MoonDragon's Pregnancy Information
THE BREECH DELIVERY AT HOME
(A Midwife's Tutorial)
Labor in a position that will help to keep her from feeling pushing urges before she is completely dilated. The knee chest position also helps to lower cord prolapse risks and baby's legs from dangling from the birth canal with a footling presentation before she is ready to deliver. This is especially important if her water has broken and the risk of cord prolase is greatest. The best advice is to keep hands off and try not to intervene. Take FHTs frequently and monitor labor carefully.
When the woman has reached complete dilation without any remaining cervix being felt and is ready to deliver:
1. Have the mother in a semi-reclining position, legs as well as back and head well supported. The side of the bed is the best position as it affords ample room in which to work and allows for easily bringing the mother's buttocks to the edge of the bed to let gravity assist in the delivery of the body. Assistants can hold her legs for her or chairs can be used to put her feet on. The angle being safest for the baby. (Another optional position sometimes used is on hands and knees.)
2. As much as possible, the delivery needs to occur by the spontaneous expulsive efforts of the mother. In general, a "hands off" attitude on the part of the birth attendant yields the best results. Do not apply traction as this may cause the fetal head to become hyperextended or the fetal arms to disengage making it more difficult to deliver.
3. Do not stretch or work the vagina. Leave everything alone to allow for further dilation of the cervix. Do not encourage the mother to push, but do not prevent the natural physiologic pushing which she will do at this time. She must reserve energy for the continuous pushing which will soon be necessary.
4. Keep your hands off of the baby until you can "hang your hat on the butt", i.e., the baby is born to the navel. Once the presenting part emerges to this point, mother should push CONTINUOUSLY, with or without contractions, until the baby is born completely.
5. Never pull on the baby or try to free the legs until the body is born to the navel.
6. Once the navel has appeared, pull down a loop of cord so there will be no strain on the baby's navel. Gently touch (do not pinch) to assess cord pulse.
7. At this point the baby must be born quickly. STAY CALM! It is possible for the baby to suffocate if not born within 5 minutes. Note: Time seems to stand still when we are under stress. Have an assistant keep track of time. What will seem like twenty minutes to you will have probably have been two!
8. It the legs are still trapped (frank and complete breech), perform a Pinard maneuver. A Pinard maneuver is the sweeping external rotation of each thigh combined with rotating the pelvis in the opposite direction resulting in the flexion of the knee and the delivery of each leg. Bring both legs down and out, one at a time. Remember to go with the bend of the knee.
9. If the birth from the navel to armpit is not accomplished with the next contraction, gentle traction on the legs (do not be tempted to grasp the baby's body as kidney damage may result) may be helpful, keeping the baby's back toward the mother's stomach. The baby's back should never turn towards the mother's back. It is almost impossible to deliver a posterior breech without damage. (If you must assist the baby's rotation to anterior, do so by using both hands like splints, one on top, the other beneath, and gently turn both hands over, rotating the baby's body as you do so.
10. Now bring the mother's buttocks over the edge of the bed, keeping her legs supported by assistants. The baby's body will drop down, easily exposing the nape of the neck and usually both arms will come down as well. Keeping one hand on the mother's perineum, grasp the baby's feet with he other hand and swing the body up and over onto the mother's abdomen. A towel or receiving blanket around the fetal pelvis will help in holding on to slippery body. Do not grasp around the abdomen to prevent squeezing the adrenals. Only handle the bony pelvis.
11. Sometimes the mother with her expulsive efforts will help move the baby on its own pass the delivery of the arms stage. Occasionally, the baby's arms will have been swept over its head. Progress ceases if the arms do not come down as the body emerges, then you must go up and bring them down one at a time. It the arms are reluctant to deliver, try rotating the fetus 180 degrees to bring the baby's arm in front of its face, then with your forefingers the arm may be swept down, across the face, to free it. Another method is to go up past the head along the top of the shoulder, hooking finger in the inside of the elbow and pulling it down. If the arms are behind the head, the child can be rotated toward the pelvis to disengage it. The actions can be repeated, if necessary on the opposite side to free the other arm. The baby will not be born if held back by the arms and shoulders.
12. Delivery of the head is the next step and once again we have to avoid the urge to apply traction. Keeping the head and neck in a flexed position reduces perinatal morbidity. Have your assistant ready to apply supra-pubic pressure. The baby is turned to face the floor. Once the hairline is noticed, the operator's hand should cover the vulva while the other hand is placed belowe to receive the fetal face. Some recommend having the fetus rest on the forearm and the index and middle fingers apply pressure to the maxillary prominences (do not pull on the maxilla as it may cause TMJ dislocation). As soon as the mouth and nose appear, suction the baby's mouth and nose. If necessary, pull the perineum down to establish an airway. Maintain perineal support and allow the rest of the head to be born slowly. IF THE BABY IS BREATHING, YOU HAVE TIME TO GET THE REST OF THE HEAD OUT. At this point the baby can be pulled up and out over the maternal abdomen. It is important to avoid an angle greater than 45 degrees above the horizontal to avoid hyperextension of the cervical spine.
13. Head entrapment can be a serious complication of breech delivery. If the baby's head is not readily born, have an assistant apply supra-pubic pressure, cut an episiotomy, and complete the delivery. (To avoid an episiotomy, the Ritgen Maneuver may be used... this is done by placing a finger deeply into the mother's rectum and pushing the baby's head forward and out.)
WISE WOMAN'S WORDS OF WISDOM
Never exert force by pulling on the baby's body while the head is still inside the mother. To do so will cause irreparable damage to the baby's spinal cord, nervous system and breathing mechanism. When an airway has been established and the baby is breathing, he is in no danger and further assistance may be summoned.
REMEMBER, DAMAGE IS MORE OFTEN DONE BY SOMEONE EXERTING TOO MUCH FORCE THAN BY THE BABY BEING STUCK.
After the baby is born, have the mom give him a good rubbing, wrap him in a warm towel and keep a close eye on him. Please do NOT hurry him! He has not had the massage that the vertex baby has had during labor and usually needs almost a full minute to get going. With this in mind, scoring the APGAR at two minutes should be done as well as at one and five. If he has lain within his mother with his feet up over his head, he will most likely lay the same way now, and look like a little frog! Sometimes, baby boys present scrotum first and they will be very swollen and purple. Reassure the father that the bruising is temporary.
The advocating of the squatting position should NOT be done in a breech delivery for four very important reasons:
1. You do not want the birth to happen quickly. Head decompression can lead to subdural hemorrhage.The breech delivery should not be steeped in mystery or be a terrifying event, but a very special event which deserves both respectful and intelligent consideration in order that a happy outcome may be achieved for both mother and baby.
2. Squatting lends itself to the baby's arms being swept up over the baby's head, further complicating the delivery, and possibly causing Erb's Palsy during the extraction of the arms.
3. The baby's body hangs straight down, causing an almost military emergence of the head, exerting undo pressure on the base of the baby's neck, and increasing the risk of spinal cord damage.
4. The mother's perineum will tear at a much higher rate.
BREECH BIRTH LINKS
MoonDragon's Pregnancy Information: Breech Presentation Information
MoonDragon's Pregnancy Information: Breech Turning Ideas
MoonDragon's Pregnancy Information: Performing External Cephalic Version
MoonDragon's Pregnancy Information: Breech Labor - What to Expect
MoonDragon's Pregnancy Information: Breech Labor - Esstablished Breech
MoonDragon's Pregnancy Information: Breech Labor - How the Attendant May Assist
MoonDragon's Pregnancy Information: The Breech Delivery at Home
MoonDragon's Pregnancy Information: Vaginal Breech Pictorial - Hospital with Episiotomy & Forceps
MoonDragon's Birthing Guidelines - The Unexpected Breech
Vaginal Breech Pictorial - Hospital without Pain Medication, Episiotomy & Forceps
MoonDragon's Pregnancy Information: Pregnancy Information & Survival Tips
MoonDragon's Pregnancy Index
MoonDragon's Womens Pregnancy Health Information Index
MoonDragon's Pediatric Information Index
MoonDragon's Parenting Information Index
MoonDragon's Nutrition Information Index
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