Born This Way: Vaginal Breech Birth

The Physiological Mechanisms for Breech Birth, Indications for Intervention, and Maneuvers

Simulation produced in partnership with the Breech Birth Network
by Brie Eteson, Medical Communications, Digital Surgery

Breech births occur in around 3-5% of pregnancies that go to term.1 Due to the positioning in the womb and possible complications for the baby, breech births are considered higher risk. The latest simulation is available for free on Touch Surgery™, and was created in collaboration with the Breech Birth Network to explore the normal physiological mechanics of breech birth, the most common interventions, and when these interventions may be indicated.

Recent research has formed the Physiological Breech Birth Algorithm, which can assist as an initial timekeeping framework for safer, timely vaginal delivery of the breech baby at term.2 This algorithm was created to regulate variations in traditional maneuvers for breech birth. By using this algorithm, clinicians can identify when intervention is needed, based on delays, descent, and rotation. The modules in this simulation guide you through the normal physiological birth mechanisms associated with vaginal breech birth and describe how maternal positional changes can facilitate the descent of the breech-presenting fetus.

Perinatal mortality rates for vaginal breech births are around 2 in 1000, compared with 1 in 1000 for cephalic births (head-first), and 0.5 in 1000 for planned Cesarean sections from 39 weeks. Relatively speaking, this makes breech births higher risk.2

What are some of the key phases of a vaginal breech birth?

The expulsive phase is the phase of labor where fetal presentation reaches the pelvic floor, and the woman begins to have the urge to push. Birth should be completed within 7 minutes from this stage.

Rumping of the breech is when the breech has descended past the women’s ischial spines and remains visible even between contractions. This is the point at which the stopwatch should be started to monitor the birth, following the Physiological Breech Birth Algorithm. The pelvis should be born within the next two minutes, and the birth should be fully complete within five minutes.

Running start position to help open the pelvis

Mother-and-baby unit

Visual assessments of the baby are crucial, as it is no longer possible to monitor the fetal heart rate as the fetus descends. Assessments of fetal color and tissue reperfusion should be made. The birth should now be completed within 3 minutes.

Normal physiological birth of a breech baby should begin with the rotation of the fetal sacrum in the direction of the maternal pubic bone. In uncomplicated births of an extended breech, the legs are born together. Following this, the sternal crease should be observed, which indicates the arms are engaged just under the perineum. The arms are then also born together. The birthing of the fetal head is next. The fetal chin should be visible in the perineum, which means it is flexed and aligned. Maternal effort and gravity are key for a spontaneous birth. Once the baby has been delivered, either left to drop on their own or braced as the head is born, pair the mother-baby unit. Provided the baby shows good tone, color and is well perfused, all neonatal assessments can then be carried out during skin-to-skin contact, with the umbilical cord still intact.

Types of Breech Birth Movements

Vaginal breech births can present in various ways, and most of the common presentations are detailed in our module on the Touch Surgery™ app. Breech presentation is sometimes not diagnosed during pregnancy, and often not felt in vaginal examinations during early labor. Therefore, it is essential to know how to safely intervene and support the mother in this situation.

  • Extended Breech (Frank)

Extended breech is the most common type of breech presentation. In this presentation, the anterior buttock descends first. The risk of cord prolapse is as low as in cephalic presentation.

Extended Breech (frank)

Flexed breech (complete)

  • Flexed Breech (Complete)

In the flexed breech presentation, the feet or toes are felt alongside the buttocks during examination. However, fetal position changes can occur, particularly during advanced labor when there is increased space under the sacrum. A ‘dropped foot’ may occur if the legs extend up or down.

  • Semi-Flexed Breech

Both hip joints are flexed, with one knee extended and the other knee flexed.

  • Kneeling Breech

In this presentation, the fetus descends in a posterior sacral position and rotates on the maternal pelvic floor.

  • Standing Breech (Footling)

This presentation is defined by the lack of engagement of the fetal pelvis. One or both feet present ahead of the pelvis, which may be the result of fibroids, a short cord, or some other anomaly. There is an increased risk of cord prolapse.

Semi-flexed breech

Kneeling breech

Standing breech (footling)

Additional modules in the simulation illustrate the mechanisms of a normal breech birth, how to recognize delays and the complications that can occur. Using the Physiological Breech Birth Algorithm as a guide, the simulation demonstrates when intervention may be required and how to perform maneuvers to help complete a safe delivery. Some maneuvers that are featured in the simulation are:

  • Simple arm sweep
  • Face-to-pubes rotation with flat hands to release a nuchal arm
  • Shoulder press with a buttock lift
  • Elevate and rotate to assist engagement of a fetal head

The simulation is authored by Shawn Walker, RM, Ph.D., and Director of Breech Birth Network, Community Interest Company. It includes video footage of a normal breech birth from Dr. Anke Reitter and an example of the shoulder press maneuver from Erasme Hospital, Brussels.

Search for the Breech Birth simulation on the Touch Surgery™ app, and dive in ‘breech’ first now!

Launch in App

or scan the QR code below.

References

1. Royal College of Obstetricians and Gynaecologists. Breech Birth at the end of the pregnancy. RCOG. https://www.rcog.org.uk/en/patients/patient-leaflets/breech-baby-at-the-end-of-pregnancy. Published July 7, 2017. Accessed December 30, 2020.

2. Louwen F, Daviss B-A, Johnson KC and Reitter A. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?. Int J Gynecol Obstet. 2017;136:151-161. https://doi.org/10.1002/ijgo.12033.

3. Bogner G, Strobl M, Schausberger C, Fischer T, Reisenberger K, Jacobs VR. Breech delivery in the all fours position: a prospective observational comparative study with classic assistance. J Perinat Med. 2015;43(6):707-713. doi: https://doi.org/10.1515/jpm-2014-0048.

4. Reitter A, Daviss B-A, Bisits A, et al. Does pregnancy and/or shifting positions create more room in a woman’s pelvis? Am J Obstet Gynecol. 2014 Dec;211(6):662.e1-9. doi: 10.1016/j.ajog.2014.06.029. Epub 2014 Jun 17. PMID: 24949546.

5. Reitter A, Halliday A, Walker S. Practical insight into upright breech birth from birth videos: a structured analysis. Birth. 2020;47:211–219. doi: 10.1111/birt.12480.

6. Walker S, Scamell M, Parker P. Principles of physiological breech birth practice: A Delphi Study. Midwifery. 2016;43:1-6. (Author version archived at City Research Online).

7. Walker S, Spillane E. Face to pubes rotational maneuver for bilateral nuchal arms in a vaginal breech birth, resolved in an upright maternal position: A case report. Birth. 2020;47(2):246-252. doi: 10.1111/birt.12486.

8. Walker S. No more ‘hands off the breech’. Pract Midwife. 2020;23(6).