|
|
In pregnancies where the baby presents by the breech it would seem that most obstetricians insist that women either labour with an epidural in situ and are delivered in stirrups by forceps, or that the women should be delivered by caesarean section. That there are good reasons for this is not disputed, the dangers of being born breech first are well documented, but not all authors agree with each other as to the specific nature or even proportion of the dangers. Kasule (1985) says `Breech presentation and delivery are associated with a high perinatal mortality and morbidity. Even when congenital malformations and intrauterine deaths are excluded, the perinatal mortality rate after breech delivery is 3 to 4 times higher than that associated with vertex delivery.' Rovinsky (1973) quoting 86,812 deliveries at the Mount Sinai Hospital, New York, between 1953 and 1970 suggests a perinatal mortality rate of 8 times higher for breech presentation at delivery than for vertex presentation. Rosen (1984) says `Inherent in the several increased risks to the breech infant when compared with the infant in the vertex position is the knowledge that breech presentations have been associated with a high incidence of low birth weight (about 20 per cent of the population) and major congenital anomalies (as high as 18 per cent).' He then goes on to list the dangers of presenting by the breech as `trauma, prolapsed umbilical cord, fetal distress and head entrapment'. As women feel hemmed in by the lack of choice and the insistence of their obstetrician that they either have a caesarean section or are delivered in lithotomy with forceps, some are turning to home birth and delivery by independent midwives. The independent midwife will invariably advise against delivery at home, and some are able to negotiate, either with their local supervisor of midwives or with a local obstetrician to deliver the woman in hospital with ready access to obstetric and paediatric help, but if the woman insists on staying at home according to the UKCC Midwife's Code of Practice `In a situation where the midwife considers that home confinement is inappropriate and the woman refuses to take the advice of the midwife to receive care in a maternity unit, the midwife must continue to give care and inform her supervisor of midwives' So the independent midwife forced into this situation has to look at the myths and practices which have grown up surrounding breech births and try to map out a course which will ensure the greatest safety for both baby and mother. She needs to be aware of the attendant dangers and has to examine the most appropriate way to deliver the baby. The principle theme underlying modern breech management is that for the baby to deliver in this position the dangers to that baby are multiplied and the risk of perinatal mortality is increased. The independent midwife needs to survey the literature (both medical and midwifery) to ascertain the attendant dangers. Myles (1962) lists the dangers to the foetus as fractures of humerus or clavicle, damage to the brachial plexus caused by twisting the baby's neck and causing Erb's paralysis, ruptured liver caused by grasping the abdomen, damage to the adrenals caused by grasping the baby at kidney level, crushing the spinal cord or fracturing the neck by bending the body backwards over the symphysis pubis while delivering the head. Collea (1978) mentions the incidence of brachial plexus injuries in vaginal delivery breeches, and Garry (1980) has a very long and depressing list of trauma which the baby can sustain `intra-cranial haemorrhage from rupture of tentorium cerebelli of falx cerebri, due to rapid moulding, dislocation of shoulder, fracture of clavicle, fracture of humerus, dislocation of neck, Erb- Duchenne paralysis, damage of sternomastoid muscles, prolapsed cord, rupture of viscus usually liver or kidney due to pressures or faulty handling, dislocation of hip joint by traction, fracture of femur in flexing extended knee, genital oedaema, disruption of knee joint and apnoea due to premature separation of the placenta'. Collea (1980) describes the problem of two babies with nuchal arms. On looking through the literature one learns that although obviously there must be increased danger of the baby's head being trapped at delivery when the cervix is not fully dilated, according to most of the literature the greatest danger to the baby seems to be the trauma caused by the person delivering the baby being over anxious and too rough in their delivery techniques. As a midwife about to deliver a baby presenting by the breech, I must take cognizance of Russell's work (1982) and I must think rationally about the position which will give the baby the most space in order to be delivered. When one considers the wisdom of having women lying down with their legs in lithotomy stirrups, one can see that although the thighs are abducted in this position the sacrum and coccyx are being pressed upwards and consequently the anteroposterior diameters of the cavity and outlet of the pelvis are reduced. Also the great benefits of gravity on the fundus which would help to keep the head flexed are lost. With the baby presenting by the breech the head is usually fairly well flexed and the largest diameter to come through the pelvis is the Sub-Occipito Frontal which measures ten cms or the Occipito-Frontal diameter which measures 11.5cms. If the anterior posterior diameters of the cavity and outlet are reduced from their normal 12cms even by one centimeter this can leave very little leeway for a safe delivery. On the other hand if the mother is encouraged to take up a squatting position, Russell (1982) describes an increase in both transverse and antero-posterior diameters of the pelvic outlet. His records observed increases of one centimeter in the transverse, so the diameter which is normally regarded as being l Icms could increase to 12cms, and an increase of two centimeters in the anteroposterior diameter increasing the normal measurement from 12cms to 14cms. The same author described in 1969 an increase of 28 per cent between the supine and squatting positions. He also points out the importance of the woman's naturally occurring rocking motion which seems almost universal when women are allowed to labour in an upright position. Dunn (1976) points out the increase in efficiency of uterine contractions when the woman is standing.White in his Emergency Childbirth Manual (published date unrecorded) says when describing how to help a woman to deliver a breech baby, `In order to add the weight of the baby to the forces helping delivery, the mother should be assisted to a position on her hands and knees,' he also advises `hands off the breech' because `more breech babies die of injuries received at the hands of their would-be rescuers than die of smothering'. It would appear to make more sense anatomically to deliver a woman standing with abducted thighs or on hands and knees with a consequent enlargement of the pelvis. Odent (1984) describes delivering breech babies in the supported squatting position. He goes on to say `We would never risk a breech delivery with the mother in a dorsal or semi seated position'. A position usually referred to as a 'supported squat`, with the woman standing, holding onto her partner and facing away from the attendant,means the baby's face becomes visible so that the nose and mouth can be aspirated - in order to release the nose and mouth the woman needs to tip her trunk forwards to bring her trunk into the horizontal plane - but this necessity is avoided if the woman is kneeling on all fours for the delivery. When a midwife has seen a baby been born in this way the rationale behind Burns Marshall manoeuvre is seen immediately as that which has to be done if the woman is upside down (as she is when in lithotomy) and gravity is not used in order to help the baby's nose and mouth to emerge.By standing in a supported squat the woman feels more in control of the situation, the attendant needs to remain calm and trust in the woman's ability to give birth. I would not encourage women with babies presenting by the breech to give birth at home, but I would encourage obstetricians to examine the way breech babies are being delivered at this moment and to ask themselves whether this way might not be rational -taking cognizance of the effect of maternal posture on pelvic diameters and the effects of gravity. References Col lea Joseph V. et al. (1978). `The rand omized management of term frank breech presentation: Vaginal delivery vs. caesarean section'. American Journal of Obstetrics and Gynaecology. Vol. 131, pp. 186-195. Collea Joseph V. et al, (1980). `The rand omized management of term frank breech presentation: A study of 208 cases.' American Journal of Obstetrics and Gynaecology. Vol. 137, Number 2, pp. 235242. Dunn, Peter M. (1976). `Obstetric delivery today. For better or for worse.' The Lancet. April 10, 1976.Garrey, Govan, Hodge, Callender (1980). Obstetrics Illustrated. Churchill Living stone.Kasule, J. et al. (1985). `A randomized controlled trial of external cephalic version' Vol. 92, pp. 14-18. Myles, M. (1962). A Textbook for Midwives. Fourth Edition. Edinburgh and London: E & S Livingstone Ltd. Odent, Michel. (1984). Birth Reborn. Random House. Rosen Mortimer, G., Chik Lawrence (1984). the choice of birth route on infant outcome in fetal breech presentation'. American 148, No. 7, pp.909-914. Rovinsky Joseph J. et al (1973). `Manage ment of breech presentation at term.' American Journal of Obstetrics and 513. Russell J.C.B. (1969). `Moulding of the pelvic outlet'. Journal of Obstetrics and Gynaecology of the British Commonwealth, Vol.76, pp.817-820. Russell, J.C.B. (1982). `The rationale of primitive delivery positions'. British Journal of Obstetrics and Gynaecology , September, Vol.89, pp.712-715. UKCC (1983). Notices concerning a Midwives' Code of Practice for midwives practising in England and Wales. London: UKCC. White Gregory J., M.D, Emergency Child birth. A handbook for policemen, ambulance drivers and Civil Defence volunteers. Summer 1989. |
|