Wednesday, July 06, 2016

Gail Tully: Visualizing (Obstructed) Breech Birth

First Amsterdam Breech Conference, Day 1
Gail Tully
Visualizing (Obstructed) Breech Birth:
Breech Complications Illustrated, 
Particularly Trouble with Rotation or Flexion

Gail Tully, CPM, BSc, is a midwife from Minnesota and founder of Spinning Babies. Her session focused on tricky breech situations, and it kept us all on the edge of our seats. It felt like we were all collectively holding our breath! She showed us videos of situations she has encountered that were far from "textbook."

Gail noted that she is an observer; she figures out what’s going on inside by observing what’s going on outside. The mother's soft tissues are very important, as they determine the baby’s rotation. Ligaments can affect a baby’s lie, and sometimes they twist the uterus. Any amount of torsion reduces the space for the baby’s head and perhaps makes it more adaptable for a baby’s bottom (a theoretical explanation of why some babies are breech).

Soft tissues matter and, in many cases, determine the baby’s position. Myofascial therapy and pelvic alignment may improve safety. Gail mentioned an OB/midwife team doing myofascial release before ECV; often the baby is head-down at the ECV appointment, or there is less resistance during the ECV.

Words of advice for working with breech babies
Another way to protect the journey is to collaborate with a team, where midwives work together with doctors. And good nutrition, of course! She advised providers to assess and chart carefully. Track how the breech baby is doing during labor and pushing.

You don’t always see a color change in the breech baby—especially in a water birth—until some other sign indicates the baby is not doing well. Be aware that a placenta can detach before the baby’s head is out.

The breech is a wonderful dilator of the cervix and the perineum.

As the presenting part comes onto the perineum, help the mother retain her confidence and calm. Some women will naturally resist those sensations. Use Ina May’s suggestion and say, “You’re going to get this big” while making a nice wide circle with your hands.

3 pillars of safe breech birth:
1. Hands and knees (upright)
2. Hands off the breech--unless the baby needs help, as indicated by its tone or position!
3. Don’t clamp the cord!

When to be hands-on:
When baby appears deflated, hollow, or limp. Kristeller (fundal pressure) might be advisable in this situation.

Gail comes from a midwifery background that highly values patience, mothers' instincts, and babies taking their time. However, she said that we can’t use a lack of understanding as an excuse for "patience." Our neglect can’t be ideologically justified; we must understand when the baby looks good or not.

What we see on the outside tells us what’s going on in the inside. 
Be observant. Look at how the baby is appearing on the perineum and how it’s rotating.

Normal: The baby’s abdomen is to the mother’s anus when torso and arms are being born. Then baby’s shoulders shift slightly to the oblique to release the arms.

Not normal: The shoulders stop in the AP diameter. You can have either unilateral or bilateral nuchal arms. The baby's spine stays facing the mother’s thigh and progress stops. Sometimes an arm/shoulder gets stuck inside the symphysis pubis (less common—she’s seen it twice).

In this illustration, the baby on the left is emerging normally; the baby on the right will need help. (Mother on hands & knees)

Illustration by Frank Louwen

To release an arm, the baby points the way. 
When the baby's spine is facing the mom’s thigh, imagine the baby pointing behind its head.

If the baby is lively, wait another contraction to see if an arm emerges. (This applies only to the posterior arm, the anterior arm will not come down on its own.) If not, reach up around baby’s chest and rotate in the way the baby is pointing (rotate a full 180 degrees). Then once that arm emerges, rotate 90 the other direction to free the other arm. You want to end up with the baby facing the mother’s anus.

Sometimes baby’s arms are over the head. 
The spine will look like it’s lined up correctly, but you won't see the full abdomen and possibly not even the umbilical cord.

Baby might attempt a tummy crunch to get the arms into the pelvis, or to get the next body part into the pelvis.

After this flexion reflect, expect to see action. If there’s no descent, then it’s your sign to take action.

When baby’s head is stuck: 
First you must know what normal looks like for the birth of the head. For an upright breech birth, you will notice:
  • Head flexion
  • Perhaps a bit of chin or face emerging from the perineum
  • Full perineum
  • Mother's anus is open

You might need to move the chair/ball/bed/husband away from under the mom so she can bend down towards the floor. If the baby is limp and nothing is happening, you can ask to move the furniture.

Rixa's note: I have seen two variations of the shoulder press, a.k.a. "Frank's nudge," demonstrated at this conference. Anke Reitter prefers holding the baby by its shoulders, the thumb in front and the fingers wrapped around the back of the shoulders.

During her presentation, Gail showed us another way to flex and free the head by pressing on the hollow space underneath the clavicle, near the shoulder. Gail made a video in conjunction with massage therapist Adrienne C. Caldwell explaining the muscles and ligaments involved in the shoulder press. I was fascinated to learn the mechanisms by which pressing on the subclavicular space presses flexes the baby's head.

In an email correspondence after the conference, Gail clarified:
I don't suggest the shoulder press. I acknowledged that there are two variations, but I am promoting the one Adrienne describes which I named the SAFE way to free the breech head: Subclavicularly Activated Flexion and Emergence. This is a major point with my talk; that's why I made a film of Adrienne explaining the technique....[Pressing on the subclavicular space] is how Frank first explained it, but he moved towards a mechanical way of working with this and so does Anke. I have just tapped the hollow spot and gotten flexion immediately without the added mechanical push.
With either variation, press straight back towards the mother's pubic bone. Don't press down!

Finger flexion technique: The baby's head is released by placing your fingers on the temporal bones, then gently flexing the head.

Stargazer babies: Reach up to the chin, slightly turn the baby's head to the oblique to bring the head down, then turn the baby's head back to the AP diameter.

If you know the principles, you can adapt to whatever position the mother is in. Mothers often rapidly change positions. When the mother is on her back, you want to see the nape of the baby's neck.

Breech and birth pools
It can be hard to make adaptations in the birth pool. Or if the mother is crouched way too far down, almost sitting on top of her heels with her torso to the floor, it can close her pelvis a bit. When women are on all-fours in the birthing pool, their thighs are flexed in varying degrees, all of which slightly or notably close the inlet (see articles by Desbriere, Guittier, and Reitter). Gail is not favorable for water births for breeches, generally. She believes that being in the water closes the AP inlet. Gravity can help bring the baby down more quickly when the mother is on land. In a post-conference email correspondence, Gail added:
When babies come quickly, water birth can be best, but when a breech is stuck, it is not desirable to have mother move so significantly as to get out of the pool with the baby's body out and head remaining inside. To open the pelvis optimally for a breech baby's head, the thighs need to move away from the abdomen, which would put a woman's head under the water!

In Sum
Frank Louwen taught us to have a formula ready for what could happen in an obstructed breech birth and to rehearse it several times in your mind. Then when the baby doesn’t go by the formula, you can figure out what’s going on and make appropriate corrections.

Comment from an attendee: If you can’t move the baby, move the mother.
A: Yes, even just getting her upright at a different angle can help.


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