Active birth is taken as a given during birth at home. Women rarely choose to birth on a bed; rather they walk, crouch, rest on hands and knees, and sway and rock their babies out. This need to move in labour is as much a way of helping the baby to negotiate his way out as it is for his mother to work with the pain or energy of labour. I have long since been convinced that bed-birthing debilitates the baby (not to mention the woman), especially if he is sedated and has less tone due to the narcotics and epidural anaesthesia that his mother has been given. Seeing the way some breech-presenting babies pedal, lurch, shrug and squirm their way out during physiological breech birth, I am equally convinced of the importance of avoiding bed-birth so the energy breech babies can have mustered for birth can be utilised. Occasional articles (Banks 2007; Berkley & Evans, 2006; Reed, 1999; Cronk 1998) but few texts (Frye 2004; Cronk & Flint 1989; Banks 1998) demonstrate or address active breech birth. Similarly lacking are descriptions of how to resolve problems with a woman in active birth positions during physiological breech birth. A ‘stuck’ baby during vaginal breech birth is rare – one estimate being an incidence of 1 in 500 (Menticoglou 2006); another reported as a nil incidence (pers. comm, S Albrechtsen, 22 March 2006) in a large hospital which, because of its support for vaginal breech birth and women choosing to birth there, expects one vaginal breech birth every other day (Albrechtsen 2006). Despite this rare occurrence midwives (and others) often verbalise “what if he is posterior?” and “what if the breech baby gets stuck?” These are worthy questions to voice and consider as the caregiver who supports vaginal breech birth needs to have strategies to remedy these rare but serious potential problems. It can be anticipated that women will be in obstetric hospitals for breech birth, except for the out-of-hospital experience that remains undiagnosed until the baby is on the perineum or, for whatever reason, the woman does not consent to birthing in hospital. It may also be that the midwife will remain the principle caregiver to facilitate physiological breech birth in hospital, not just simply as the woman’s choice, but because there is anecdotal evidence that the midwife has been the caregiver with most expertise in vaginal breech birth in obstetric hospital settings. Thus resolving problems during breech birth sits with midwives as well as obstetricians. This article discusses posterior breech and puts forward some thoughts about remedying the (very) rare problem of a deflexed head during birth with a posterior breech presentation. It should be noted that the strategies proposed are not intended to be ‘the definitive way’ to resolve a deflexed posterior breech. Having never experienced such a problem, my workings are purely theoretical. Rather, they are offered for analysis, critique and discussion – the thoughtful exchange process.
Is posterior breech a problem in itself?
Midwifery and obstetric texts alike stress the importance of keeping the baby’s back anterior following rumping (birth of the hips). The breech baby in a posterior position has at least two opportunities to turn anteriorly. This first turn of the baby’s backline from a posterior position can be visualized by examining Figure 1. The posterior position of the sacrum can be identified with this footling breech as his toes point forward towards the mother’s abdomen; his back lies against his mother’s spine. As his hips and, therefore, the bitrochanteric diameter rotate internally from a posterior to an anteriorposterior position, his feet will turn to point to his mother’s inner thigh, as in Figure 2.
This internal rotation enables his hips to negotiate under the public arch and, with a baby with extended legs (Figure 3), will result in the anterior buttock being seen first followed by the posterior buttock sweeping over his mother’s perineum.
Once both buttocks have come under the pubic arch (pelvic outlet) he will have rumped and may rotate so his back is anteriorly, rather than posteriorly, positioned (Banks 1998: 13-14). Some babies will not turn anterior until a second opportunity arises. Internal rotation of his shoulders to the oblique and then anteriorposterior orientation is repeated, this time as his shoulders first enter the pelvic inlet and then come under the pubic arch. As unusual as posterior breech is, discussion with midwives indicates that, with the few incidences that do occur, it is usually the second opportunity that a baby will take to turn anteriorly so his back lies in line with his mother’s abdomen. Should a posterior position persist following birth of the shoulders, as long as the baby’s head is well flexed and there are no contraindications as for normal breech birth (Banks 1998: 13-14), the baby’s descent continues by both gravity and maternal effort, and can be assisted by positioning. For example, the woman on her hands and knees, standing and leaning forward onto a support person, a table or the back of a couch will all help maintain flexion of the baby’s head. Once the root of the nasal bone is under the pubic arch, the glabella (the flat area between the root of the nose and the upper eye socket) pivots under the pubic arch, which acts as the fulcrum. The occiput and crown sweep over the perineum with the forehead appearing last.
In terms of the direction that the baby moves through the pelvis, it is valuable to remember that Nature’s design of the pelvis, particularly the posterior space and the pubic arch, ensures that the internal spiraling down movements of the baby through his mother’s pelvis bring him in the direction of his mother’s waiting arms.
Irrespective of presentation, whether the woman is standing, kneeling or on hands and knees, and whether baby is anterior or posterior, it should always be remembered that his direction is forward into those waiting arms and not towards his mother’s back. This forward moving direction can be seen in Figure 4 of an anteriorly positioned, extended legs breech. In contemplating ‘simple’ (sic) posterior breech, during an email discussion, of her experience as the second midwife, American home birth midwife, Carol Gautschi noted two of her three posterior breech experiences rotated spontaneously to the anterior position following rumping (Gautschi 2008).
Posterior breech with a deflexed head
It is the deflexed head of the posterior breech baby which has the potential to halt progress. In all the stories I have taken of midwives facilitating breech birth, I have only heard of two ‘stuck’ posterior breech babies. The first was a preterm baby with his head stuck at the sacral promontory of his bed-birthing mother. Once born to the shoulders the nape of the neck was not visible. He freed himself by shrugging off the position while the midwife was trying to remedy it. The baby was born promptly in good condition from that point on. In the second instance, a second twin of an active birthing mother, may not have had flexion of his head maintained by firm abdominal muscles and a well contracted down uterus following the birth of the first baby. This second twin was a deflexed, posterior breech. This deflexion resolved when the second midwife flexed the baby’s head abdominally and tucked his chin under the pubic bone. This avoided the “tricky and dangerous manouevre” (Frye 2004:967) of the baby’s chin being used as the pivotal point on the pubic arch and saw the baby born without further delay (Gautschi 2008). This intuitive action by the midwife also appears in the obstetric literature, along with description, in a bed-birthing situation. In that case, after having tucked the baby’s chin under the pubic bone, accompanying oblique pressure was applied to roll the baby’s head into a flexed position (Tunde-Byass & Hannah 2003) (similar as getting the shoulder over the pubic bone as with shoulder dystocia). Should this not be possible, it is likely the baby has a deflexed head with the occiput held on the sacral promontory and the brow held at the pubic bone (pelvic inlet). In this case he would need to be raised slightly to dislodge him from his stuck position so his head could then be flexed. To achieve this, (along with a great deal of prayer and engagement with midwifery energy!), the woman would need to assume the most open position possible – standing with a leg cocked up on the edge of the birth pool, window sill or chair (depending on her height), and leaning into the cocked leg to give maximum leverage and openness to her pelvis. Some midwives work from behind the woman who is on her hands and knees but there would be more room to move from the front with the woman standing if there is a problem like this. Equally, there is considerable value for the midwife and the woman to be able to make eye contact so, while initially not pushing until the deflexion is corrected, the woman and midwife remain totally engaged. This engagement with the woman extends to talking to the baby as the midwife works so he also ‘knows’ what to do. Working with the baby sitting in the crook of the arm, the baby’s head is lifted up and off the sacral promontory by pushing up as high over the occiput shelf (occipital protuberance) as the roomy posterior space allows.
Simultaneously, the baby needs to be held at the front as high as possible, which may only be at the lower jaw but could be at the level of the cheek bones, with one finger over each as in Figure 5. The midwife would be working very high in the woman’s pelvis. This is achievable as my experience of resolving a severe shoulder dystocia has shown me. It is surprisingly pain free when women know what is happening and you are working together. Once off the sacral promontory, the second midwife can (lovingly but) firmly apply oblique roll over pressure abdominally to flex the baby’s head and assist it through the pelvic inlet. The baby can be pressed towards the posterior space by continuing the cradling of his head and applying pressure over his cheek bones once he is past the pelvic inlet. It would be of doubtful value to try turning the baby anteriorly as the deflection is most likely the problem, not the fact that he is posteriorly positioned. It is likely, however, that the baby who has been stuck at some point will need ongoing assistance to maintain flexion and bring his head down the birth canal until the nasal bone is under the pubic arch. It may be that he is ‘seesaw-ed’ back and forth and down in small increments of progress in a manner similar in the way it can be necessary with a shoulder dystocia before one can reach the posterior arm. Continuing to cradle his head over the cheek bones and over the occiput, and draped over the midwife’s arm, he can be securely held until he is born and, as with any birth, placed in his mother’s arms for assessment of his wellbeing.
In the absence of neck or uterine tumors or webbing of the baby’s neck, it is most likely that an extended head has been created by manipulation or extraction of the baby, remembering that the baby’s hands up by his cheeks are important in keeping the head well flexed. The caregiver should therefore resist the temptation to bring down the baby’s arms in the absence of a specific need to do so. It should also be remembered that any vigorous handling such as, bringing down arms, may well activate the startle reflex and cause a deflexed head. In remedying a deflexed posterior breech, the with-woman space the midwife occupies is imperative to maintain. It is this cohesive working together – woman, baby and midwife which minimises (everyone’s) anxiety and uses the emotional and spiritual energy integral to midwifery practice, even when faced with such challenges. This space also utilises the innate actions that a woman can take which may lessen or remedy the problem in the first place, such as ‘sucking up’ her baby with her perineal and abdominal muscles. As with any birthing, episiotomy should be avoided to ensure the perineal floor remains responsive to the birth energy which can bring on such occurrences. Active birth ensures that intuitive movements by the woman (and baby), and intuitive actions by the midwife are not hampered by the static positioning of bed-birth and, therefore, can circumvent potential problems. Rather than being promoted as a value-free choice when birthing, active birth needs to be recognised as an important safety strategy for avoiding pelvic entrapment and bed dystocia. It is also a valuable strategy for resolving problems, if, and when, they arise.
(Figures 3-5 supplied by author. Thanks to Jenny Johnston of Te Puru for Figures 1&2, and to the women for allowing use of their personal photographs.)
First published in Birthspirit Midwifery Journal 2009; 2: 61-64.