Three Surprise Breeches
by Ina May Gaskin, CPM
© 2005 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 74, Summer 2005.]
Complications may not be what we ask for, but sometimes we get them anyway. I've been blessed to deal with three surprise breech presentations in less than a year. Each birth was instructive in its own way.
The first surprise was a first birth for the 38-year-old mother-to-be. Two very experienced midwives, my partners, did three vaginal exams in labor. Each time they clearly palpated the baby's head. The mother then chose to labor for the next few hours in the water tub. Later, after the baby had been born, she said that during this period she felt a lot of unusual movements from the baby.
In labor, once dilation was complete, the mother wanted to get out of the water. She squatted as she pushed. I was sitting on a chair next to her, and after one powerful push, I reached down to assess with my fingers how far the baby's head had descended. Looking at a dark blob on my withdrawn fingers, I thought, That's not old blood. That's meconium. I knew what that meant.
Sure enough, a few more pushes brought down the bottom of a frank breech girl. Her legs, arms and head were all born without real difficulty. This birth taught me that it truly is possible for the babies of first-time mothers to turn from vertex to breech during labor. I have attended several labors of grand multiparous women in which the baby changed from vertex to breech during labor, but this was the first time I had encountered this phenomenon in a first-time mother.
Most of the discussions about breech birth in medical literature ignore the possibility of the undiagnosed breech at all, but it can and does happen. For this reason, it is vital for midwives, physicians, nurses, paramedics and emergency medical technicians to be familiar with the basic principles and maneuvers of breech birth.
The Burns-Marshall Maneuver
The second breech birth was to be the 12th baby of an Old Order Amish couple. The mother had had several complicated births before; most of her births had been long and difficult. She was originally booked with one of my partners, who also works two-day shifts sometimes at an area hospital. My partner's intuition told her that she might miss this birth, so she took me and another partner to meet the woman in case we were needed. Checking the baby's presentation, I found it to be a frank breech. As easy as could be, I nudged the baby's head from breech to vertex position, then asked the mother to get up and walk around for a while, in hopes that the baby would remain head-down.
That night the father asked his neighbor to phone me to say that his wife was in labor. When my partner and I reached her side, I found the baby presenting breech again, and the water bag had broken. With the water broken and the baby's bottom deep in the pelvis, external version didn't seem a good idea.
Labor was hard. The Amish woman walked and walked. Then she sat in her rocking chair for a while. She prayed, supported by her husband, who was very tender and helpful. As is my usual practice in a breech labor, when she began to want to push, I asked her to keep from bearing down until the urge couldn't be squelched. (This is my strategy for keeping the cervix at maximum dilation for the aftercoming head).
By the time the mother was ready to push the baby out, she was kneeling on the floor, leaning forward with her torso supported by a chair. I have assisted many breech babies birthed from this position and prior to this birth never had any problem in delivering the head. She pushed and pushed, and little by little, the baby's bottom descended. I wondered briefly what I would do if the baby's head were extended, never having dealt with this complication during a breech labor in the kneeling position.
As I mentioned earlier, this woman tended to have long, drawn-out labors. Her pregnancies had been close together. At 39, she didn't have the stamina she had had when she was younger. Whatever the reason, her uterus no longer contracted effectively enough to help descent once the bottom was born. I had to reach up very high to be able to reach one of the baby's arms and sweep it down across her face. The second arm was easier to extract, but her head remained quite high in the pelvis, chin extended.
I reached higher with my fingers—impossibly high, it seemed—before I could reach the baby's mouth. Pressing my fingers against her cheekbones, I tried to flex her jaw onto her chest but couldn't budge it. I wondered briefly if we might be able to establish an airway, but that clearly wasn't going to work either. The head was far too high for that.
What did work to free the head was to help the mother turn from the kneeling position to lying on her back on the floor. This change of position made it possible for me to easily flex the head and deliver it, once the mother was lying on the floor. Would it have been easier to do all this on the bed? Yes, I think it would have.
I still like the kneeling position for most mothers, but I will keep in mind that it had its limitations for this grand multiparous woman with her sudden inability to push with the half-born baby. I believe the chief factors leading to this difficulty were uterine exhaustion and the slackness of her abdominal muscles.
We had to work on the baby for a few minutes. She was born with a heart rate slightly less than 100 and plenty of fluid in her airway. Back blows between the shoulder blades were needed to clear her airway, and CPR brought her around so that her 10-minute Apgar was 8. From that point on, the baby did well.
Given another breech presentation for a grand multiparous woman, I would probably prefer a delivery position on a bed, with her bottom near its edge. This position is good for use of the Burns-Marshall maneuver, when the aftercoming head is extended. There are two ways of determining that the head is extended. First, the baby's hairline at the nape of the neck is not visible. That sign alone shouts: DO NOT ATTEMPT TO DELIVER THE HEAD YET, AS YOU COULD BREAK THE BABY'S NECK. The second way of knowing is that your fingers can feel that the baby's chin is not flexed onto its chest.
The remedy is to make sure that the mother's bottom is right at the edge of the bed. Allow the baby's body to hang (it's a good idea to have a warm receiving blanket around the baby) unsupported for five to 10 seconds. This is usually long enough for the weight of the body to pull the baby's head into the flexed position. Once the hairline is visible, it is safe to deliver the head.
Better Safe than Sorry
My third surprise breech in a year was with a first-time mother who was 35 weeks pregnant when she arrived at our center. An abdominal examination revealed the frank breech presentation of her baby. The plan was to try an external version after she had had a good night's sleep. However, her water bag broke that night, and labor began. Although we palpated and estimated her baby to be a little over six pounds, it did not seem wise to attempt an out-of-hospital birth because of the baby's gestational age. The obstetrician on duty at the hospital that day did agree to a trial of labor, but after ten hours (and no food), including an hour and a half of oxytocin augmentation, the decision was made to do a cesarean. The baby weighed 6 lb 11 oz, and his head measured 36 cm. Clearly five weeks early, he had transient respiratory distress (mild retractions), but after a few hours in the nursery, he latched well onto his mother's breast and stayed with her from then on.
The lesson of this third birth? It is better to be safe than sorry. While it is possible that this baby could have been safely born at our center, it seemed unwise to attempt an out-of-hospital birth when there had been so little time to form a close relationship with the mother-to-be and her family members.
Ina May Gaskin, CPM, is the founder and director of The Farm Midwifery Center in Tennessee (USA). She is the author of Spiritual Midwifery (1975) and Ina May's Guide to Childbirth (2003). She was president of Midwives' Alliance of North America (MANA) from 1996 to 2002 and is a prominent national and international speaker. She has been a homebirth midwife for more than 34 years.
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