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Turning breech birth upside down: upright breech birth by Shawn Walker
Prior to the early 17th century in France, accoucheurs attended birthing women most commonly in the squatting position or on the birth stool (Speert 1957, Dunn 1991, Dunn 2004). Doctors, such as Francois Mauriceau, popularised the practice of women birthing on a bed and it was from this that differences in the physiology of birth were observed, especially with breech babies, who required additional assistance to be born. Women birthing in the supine position provided Mauriceau with the opportunity to practise his breech extraction skills.
Those were the days when observation, experience and literacy were enough to write a world-leading textbook, and Mauriceau’s method of actively managing breech births, with the woman on her back, is still considered the best mainstream obstetric practice worldwide. Thankfully, ‘best practice’ has abandoned his original advice which was to begin the breech extraction, ‘as soon as the Surgeon will have recognised that the infant is presenting in this position,’ by manually dilating the cervix and pulling the fetus out by the feet, using fresh butter to lubricate, after making sure his nails are cut short (Speert 1957:373). The advice to intervene immediately and dramatically is still frequently followed, but the route of delivery has changed.
Thus, an interventionalist approach to breech birth has been undermining professional knowledge of physiological breech birth for at least 400 years. Those who have argued that active maternal positioning throughout breech labour and birth makes breech birth easier and safer have in recent history been marginalised, often forced to practise in out-of-hospital settings (Cronk 1998, Evans 2007), and asked to provide ‘evidence’ that such methods are as safe as assisted breech deliveries in lithotomy (Beech 2003).
Now those notable exceptions to standard breech practice, the innovators at the fringes, are beginning to move into the centre. In the past year, for the first time, two studies have been published indicating acceptable neonatal outcomes when women birth in non-lithotomy positions, in large teaching hospitals, under obstetric care. The data confirms what midwives have been saying in professional literature for some time: upright positioning offers potential physiological advantages which at the very least deserve further investigation.
What is upright breech birth?
In my own research* I define upright breech birth as, ‘a vaginal breech birth where the woman is encouraged to remain upright and active throughout the first stage of labour and supported to assume the position of her choice for the birth.’
This broad definition focuses on the woman’s agency and ability to move, so includes a variety of actual birthing positions: kneeling, standing, squatting, sitting on a birthing stool, hands–knees, and even in water, side-lying or semi-supine, where the woman has chosen it. Some call it active breech birth, and because births occur spontaneously, more often using this approach, some call it physiological breech birth. I refer to the practice as upright breech birth in my research because the ability to facilitate births when women are in upright positions is qualitatively different from standard lithotomy practice, especially the performance of manoeuvres to alleviate obstruction. However, these skills are only one aspect of a holistic approach to care which aims to enhance the physiological processes of breech births, rather than control them by performing a vaginal breech delivery (Evans 2005, Evans 2012a).
When women are in upright positions, the descent of the fetus, the curve of the birth canal, and the forces of gravity are aligned. In addition, self-supported positioning enables spontaneous maternal movement, altering the shape of the pelvis, and assisting the progress of the birth (Reitter et al 2014). The fetus makes a series of spiralling movements in this descent, known as the mechanisms of breech birth (Evans 2012a, Frye 2013). These movements, the progress of the birth and the condition of the baby are all most easily observed when the woman is in a kneeling position, because the caregiver faces the emerging fetus.
The images in this article are credited to Shawn Walker and were published with kind permission from the woman presented in the images.
The full article can be found: MIDIRS Midwifery Digest, vol 25, no 3, September 2015, pp 325-330
Original article. © MIDIRS 2015
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