements had been described previously,
some in historical papers (Johnstone 1951, Plentl & Stone 1953,
Myles 1975) but that a complete description has not yet
been published.
Essentially MIDIRS • February 2012 • Volume 3 • Number 2 17
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midirs
Focus
“The onset of labour should be
spontaneous with no induction or
‘encouragement’ of any sort
In this article I wish to describe the mechanisms and
movements the mother and the baby will employ to
achieve a spontaneous vaginal breech birth. This is
different to a vaginal breech delivery, where the birth
attendant manoeuvres the baby, although the
manoeuvres may appear similar in many instances.
In 3-4% of all normal term pregnancies the baby will present in a breech position. There is a clear route for these babies to negotiate the birth canal safely. This applies to a well grown, full-term baby ie 37-42 weeks’ gestation. In such an infant the bitrochanteric diameter is likely to be a similar size to the biparietal diameter, unlike a baby who is premature or has intrauterine growth retardation (IUGR).
The onset of labour should be spontaneous with no
induction or ‘encouragement’ of any sort – not even
non-invasive or complementary therapies. The
progress of labour should be spontaneous and steady
with the contractions getting stronger, lasting longer
and coming oftener. No augmentation should be
used to speed up labour. In the second stage of labour
the onset of expulsive contractions and descent of the presenting part should, again, be spontaneous, with no augmentation and no directive pushing.
Throughout this article the baby will be referred to as ‘he’ or ‘his’ to avoid the impersonal ‘its’ or the overly-complicated ‘their’. The author would like to emphasise that girls are also born in the breech position, as shown by the recent arrival of her granddaughter!
It is paramount that the labour is completely spontaneous as this allows the baby time to adopt his own optimal position and to progress at his own pace through the various planes of the pelvis. The labour may spontaneously stop. This should be respected as possibly being nature’s way of indicating that this labour needs help. It would be unwise to attempt to push a baby, who is in a breech presentation, through a pelvis that it is unable to negotiate naturally. The safest way forward, in a resource-rich country, may well be to consider a caesarean section operation.
Pain relief should be non-pharmaceutical, as the woman needs to be responsive to the signals her body and her baby are sending her. Epidural anaesthesia is precluded as it will block these messages and will also curtail the spontaneous movements the woman may need to make. It is also very important to keep the atmosphere in the labour environment calm, non-stressed and peaceful. This will allow the appropriate hormones to act and for the pelvic floor muscles to relax and open. It is important to remember that the largest of these, the levitor ani muscle complex, are under subconscious control and that any stress during labour may cause the woman to feel unsafe and subconsciously tighten those muscles, therefore impairing the progress of the birth. Midwives experienced in breech birth have noticed that most successful vaginal breech births progress more rapidly than a cephalic presentation, and a first labour will take an average of 6–8 hours rather than 12–14 hours.
In 3-4% of all normal term pregnancies the baby will present in a breech position. There is a clear route for these babies to negotiate the birth canal safely. This applies to a well grown, full-term baby ie 37-42 weeks’ gestation. In such an infant the bitrochanteric diameter is likely to be a similar size to the biparietal diameter, unlike a baby who is premature or has intrauterine growth retardation (IUGR).
induction or ‘encouragement’ of any sort – not even
non-invasive or complementary therapies. The
progress of labour should be spontaneous and steady
with the contractions getting stronger, lasting longer
and coming oftener. No augmentation should be
used to speed up labour. In the second stage of labour
the onset of expulsive contractions and descent of the presenting part should, again, be spontaneous, with no augmentation and no directive pushing.
Throughout this article the baby will be referred to as ‘he’ or ‘his’ to avoid the impersonal ‘its’ or the overly-complicated ‘their’. The author would like to emphasise that girls are also born in the breech position, as shown by the recent arrival of her granddaughter!
It is paramount that the labour is completely spontaneous as this allows the baby time to adopt his own optimal position and to progress at his own pace through the various planes of the pelvis. The labour may spontaneously stop. This should be respected as possibly being nature’s way of indicating that this labour needs help. It would be unwise to attempt to push a baby, who is in a breech presentation, through a pelvis that it is unable to negotiate naturally. The safest way forward, in a resource-rich country, may well be to consider a caesarean section operation.
Pain relief should be non-pharmaceutical, as the woman needs to be responsive to the signals her body and her baby are sending her. Epidural anaesthesia is precluded as it will block these messages and will also curtail the spontaneous movements the woman may need to make. It is also very important to keep the atmosphere in the labour environment calm, non-stressed and peaceful. This will allow the appropriate hormones to act and for the pelvic floor muscles to relax and open. It is important to remember that the largest of these, the levitor ani muscle complex, are under subconscious control and that any stress during labour may cause the woman to feel unsafe and subconsciously tighten those muscles, therefore impairing the progress of the birth. Midwives experienced in breech birth have noticed that most successful vaginal breech births progress more rapidly than a cephalic presentation, and a first labour will take an average of 6–8 hours rather than 12–14 hours.
– not even non-invasive or
complementary therapies”
Possible positions of a breech presenting baby
There are several positions that a baby in the breech position may adopt which include flexed (complete), extended (frank), footling and, most rarely, knee presentation. Although many of these will slightly change the mechanisms the basic route and movements should remain the same and, although not all are optimal, all can
still be born safely vaginally. The most common of these positions, especially in a primiparous pregnancy, is the extended (frank) breech, with both legs flexed at the hip and straight at the knee and the feet up near the baby’s face. This is also the position where the baby is least likely to spontaneously turn from, or for an external cephalic version (ECV) to be successful, as there is less spontaneous leg movement and the legs act as a splint to the body.
As with a cephalic presentation the position of the baby is described in relation to the mother’s pelvis with the marker point on the baby being the sacrum. Breech babies can be described as being left sacrum anterior (LSA), left sacrum lateral (LSL), left sacrum posterior (LSP), direct sacrum posterior (DSP), right sacrum posterior (RSP), right sacrum lateral (RSL), right sacrum anterior (RSA) and direct sacrum anterior (DSA). As with cephalic babies favouring the left occipitoanterior (LOA) position, the RSA position appears to be favoured by, and optimal for, breech presenting babies. As the extended (frank) breech in RSA position appears to be the most common, and indeed optimal, presentation and position for a breech presenting baby, I shall employ this to describe the mechanisms for a spontaneous vaginal breech birth.
The mechanisms of an extended (frank) breech presenting baby as it passes through the pelvis in the RSA position
These descriptions are probably easiest when read in conjunction with using a doll and pelvis.
During the latter weeks of pregnancy the baby will usually drop into the brim of the pelvis in the RSA or DSA position. The bitrochanteric diameter, being the largest of the presenting part, will therefore enter the widest (transverse or oblique) diameter of the pelvis (Fig.1).
There are several positions that a baby in the breech position may adopt which include flexed (complete), extended (frank), footling and, most rarely, knee presentation. Although many of these will slightly change the mechanisms the basic route and movements should remain the same and, although not all are optimal, all can
still be born safely vaginally. The most common of these positions, especially in a primiparous pregnancy, is the extended (frank) breech, with both legs flexed at the hip and straight at the knee and the feet up near the baby’s face. This is also the position where the baby is least likely to spontaneously turn from, or for an external cephalic version (ECV) to be successful, as there is less spontaneous leg movement and the legs act as a splint to the body.
As with a cephalic presentation the position of the baby is described in relation to the mother’s pelvis with the marker point on the baby being the sacrum. Breech babies can be described as being left sacrum anterior (LSA), left sacrum lateral (LSL), left sacrum posterior (LSP), direct sacrum posterior (DSP), right sacrum posterior (RSP), right sacrum lateral (RSL), right sacrum anterior (RSA) and direct sacrum anterior (DSA). As with cephalic babies favouring the left occipitoanterior (LOA) position, the RSA position appears to be favoured by, and optimal for, breech presenting babies. As the extended (frank) breech in RSA position appears to be the most common, and indeed optimal, presentation and position for a breech presenting baby, I shall employ this to describe the mechanisms for a spontaneous vaginal breech birth.
The mechanisms of an extended (frank) breech presenting baby as it passes through the pelvis in the RSA position
These descriptions are probably easiest when read in conjunction with using a doll and pelvis.
During the latter weeks of pregnancy the baby will usually drop into the brim of the pelvis in the RSA or DSA position. The bitrochanteric diameter, being the largest of the presenting part, will therefore enter the widest (transverse or oblique) diameter of the pelvis (Fig.1).
18
Essentially MIDIRS • February 2012 • Volume 3 • Number 2
At the onset of labour the presenting part will be the buttocks.
These will descend through the pelvis, gradually rotating clockwise
(if viewed from the top of the maternal pelvis) on the internal pelvic
floor muscles to RSL, (1/8th of the pelvic radius from RSA to RSL)
which brings the right buttock anterior, and the genital cleft into the
transverse diameter (Fig.2).
The first stage of labour then continues until full dilatation of the cervix is reached, adjacent soft tissues are compressed and the vaginal wall expands and opens. As with any birth the woman should be encouraged to labour in the position she finds most comfortable. Only when the birth canal is fully prepared will the woman commence spontaneous expulsive efforts. It is vitally important not to encourage pushing at any point as the dilatation of the cervix, birth canal and position of the baby may not be optimal. The woman’s body will have the best knowledge of when everything is sufficiently prepared to allow the baby to pass through. An internal examination will confirm that the cervix is fully dilated but may also cause the pelvic floor muscles to contract, thus delaying progress into the second stage of labour. If the baby is disturbed by an internal examination it could trigger the startle reflex, which would cause the arms to extend and the head to deflex. It may be advisable to avoid this procedure unless there is a real clinical need for information that may impact on the advice for the management of the birth, and that cannot be gained in any other way.
With the start of the expulsive part of the second stage of labour the baby descends further through the pelvis still in the RSL position. The woman and baby may be seen to make rocking movements of their pelvises, which facilitate the descent and correct positioning for further progress. Most women in western society, where chairs are
Figure 1 Figure 2
The first stage of labour then continues until full dilatation of the cervix is reached, adjacent soft tissues are compressed and the vaginal wall expands and opens. As with any birth the woman should be encouraged to labour in the position she finds most comfortable. Only when the birth canal is fully prepared will the woman commence spontaneous expulsive efforts. It is vitally important not to encourage pushing at any point as the dilatation of the cervix, birth canal and position of the baby may not be optimal. The woman’s body will have the best knowledge of when everything is sufficiently prepared to allow the baby to pass through. An internal examination will confirm that the cervix is fully dilated but may also cause the pelvic floor muscles to contract, thus delaying progress into the second stage of labour. If the baby is disturbed by an internal examination it could trigger the startle reflex, which would cause the arms to extend and the head to deflex. It may be advisable to avoid this procedure unless there is a real clinical need for information that may impact on the advice for the management of the birth, and that cannot be gained in any other way.
With the start of the expulsive part of the second stage of labour the baby descends further through the pelvis still in the RSL position. The woman and baby may be seen to make rocking movements of their pelvises, which facilitate the descent and correct positioning for further progress. Most women in western society, where chairs are
Figure 1 Figure 2
used for sitting rather than squatting, will spontaneously adopt an
upright, forward leaning, kneeling position at this stage.
The woman may be seen to start actively pushing whilst sitting on her heels. This will still bring the baby down and will encourage flexion of the baby, which is beneficial for a breech birth.
Gradually the transversus perinei muscle retracts and the anal sphincter and bulbocavernosus muscle relax, allowing the anterior buttock (right buttock) of the baby to descend and appear at the intriotus of the vagina; the baby’s anus, genitalia and the posterior buttock soon follow. Progress continues and the widest diameter of the baby’s buttocks, the bitrochanteric diameter, is born with lateral flexion. This is generally known as ‘rumping’.
After rumping and with further descent the baby rotates anti-clockwise (viewed from the top of the maternal pelvis) to bring the sacrum to DSA, with the sacrum rotating under the mother’s pubic arch (Fig.3).
While this is occurring the baby’s shoulders are coming into the oblique or transverse diameter of the brim of the pelvis, which is the widest diameter in a gynaecoid pelvis (Fig.4).
Descent continues as the baby’s thighs, popliteal fossa (knee pit) and lower legs become visible. Once the baby’s pelvis has been,born he arches his spine backwards, extending his pelvis, which will cause his lower torso to round the maternal symphysis pubis. This places tension on the extended legs, thus freeing the legs from the intriotus. This movement simultaneously causes the baby’s head to move back and round the internal sacral prominence of the maternal pelvis (Fig.5). The Rhombus of Michaelis is often clearly visible at this time as the maternal sacrum lifts to maximise the pelvic diameters. The release of the legs is spontaneously and easily accomplished, by
Figure 3 Figure 4
Figure 7 Figure 8
The woman may be seen to start actively pushing whilst sitting on her heels. This will still bring the baby down and will encourage flexion of the baby, which is beneficial for a breech birth.
Gradually the transversus perinei muscle retracts and the anal sphincter and bulbocavernosus muscle relax, allowing the anterior buttock (right buttock) of the baby to descend and appear at the intriotus of the vagina; the baby’s anus, genitalia and the posterior buttock soon follow. Progress continues and the widest diameter of the baby’s buttocks, the bitrochanteric diameter, is born with lateral flexion. This is generally known as ‘rumping’.
After rumping and with further descent the baby rotates anti-clockwise (viewed from the top of the maternal pelvis) to bring the sacrum to DSA, with the sacrum rotating under the mother’s pubic arch (Fig.3).
While this is occurring the baby’s shoulders are coming into the oblique or transverse diameter of the brim of the pelvis, which is the widest diameter in a gynaecoid pelvis (Fig.4).
Descent continues as the baby’s thighs, popliteal fossa (knee pit) and lower legs become visible. Once the baby’s pelvis has been,born he arches his spine backwards, extending his pelvis, which will cause his lower torso to round the maternal symphysis pubis. This places tension on the extended legs, thus freeing the legs from the intriotus. This movement simultaneously causes the baby’s head to move back and round the internal sacral prominence of the maternal pelvis (Fig.5). The Rhombus of Michaelis is often clearly visible at this time as the maternal sacrum lifts to maximise the pelvic diameters. The release of the legs is spontaneously and easily accomplished, by
Figure 3 Figure 4
Figure 7 Figure 8
Figure 5 Figure 6
Essentially MIDIRS • February 2012 • Volume 3 • Number 2 19
midirs
Focus
the baby, when the woman is in the upright, kneeling position
described earlier. Again the woman may drop her bottom down so
the baby is sitting on the floor, which again encourages the baby
into flexion.
The baby’s legs are now free and the umbilical cord is visible.
With further descent and continued anti-clockwise rotation the
head is coming into the brim of the pelvis with the sacrum in the LSA position. The shoulders meanwhile are rotating in the mid cavity of the pelvis, guided by the pelvic floor muscles. This continued anti-clockwise rotation facilitates a natural ‘Løvset manoeuvre’, which brings the arms down through the mid cavity of the pelvis, again guided by the pelvic floor muscles. The left arm, which started labour in the posterior position, has now rotated to being the anterior arm and releases from under the pubic arch, closely followed by the right arm, which is now posterior. The chest will appear creased if the arms are in an optimal, anterior position,
across the chest. Breathing movements may be seen but it is wise
to remember the mature baby will have been making such movements in utero.
With the birth of the arms and shoulders the head has come into the brim of the pelvis in the same diameter as if the baby had been head down and LOA position (Fig.6). The baby then restitutes (1/8th of the pelvic radius movement clockwise when viewed from the top of the maternal pelvis) as the head comes through the mid cavity of the pelvis, from LSA to DSA, which brings the occiput directly anterior and onto the internal aspect of the symphysis pubis. External observation of the baby, with the mother in the upright kneeling position, will show the shoulders now in the transverse diameter, and the abdomen and chest facing the maternal spine.
At this point several things occur simultaneously. The baby will flex his legs up towards his abdomen and his arms up towards his shoulders, as if trying to do a sit-up or a tummy scrunch. This movement causes the baby to flex his head, bringing chin down onto chest, and thus pivoting his occiput on the internal aspect of the symphysis pubis (Fig.7). This, in turn, stimulates the mother to spontaneously drop, from an upright kneeling position, to all fours or even a knee-chest position, thus moving her pelvis round the baby’s flexing head (Fig.8). This allows the baby’s chin, mouth, nose and face, followed by the after-coming head, to smoothly pass the perineum. The birth attendant needs only to be ready to support the baby as the head is spontaneously born.
As can be seen from this description of a spontaneous vaginal breech birth there is normally no need for any handling of the baby and so danger of iatrogenic damage to the baby is negligible. The woman should never be asked to drop forward unless the practitioner is physically rotating the head, as described later
in the article.
During the birth, with the woman kneeling upwards and forwards, gravity is used to aid the mechanisms and free movement of the maternal pelvis allows maximum space for the baby. The birth attendant has a clear view of progress and can observe, and record, the baby’s colour, muscle tone and, after the legs have released, the integrity of the umbilical cord to assess the baby’s well-being. There should be steady progress with each contraction. If any of these are cause for concern then further action should be considered.
The baby’s legs are now free and the umbilical cord is visible.
With further descent and continued anti-clockwise rotation the
head is coming into the brim of the pelvis with the sacrum in the LSA position. The shoulders meanwhile are rotating in the mid cavity of the pelvis, guided by the pelvic floor muscles. This continued anti-clockwise rotation facilitates a natural ‘Løvset manoeuvre’, which brings the arms down through the mid cavity of the pelvis, again guided by the pelvic floor muscles. The left arm, which started labour in the posterior position, has now rotated to being the anterior arm and releases from under the pubic arch, closely followed by the right arm, which is now posterior. The chest will appear creased if the arms are in an optimal, anterior position,
across the chest. Breathing movements may be seen but it is wise
to remember the mature baby will have been making such movements in utero.
With the birth of the arms and shoulders the head has come into the brim of the pelvis in the same diameter as if the baby had been head down and LOA position (Fig.6). The baby then restitutes (1/8th of the pelvic radius movement clockwise when viewed from the top of the maternal pelvis) as the head comes through the mid cavity of the pelvis, from LSA to DSA, which brings the occiput directly anterior and onto the internal aspect of the symphysis pubis. External observation of the baby, with the mother in the upright kneeling position, will show the shoulders now in the transverse diameter, and the abdomen and chest facing the maternal spine.
At this point several things occur simultaneously. The baby will flex his legs up towards his abdomen and his arms up towards his shoulders, as if trying to do a sit-up or a tummy scrunch. This movement causes the baby to flex his head, bringing chin down onto chest, and thus pivoting his occiput on the internal aspect of the symphysis pubis (Fig.7). This, in turn, stimulates the mother to spontaneously drop, from an upright kneeling position, to all fours or even a knee-chest position, thus moving her pelvis round the baby’s flexing head (Fig.8). This allows the baby’s chin, mouth, nose and face, followed by the after-coming head, to smoothly pass the perineum. The birth attendant needs only to be ready to support the baby as the head is spontaneously born.
As can be seen from this description of a spontaneous vaginal breech birth there is normally no need for any handling of the baby and so danger of iatrogenic damage to the baby is negligible. The woman should never be asked to drop forward unless the practitioner is physically rotating the head, as described later
in the article.
During the birth, with the woman kneeling upwards and forwards, gravity is used to aid the mechanisms and free movement of the maternal pelvis allows maximum space for the baby. The birth attendant has a clear view of progress and can observe, and record, the baby’s colour, muscle tone and, after the legs have released, the integrity of the umbilical cord to assess the baby’s well-being. There should be steady progress with each contraction. If any of these are cause for concern then further action should be considered.
With ALL breech-presenting babies the cord is born before the head.
By looking carefully at the mechanisms of breech birth it can be seen
that this should not be a problem. The most likely time for cord
compression to occur is as the head descends into the pelvic brim.
The head is not near the pelvic brim until the shoulders are being
born and birth is imminent. The cord is, by this time, clearly visible
and the fullness can be observed. With the upright, forward leaning
position the baby’s body weight is directed away from the cord and
is thus less likely to be compressing the cord, which would also be
protected by the baby’s extended legs.
Although there are some practitioners who support the practice of breech water births, I personally advise against actually giving birth in water when the baby is a breech presentation. This is because
the buoyancy of the water works against gravity and impedes the mechanisms. If the breech presentation is undiagnosed and the woman is in the pool already, she will often instinctively adopt a semi-reclining position which allows the buoyancy of the water to lift the baby in a way similar to the ‘Burns-Marshall manoeuvre’. When such a birth is progressing rapidly it is important to keep the birthing room very calm and just observe progress before disturbing the woman, by asking her to exit the pool. It may be better to proceed with an underwater birth than to interrupt it unless help is needed Water is, however, very good for pain relief in the first stage of labour
These mechanisms may not always be as clearly defined with the other breech presentations and may appear modified, but the basic moves remain the same. As with cephalic birth there will be variations, which, while not necessarily causing a problem, should be noted by the birth attendant, as they may indicate a less than optimal position for the baby.
A baby in the LSA position will not make the full rotation to bring the arms down through the pelvis, so the birth attendant may need to assist with a modified ‘Løvset manoeuvre’ by using the pelvic or shoulder girdle to turn the baby. If any delay occurs in the normal progress of a particular labour, appropriate action may be required before the baby is compromised.
If help is needed it would normally require rotation not traction
in the direction which would release the obstructed part. The normal mechanisms will usually recommence rapidly once release is obtained.
If there has been no traction on the baby the arms and head are rarely extended as the contractions and progress of the labour would normally flex the baby’s head, but, if help is required, with the woman in the upright, kneeling, leaning forward position the whole of the sacral cavity is accessible for any manoeuvre needed. A manoeuvre to reduce an extended head has been described by Louwen (2009); with the shoulders born and the baby in DSA but with an extended head, the practitioner presses their thumbs into the baby’s subclavicular space whilst minimally lifting the baby and rotating the shoulders forward. This manoeuvre may need
to be repeated until the head flexes sufficiently to allow the ‘Mauriceau-Smellie-Veitmanoeuvre’tobeperformed. The ‘Mauriceau-Smellie-Veit manoeuvre’ can easily be performed with the woman in this position should the head need to be helped out; again, using rotation not traction. It is only at this point, with hands on the head, flexing it, that the practitioner may ask the woman to
Although there are some practitioners who support the practice of breech water births, I personally advise against actually giving birth in water when the baby is a breech presentation. This is because
the buoyancy of the water works against gravity and impedes the mechanisms. If the breech presentation is undiagnosed and the woman is in the pool already, she will often instinctively adopt a semi-reclining position which allows the buoyancy of the water to lift the baby in a way similar to the ‘Burns-Marshall manoeuvre’. When such a birth is progressing rapidly it is important to keep the birthing room very calm and just observe progress before disturbing the woman, by asking her to exit the pool. It may be better to proceed with an underwater birth than to interrupt it unless help is needed Water is, however, very good for pain relief in the first stage of labour
These mechanisms may not always be as clearly defined with the other breech presentations and may appear modified, but the basic moves remain the same. As with cephalic birth there will be variations, which, while not necessarily causing a problem, should be noted by the birth attendant, as they may indicate a less than optimal position for the baby.
A baby in the LSA position will not make the full rotation to bring the arms down through the pelvis, so the birth attendant may need to assist with a modified ‘Løvset manoeuvre’ by using the pelvic or shoulder girdle to turn the baby. If any delay occurs in the normal progress of a particular labour, appropriate action may be required before the baby is compromised.
If help is needed it would normally require rotation not traction
in the direction which would release the obstructed part. The normal mechanisms will usually recommence rapidly once release is obtained.
If there has been no traction on the baby the arms and head are rarely extended as the contractions and progress of the labour would normally flex the baby’s head, but, if help is required, with the woman in the upright, kneeling, leaning forward position the whole of the sacral cavity is accessible for any manoeuvre needed. A manoeuvre to reduce an extended head has been described by Louwen (2009); with the shoulders born and the baby in DSA but with an extended head, the practitioner presses their thumbs into the baby’s subclavicular space whilst minimally lifting the baby and rotating the shoulders forward. This manoeuvre may need
to be repeated until the head flexes sufficiently to allow the ‘Mauriceau-Smellie-Veitmanoeuvre’tobeperformed. The ‘Mauriceau-Smellie-Veit manoeuvre’ can easily be performed with the woman in this position should the head need to be helped out; again, using rotation not traction. It is only at this point, with hands on the head, flexing it, that the practitioner may ask the woman to
20 Essentially MIDIRS • February 2012 • Volume 3 • Number
“There are still undiagnosed”beech
births and we must be skilled enough
to facilitate a calm, safe birth
drop forward to move her pelvis round the baby’s head. A baby References
drop forward to move her pelvis round the baby’s head. A baby References
who has needed help to be born is more likely to need resuscitation
but with the cord left intact, the baby will often begin his own presentation at term still an option? Results of an observational prospective survey in
but with the cord left intact, the baby will often begin his own presentation at term still an option? Results of an observational prospective survey in
resuscitation by flinging his arms above his head, expanding his
lungs and crying. Hannah ME, Hannah WJ, Hewson SA et al (2000). Planned caesarean section versus
lungs and crying. Hannah ME, Hannah WJ, Hewson SA et al (2000). Planned caesarean section versus
The overriding skill required for supporting a woman to birth her
breech presenting baby spontaneously is to quietly support and
breech presenting baby spontaneously is to quietly support and
planned vaginal birth for breech presentation at term: a randomised multicentre trial.
Lancet 356(9239):1375-83.
observe. Women who have a history of abuse may need to be planned cesarean section versus planned vaginal birth for breech presentation at term:
counselled that the spontaneous movements made by the baby
during labour and birth may trigger flashbacks but most are able to
manage these if they are forewarned. It is imperative to keep the
birth area calm and quiet to facilitate the birth.
The skills for ECV were nearly lost, due to equivocal research, but thanks to the Term Breech Trial (Hannah et al 2000) these have been rescued. I hope that by gathering and sharing information on facilitating spontaneous breech birth we, as professionals, can similarly keep the skills of safe vaginal breech birth alive so the women we are working with have viable options when their
babies present by the breech.
It is our duty not to cause harm and, as the current evidence is still equivocal (Hofmeyr et al 2003, Goffinet et al 2006, Maier et al 2011), and does not appear to indicate any statistical improvements to the women, or the babies, there is little to support elective caesarean section operation for every breech presenting baby; particularly when a skilled birth attendant is available. There are still undiagnosed breech births and we must be skilled enough
to facilitate a calm, safe birth (Royal College of Obstetricians
& Gynaecologists 2006, Kotaska 2009). It is unacceptable to make caesarean section operation the only option for those women whose baby is presenting breech, just because we professionals have lost the knowledge and skills to assist them in a safe, spontaneous, vaginal breech birth.
The skills for ECV were nearly lost, due to equivocal research, but thanks to the Term Breech Trial (Hannah et al 2000) these have been rescued. I hope that by gathering and sharing information on facilitating spontaneous breech birth we, as professionals, can similarly keep the skills of safe vaginal breech birth alive so the women we are working with have viable options when their
babies present by the breech.
It is our duty not to cause harm and, as the current evidence is still equivocal (Hofmeyr et al 2003, Goffinet et al 2006, Maier et al 2011), and does not appear to indicate any statistical improvements to the women, or the babies, there is little to support elective caesarean section operation for every breech presenting baby; particularly when a skilled birth attendant is available. There are still undiagnosed breech births and we must be skilled enough
to facilitate a calm, safe birth (Royal College of Obstetricians
& Gynaecologists 2006, Kotaska 2009). It is unacceptable to make caesarean section operation the only option for those women whose baby is presenting breech, just because we professionals have lost the knowledge and skills to assist them in a safe, spontaneous, vaginal breech birth.
Jane has also written a Joined-up Knowing for Essentially MIDIRS, which will be published in the March 2012 edition.
Jane Evans RN, RM
Jane Evans worked in the NHS as a nurse and a midwife for 20 years, and has been working as an independent midwife since1991. Sheisco-directorofSharingtheSkillsandhastaughtaboutbreechbirthandmidwiferyskillsbothnationally and internationally. She has four children and three grand-daughters, one of whom was a breech presentation, born spontaneously last year.
Jane Evans RN, RM
Jane Evans worked in the NHS as a nurse and a midwife for 20 years, and has been working as an independent midwife since1991. Sheisco-directorofSharingtheSkillsandhastaughtaboutbreechbirthandmidwiferyskillsbothnationally and internationally. She has four children and three grand-daughters, one of whom was a breech presentation, born spontaneously last year.
Goffinet F, Carayol M, Foidart JM et al (2006). Is planned vaginal delivery of breech
France and Belgium. American Journal of Obstetrics & Gynecology 194(4):1002-11.
Hannah ME, Whyte H, Hannah WJ et al (2004). Maternal outcomes at 2 years after
the international randomised Term Breech Trial. American Journal of Obstetrics &
Gynecology 191(3):917-27.
Hofmeyr GJ, Hannah M, Lawrie TA (2003). Planned caesarean section for term breech
delivery. Cochrane Database of Systematic Reviews, Issue 3.
Johnstone RW (1951). The midwife’s text-book of the principles and practice of midwifery. London: Adam & Charles Black.
Kotaska A, Menticoglou S, Gagnon R et al (2009). Vaginal delivery of breech presentation. JOGC [Journal of Obstetrics and Gynaecology Canada] 31(6):557-66.
Louwen F(2009). Conversation with Jane Evans, 15 October. 2nd International Breech Birth Conference. Ottawa: Canada.
Maier B, Georgoulopoulos A, Zajc M et al (2011). 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 39(4):385-90.
Maternal and Child Health Consortium (2000). Confidential Enquiry into Stillbirths and Deaths in Infancy [CESDI] 7th annual report. London: Maternal and Child Health Consortium.
Myles M (1975). Textbook for midwives: with modern concepts of obstetric and neonatal care. 8th ed. London: Churchill Livingstone:329-43.
Plentl AA, Stone RE (1953). The Bracht maneuver. Obstetrical and Gynecological Survey 8(3):313-25.
Robinson J (2000/01). Breech babies - caesarean or vaginal birth?. AIMS Journal 12(4):12-3. Royal College of Obstetricians and Gynaecologists (2006). The management of breech
presentations. London: RCOG.
Whyte H, Hannah ME, Saigal S et al (2004). Outcomes of children at 2 years after planned cesarean birth vs planned vaginal birth for breech presentation at term: the international randomised Term Breech Trial. American Journal of Obstetrics & Gynecology 191(3):864-71.
Gynecology 191(3):917-27.
Hofmeyr GJ, Hannah M, Lawrie TA (2003). Planned caesarean section for term breech
delivery. Cochrane Database of Systematic Reviews, Issue 3.
Johnstone RW (1951). The midwife’s text-book of the principles and practice of midwifery. London: Adam & Charles Black.
Kotaska A, Menticoglou S, Gagnon R et al (2009). Vaginal delivery of breech presentation. JOGC [Journal of Obstetrics and Gynaecology Canada] 31(6):557-66.
Louwen F(2009). Conversation with Jane Evans, 15 October. 2nd International Breech Birth Conference. Ottawa: Canada.
Maier B, Georgoulopoulos A, Zajc M et al (2011). 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 39(4):385-90.
Maternal and Child Health Consortium (2000). Confidential Enquiry into Stillbirths and Deaths in Infancy [CESDI] 7th annual report. London: Maternal and Child Health Consortium.
Myles M (1975). Textbook for midwives: with modern concepts of obstetric and neonatal care. 8th ed. London: Churchill Livingstone:329-43.
Plentl AA, Stone RE (1953). The Bracht maneuver. Obstetrical and Gynecological Survey 8(3):313-25.
Robinson J (2000/01). Breech babies - caesarean or vaginal birth?. AIMS Journal 12(4):12-3. Royal College of Obstetricians and Gynaecologists (2006). The management of breech
presentations. London: RCOG.
Whyte H, Hannah ME, Saigal S et al (2004). Outcomes of children at 2 years after planned cesarean birth vs planned vaginal birth for breech presentation at term: the international randomised Term Breech Trial. American Journal of Obstetrics & Gynecology 191(3):864-71.
midirs
Focus
Essentially MIDIRS • February 2012 • Volume 3 • Number 2 21
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