Sunday, July 03, 2016

Betty-Anne Daviss: Cardinal Movements and Crowning Touch

First Amsterdam Breech Conference, Day 1
Betty-Anne Daviss, RM, MA
The Usually Reliable Cardinal Movements of the Vaginal Breech

After some introductory remarks, Canadian midwife and researcher Betty-Anne Daviss noted that the term cardinal movements is a bit of a misnomer, because there are more variations in the descent of a breech breech than of a vertex baby. She briefly reviewed the cardinal movements of a breech baby through the maternal pelvis, noting instances that indicate a vaginal breech birth will not happen or will be problematic. For example, if the baby stays right lateral and doesn’t descend, that probably means a vaginal birth won’t happen. Both the posterior or anterior arms can become caught in various locations: on or under the sacral promontory or on the symphysis pubis.

I won't summarize the cardinal movements here, so I suggest you visit Jane Evan's video demonstrating the cardinal movements of the breech baby (from the 2nd International Breech Conference in Washington, DC 2012).

The most fascinating part of Betty-Anne's lecture was a description (including videos and reconstructions using a doll and pelvis) of a technique she calls the "crowning touch." She attended a birth where the head became hyperextended after the arms were born. She went up inside the mother with one hand, all the way along the side of the baby's head to the parietal bone, and she was able to then flex the head and bring it down. She suggested trying first with the cheekbone, and if that doesn't work, you can go up further and try on the parietal bone.

She wondered why obstetricians in the past have not done this and theorized that perhaps their hands were too large. Her hypothesis is that hand size/width might be an important consideration for the birth attendant, and hands might be a better replacement for forceps. For midwives who are not trained or not allowed to use forceps, using one's hand is a way out of feeling like you *have* to have forceps.

She also noted that the Frankfurt team has never had to use forceps to date, nor Andrew Bisit's unit in Sydney. She has also never seen a cervix clamp down over the baby's head, because once the baby is descending, the head comes right out.

Tips & tricks

  • Follow what the women are doing. For example, at her first solo breech birth at her hospital (where she was able to do the birth on her own, rather than transferring care to an obstetrician), the woman was on H&K on the bed and not much progress happened until she got on the birth stool.
  • Traditional midwives taught her to have the laboring woman grab a rope, sit and squat. They noted that women would often spontaneously fall over onto hands & knees when the baby was breech or had a (cephalic) shoulder dystocia. 
  • When you’re doing Frank’s nudge (aka the shoulder press), be sure the baby's head is turned to the front, rather than facing to the side. 
  • She’s learning as much about resuscitation in Frankfurt as about breech birth. They bring the baby to the mother and wait, rather than cutting the cord and removing the baby. 

Question & Answer Session

Q: Hypothetical question: In order to flex the head, you described pulling the face down. Would it be possible to put a hand up the back and push the occiput back?
A: Yes, certainly, depending on where the baby is in the pelvis. Try one or the other. I haven't caused any tears with this technique.

Q: OB from Sheffield: I have used my hands twice to push on the occiput, but both times were with face presentations for vertex babies.

Q: Why don’t you describe this maneuver and get your name on it? (said jokingly)
A: I’m Canadian and I don’t like drawing attention to myself. I really like calling it the “crowning touch.” It’s the final thing you might have to do if it’s really needed.


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