Session 4: Clinical aspects of physiological vaginal breech birth
- Duration: 60 Mins
- Credits: 0.275 Midwifery CEU, 2.75 ACM CPD Hours, 2.75 ACNM
- Learning Format: Webinar
- Handout: No
Abstract:
This session is the first of two that are intended to present a practical framework for the practitioner to approach attending physiological vaginal breech birth. In this session I focus on understanding the mechanisms of vaginal breech birth, i.e., the movements of the baby through the pelvis from rumping to birth, and on what those movements look like to the attendant.Part I. Normal breech birth:
Vaginal breech birth, unlike vaginal cephalic birth, has the advantage that all of the cardinal movements of the passage of the trunk, head, and upper extremities of the baby through the pelvis can be determined by directly visualizing the movements of the exposed portion of the baby from rumping through birth. The bulk of this presentation will focus on videos of actual breech births, most of which I attended, and relating what is seen to the movements unfolding as the trunk, shoulders, upper extremities, and head navigate their way through the pelvis. I will describe signs that the baby is assisting in its own birth, which both reinforce the traditional assessments of fetal well-being and reassure the attendant that the mechanism is intact and proceeding normally. There will be extensive focus on the timing of the events once rumping begins. The actual passage through the pelvis is normally completed within 7 minutes. Primiparous moms may take two to three minutes longer, and are more likely to require resuscitation; however, the evidence suggests that there is no difference in outcomes between multiparas and primiparas beyond 1 minute Apgars.
Part II. Selection criteria:
I review the various selection criteria for appropriate candidates for a vaginal breech birth and summarizing the evidence for those criteria. Many commonly accepted criteria have little to any support in the obstetric and midwifery literature, so the emphasis will be on those that have reasonable support in at least a portion of the literature. Part III. Abnormal breech birth:
This lecture will review the mechanisms of normal birth with an emphasis and where and what causes those mechanisms to fail. The points of obstruction will be presented obstructions will be shown in videos of actual births. This portion will conclude with the students reviewing breech birth videos, detecting the abnormality seen, and explaining the obstruction causing it. I present a decision tree for deciding when and how to intervene.
Part IV. Maneuvers (Optional)
I review the main supine and upright maneuvers for resolving obstructed breech births
Learning Objectives:
At the end of the session the participant should be able to:
Objective 1: List and distinguish the accepted and controversial selection criteria for VBB.
Objective 2:Describe a frank (extended knee) breech presentation and distinguish from non-frank (flexed knee) breech presentation.
Objective 3: List the fetal movement events that begin with the onset of rumping and end with the completed birth of the baby, including the approximate time line for those events.
Objective 4: Identify the outward visual appearance of the fetal movements listed in the above objective and connect each with the underlying mechanism.
Objective 5: List the measures of fetal assessment available during breech labor.
Objective 6: List the advantages of upright maternal position in facilitating vaginal breech birth.
Objective 7: Demonstrate the mechanisms of VBB on the obstetric simulator.