Hands Off the Breech

For good reason, experienced midwives and obstetricians emphasize a hands-off approach during breech delivery. “Sit on your hands, if necessary”.1 Midwife Carolyn Flint has described her approach to second stage breech as: “My bottom line is to try to never do anything”1 Most experienced midwives and doctors agree that one must encourage the mother to push, keep your hands off. Encourage nurses not to touch it .2 The temptation to pull on the baby is common but potentially lethal for the baby. Damage to the baby, when anxiety provokes the attendant to pull includes: damage to the brachial plexus caused by twisting the baby’s neck and causing an Erb’s palsy, ruptured liver from an attendant grasping the baby’s abdomen, damage to a baby’s adrenal glands caused by grasping the baby at the level of its kidneys, or crushing the spinal cord or fracturing a baby’s neck by bending the body backward over the symphysis pubis while delivering the head.

But, this is all preventable. Pulling on a breech baby during delivery increases the risk of deflexion of the fetal head and extension of the fetal arms which greatly increases difficulty of the delivery and risks of fetal trauma. Caroline Flint, following her review of the literature on vaginal breech trauma: “. . . according to most of the literature, the greatest danger to the baby seems to be caused by the person delivering the baby being over anxious and too rough in their delivery techniques .3 Jane Evans, however, emphasizes that “it’s no good saying ‘hands off the breech’ until the baby dies. You have to know the mechanisms for helping the baby in the very rare event of a problem.4

According to Dr. David Hayes, “If you don’t know what you are doing, don’t do anything5.The hardest part of attending a vaginal breech birth is not learning the maneuvers or the mechanics. It is the art of doing nothing and sitting on one’s hands, when appropriate. . . .It is not routinely interventive, nor is it simply watching and waiting in all cases. It is a wise, watchful, thoughtful approach to breech birth. It respects the normal physiological processes and also accepts that the intervention can be necessarily life-saving when applied appropriately.6

Head Entrapment

It is worth noting that there are three factors potentially responsible for difficulty in the birth of an aftercoming head. This is a universally anxiety provoking complication that consumes the minds of those who are apprehensive regarding this complication. The three factors considered responsible are: 1) head entrapment due to an incompletely dilated cervix, 2) hyperextension of the fetal head, 3) unrecognized disproportion between the size of the fetal head and the dimensions of the fetal head in relation to the maternal pelvis.7

Hyper-extension is an indication for cesarean section and should be discovered on ultrasound before a labor has started.8 However, the baby’s head becoming extended during delivery is rare and avoidable.9 It is most likely to occur if the baby’s body is pulled down, rather than allowing the baby’s body being left to descend on its own. Scorza suggests that moderate suprapubic pressure can be applied in order to keep the baby’s head flexed, if necessary.10

Bedside Resuscitation With Intact Umbilical Cord

Dr. Michael L. Hall, M.D. states that one of the key components in a safe delivery, especially in primigravid patients with breech deliveries, is a competent bedside resuscitation of the baby. Breech babies are often floppy at birth due to blood in the umbilical cord being compressed back up to the placenta during delivery. Bedside resuscitation is favorable because the physiologic process in delayed cord clamping allows an auto-transfusion of the neonate’s own blood, which is readily available. The process may take as long as the next contraction which forces the blood from the placenta to the baby. “ It is remarkable to witness if one is patient enough to wait.”11

At the bedside, Dr. Hall positions the baby lower than the mother to allow blood to flow from the placenta to the baby. During this time, the pharynx and nose are gently suctioned to remove large mucus obstructions while not so vigorous to vagal the baby. The baby is then gently dried and stimulated. A physiologic build-up of CO2 during this time will cause the baby to gasp and then cry. Once the baby cries O2 and CO2 will equilibrate and baby can be passed to the mother (with the cord still intact).12

Dr. Hall notes that this resuscitation technique may result in lower cord gas readings, initially, but that the baby does better. He also notes that there is a limit for this time frame, however studying this is impossible for ethical reasons. In his experience, Dr. Hall has seen babies take 3-4 minutes to take their first breath and experienced neonatal nurse practitioners need to assess what their comfort level is in regard to attending these types of delivery. The best resuscitation is conducted with expert and experienced NNPs at the bedside who will tolerate the physiological delay often encountered with breech babies. A calm and patient approach is essential.13

Finally, it is common for breech babies to be slower to breathe immediately after birth, though many may breathe without help and have high Apgar scores.14 It is important for staff and parents to be prepared for this eventuality, to avoid unnecessary concern.15

1. Breech Birth by Benna Waites. First published in Britain in 2003 by FREE ASSOCIATION BOOKS. www.fabooks.com. Page 129.

2. Breech Birth; Savage, Wendy (2000) Personal Communication pg. 129.

3. Flint, C. (1989) Babies Presenting By Breech. Obstetric and Gynecological Product News (Summer): 21-3

4. Evans, Jane (2001) Personal Communication

5. Flint, C. (1989) Babies Presenting By Breech. Obstetric and Gynecological Product News (Summer): 21-3

6. A Guide To Physiological Breech Birth. By Rixa Freeze, PhD, David Hayes, MD, Kristine Lauria, CPM: BREECH WITHOUT BORDERS; Breech Training, education, and Advocacy: pg 197.

7. Breech Birth. Scorza, W.E. (1996) Intrapartum Management of Breech Presentation. Clinics In Perinatology 23(1): 31-49

8. Breech Birth pg. 141

9. Ibid.

10.Ibid.

11. A Guide To Physiological Breech Birth. (Birth Without Borders) Dr. Michael L. Hall pg 111. Flint, C. Babies Presenting by Breech.

12. Ibid.

13. Ibid. pg 110-111

14. Keep your hands off the breech. AIMS Journal 10(3): 6-9.

15. Breech Birth pg 144

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Midwifery and Vaginal Breech Delivery - Part II

Midwives and Vaginal Breech Delivery - Part III

Midwifery and Vaginal Breech Deliveries - Part I