Sunday, March 6, 2016

Waterbirth and Breeches

I've been talking about maternal positions in general and the previous blog post gives you basic knowledge. This post talks about water birth and breech.

For the safe breech water birth you need to have uterine moment and an open pelvis.
Cornelia Enning, German Midwife, solved that by having the mother standing in a rain barrel. Literally a rain barrel. That is quite different than a typical water birth tub.


When a woman gives birth in a regular birth tub she is:
  • Less likely to rock fully back and forth bringing the baby's arms through the curve of carus, the curve of the pelvis
  • Unable to put her chest to the floor which opens the brim when women are on their knees
  • Less likely to raise their buttocks to protect their baby from taking a breath of air only to be dipped back under water


This picture of a recent breech birth "in air" shows the baby in the ideal direction for the arms to be born. The baby's spine is towards the mother's front. The mother's kneeling position encourages this position. Her rocking encourages muscle relaxation and the little movement helps baby descend.
This baby's right elbow has just been born. Baby's toes are curled showing good tone. The cord is actively circulating blood and the baby is an active particpant in bringing the arms and head out.
Muscle movements in the baby's abdomen (seen more easily with mother on her knees) show the baby flexing to bring down the larger parts of her own body.





This baby has floated into the oblique diameter after the birth of the arms. Is the head oblique, too? The mother is curled over her knees, shutting her pelvis down a little bit. This baby required help to get the head out. See the mother's deep crease compared to the above picture of the full perineum? 
This is a clue that the head is not flexed. The lack of maternal movement in the tub or length of descent in any breech birth - even before the umbilical cord is seen - can reduce oxygen when the placenta may begin to separate. Don't wait when you see a deep crease. Go get your baby. 


Open the diameters of the inlet by putting chest to floor... oh, oops, you can't dunk the mother to do this. So she can open her pelvis by: 

  • Raising her bottom by pushing up on the top of her feet - starting to straighten her legs
  • Anterior pelvic tilt (increase the curve shape of the lower back by pushing the buttocks out)
  • Standing and anterior pelvic tilt 

  • Get out of the tub (Seems dangerous to baby's neck! Seek chiropractor for atlas adjustment.)
  • Kneel on the floor and put chest on the floor


and in both cases Midwife does one of the following to flex the head: 
  • Frank's nudge (touch subclavical nerve under the collar bone, between shoulder and ribs in the dip. This is the 2009 version as explained by Adrienne Caldwell in 2012. I like this version because it uses physiology rather than force.)
  • Mariceau-Smellie (pronounced Smiley)-Cronk (not Veit, in all-fours position)
  • Lift the baby's chest to the perineum (towards baby's chin) and then slide baby forward to mom's belly
  • Finger forceps the perietal bones to tuck the chin. Do this by rotating the top of the head with your finger tips on either (or one) side. This is like making baby nod "yes" and the chin will tuck.


Then the midwife can use fundal pressure to bring baby out if the mother can't push the baby out. 
Remember the head is in the vagina and not every uterus will push out the baby's head by the time involution is well under way, though of course, by far, most will. When you need baby out to help start breathing and heart beating, you can do Kristeller's maneuver which is simply push down on the TOP of the uterus. This is not suprapubic pressure as in shoulder dystocia. You get on the top of the uterus and give a tap or a mighty push, depending on which is necessary. How hard you press depends on whether the pelvic floor is that of your average pelvic floor or of an athlete. 


Baby's head must be flexed and facing mom's anus, not her hip, to fit out the bottom pelvic level. 


Breech birth is a clever adaptation of the baby when the baby doesn't have room to be head down in the pelvis. Balance the ligaments, fascia and muscles to allow baby head down. Some breechings stay breech because of uterine shape (bicornate or other shape), anterior placenta, low thyroid function, or physical anomaly. I believe it is more often a twist in the pelvis, sacrum, or cervical ligament causing the breech position. A second twin or a triplet may just be matching available space and can flip head down once their sibling is born or with a little help from maternal positioning with gravity or the provider's skill, if necessary.

Because I mention some things about breech here, doesn't mean this is the whole story of all you need to know to help a breech or that I am not mindful of the skills needed. I simply want to address one issue of the breech and water birth in the "horizontal" birth tub. 

We can't compare Cornelia Enning's breech water birth outcomes with other tubs. Mothers stand up in her "vertical" tub and she has them put one foot on a stool. She gets into the tub if the baby needs help (Midwifery Today, Oct. 2013; Sao Paulo, Brazil SiaParto, June 2015; Midwifery Today, Bad Wildbad, Germany, Oct. 2015) Her pool water is typically cooler than American custom, as well.
My supposition is that standing with a foot on a stool opens the pelvic diameters while allowing mother to move instinctively. Babies might still get stuck, but not because of the mother kneeling over her knees.
Now the midwife can touch the self-progressing breechling.
Mom has lowered her shoulders to the bed and opened her pelvic diameters to release her baby.
Photo by Indigo Birth Photographer, Allie Parfenov.

In a horizontal tub, sitting upright on a stool may be better for birthing a breech. But the two times I've helped in that position the babies needed help, one for an arm and one because the placenta separated before the birth was complete. But in hands and knees water birth I've found issues due to maternal position. 

Now midwives will say, "But, I've seen breech babies shoot out in the water." Yep, so it isn't all breeches. It's simply too many to ignore. A surprise breech will come fast most of the time without getting caught. That is one reason there wasn't time to transfer to the hospital or even discover baby was breech. Planning a breech birth puts the matter in to another category. 

Learn the diameters of the pelvis so you know what maternal movements open which part of the pelvis. You can then suggest a subtle move that can save a life. You can also know how to rotate baby to free the stuck body part (arms or head in the breech) and figure out what to do more easily if the
baby is stuck in a way that is not in the books. That happens when baby is stuck inside the symphysis pubis, for instance, and baby can be lifted and rotated or the arm brought back into the pelvis.

Ok, I've exhausted this post. Learn more about breech at the Spinning Babies 2016 World Confluence, Sept. 23rd on the Interest Track day's breech session. Dr. Anke Reitter and Midwife Jane Evans will be sharing the skills they've spent their lifetimes perfecting. 









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