vb and a breech baby

[flippineck]

Quick bit of background: DD was breech, but not diagnosed until I was well into labour. I was very lucky that the consultant 'allowed' () me to carry on labouring, and she was born vaginally, bum first - but in theatre, feet in stirrups, episiotomy and an attempted (though failed because of broken pump!) syntocinon drip to speed things up.

I'm pregnant again, and given my story, and the fact that there is a history of breech babies in my family, I'm expecting this one to be breech too - the mw has agreed that I should have a late scan to confirm the position, whatever external examinations say. The mw has also agreed that as I've done it once, I should be able to have have a vaginal birth if it is breech, although I would have to go to the hospital, not stay at home or mlu.

So, after all that, does anyone have any top tips for breech births? Positions, tips for dealing with mws, arguments to be prepared for, anything? What should I be asking the mws at the hospital? Should I meet the hospital mws in advance to discuss it in more detail?

I have read the Benna Waites book (although quite a while ago, and can't get it from the library atm as someone else has it), is there any other recommended reading?

In an ideal world, I'd have an independent midwife who is experienced in breech births, but the money I had earmarked for that had to be spent on a new car .

I went though all of this and did the research - google Mary Cronk.

If I remember correctly:
lay off the epidural
all fours
dont' touch!

As it was ended up with a CS for failure to progress - but gave it a good go!

Forgot to add DS1 was breech but DS2 presented normally

There's a book called "Breech Birth: What are my options" by Jane Evans (published by AIMS), which is also very good.

Google Mary Cronk (seeing a trend yet ?).

Make sure you're fully conversant with the difference between a vaginal breech birth (MW led, on all fours, "hands off the breech") and a vaginal breech delivery (pretty well what you had last time ), and that your care providers are also familiar with the differences and know what you expect. This article by Mary summaries the differences quite nicely.

The guidelines we were given were that the baby should be normally developed and term (ie greater than 37 weeks), labour should start completely spontaneously (we weren't even offered a sweep and I went to 41+3) and progress completely naturally - if all of those are met then most breech births are straightforward, and if they're not then listen to the signs and be glad a CS is a pretty safe option these days.

DD was born as a breech baby at home with IMs. After doing a lot of reading, we came to the conclusion that a breech birth is not intrinsically dangerous - but the risks increase dramatically if you turn that into a breech birth with MWs that don't have breech experience. If I were doing it on the NHS I would want to talk to them first to be sure that they had MWs with breech experience and that those MWs would be available when I went into labour.

Could you cope with the cost for IMs in installments? Many are happy to do payment plans, or will consider payment (or part payment) in kind - one of mine was desperate for a decorator. Its worth asking - the worst they can do is say no. If an IM is really beyond the budget, how about a doula? One of my fears of going into hospital was that I'd be put in a position where I couldn't make reasoned decisions - having someone familiar with the process and the environment that could be your advocate might be invaluable (such as telling the Dr they're very welcome - but they should bring a mug of tea, sit in the corner and drink it very slowly while leaving the forceps in the cupboard...)

Fingers crossed things go well for you

flippineck, it's great that you're looking into it all early - good luck! i'll be watching your thread with interest also.

(sorry to hi-jack for a sec)
Ooh - Tangle... just wanted to say thanks, i was in a similar position, or rather ds was, a year or so ago and you gave me some excellent advice! Thank you!

have they mentioned having an ecv if the baby is breech?

my dd was discovered to be breech at 39 weeks and was too late to turn. I ended up having a el cs. I was a breech baby myself who was turned by ecv. when pg with my ds, myself and the mw were sure he was presenting breech until 35 weeks. I spent a lot of time on all fours with my bum in the air. He turned the day before my scan. He stayed head down and I got my vbac.

Hopefully this baby is the right way round and it wont be an issue.But do bear in mind that nowadays there are very few planned vag breech del.s in the UK most mums being offered External cephalic version or a CS!One of the results unfortunately is that very few Dr's let alone MW's are doing such del's regularly enough to be competent at managing those breech del.s which dont just 'drop out'!I would be surprised if the majority of consultants did more than one such del. a year, so bear this in mind!!!

Thanks all so far. I'd forgotten about Mary Cronk, had come across her AIMs article when I was kind of de-briefng myself after DD's birth.

Tangle - I wondered if you'd post - we've sort of 'spoken' before, I used to post under another name. I don't think an IM is an option at all, sadly - money is pretty tight at the moment. And also I think DH is slightly nervous about the idea too, it's always been me who's pushed it.

Someone - Mary Cronk, I think - refers to medicalised breech deliveries as extractions, and although mine wasn't quite that extreme (no forceps, fairly hands off apart from the cutting and failed drip), I really don't think it needs to be like that. I guess I need reassuring that it can be done on the NHS.

nulgirl - I don't know what I'd do if offered an ECV. I think I might refuse, but DH and I need to talk it through.

Nina99 - you're right, I guess that's what worries me. The older midwives I've come across have been very much more positive about it than the younger ones - one even told me that I should just stay at home until it's far too late to do anything else then it wouldn't have to be medicalised! I'm not that brave though. But at least nearly all the mws I've seen have agreed that as I have done it once I should be able to do it again. However, what worries me is that their idea of a breech birth and mine differ so wildly, hence the need to be really well informed.

I'm due in May, so 10 weeks to get as much info as I can. And of course, there is a chance that this one will be the right way up!

Flippineck - a woman on the Fab Feb 09 thread (Chilledmama) just had a homebirth with a breech baby (she had choice of homebirth or in CLU - was not allowed in MLU). Was a quick birth - 5 hours in total - and sounds like it went well. She had a very detailed and specific birth plan to deal with all contingencies as she wanted a breech birth, not a breech extraction. You may want to post asking Chilled to respond with her experiences. Congratulations and good luck!

dinkystinky - thanks! I've put a message of the Feb thread to see if chilledmama comes back to me. Very detailed birth plan sounds interesting.

flippineck - trying to work out where we've "met" before now

You're right - it doesn't have to be like that. Vaginal breech birth can be done on the NHS - there are MWs there that have strong breech skills and it sounds like some of them work in your hospital. Lots of what you've said strikes me as really +ve in terms of getting a well supported vaginal breech birth. Interestingly, Mary comments that when she was an NHS employee (I think this is going back to the 60s), homebirth was the norm and breech wasn't seen as a reason to go to hospital, let alone a reason for a CS - older MWs have probably seen a LOT of vaginal breeches.

If I were you I'd ask for an appointment with the Head of Midwifery and go through your concerns - explain the type of breech birth you'd like (or take in that article) and ask how many of her staff have those skills. I'd be pushing to see how staffing could be organised such that the MWs with breech skills would be available or on call around your due date (the MWs themselves might be quite keen on this - it gives them a chance to use their skills, afterall). You could even suggest using your birth as a mini-training exercise - many breech babies are undiagnosed before labour, so having MWs with breech skills is a very good idea. If they don't have those skills in house but a local IM does, they could bring the IM in to support the birth such that their staff could learn (I've heard of a PCT funding an IM in a situation like this - so it can be done).

I'd try and avoid talking to the consultants unless you want an ECV and/or to discuss a CS - consultants tend to be surgeons who specialise in abnormal pregnancies and often apply surgical solutions. A breech isn't abnormal - its just a bit unusual.

From talking to experienced MWs, the skill in attending a breech birth is largely in having the confidence to let the labour progress all by itself and the experience to recognise when that isn't happening. If a breech birth is going to work they tend to be fairly quick (mine was 7 hours, start to finish) and be fairly straightforward.

Arguments to be prepared for...

The top 10 list of "reasons we recommend a CS for breech" would probably be headed up by the Term Breech Trial by Hannah et al, published in The Lancet in 2000 (you can read the whole thing if you're interested - just subscribe to the Lancet site for free and you can access the article). They found that CS dramatically reduced risks for breech babies and, on the back of that, policies were changed around the world. The study has now been strongly critised in a large number of respects, and is generally considered to be so badly flawed it should be chucked in the bin (have a look here for starters). Unfortunately you can't turn back the clock - skills have been lost and a surgical solution is much more comfortable for most consultants. As consultants are closer to the decision centres than MWs tend to be, putting breech back into the realms of "normal birth" isn't going to be easy.

Another gem of wisdom that gets bandied around is "the head could get stuck" - if you talk to MWs such as Mary, they have NEVER heard of a case where that has happened in a normally developed term breech birth (where all those conditions re. spontaneity of labour are met) anywhere in the world. Its considered more likely in instances where labour is preterm (head dispraportionately large), or where a labour is forced (induced or augmented).

The risk that everyone agrees on is of cord prolapse. That said, whilst its more common with breech babies (especially full or footling breech), there's at least one study that suggests the consequences are much less severe than a cord prolapse in a cephalic presentation (the presenting parts aren't nearly as hard as a skull so there's less compression). But then a CS isn't risk free either - its finding the set of risks your more comfortable with.

For what its worth I declined an ECV - although that was partly because I had a lot of confidence in the breech skills of my IMs. Again, its how you personally feel the risks balance out for you.

Hope something in all of that is useful (I'm scared to see how long I've managed to go on this time ). Life would be much easier if they turned, wouldn't it. Its worth checking with your MW about moxibustion - they can sometimes give you instructions and moxa sticks for free.

Fingers crossed for you

Hiya

My DD, 1st baby was water birth at home delivered by independent midwife.

My Ds (2nd baby)was an undiagnosed breech (sounds a bit like your situation) He was delivered naturally in hospital in stirrups no intervention strictly 'hands off'. Midwife was older and clearly not concerned and experienced. Because first birth was 'normal' and son was undiagnosed breech I was at home and planned a home birth. Home MW (NHS) was very concerned when she completed internal to find testicles and not a head presenting!!! I ended up transferring to hospital (30 min journey told not to push!)If theatre had not have been busy they would have C-sectioned me for sure- consultant told me

I thought I would add my views to this thread as first birth was with independent midwife and she was excellent, would highly recommend it if have any more children. I know you did not ask this question but it may be worth speaking with an independent midwife for a consultation. They usually charge £50/70 for this.
Also I had one internal during my labour first birth, too many to count second time. I cannot recommend independent midwifery enough, although appreciate finances. Our local one let me pay by monthly installments.

Depending on where you live the policy is likely to vary around breech delivery. A lot of places are very nervous about it, especially consultants and many newly qualified MW as they have never had the opportunity to deliver this way (only found this out after my son was born) we were a bit of a novelty for every mw that visitied and whilst in hospital.

Also my first child was not breech, second child was.

Not sure if that helps.......

Why are you worrying about this, lots of people have first babies that are breech and the majority of them have head first ones the second time around. Don't worry about it until you get to 36 weeks and it is deffo breech.

Wow -thanks all for some more fascinating and useful information!

Tangle - I used to be fiendish, don't often post on MN (well, until my new antenatal thread!) but get sucked into breech discussions every now and again.

maxbear - I guess I'm trying to get prepared now so that I've got enough time to prepare if/when I need to. The family story is hard, my mum had four breech babies in a row, but was never given a definite reason why. Very sadly, the first baby (before I was born) died in labour (the rest of us were c-sections), so of course as soon as DD was diagnosed this was on my mind. Obviously my mum's story could be no indicator of anything for me, and DD could have been just a coincidence, but it's always there, iyswim.

fufflebum - I fully sympathise about the hospital transfer, I had that too! The mw and paramedic saying 'don't push', have they ever tried not pushing?! Well maybe the mw had, but the male paramedic certainly won't have! Roundabouts in the back of an ambulance aren't fun.

Loopymumsy - thanks! This is defintiely not her priority right now, babymooning is very much more important. Like I say, I've got 10 weeks yet.

Last night, I said Mum had four breech babies - actually, it might have been four, it might have been three, she can't remember which way round my last sibling was! Mind you, she has problems remembering our names some days, so remembering something that happened well over 30 years ago might be tricky!

I had a lovely breech delivery on the NHS. Undiagnosed breech, unplanned homebirth. The midwives hadn't ever done a breech delivery but they were very experienced and had training every year where they practiced on a dummy! They weren't "hands off" - the one who did the delivery kind of wriggled the baby around during delivery to free up her limbs. They got me out of the bath and onto my back which I know isn't how one would plan it. It was a very quick labour so there wasn't really time to discuss things! It was a wonderful experience. Best day ever . Tiny little tear, very calm and lovely.

Rolf - that sounds lovely! Quite different to my experience.

flippineck-sorry haven't been on-line...as loopmumsy said...babymooning

Here is my very detailed birth plan...as you can see I planned to have a Homebirth but was prepared for hospital under certain circumstances. (grin]

At Home

Early Pains

? Walking
? Massage ? If David home.
? Shower
? Phone Joy
? Phone David if away.

As Pain Increases

? Massage ? If David home.
? Bath
? Phone NHS ? as progress could be v. quick.

Active Labour

? Bath
? Bedroom if needed out of bath & for further checks.
? Keep upright & mobile if not in bath.
? NO Episiotomy.
? Plan to use Entonox throughout Active Labour.

Birth

? Probably in bedroom for ease of access
o Prayer position/other gravity based position (Christian & Muslim prayer position).

Baby

? If baby needs air bag on delivery this should be done as close to me as possible.
? If baby requires any further treatment, David should stay with baby.
? If birth is considered difficult or traumatic then baby to be given Vit K by injection otherwise oral Vit K preferred.
? If cord required to be cut immediately then it should be cut long so that it can be trimmed later for cord band to be applied rather than clip.

Me

? If all well on birth ? birth and straight to chest for skin/skin and first feed.
? Physiological 3rd stage.
o Wait & see if Syntometrine needed.
o At least until cord stops pulsating.

Afterwards

? Baby to go to David.
? If I have a tear which requires stitches then please do so.
? Would like to see placenta but not keep ? to be disposed of by NHS.

Transferred to Hospital

Reasons for transfer:

1. Pompey playing at home during early labour i.e. ambulance may not be able to get to hospital easily.
2. Joy unable to attend.
3. Lack of progress during early labour i.e. failure to dilate sufficiently in opinion of Joy Horner.

Pompey playing at home/Joy unable to attend

? Pain plan as per home plan.
? NO Episiotomy.
? Keep upright and mobile.
? Plan for NORMAL breech birth i.e. HANDS OFF.
? NO Continuous Foetal Monitoring ? Foetal monitoring can be conducted using mobile sonicaid as per normal birth.
? HAPPY for regular internal exams to be performed to assess progress of dilation.
? NO drips/butterfly needles shall be put in.
? NO epidural is to be offered. If I want an epidural I will request one.
? NO oral ranitidine shall be administered.
? NO Syntocinon/other pesseries etc will be given to help dilation.
? NO students to administer care.
? Please encourage me to stay upright & mobile and adopt prayer position for birth.
? Plan to use Entonox throughout Active Labour.

Birth

? If baby needs air bag on birth this should be done in the delivery room and as close to me as possible.
? If baby requires any further treatment, David should stay with baby.
? Baby shall NOT be given a Breast Milk substitute for any reason other than maternal death.
? As per rest of home plan.

If no progress of labour either at home or hospital

? Lack of progress to dilate as defined by a MW.
o C-Section.

C-Section

? Will likely be Emergency C-Section rather than crash.
? Given appropriate anaesthesia i.e. epidural/spinal block/GA.
? If baby needs help on delivery, David to stay with baby.
? If baby well, to be delivered directly onto my chest for skin/skin and first feed.
? If I am unable to have skin/skin contact then David should be given baby for skin/skin.
? Cord to be cut long so that it can be trimmed later for cord band to be applied rather than clip.
? Suffer from over-scarring so please take into account.
? Epidural/Spinal block canula to be removed straight away.

I would cerainly second everything Tangle said. I understand implicitly why you don't want to wait until presentation is confirmed. I really pushed to have an early ECV as my DS came early because he ran out of space so I knew that if they waited until their usual 37-38 weeks that I would have no chance of her being turned.
I had an IM but my husband is/was uncomfortable with the insurance issue so we wanted to engage the NHS for interpartum care. This proved quite a challenge!!!!! Basically, and unless you want the long version...they wouldn't let me labour/birth in the MLU but the consultant did agree that I was a perfect candidate for a vaginal delivery but that if I wanted an ELCS he would be quite happy to book it right now
I asked what the protocol was was breech deliveries in the hosptial and was horrified to read a list of bullets basically preparing me for the inevitable CS I would be having. They would not guarantee me any breech experienced MWs but did guarantee me a large delivery room as they would need lots of space for all the people who would have to be there!!
Very luckily!!!!!!My IMs NHS supervisor is the head of the MLU and knows how good my IM is and only because SHE MADE it happen did I get the birth I wanted. She knew several MWs who had experience and were willing to put themselves on call for me. I virtually had MWs drawing straws to see who could come out to observe.
In the end, it all went smoothly.
I am happy for you to ask any direct questions you want or if you feel you want more info I can certainly direct you well...having done quite a lot of reading on the subject reently!!!
Good luck and please let me know how you get on!

chilledmama - Joy's lovely, isn't she

Tangle-She is very definately a lovely lady. I had her as my Im last time too...It was pure luck that she turned out to the expert I needed for birth no.2
How do you know Joy??

The obvious answer - she was one of my IMs

"The risk that everyone agrees on is of cord prolapse. That said, whilst its more common with breech babies"

Tangle, isn't the point with breech births that the cord has to come through with the head and that therefore pressure on the cord from the head is inevitable? So you have the equivalent of a prolapse of the cord in a cephalic birth every time with a breech.

A doctor friend of mine attended a breech birth where the baby's head got stuck.

Sorry, I am not trying to put a downer on what are some lovely stories and fine encouragement, but the risks are real.