Wednesday, May 24, 2017

Gail Tully: Breech Complications Illustrated

Gail Tully
Breech Complications Illustrated (particularly rotation and descent)
North of England Breech Conference, Sheffield
Day 2

Gail Tully is a midwife in Minnesota and founder of Spinning Babies. She expressed her gratitude for being here today and says she feels like the "little sister" among all of the breech experts--"a less developed observer who, therefore, is likely to come up with some surprise perspectives."

Gail thanked the influential people who have taught her about breech: Ina May Gaskin in the 80s and 90s, presenters at the 2009 International Breech Conference in Ottawa, UK midwives such as Mary Cronk and Jane Evans, Anke Reitter, Frank Louwen, and Betty-Anne Daviss.

Gail asked the question: Who is the new face of the US breech expert? Her answer was both funny and sobering: It is the fireman, the policeman, and the paramedic. These are the people who are allowed to attend vaginal breech births in the US. Doctors and midwives are not.

Improving the safety and success of ECV
If we help prepare and loosen the soft tissues, we theoretically can make the ECV more successful. Self-care, body-balancing, fascia therapy, and pelvis alignment may all improve safety and success in ECV. There’s a midwife/doctor team in Rio who are sending parents home for a week with these techniques with great results. (Rixa's note: I'd love more information on this team if anyone is familiar with their work.)

3 pillars of safe breech
1. Hands and knees
2. Hands off the breech--Unless baby needs help!
3. Don't clamp the cord

Her session will address pillar #2: when to help.

Frank Louwen has taught us that what you see on the outside tells you what’s going on inside. In the US, providers often don’t know when to step in or not. Gail critiqued American home birth midwives for waiting too long to intervene in a breech when there are clear signs that the baby needs help. If the baby's tone and color seem good, but descent has stopped, help the baby without delay.

Review of the cardinal movements of the breech baby
Gail showed us how the pelvic floor muscles guide the rotation of the baby, explaining why the breech baby generally rotates to sacrum lateral. For more details, consult Anne Frye's Healing Passage p. 89. Next, the baby descends and the chest rotates to sacrum anterior.

When to be hands-on
1) When descent stops
2) When the baby appears deflated, hollow, or limp. If the baby's head is well-flexed, use Kristeller (fundal pressure).

Can we reduce complications with breech births? Gail thinks we can when we consider the anatomy.

Match the baby to the pelvis
When progress stops, ask, “what has happened inside?” First, figure out where the stuck part is within the pelvis (inlet, mid-pelvis, outlet). Then use solutions that match the pelvic diameter.

From Gail's presentation, I learned that breech babies can be incredibly resourceful in how they get themselves stuck inside the pelvis. You have to outsmart these babies--kind of like figuring out a 3-D brain-teaser.
For detailed illustrations of all these solutions, I highly recommend purchasing Gail's Breech Birth Quick Guide, available as a spiral-bound booklet ($24 USD) or digital download ($19.95 USD). Gail's presentation went over many of these, but quite quickly. My summary won't be able to supply all of the necessary details. (I have no financial arrangements with Gail--just a deep appreciation of her knowledge of the maternal pelvis.)

Inlet dystocias (stations -2, -3, -4)
When the arms are stuck, this occurs in the pelvic inlet. You'll see the lower ribs visible. The baby will usually be turned facing sideways, rather than facing the mother's anus. Different ways the baby can be stuck in the inlet:
  • The baby might have one or both shoulders stuck in the inlet with its arm(s) behind its head. 
  • The baby's upper arm might be trapped inside a separating symphysis (which Gail has encountered).
  • The baby might have its arms crossed over its face--sometimes the baby will be rotated to direct anterior or posterior, but then descent halts. The baby might do the tummy crunch to get the next body part into the pelvis. If the baby does this and no descent happens, you must take action! 
  • The baby's head might be caught up high on the inlet or brim (stargazer). In this case, the shoulders will be born but the perineum will be empty. 
  • The baby is anterior and its head is caught on the sacral promontory (rare). 
  • The baby is posterior and its chin is stuck on the symphysis (rare). 

Use solutions that turn the shoulders to oblique and transverse diameters to permit descent. You might need to:
  • Rotate the baby by grasping the shoulder girdle and rotating 180, then 90 the opposite direction. Baby's hand points the way of the first rotation. Baby faces mother's anus when you are done. 
  • Open the pelvic inlet via maternal positioning (H&K: posterior pelvic tilt. On back: Walcher's)
  • Turn the baby's head/chin to the oblique. 
  • Lift & rotate the stuck part off the symphysis/sacral promontory. 

Mid-pelvis dystocias (stations -1, 0, +1)
The baby's head can be stuck in the mid-pelvis when the head is still turned to the oblique and not fully flexed. You will see the baby's body full born. The chest might be facing you or turned to the oblique.

  • Have the mother do a diagonal lunge, also called the "running start"
  • Reach in to turn the baby to OA, then flex the head

Outlet dystocias (stations +2 and lower)
At this point, the baby is born to the neck. When a baby's head is well-flexed and in the pelvic outlet, the mother's anus and perineum appear full or bulging. You might even see a bit of the chin. These are all good signs.

If the anus or perineum appear empty or hollow, this is a sign that the head is extended. You must flex the head.

  • Use maternal positions that open the pelvic outlet (anterior pelvic tilt, running start, Walcher's).
  • Flex the baby's head by pushing up on the occiput and dragging down on cheek bones.
  • Flex the baby's head using finger flexion: put your fingers on the temporal bones and flex the head.
  • Gently press the baby's subclavicular space to encourage the baby to flex its head. This is called SAFE: Subclavicularly Activated Flexion and Explusion. This is a variation on Frank's nudge that uses a physiologic response instead of mechanical pressure. SAFE was developed by Adrienne Caldwell, Therapeutic Massage Therapist and anatomical adviser to Spinning Babies.

Gail showed us slides and videos of many breech births she has attended with various kinds of dystocias. One birth in particular stuck out to me--the baby had multiple dystocias that Gail resolved over a total time of 2.5 minutes. This included a baby with shoulders stuck in the inlet, an arm stuck inside the partially separated symphysis, a head stuck in the midpelvis due to a tipped coccyx, and then a head that needed manual flexing. This required a deep knowledge of the pelvis and of how a baby should descend through the various diameters. Thanks to Gail's skilled hands, this baby made it safely with Apgars of 10/10. (And extra kudos to the mama--this was not just a breech baby, but also a VBAC!)

Again, I highly encourage you to purchase a copy of Gail's Breech Birth: Quick Guide. All of these problems and solutions are illustrated with both photos and drawings. Study this booklet until you know it by heart, backwards and forwards.

Reviewed by Gail Tully, May 24, 2017. 


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