Remote Primary Health Care Manuals

Breech birth

  • Baby's bottom or foot comes out first. Many breech babies are born with little help 
  • If baby preterm — increased risk of cord prolapse or head getting stuck
  • Baby more likely to pass meconium (faeces). May be just before birth, but if earlier in labour baby ​may be distressed
  • Only do vaginal exam ​if skilled

Baby’s oxygen supply may be decreased​. Be ready to resuscitate baby

2 methods to manage breech birth

  • Normal (unassisted) breech birth — no need to touch baby, it comes by itself
  • Assisted breech birth — need to help baby to be born

Equipment

Figure 1.21   

The Sims is a roughly U spaced vaginal speculum.

Do first

  • Call for help — have midwife/doctor/obstetrician on speaker phone, if none locally
  • Find support people, if possible female ATSIHP or older women familiar with birthing
  • Reassure woman and explain what is happening, have someone stay with her for support
  • Get ready to send to hospital
  • Do 'first check in labour' — see Labour and birth

If in labour​

  • Unless birth is about to happen try to stop labour — medical consult
  • Make sure woman has emptied her bladder

If labour ​continues and birth likely

  • Put in IV cannula — largest possible, insert 2 if time
  • If waters break ​— check for cord prolapse. Cord may be seen at vulva or felt just inside vagina. More common in breech birth
  • If baby’s foot seen at vulva or felt — wait
    • Baby’s foot may have slipped through cervix that still needs to dilate
    • Baby will not be born until its bottom is at vulva — may take some time
    • Dilation may take some time — you may be asked to try to stop labour​
  • Get everything ready as you would for a normal birth

Normal (unassisted) breech birth

Next steps outline birth that progresses normally

  • Have midwife/doctor/obstetrician on speaker phone, if none locally
  • If no progress with every contraction — see assisted breech birth

Do

  • Make sure woman is in comfortable upright position (not lying down)
    • Standing with buttocks leaning against edge of bed so she can rest in between contractions and baby can hang as it slowly comes out — Figure 1.22 OR other comfortable position — Figure 1.23 for examples

Figure 1.22   

Heavily pregnant women braces herself against side of bed.

Figure 1.23   

5 upright birthing positions.

  • Gravity will help with birth. Be ready as birth can happen quickly, especially if baby preterm
    • Do not touch the baby — keep your ‘hands off the breech’
    • If progress seems slow — ask woman to change to another upright position
  • Woman should push when she wants to — unless baby distressed. If distressed — see Assisted breech birth straight away
  • Make sure baby’s back stays opposite to woman’s back
    • If you are in front of woman — you will see baby’s back
    • If you are behind woman — you will see baby’s abdomen — Figure 1.24
    • If baby starts to turn so it is facing the same way as woman — see Assisted breech birth to help turn it back

Figure 1.24   

Attendant behind standing mother sees the front of the breech birthing baby.

  • Watch for progress with each contraction ​— Figure 1.25
  • ‘Hands off’ — Figure 1.26. But be ready to catch baby — Figure 1.27
  • Rub baby dry vigorously with warm towel. Breech babies often need more stimulation — may need resuscitation

Figure 1.25   

Baby's bottom is clear of the vagina.

Figure 1.26   

Baby's legs and torso are clear, head, shoulders and arms still inside women. Attendant ready to assist but not touching baby or woman.

Figure 1.27   

As baby's head births, attendant supports baby with one hand under baby's bottom and the other across chest and under arms.

Assisted breech birth

Do not

  • Do not pull on baby — can cause head or shoulders to get stuck
  • Do not hold baby by its abdomen — hold hips (bony pelvis) by putting your thumbs on baby’s buttocks and your fingers around its thighs

Do

  • If no birth progress with each contraction ​— change woman’s position
    • On bed with head of bed elevated to keep her as upright as possible
    • Bring buttocks to edge of bed in half sitting position with someone holding legs up toward her abdomen. Support legs wide apart
    • OR If you have no help — get woman to hold her legs behind the knees, pull them back toward her chest — Figure 1.28

Figure 1.28   

Mother grips her thighs under the knees and pulls her legs up as close to her body as possible.

  • Ask woman to push with each contraction ​
  • If baby is out to its umbilicus but legs are not fully out
    • Put 1 finger into vagina, find back of baby's knee — push gently to bend knee then help the leg out
    • Repeat for other leg
  • Birth should keep progressing with each contraction ​
  • Baby might start to turn on its side when shoulders are coming out — make sure baby doesn’t turn too far

Remember when facing woman you should see baby’s back

If arms not coming and not seeing progress

  • Need to help birth by turning baby to help arms and shoulders out

Do not hold baby by its abdomen AND do not pull baby — hold hips (bony pelvis) by putting your thumbs on baby’s buttocks and your fingers around its thighs

  • Turn baby on its side with a contraction. Lower baby to let baby’s weight bring top arm out —  Figure 1.29

Figure 1.29   

Attendant grips baby's hips in both hands and turns baby onto its side, then lowers trunk to help top shoulder out.

  • If baby’s arm doesn’t come — put finger into vagina along baby’s back, over its shoulder and down chest, sweeping arm out
  • Lift baby up to let other arm come out — Figure 1.30

Figure 1.30   

Attendant grips baby's hips in both hands and lifts trunk to help bottom shoulder out.

  • If you see shoulder but arm doesn’t come — put finger into vagina along baby’s back, over its shoulder and down chest, sweeping arm out
  • Once shoulder blade is visible the shoulders should be born with next push. Usually happens without difficulty
If arms still don’t come
  • Keep holding baby by its hips. Turn baby half circle (180°) to face opposite side, lower baby to let baby's weight bring top shoulder toward front and under pubic bone — Figure 1.31
  • When turning baby
    • Keep baby’s back opposite to woman’s back at all times
    • Try to turn baby during a contraction

Figure 1.31   

Attendant grips baby's hips in both hands and turns baby clockwise bringing other shoulder to the top, then lowers trunk to release shoulder.

  • If arm doesn’t come out — put finger in vagina along baby’s back, over its shoulder and down chest, sweeping arm out
  • To get other arm out — turn baby back another half circle (180°) in opposite direction — Figure 1.32.  Put finger in vagina along baby’s back, over its shoulder and down chest, sweeping arm out

Figure 1.32   

Attendant grips baby's hips in both hands and turns baby anticlockwise, so remaining shoulder is at the top.

Figure 1.33   

Attendant grips baby's hips in both hands and turns baby so it is facing mothers back then lets baby go.

To deliver head
  • Let baby hang and birth slowly until you can see nape (back) of baby’s neck — Figure 1.34
  • Ask woman to pant — not push. Let head come out slowly

Figure 1.34   

Baby hangs unassisted from mother's vagina, the weight of the baby's body assists birth.

If head doesn’t come out easily
  • Let baby rest on your forearm
  • Put your index and middle fingers on baby’s cheek bones or in baby’s mouth — Figure 1.35
  • Helper pushes down with suprapubic pressure (closed fist just above pubic bone) — Figure 1.35 — helps to keep baby’s head flexed
  • Put other hand across baby’s shoulders and push middle finger against back of occiput (baby’s skull) — Figure 1.35

Figure 1.35   

Baby's head is flexed by one attendant pulling on chin with lower hand and pushing on occiput with upper hand, second attendant applying external pressure to top of head.

Figure 1.36   

Attendant holds front and back of baby, lifting body up and away as head is born.

  • Push back of head forward and pull finger in mouth down and backward while helper pushes from above — do not twist baby
  • Ask woman to pant and let head come out slowly
  • Chin and mouth come out first, head will follow. As head is born through this flexing motion — lift (not pull) baby upward and let baby’s head come out slowly — Figure 1.36

If head still won't come

Sometimes during delivery of preterm breech baby the head may become trapped by undilated cervix. Don't panic — do not pull on baby and get help urgently

  • Lay mother down. Hold baby by legs and lift body up
  • Pass Sims' speculum (or bottom of bivalve speculum) along back wall of vagina, past baby’s mouth and nose — leave it there
  • Suction out secretions in vagina, around baby’s mouth and nose
  • Baby now has clear passage of air if it starts to breathe
  • Place oxygen tubing along Sims’ speculum, give oxygen at 2L/min
  • Midwife/doctor/obstetrician consult straight away
  • Stay calm and talk woman through what you are doing

After baby born

  • See Labour and Birth after the birth and follow the rest of the steps for care of mother and baby

Follow-up

  • Talk with mother and others at the birth and explain what you were doing
  • Talk with doctor and midwife about follow-up for mother and baby
  • All breech babies need to be seen by paediatrician to check hips ​and for congenital anomalies ​that may have caused breech position