Monday, August 3, 2009

Can this cause a breech position?

"Hi Gail,

"I wanted to run something by you... We had a client a couple weeks ago with a somewhat irregular but progressive labor pattern, and we used the rebozo to do a little sifting, plus some abdominal lifting (which seemed to regulate and intensify ctx). After several hours things picked up rapidly, her water broke, and we went to the hospital. Upon arrival she was 7cm, baby's shoulder was presenting and by birth (by c/s) he was full breech. The CNMs were stunned, as they'd thought baby was vertex for months. [My doula partner's] question to me was, "did we cause this with the rebozo??" I couldn't imagine how, but she spoke with another homebirth midwife who said indeed it was possible. Thoughts??"


Dear [Doula],
Is it possible the sifting caused the baby to go breech or the abdominal lifting? I would think not. But let's analyze this in detail. Lets examine the possibilities.

Sifting with the Rebozo will relax the broad ligament of the uterus. A relaxed broad ligament will not cause a breech presentation. Sifting is done with the mother either on her back or, more comfortably, on her hands and knees. Neither posture is likely to cause a baby to flip to a breech position. I doubt that sifting was the cause of the breech presentation.

If one of these techniques caused the breech, I would suspect that doing the abdominal lifting too much might be a possible cause, but not the sifting. The reason to do an abdominal lift is to relieve distracting back pain or reposition a stuck posterior head. A fetal head in the posterior position is also often deflexed, the chin is up.
Abdominal lifting will lift the baby's head and reangle it, ideally to fit the pelvis better. Abdominal lifting helps tuck the posterior baby's chin towards the baby's chest, making rotation and/or descent easier to accomplish.

It is incorrect to lift the baby aggressively, or too high out of the pelvis in some cases. Its incorrect to use an abdominal lift without the need for one. A fast, progressing labor would not indicate an abdominal lift, even with incoordinate contractions.

Done incorrectly, the abdominal lift can bring up the head and, if the pelvic alignment were to be off or the pelvic floor asymmetrical there could be a possibility that the baby might flip in response.

Now I would like to examine signs that the baby may flip on its own in response to labor.

Was this baby posterior before flipping breech? If so, labor may have been the cause of the flip, or labor with abdominal lifting.
Incoordinate contractions indicate an asymmetry in how the baby is presenting in the pelvis. Likely the fetal position is dependent on a preexisting asymmetry in the Asymmetry in the pelvis is associated with a higher rate of malpositions, in my experience. Carol Phillips, DC, explains how the misalignment of the bony pelvis pulls the soft tissues out of alignment, including the pelvic floor. The baby is forced to accommodate as best he or she can. Sometimes, rarely, this includes flipping to a breech presentation. It usually means, a posterior or asynclitic presentation.

While rare that a baby would flip in labor, this has been a summer of breech babies, and some babies do flip in labor.

In other words, doing nothing may also have seen a flip because the downward movement of the baby's head may have brought the head into contact with a type of restriction that can cause a breech presentation.

...This is a very important consideration. Unless we start sharing these experiences we won't know if the techniques themselves can cause a malposition. I don't think so at this point, but without dialogue, we'll never know.


In the mystery,
Gail



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