When determining the feasibility of attempting a breech delivery, this scoring
index is of great help. However, it remains paramount that the midwife use her
own judgment as well. Never attempt a delivery for which you have neither the
skill nor the experience. Even when you have determined that there are no predisposing
factors against the delivery, if your heart shouts "No!", don't do it!
Breech Index Scoring System
0 1 2
Parity Primip Multip
Gestational Age >/=39 wks 37-38 wks. 36-37 wks.
Estimated Weight 8 lb. 7-8 lb. 5-7 lb.
Dilation 2 cm. 3 cm. >/=4 cm.
Station -3 -2 </= -1
Previous breech 0 1 >/=2
This assessment is designed to be made at the onset of labor. A client would
be scored as follows:
- A multipara (score 2) with a baby who weighs between 7 and 8 pounds (score 1), at station -3 (score 0), dilation 4 cm (score 2), no previous breech babies (score 0), would have a total score of 5.
- A score of less than 3 would indicate the need for a cesarean section.
- A score of 4 to 5 indicates a careful review must be made and suggests one should proceed with caution.
- A score of 5 or more would indicate a reasonable chance for a successful vaginal delivery.
- Of course, some moderating factors exist. If a multipara has had two 9-pound babies vaginally and this baby is of similar size, she should do fine as long as the baby does not go postdates.
- I usually subtract one point for footling breeches because they are somewhat more difficult to manage.
In general, I have found this system to be very reliable for predicting outcome.
- Valerie El Halta, "Normalizing the Breech Delivery," Midwifery Today Issue 38
TO READ THIS THOROUGH ARTICLE IN ITS ENTIRETY, order Midwifery Today Issue 38.
If visualization alone does not lead to spontaneous version, have the mother
begin the breech tilt at 30-32 weeks. Prop an ironing board or other flat object
the height of a couch; pad the board. Have the woman lie on the board, head down,
for 15-20 minutes, 6-8 times daily. Mother should massage the baby, preferably
in a face/head-forward position with one hand cupped around the occiput and one
cupped around the breech, moving the head forward and lifting the bottom in a
rotating motion. As soon as the baby turns, get up and walk or squat. Often, if
mother performs the tilt three days in a row as described and then stops for the
fourth day, the baby seems to assume the vertex position on its own in anticipation
of the exercise.
In particularly stubborn cases, midwives have had success with some seemingly
unlikely methods. Try placing a radio in mom's underwear, low in the abdomen,
or move a flashlight over the belly while she is in tilt position. You could even
draw a picture of a vertex, anterior baby on the mom's belly with a washable marker,
particularly if mom has trouble visualizing the head-down position. Others have
used the Bladder 56 acupuncture technique, homeopathic pulsatilla, or Webster's
Babies have rotated anterior in many cases as a result of this positioning:
Determine the position (side) of baby's back, and have the mother rest and sleep
by lying on the side opposite the baby's back. Have her prop her hip on a pillow,
flexing her top leg and bringing it up toward her chest, propping it with a pillow
for comfort. Remind her to visualize the baby anterior; have her visualize the
baby head down, face down at birth.
- Anne Frye, "Bottoms Up," Midwifery Today Issue 18
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Midwifery Today's Online Forum
I recently had a very traumatic birth as a result of a prolapsed cord. I was
also given Cytotec for induction. From what I've read Cytotec can cause a very
hard and fast birth and a prolapsed cord could come from a gushing or too hard
breaking of the bag of water. I had both of these. Do you think the Cytotec is
related to the cord prolapse? If not, could I have more information on prolapsed
cords? My doctor told me it is very rare and unpredictable and there is nothing
that could've been done to change the outcome. My son was born unresponsive and
was not expected to survive. He did and is now home but has brain damage.
To share your thoughts and experience, go to Midwifery Today's Forums.
Question of the Week (repeated)
Q: When you attend homebirths, what do you keep in
your kit ahead of time for those unexpected, middle-of-the-night calls? And what
is the most effective way to organize and carry your materials and supplies?
SEND YOUR RESPONSE to firstname.lastname@example.org
with "Question of the Week" in the subject line.
LUCK OF THE DRAW: We'll draw a name from among the respondents to this question--the winner will get a free copy of our latest Tricks of the Trade book!
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Know a strong woman? Helping empower one? If you haven't already done so, please
forward this issue of Midwifery Today E-News to one or two of your friends or
business associates. Thanks so much!
I am a student at the University of Puerto Rico in Humacao and I'm looking for
information about birthing centers, the risks involved in using them, the positive
and negative experiences of birthing in a center, etc. I had my last baby in a
birthing center and feel very strongly about women having more choices available
to them. Here in Puerto Rico birthing centers are yet to become legal, so the
only place to have a baby is in a hospital. Some hospitals offer birthing rooms,
but we still have a long way to go. Efforts have been made to pass a law supporting
birthing centers, but twice the petition has been pushed through both houses only
to be defeated by the governor, who ignores the petition until the time has passed
for either vetoing it or signing it into law.
I want to produce an investigation and write a thesis on the pros and cons to
add to the information already existent so there can be another go at pushing
the measure through and becoming law. Any suggestions about how to go about doing
this will be greatly appreciated.
- Elaine Soto-Martis
Proyecto La Estancia
Calle 8, K-23
Humacao, Puerto Rico 00791
My daughter wrote this a short while ago after watching me nurse her little brother. I think it is too beautiful to keep to myself.
The breast of a woman is beautiful to a tiny baby boy.
It is like a pillow of soft white fur,
he feeds on his Mother's milk and is safe,
and he sleeps beneath her dress and she loves to stroke his bare butt.
- Kimberly Wilson
Students who are confused about the various methods of calculating EDD [Issue
3:47] should be reassured that Wood's method is the same as Naegele's. Naegele's
Rule--calculating EDD by subtracting 3 months from LMP and adding 2 weeks--is
the SAME as Wood's (adding one year to LMP, and then subtracting 2 months and
Wood recommends adding or subtracting days according to the average length of the woman's individual cycles, but so did Naegele. It's just not often remembered.
The only change is Wood's recommendation to use a different calculation for multiparas.
This would subtract 4 days from Naegele's dates.
- Gail Hart
In response to Claire Winstone [Issue 3:47]:
Epidurals carry risks. Cesareans carry risks. Breathing carries risks! However,
there are very real benefits sometimes from even the most potentially dangerous
activities. Opponents of homebirth [sometimes] make misguided statements about
the risk of out of hospital birth. They caution families that they are "risking
the baby's (or mom's) life" and they tell horror stories, often out of context
and unsubstantiated. The burden is on the out of hospital community to demonstrate
It's exciting to have research to back our position. It's sobering and useful
to have research to demonstrate the potential risks of routine hospital procedures.
I do not believe it benefits providers or clients to present information in an
emotionally loaded manner.
I have not encountered any information in my training as a midwife that demonstrates
a relationship between epidurals and the negative outcomes described in Claire's
letter, e.g., babies exposed to more than an hour's worth of obstetrical medications
being more predisposed to become substance abusers, and feeling disconnected from
their bodies, fuzzy thinking when under stress, feeling inadequate and incapable
of completing things they start, and a whole list of other possible consequences.
I strongly believe in giving families accurate information. When I talk to women
(and men) about the risks and benefits of a treatment or procedure, I give them
documentation. I quote studies and I encourage them to research on their own and
share their information with me. I work very hard to ensure that my biases do
not become the foundation of my clients' decisions. Giving women information that
cannot be independently confirmed is not giving informed choice.
- Melissa Jonas, licensed midwife
This is a profound and extremely negative outcome for any mother to be risking.
I decided to do a literature review using PubMed (National Library of Medicine,
"PubMed, a service of the National Library of Medicine, provides access to
over 11 million MEDLINE citations back to the mid-1960s and additional life science
to see if any evidence exists for this distressing outcome. I could find plenty
of reasons for women to avoid epidurals, including reduced suckling behavior in
neonates and increased risks of malpositioning in the second stage of labor. I
found nothing whatsoever to even remotely indicate babies whose mothers have had
epidurals are at increased risk for becoming substance abusers or suffering long-term
adverse psychological outcomes. I also searched for effects cited by Ms Winstone
such as longer breastfeeding in mothers who do not opt for an epidural and found
that, on the contrary, there is no difference in breastfeeding length in women
who choose epidurals over those who do not (see J Hum Lact. 2000 Feb;16(1):7-12).
Further, I find I am at a complete loss to understand how one would "inform
an unborn baby of any procedure" or "include the baby in planning and
decision making" as promoted by Ms Winstone.
Finally, I found an article that states that 88% of women who request an epidural
after planning natural childbirth express being less satisfied with the birthing
experience. Their main source of 'loss of satisfaction' arose from concerns about
the effects of epidurals on their baby (Reg Anesth Pain Med 2001Sep-Oct;26(5):468-72).
Are the concerns that rob women of satisfaction in their labors and deliveries
being fostered by apparent misinformation such as "babies of women who choose
epidurals are more likely to become substance abusers" being spread among
the midwifery community?
When I was pregnant with my first child I got into a disagreement with my physician
about episiotomy. He was a proponent of routine episiotomy for all his patients
and I was refusing to consent to it. He presented one reason after another for
the routine episiotomy, but being well armed after a thorough literature review,
I was able to refute all his arguments. He became increasingly impatient with
me and he told me if I did not agree to routine episiotomy my husband would not
be able to enjoy sex with me because I would be left with a vagina you could drive
a truck into and my uterus would fall out at age 40. At that point I decided he
was using his position and authority to state things unsupported by research as
if they were facts in order to bully me into agreeing to what he felt was in my
best interests. I switched doctors and subsequently delivered without an episiotomy,
my sex life intact and my uterus still in place nearly two years after the deadline.
When I read the letter by Ms Winstone I found myself recalling that experience
and feeling a powerful sense of deja vu. I would be very happy to be proven wrong
by references to the literature she is citing.
- Natalie K. Bjorklund
In response to Liz Worchester [Issue 3:45]: "Varney´s Midwifery,"
3rd edition, 1997, Chapter 28, pp. 521 mentions "third stage hemorrhage is
due to partial separation of the placenta, the most common reason for partial
separation is mismanagement of the third stage, usually involving uterine massage
prior to placental separation..." In the reference section there are five
references, of those I believe that the first and the last are the most pertinent
to this situation.
- Dombrowski, M.P., et al. Third stage of labor: Analysis of duration and clinical
practice. Am. J. Obstet. Gynecol. 172(4,part I):1279-1284 (April) 1995.
- Diagnoses and management of postpartum hemorrhage. ACOG Technical Bulletin Number
143. Jupy 1990.
- Aiyana Gregori, student midwife
Does anyone have information about hypoplasia breast or hypoplastic breast?
This is also referred to as an underdeveloped breast and can interfere with milk
production. Any information or resources where I could get information would be
To LaDonna [Issue 3:47, placental abruption]:
Contact a hypnotherapist to reprogram the tapes in your head about your previous
births so you don't bring previous experiences to the next birth as expectations.
You might also want to attend HypnoBirthing classes to reinforce that your body
works perfectly in birth. Hypnosis can tell your placenta to keep doing its job
until you're term, or when it's safe for the baby to come.
www.HypnoBirthing.com can give you lots
of basic info and and can help you find a hypnotherapist with a birthing background.
- J. West, LM, CPM
She should take extra vitamin E (a good natural form) during the last trimester
of her pregnancy and be sure that she does not take anything with dong quai (angelica)
in it during her pregnancy. Some combinations have it, such as 5W and some herbal
- Judy, CPM
Re: separation of abdominal wall [Issue 3:46-47]: The following is from an article
by Jennifer Goldberg entitled "Physiology of the Puerperium." The credits
were: Principles of Anatomy and Physiology, Nurse-Midwifery (Varney), Myles Textbook
for Midwives, Heart and Hands, Maternity and Gynecologic Care, and Holistic Midwifery.
"The abdominal muscles can't retain the abdominal contents for the first
few days postpartum (pp). The abdomen protrudes and is relaxed until 2 weeks pp.
By 6 weeks pp the abdomen wall is at its nonparous state. The skin regains most
of its previous elasticity and some striae (stretch marks) persist. The return
of the muscle tone depends on the previous tone, exercise and amount of adipose
All pp women have some degree of abdominal wall muscle separation, called diastasis
recti abdominis. Most women have about half an inch of separation, some very little.
With time it becomes less apparent. Severity depends on a number of factors: woman's
general condition and muscle tone, if she exercised after previous pregnancies,
her parity (regaining complete muscle tone becomes more difficult with increasing
parity), whether or not there was time for her to regain tone between pregnancies,
overdistended abdomen. Diastasis may or may not occur with or without a large
baby. If abdominal tone is not regained, the space between the rectus muscles
fills in with fat, peritoneum and fascia. Subsequent pregnancies may not have
the necessary muscle support, resulting in a pendulous abdomen.
Have the woman lie down and have her lift her head and shoulders as you place
fingertips along the juncture of the abdominal muscles running from the umbilicus
to the pubic bone. If you feel some gaping, suggest abdominal exercises. Single
leg lifts progressing to sit-ups with knees bent and yoga help. Fajas (belly bands)
- Detrah Hele, CPM
I am looking into becoming a midwife and I have heard that it is harder to become
one if you have a degree in nursing. But I have also heard that you have to have
a degree in nursing to become a midwife. Please help!
- Heathyrre Henderson
I've all but given up suggesting the kinds of wholesome remedies for my pregnant
"patients" mentioned by Raven in The Art of Midwifery by Raven [Issue
3:47, tips for heartburn]. My "patients" want Tums, they want Zantac,
they want what their uncle takes for his heartburn. Call me a cynical CNM.
And I call them patients because that is what they are. They are not clients, although I wish they were.
EDITOR'S NOTE: Only letters sent to the E-News official email address,
will be considered for inclusion. Letters sent to ANY OTHER email addresses will
not be considered.
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