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   

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   

Figure 1.23   
  • 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   
  • 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   

Figure 1.26   

Figure 1.27   

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   
  • 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   
  • 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   
  • 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   
  • 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   

Figure 1.33   
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   
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   

Figure 1.36   
  • 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