Following a recent post, where a student mentioned that she had to "birth a breech" during her Viva, I thought it would be good to start a discussion on the way we are taught this technique.

During my training I was taught the necessary manoeuvres to deliver a breech baby vaginally, with the woman on her back and in lethotomy. Since qualifying this is a skill that I have revisted every year during the "Skills Drills" days that I attend.

We are taught "hands off the breech"! - This is because handling the baby before the head is born could cause the baby to take a gasp, before the head is born. The manoeuvres we are shown are anything but "hands off"! See this page.

Why are we shown these techniques and required to show our competance at using them? It wis because the women we see in hospitals are required to be flat on thier backs. Of course the breech baby will need assistance to be born, with the woman in this position! Why can't we be taught an alternative?

As far as I can tell a true "hands off" delivery can only be achieved when the woman is on all-fours, or in an upright position. There is a great photo of a vaginal breech delivery here. In this position the baby's body is suspended very naturally and, with the aid of gravity, follows the curve of the pelvis as it is born, without the need for all the complicated manoeuvres shown in the first link that I gave.

I have only ever cared for women where the breech baby is born with the mother in the lethotomy position. It would be great to hear from any midwives who have experience with vaginal breech births.

Breech Birth, by Benna Waites is a really good read on this topic.

Enough from me. What do you think.....???

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When I started on delivery suite, I asked my mentor why almost every breech presenting baby was born by caesarean section now rather than vaginally.

She said it came from a study that was done some years ago that said it was safer to deliver baby's that way, and that this study (or research?) was flawed. But as a result of this, most midwives have lost the skills to deliver a breech vaginally, I think that is very sad.

Sorry a bit of topic.

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Student Midwife 2007

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No, I don't think that is off-topic. I think it's very relevant.

Yes, we are losing the skills. The study was the "Hannah trial" and showed that breech babies born vaginally had a higher chance of brain damage etc. But, the study did not take into account the experience of those conducting the delivery and there were a number of other flaws in the trial. The suggestion is that, where staff are confident these babies are at no greater risk. However, many consultants choose not to look at all the facts and simply say that "vaginal breech is not safe".

So, the fewer vaginal breeches there are, the fewer doctors there are that have the experience and the confidence.

It's a sad spiral to be in.

Here's a link to read more about the Hannah Trial.

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I agree it is very sad, especially when it is possible to deliver a breech baby normally with the right skills and experience.

Do you think things will ever change to facilitate normal breech births?

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Student Midwife 2007

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Educational Resources Manager

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If those that are confident are able to speak up and share their practice in a forum where they will be heard, then may be. I think independent midwives have a role to play here. And hospitals like Shrewsbury, who (from what I have heard) are willing and confident to deliver baby's breech vaginally.

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It doesn't sound very hopeful then of becoming accepted practice everywhere which is sad.

In our assessment of practice book it staes that we will be very unlikely to witness a vaginal breech, and so our training will be 'simulated'

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Student Midwife 2007

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Educational Resources Manager

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We discussed these problems in our lecture on monday, the continuing lack of skills by midwives for vaginal breech and twin births also. Our scenario was a woman requesting a twin home birth and we had to discudss what we would do.

We then went off topic slightly by mentioning how rare breech is vaginally these days.

I remember vividly being on the albour ward a few months ago and seeing a woman rushed to theatre.. I said 'what's going on?' (thinking it was really bad) turns out it was an undiagnosed breech and the lady was pushing...

There appears to be very few midwives in the hospital who have ever delivered a breech baby, how sad.

My second mentor on community delivered a breech baby at home, she performed a VE to confim full dilatation as she had some idea that something 'wasn't quite right' she got a surprise and a finger of Meconium and calmly told the woman...she delivered a baby boy thirty minutes later, no problems

Thankyou for the links, I will have a read, it is another thing I know little about as yet, but know vaginal breeches do not happen in our trust and are instant C/S

Thanks, Shoshana!

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Breech births are not unheard of where I work. We have one consultant, who is competant with ECV (external cephalic version). She is happy for multips with a breech presentation to deliver vaginally.

We also had a woman recently who refused an elective section for breech. She went on to have a vaginal breech delivery with no problems. She was a primip.

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Yes and it never gets mentioned does it? We also had an undiagnosed at home recently and the midwife was scared she would be pulled up for not realising, and for letting it continue when she did (when the woman was pushing) how sad is that, she wasn't bothered about the delivery just the backlash!!!

We also have been taught "hands off the breech" to let the baby literally hang, unless the legs do not deliver, then use popliteal pressure (back of the knee) then the leg should just deliver. We are taught to check the appearance of the cord, and to gently drape a warm towel across the baby, ensuring it doesn't get cold. If the shoulders don't deliver, we are told to keep the back uppermost and rotate holding the hips, then back the other way, if that fails then anti-cubital fossa pressure (inside elbow) and bring the arm down (across the babes face) then when both are delivered let the baby hang, for flexion of the head, then the Mauriceau Smellie Veet manoevre, left index and ring fingers on the shoulder blades middle finger puts slight pressure on the occiput (back of head), whilst the right hand (right index and ring finger) on the cheekbones and middle finger on the chin in unison, to aid delivery of the head! Phew and thats what we do year in year out in mandatory training, I've recently done the PROMPT course and we did it the same way on that too xx

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I think it's great Shoshana that you have vaginal breech deliveries in your trust, and you get taught it Tracy too. I don't know if we get taught how to, one hopes we will in year 3, but will we ever get to see it, let alone do it?

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