First Stage of Labour: Vaginal Breech at Term

Chapter 17:

First stage of labour: vaginal breech at term

This section considers the physiology and intrapartum care in the ﬁrst stage of labour of those term pregnancies presenting by the breech. In addition, the controversies surrounding the evidence of breech birth and the eﬀect on women's choice for labour and birth are explored.

Incidence of breech presentation

Breech presentation involves a longitudinal lie of the fetus, with the buttocks in the lower pole of the maternal uterus. The presenting diameter is the bitrochanteric (10 cm) and the denominator is the sacrum. As pregnancy progresses, the incidence of breech presentation reduces: being around 15% at 28–32 weeks to around 3–4% by term as a result of spontaneous version (MIDIRS 2008b). It is worth considering, therefore, that a breech presentation at term is not an abnormality, it is just unusual and so a normal labour and spontaneous vaginal birth should not be excluded. Although in Western childbirth culture a breech birth has the status of an emergency, in many parts of the world a vaginal breech birth is part of normal practice (Burvill 2005). This used to be the case in the UK for most community midwives during the last century (Allison 1996). Following the Peel Report (Maternity Advisory Commifee 1970 ) that gave rise to the transfer of childbirth from the home to the hospital environment, such skills of the midwife regarding vaginal breech births have been eroded as midwifery became subsumed into a medico-technocratic model, where obstetric intervention prevails.

Since the early 1990s, there has been much sociopolitical inﬂuence in the UK, aimed at improving childbirth choices and quality of maternity services for women. This has provided the opportunity for midwives to re-examine their role in providing a more holistic model of maternity care (DH 1993, 2004a, 2004b, 2007, 2008a, 2008b, 2010a, 2010b). The consequential reduction in junior doctors' hours (DH et al 2002) provided further opportunities for NHS Trusts to embrace collaborative working between health professionals (DH 2001), leading to a redeﬁning of roles and responsibilities for midwives and their medical colleagues.

The clearly documented accounts from Cronk (1998a, 1998b), Reed (1999, 2003) and Evans (2007, 2012a, 2012b) provide ﬁrst-hand detail of how midwives can support women with a breech presentation to give birth naturally other than by caesarean section and are an inspiration to other midwives seeking to develop or re-establish skills in this area.

However, not all breeches can, or should be, born vaginally.

Types of breech presentation and position

There are six positions for a breech presentation, illustrated in Figs 16.21–16.26.

FIG. 16.21 Right sacroposterior.

FIG. 16.22 Left sacroposterior.

FIG. 16.23 Right sacrolateral.

FIG. 16.24 Left sacrolateral.

FIG. 16.25 Right sacroanterior.

FIG. 16.26 Left sacroanterior.

FIGS 16.21–16.26 Six positions in a breech presentation.

Breech with extended legs (frank breech)

The breech presents with the hips ﬂexed and legs extended on the abdomen (Fig. 16.27). This type is particularly common in primigravidae whose eﬃcient uterine muscle tone

inhibits ﬂexion of the legs and free turning of the mobile fetus. Consequently, this type of breech constitutes 70% of all breech presentations.

FIG. 16.27 Frank breech.

Complete breech

The fetal afitude is one of complete ﬂexion ( Fig. 16.28) with hips and knees both ﬂexed and the feet tucked in beside the buttocks.

FIG. 16.28 Complete breech.

Footling breech

One or both feet present due to the fact that neither hip is fully ﬂexed (Fig. 16.29). The feet are lower than the bufocks, distinguishing it from the complete breech. This type of breech is rare.

FIG. 16.29 Footling breech.

Knee presentation

This breech type is particularly rare and presents with one or both hips extended, with the knees flexed (Fig. 16.30).

FIG. 16.30 Knee presentation.

Causes of breech presentation
Ohen there is no identiﬁable cause, but / the / following / situations / favour breech
presentation:
• Extended legs
• Preterm labour
• Multiple pregnancy
• Polyhydramnios
• Hydrocephaly

• Uterine abnormalities such as a septum or a fibroid

• Placenta praevia

Diagnosis of breech presentation

In pregnancy

The woman may inform the midwife that she can feel something very hard and uncomfortable under her ribs that makes breathing uncomfortable at times. If the fetal feet are in the lower pole of the uterus, the woman is likely to experience some very hard kicks on her bladder. The use of ultrasound examination may be used to conﬁrm a breech presentation where there is some uncertainty, however a decision on subsequent care, such as undertaking an external cephalic version (ECV), is usually deferred until nearer term. Some women may also afempt the use of moxibustion from 34 weeks' gestation to reduce the need for ECV (Tiran 2010b; Smith 2013).

Abdominal palpation

In primigravidae, diagnosis is more diﬃcult because of the woman's ﬁrm abdominal muscles. The lie will be longitudinal with a soft presenting part felt in the lower part of the uterus. The head can usually be felt in the fundus as a round hard mass, which the midwife may be able to move independently of the back by balloting it with one or both hands. If the legs are extended, the feet may prevent such movement of the head. When the breech is anterior and the fetus well ﬂexed it may be diﬃcult to locate the head. However, the woman may complain of discomfort under her ribs, especially at night, owing to pressure of the head on the diaphragm, thus contributing to the diagnosis.

Auscultation

Prior to the breech passing through the pelvic brim, the fetal heart will be heard most clearly above the umbilicus. When the legs are extended, the breech descends into the pelvis easily such that the fetal heart is heard at a lower level.

During labour

Abdominal examination

A previously unsuspected breech presentation may not be diagnosed until the woman is in established labour. If the legs are extended, the breech may feel like a head on abdominal palpation and also on vaginal examination should the cervix be less than 3 cm dilated and the breech is high.

Vaginal examination

The breech feels soh and irregular with no sutures palpable. On occasion the sacrum may be mistaken for a hard head and the bufocks for caput succedaneum. In addition, the anus may be felt and should the membranes have already ruptured, fresh meconium on the examining ﬁnger is diagnostic. If the legs are extended (Fig. 16.31) the external genitalia are very obvious, however, as these become oedematous, a swollen vulva can be mistaken for a scrotum.

FIG. 16.31 No feet felt: the legs are extended.

FIG. 16.32 Feet felt: complete breech presentation.

FIGS 16.31–16.32 Vaginal touch pictures of left sacrolateral position.

If a foot is felt (Fig. 16.32) the midwife should diﬀerentiate from the hand. Toes are all the same length, are shorter than ﬁngers and the big toe cannot be opposed to other toes. The foot is at right-angles to the leg and the heel has no equivalent in the hand.

Mode of birth: the evidence

The evidence regarding the safest mode for breech babies to be born has been somewhat controversial and misleading, with the randomized multicentre Term Breech Trial conducted by Hannah et al (2000) concluding the safest way to give birth was by planned caesarean section. This has had a major impact on the choices oﬀered to women who may be presenting with a breech towards the end of their pregnancy regarding mode of birth, leading to a consequential increase in planned caesarean sections. By 2004 doubts had been cast on Hannah et al's (2000) research, with questions being raised over the validity and ethical basis of using a RCT for such a study and further research distrusting the results and recommendations (Alarab et al 2004; Háheim et al 2004; Kotaska 2004; Ulander et al 2004; Pradham et al 2005; Glezerman 2006; Fahy 2011). Furthermore, the two-year follow-up study by Whyte et al (2004) and Hannah et al (2004) did not show any diﬀerences in long-term outcomes between planned caesarean section or planned vaginal breech births.

Two further prospective trials undertaken by Goffinet et al (2006) and Maier et al (2011) clearly found that where planned vaginal breech birth is common practice and when strict criteria are met before and during labour, vaginal breech birth at term can still be a safe option. For a successful outcome, the evidence indicates that the most important factor is the presence of an experienced health professional, be it a midwife or obstetrician, facilitating the birth. As approximately one-third of all breech presentations are undiagnosed until labour and there is no evidence to support a caesarean section at this late stage, unless there is another clinical indication, it is important that midwives and obstetricians are competent to support vaginal breech birth. Consequently, the RCOG (2006) recommended that the most experienced available practitioner should be present at a vaginal breech birth and that all maternity units have guidelines in place, including structured simulated training for all staﬀ who may encounter vaginal breech births.

Place of birth

Vaginal birth should be presented to the woman as the norm for breech presentation (MIDIRS 2008b) provided there are no contraindications or complications. The woman should also be informed that there is an increase in the risk to the mother associated with Caesarean section births (Chapter 21). If a vaginal breech birth is planned for the home environment it is important that the midwife is competent to facilitate the birth and has clear lines of communication and support from her colleagues, including the Supervisor of Midwives, with a second midwife being present for the birth itself (NMC 2008, 2012). However, according to NICE (2007), a breech is considered to be a malpresentation indicative of risk, and recommends the labour and birth should be planned to take place in an obstetric unit. Outside of the hospital environment, any decision to transfer the woman from the home should be made promptly taking into consideration the time it would take to complete. An action plan for the labour and birth should be made with the woman that includes specifying those situations where midwives would make the decision to transfer to hospital, namely where there is a lack of progress or fetal compromise.

Posture for labour and birth

When women labour instinctively, without interruption or direction, they rarely choose to labour in a semi-recumbent position. In the campaign for normal birth, the RCM currently endorses an upright position for breech labour and birth as this aids descent of the presenting part, assisting the normal physiology of labour as well as reducing the risk of aorto-caval compression with subsequent improvement in placental blood ﬂow (RCM 2005) (Chapter 17). However, as the upright position has not been fully evaluated, the RCOG (2006) still recommends the woman to be in a dorsal position for the actual birth.

Care in labour

Basic care during the ﬁrst stage of labour is the same as those labours where the presentation is cephalic: minimizing intervention and enabling the normal physiology to progress. The breech with extended legs ﬁts the cervix quite well, but with a less well applied presenting part as in the complete breech there is a tendency for the membranes to rupture early, increasing the risk of cord prolapse ( Chapter 22). Should this occur, the midwife must undertake a vaginal examination to exclude cord prolapse and assess the fetal heart rate. It is not uncommon to ﬁnd meconium staining of the amniotic ﬂuid liquour with a breech presentation due to the compression of the fetal abdomen, and for this reason is not always a sign of fetal compromise.

Prelabour rupture of fetal membranes at term (PROM)

Prelabour rupture of membranes (PROM) at term (>37 weeks) complicates between 8 and 10% of all pregnancies and most women with PROM will labour spontaneously within 24

hours (NICE 2007). Following PROM with no signs of labour, regardless of whether or not liquor is draining, digital examination should be avoided owing to an increased risk of ascending infection (NICE 2007; NICE 2013). If there is doubt about whether the membranes have ruptured, a sterile speculum examination can be performed in order to observe whether there is pooling of liquor in the posterior fornix of the vagina (NICE 2013). If there are no facilities for this, the woman can be encouraged to wear a sanitary pad for an hour or two in order for the midwife to re-assess for signs of any liquor before a deﬁnite diagnosis can be made. The taking of low vaginal swabs is not recommended (NICE 2007). Initial assessment of the woman should include observation of her pulse, respiration rate, blood pressure, temperature, oxygen saturation and urinalysis. An abdominal examination should be undertaken and the fetal heart auscultated.

Following PROM the risk of serious neonatal infection is increased from 0.5% to 1%, compared with women whose membranes remain intact, and the woman should be advised of this (NICE 2007). In view of this, and in the absence of any clinical indication for immediate induction, such as Group B Streptococcus, maternal infection or meconium staining of the liquor, it is usual practice to advise the woman that if she does not go into spontaneous labour within 24 hours, labour should be induced aher PROM (NICE 2007) (see Chapter 19). Women should be given adequate information to decide between expectant management and active management of labour following PROM. Hospital admission, in the absence of any other concerns, is not required whilst waiting for induction to take place.

Until the induction is commenced or if expectant management beyond 24 hours is chosen by the woman the following recommendations regarding advice to women and subsequent care should be followed (NICE 2007):

• Bathing or showering are not associated with an increase in infection, but having sexual intercourse may be.

• Body temperature should be recorded every 4 hours during waking hours and any change in the colour or smell of the vaginal loss should be reported to the midwife immediately.