I need to ask a favor from anyone who
1) had a vaginal breech birth in the hospital,
2) had one at home because that was your only option, or
3) was pressured into a cesarean because it was not an option due to hospital policy or lack of experience of attendant
I am getting a lot of pressure to stop attending breech and despite my best efforts to get privileges at a tertiary care hospital with neonatology, it is not happening.
Please send your impassioned pleas and experiences to:
Sutter Davis Hospital Birth Center
2000 Sutter Pl
Davis CA 95616
Thanks![And please also send me a copy of your letter so I can forward it on to the OB!]
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| Image source |
‘‘The air-pipe, as a big as a swan’s quill in the inside, ten inches long, is made of a small common wire, turned very close (in the manner wire-springs are made) will turn any way; and covered with thin soft leather, one end is introduced with the palm of the hand, and between the fingers that are in the child’s mouth, as far as the larynx, the other end external.’’Pugh initially advocated the use of his air-pipe in cases of breech extraction during delay in delivery of the after-coming head. He used the air-pipe in the manner quoted above as ‘‘I found many children were lost in this situation, for want of air…’’ Pugh then described an alternative method which he had developed making the use of his air-pipe rarely necessary:
‘‘You must then introduce the fingers of your left hand into the vagina, under the child’s breast, and put the first and second fingers into the child’s mouth pretty far, so far, however, that you are able to press down the child’s tongue in such a manner that by keeping your hand hollow, and pressing it upon the mother’s rectum, the air may have access to the larynx, you will soon perceive the thorax expand, as the air gets into the lungs.’’Pugh emphasised the risk of asphyxia to the fetus during delivery of the after-coming head of the breech saying ‘‘…every operator must know there is difficulty, and grave danger of losing the child by its stay in the passage; by my method of giving the child air, I have saved great numbers of childrens’ lives, which otherwise would have died’’. Furthermore, Pugh goes on to give a remarkable early description of mouth-to-mouth respiration.
‘‘If the child does not breath immediately upon delivery, which sometimes it will not, especially if it has taken air in the womb; wipe its mouth, and press your mouth to the child’s, at the same time pinching the nose with your thumb and finger, to prevent the air escaping; inflate the lungs, rubbing before the fire: by which method I have saved many.’’
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| Image from Baskett 2000 |
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| Image from Giving birth--the most dangerous thing an African woman can do? |
The implication of this finding is that in well selected patients, neonatal outcome following assisted vaginal breech delivery and planned caesarean section may not be different. Owing to the high level of aversion to caesarean section by our women (Aziken et al., 2007; Ezechi et al., 2004), as well as the associated surgical risks, a whole scale policy of caesarean section for all cases of term breech delivery may not be feasible in our environment. Moreover, the policy will inevitably lead to an overall increase in caesarean section which will put a strain on the very limited resources in the region. As breech presentation is not a recurrent indication for caesarean section, most of these women who had caesarean section will attempt vaginal delivery in their subsequent pregnancies with the associated risk of uterine rupture. Owing to the very high premium placed on vaginal delivery by the African women and the fear of a repeat caesarean section, a significant number of these women may not present to a proper health facility for management. The consequence is increased likelihood of uterine rupture and the attendant maternal mortality and morbidity.
Furthermore, in Africa, labour and delivery are not just medical matters, but carry a huge cultural significance. Any intervention that will affect the attitude of the people towards labour and delivery must consider the cultural aspect.
It is impossible to deliver all term breeches by CS, as a systematic review has suggested 9% of women still have a vaginal breech delivery (Conde-Agudelo 2003). This is due to: maternal request; advanced or precipitate labour; or the presence of a second fetus in twins. This further highlights that the obstetrician providing intrapartum care should be able to conduct vaginal breech delivery....
Obstetricians are trying to follow the guidelines provided by the Royal College and are adopting a policy of CS as recommended. However, the short- and long-term maternal complications and the effects on family and society, which have huge emotional and economical implications, are ignored. The impact on women of developing countries has not been considered thoroughly and data have not been compared against developed countries. These developing nations are still struggling to provide basic antenatal care to mothers and reduce the maternal mortality rates (MMR). In 2005, the MMR in India was 450 per 100,000 in stark contrast to developed regions (9 per 100,000)….However, a significant decline in perinatal mortality has not been seen, despite the high CS rate in recent years and decrease in vaginal breech deliveries from 70.4% in 1994 to 13.1% in 2004....
[O]ffering CS to all patients does not improve the neonatal outcome significantly. This study highlights that case selection for planned vaginal deliveries is still a viable option.
Recently, it has been highlighted that CS is not always safe and is associated with severe maternal morbidity. In developing countries where anaemia is prevalent and blood and blood products are not readily available, abdominal delivery further contributes to high morbidity and mortality. There is a lack of support for the women, society and cultural values are different and health economy is of paramount importance....
For possible small improvements in perinatal outcomes, the impact and consequences of CS on future pregnancies in women who do not understand the benefits of antenatal care is more risky than vaginal breech deliveries....
Vaginal breech deliveries cannot always be avoided and will continue to occur, even in institutions with a policy of routine CS deliveries. There are situations such as precipitate delivery, home birth, fetal anomaly or fetal death and mother’s preference for vaginal birth. As a result, it is essential for clinicians to maintain the skills needed for breech deliveries. Moreover, at the hospital catering for this kind of population, several patients will continue to choose vaginal breech delivery....
CS section should be performed in selected cases after full consideration and with the involvement of the patient and their relatives and where appropriate, with a clear indication and aim of what is going to be achieved. It is ironic that where maternal morbidity and mortality is very high we are concentrating on a very small subset to reduce the perinatal morbidity and mortality. This study highlights that vaginal breech delivery remains a viable option in some patients and should be discussed with patients with a full explanation. They might choose maternal health as a priority and accept the small risk to the neonate. [Emphasis mine]
Vaginal birth is generally considered better for mothers than cesarean section, as one avoids the operative complications associated with major abdominal surgery and an increased cost of birth. In developed countries, the risk of maternal death due to cesarean delivery is 2 to 30 times higher than that observed with the vaginal births. However, in developing countries, these figures are alarming, where there are 3-6 maternal deaths for every 1000 cesarean deliveries and where every eighth in-hospital maternal death is attributed to cesarean section. Moreover, trial of scar is associated with the risk of uterine rupture (7/1000) and there is a significantly greater post-partum morbidity after repeat cesarean section than after a vaginal delivery.
In Pakistan, this issue is further complicated by the lack of adequate documentation about the indication for the previous cesarean section, the stage of labor at which it was performed, the type of uterine incision and the course of post-operative morbidity/recovery. Moreover, the patient’s desire to avoid cesarean birth due to social pressure may result in avoidance of antenatal care and hospital deliveries in subsequent pregnancies. As more and more obstetricians turn towards elective cesarean section as delivery mode of choice for breech infants, the trainee obstetricians would loose [sic] the opportunity to acquire skills for safe vaginal birth, with the resultant loss of this delivery option to be offered to the parents.
[T]he policy of wholesale Caesarean section for delivery of term breech infants as being advocated and practiced in many centers in developed countries needs re-appraisal. There is no clear benefit of abdominal delivery where strict selection criteria is employed...increased maternal morbidity attending abdominal delivery would make Caesarean delivery a less favourable option, especially in our environment where there is a great aversion to Caesarean section and where the woman cannot be guaranteed to report for monitoring in subsequent pregnancy if at all such monitoring facility is widely available.
However, the meta-analysis by Hofmeyr and Hannah (2001), which alluded to the findings of previous authors [Golfier 2001, Herbst 2001, Hannah 2000], did not assess the cost and future morbidity as a result of the caesarean section scar. This will be very relevant in our society, where grandmultiparity is common and patients may be having their 6th or 7th caesarean section….
Although it may be difficult to elucidate clearly the reasons for these changes, there is no doubt about the fact that the preferred route of delivery of a singleton breech at term is by elective caesarean section in the developed world. Perhaps we need to consider whether it is necessary to follow management trends elsewhere in the world without taking cognisance of the culture of the society in which we practice…. [Emphasis mine]
Our community, being a developing one, still prides itself on the size of the family and, as such, it seems logical to try to allow vaginal delivery in breeches with the safety of the mother and baby still the priority. With a sizable proportion of childbearing women in our society being grandmultiparae, the risks of repeat caesarean section especially placenta praevia accrete increases. It was shown by Zaki et al. (1998) that the incidence of emergency hysterectomy in cases of placenta praevia accreta was 50% compared to 2% in non-accreta. It will therefore seem reasonable to attempt to reduce the trend of caesarean section for breeches in our community….
This study showed no birth trauma in 1997 while birth trauma resulting from breech delivery was highest during 2000. This may be due to the quality and experience of the registrars working in the department at the specific periods in time.
In developing world settings, and especially in rural conditions, a proper management plan before the onset of labour is often not achievable. The unpopularity of the prospect of a CS prompts women to delay admission to the labour ward until in established labour.
Increasing the number of CS should be strongly discouraged since the case fatality rate in this rural setting was found to be very high: 18/1093 women died after CS (for any indication) within 42 days after the operation (1.6%); 15 within 24 h. Haemorrhage was the major cause of death....
[The very high case fatality rate of 1.6% for CS] is a reason for great concern. We calculate that delivering 1000 babies in breech presentation by CS (excluding those whose outcome cannot be influenced by labour management) would save 137 babies, while 16 mothers would die as a result of the operation. Assuming that each woman will have two more deliveries and one third of these will be by CS, this policy would cause 656 (984 x 2/3) additional CS in the future, and 11 more maternal deaths, and this does not include the women who will die from a ruptured uterus during a subsequent pregnancy before they can have a repeat CS. Therefore, delivering all term breech presentations by CS would save 137 babies, but at least 27 women would die. In our view, this is totally unacceptable. In addition, orphaned babies also have a high risk of dying....
In this rural setting only a minority of women deliver in district hospitals. Thus, women with an easy vaginal breech delivery (at home or in a clinic) resulting in a live baby were not taken into account in this study. If all breech presentations at term were delivered by CS, then even more CS would be performed but at a lower percentage of babies would benefit.
The lack of correlation between the BrPNMR [breech-related perinatal mortality rate] and the CS rate, and the high mortality rate after CS, make a strong case against the systematic delivery of [breech presentations] by CS in this setting. Rather, attention should be given to improving the overall management of breech deliveries.
Thayla was born on a rainy Sunday in May 2017. The initial plan was a home birth, but she was breech (with her butt down and her head up), so it was recommended that she be born in a hospital. The family stayed at home accompanied by midwives Paula Leal and Silvia Briani of Mamatoto team and doula Thais Olardi, until her mother, Thais, was 7 cm dilated. In this hour they went to the Hospital and Maternidade Sepaco where, after a short time, Thayla was born in a totally natural way, without any intervention, in a respectful and humanized way. In the hospital the family received the support of the obstetrician Camila Escudeiro and the neonatal pediatrician Nicole Martin.
It is with great generosity that the family opens up their intimacy and discloses the video of the birth of Thayla. Parents believe that good stories deserve to be told and that it is indeed possible for pelvic babies to be born naturally. The biggest message that Thais leaves to all mothers is: "Believe in yourself, believe in the strength and perfection of your bodies!"
Clareou Films took great pleasure in following this story and is flattered to share with you a story of faith, determination and a beautiful happy ending!
Congratulations to the dads and thank you for sharing this special moment in your life with other families! Welcome, Thayla
The manual aid by Tsovyanov I in frank breech presentations.
The aim of the manual aid: to prepare the maternal ways to the delivery of the head and shoulders and to keep the normal attitude of the fetus.
In the frank breech presentation the fetus extremities are flexed at the hips and extended at the knees and thus the feet lie in close proximity to the head. The circumference of the thorax with the crossing on it arms and legs is larger than circumference of the head and the after-coming head deliveries easily.
The technique. The aid begins after the delivery of the buttocks. The obstetrician’s hands are applied over the buttocks, the thumbs placed on the fetus sacrum and other fingers on the legs. The doctor gently supports the legs to avoid its flexion. If the normal attitude of the fetus is keeping the head deliveries easy.
The manual aid by Tsovyanov II in footling presentations.
The aim of the manual aid: To perform [convert?] the footling presentation to the incomplete breech and to prepare the maternal ways to the delivery of the head and shoulders.
The doctor covers the area of the vulva with the sterile napkin and puts up resistance to the delivery of the feet. The feet are flexing and the footling presentation becomes incomplete breech presentation. Than the delivery manage as in incomplete breech presentation.
Were you coerced, forced or pressured to have a procedure(s) during labor and birth? Such procedures may include: epidural, episiotomy, induction of labor, augmentation of contractions, IV medication or fluids, cesarean section, Pitocin, antibiotics or other medications, electronic monitoring, movement or lack of movement, or pushing position.For more information, contact:
If so, we would be interested in learning about your experience.
We are conducting a study that examines the experiences of women who have been forced or coerced to have a procedure, including cesarean sections, during labor or birth. If you have had such an experience and are willing to share your experience, please click on the link at the bottom of this post. You will be directed to our secure and confidential survey site. The survey will include questions about you, your reproductive history and questions about the pregnancy, labor, and birth that involved a forced or coerced procedure(s). Participants will also be asked about any consequences of having the forced or coerced procedure. Completion of the survey is expected to take about 30 minutes. Participants names will not be used in any publication of results. To access the Spanish version of this survey, follow the link bellow and select the language option in the top right corner.
The individual woman's wishes must be taken into consideration as for some, labour is an integral and treasured experience and a vaginal delivery is a life event of enormous magnitude.
Vermelin's non-interventionist method
Expulsion then takes place through uterine contractions and maternal expulsive efforts.
The operator attends the physiological delivery as described above and plays the role of "attentive observer," ensuring that dystocia does not occur. See appendices I and II.
A hard surface is placed under the perineum to receive the fetus.
The practitioner can pull down a loop of cord as soon as the abdomen has emerged and perform a Bracht maneuver to assist the expulsion of the fetal head, preceded or not by a Lovset maneuver (Lansac 2006). (p. 13-14)
France takes part in the approach of not using any systematic prophylactic maneuvers but instead resorts to them in cases of dystocia (DuBois 1990). For Bracht in 1938, "the number and the precocity of interventions" during the birth of the breech was the cause of the high fetal mortality rate; he therefore advocated abstention from maneuvers and promoted spontaneous emergence of the fetus for as long as possible. In 1948, continuing Bracht's advocacy, professors Vermelin and Ribon of Nancy also advocated spontaneous breech birth, showing that childbirth can take place entirely spontaneously; the hands-off "Vermelin method" was fairly widely adopted. (p. 17)
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| Appendix I: Spontaneous birth of the frank breech. |
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| Appendix II: Spontaneous birth of the nonfrank breech |
At the beginning of the 20th century, most authors considered the breech presentation to necessitate obstetric intervention: prophylactic lowering of the foot, full extraction or release of the arms as promoted by Lovset in 1937. In 1938, Bracht reacted to this attitude and advocated abstention until expulsion. He then presented his maneuver for freeing the head, which we shall discuss later.Moncollin notes that French obstetricians today are not as hands-off as Vermelin advocated for; they generally assist with the birth of the arms and the head:
In 1948, the authors Vermelin and Ribon of Nancy defended an even more absolute abstention from obstetrical maneuvers. For Professor Vermelin it was important not to see pathology where it did not exist. While breech delivery was considered abnormal, even obstructed, at the time, Professor Vermelin wanted to show that a breech delivery could unfold in its entirety without intervening at all. He demonstrated that Mauriceau's maneuver, apparently innocuous, could be the starting point of cerebro-meningeal lesions, neonatal death factors, or psychomotor sequelae, and that it was better to do without the maneuvers. Thus Vermelin's technique of spontaneous delivery of the breech remains a classic for obstetricians of the Ecole de Nancy (see Vermelin 1956). (p. 28)
We have seen that the School of Nancy was marked by the Vermelin technique for the birth of the breech (he was a professor at the Maternité de Nancy from 1943 to 1961), but what about 50 years later? (p. 67)
The birth of the breech according to Vermelin (1948) consisted of complete abstention from maneuvers. Thus, no maneuvers were practiced. However, to prevent asphyxia in the fetus, it is now advisable to finish the delivery, when the point of the shoulder blades appears in the vulva, by releasing the arms that are in the vagina and then the head. The Lovset (1937) maneuver will facilitate the expulsion of the shoulders, then the Bracht (1938) or Mauriceau (1668) maneuvers will free the fetal head. (p. 53)She also makes this comment about breech birth at home:
Home birth:
Do not touch the breech presentation if obstetric maneuvers are not perfectly known. In this case, it is advisable to adopt the Vermelin maneuver. (p. 66)
