November 28, 2001
Volume 3, Issue 48
Midwifery Today E-News
“Breech Delivery”
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Shoulder dystocia. Breech birth. VBAC and Cesarean prevention. Prolonged labor. Complicated Birth.

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Quote of the Week:

"Walking into a labor at 3 o'clock in the morning, 40 minutes away from the nearest hospital, and finding the baby out to its armpits affords no time to get out the books or to regret one's lack of knowledge."

- Valerie El Halta

The Art of Midwifery

For posterior cervix:

Pelvic tilt to move baby's head toward the cervix during labor: When the mom is on all fours, she arches her back in a cat stretch, then relaxes the muscles and releases the stretch. She may also do this stretch while standing.

For vaginal exams: Ask the mom to place both fists beneath her hips. This tips the cervix forward, making it easier to examine and more comfortable for the mom.

- Midwifery Today Forums

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News Flashes

A Johns Hopkins University study of preterm delivery among 735 low-income American black women found that feelings of being stressed and out of control doubled the risk of premature birth, which is the second leading cause of newborn deaths in the United States, according to the Centers for Disease Control. For the participants in the study, the key differences showed up not in whether they had enough basic resources to meet their needs (e.g., heat, housing, furniture) but in whether they had some of the extras that can help them feel in control of their lives.

- Paediatric and Perinatal Epidemiology, May 2001

Breech Birth

When determining the feasibility of attempting a breech delivery, this scoring index is of great help. However, it remains paramount that the midwife use her own judgment as well. Never attempt a delivery for which you have neither the skill nor the experience. Even when you have determined that there are no predisposing factors against the delivery, if your heart shouts "No!", don't do it!

Breech Index Scoring System

0 1 2

Parity Primip Multip
Gestational Age >/=39 wks 37-38 wks. 36-37 wks.
Estimated Weight 8 lb. 7-8 lb. 5-7 lb.
Dilation 2 cm. 3 cm. >/=4 cm.
Station -3 -2 </= -1
Previous breech 0 1 >/=2

This assessment is designed to be made at the onset of labor. A client would be scored as follows:

  • A multipara (score 2) with a baby who weighs between 7 and 8 pounds (score 1), at station -3 (score 0), dilation 4 cm (score 2), no previous breech babies (score 0), would have a total score of 5.
  • A score of less than 3 would indicate the need for a cesarean section.
  • A score of 4 to 5 indicates a careful review must be made and suggests one should proceed with caution.
  • A score of 5 or more would indicate a reasonable chance for a successful vaginal delivery.
  • Of course, some moderating factors exist. If a multipara has had two 9-pound babies vaginally and this baby is of similar size, she should do fine as long as the baby does not go postdates.
  • I usually subtract one point for footling breeches because they are somewhat more difficult to manage.

In general, I have found this system to be very reliable for predicting outcome.

- Valerie El Halta, "Normalizing the Breech Delivery," Midwifery Today Issue 38




If visualization alone does not lead to spontaneous version, have the mother begin the breech tilt at 30-32 weeks. Prop an ironing board or other flat object the height of a couch; pad the board. Have the woman lie on the board, head down, for 15-20 minutes, 6-8 times daily. Mother should massage the baby, preferably in a face/head-forward position with one hand cupped around the occiput and one cupped around the breech, moving the head forward and lifting the bottom in a rotating motion. As soon as the baby turns, get up and walk or squat. Often, if mother performs the tilt three days in a row as described and then stops for the fourth day, the baby seems to assume the vertex position on its own in anticipation of the exercise.

In particularly stubborn cases, midwives have had success with some seemingly unlikely methods. Try placing a radio in mom's underwear, low in the abdomen, or move a flashlight over the belly while she is in tilt position. You could even draw a picture of a vertex, anterior baby on the mom's belly with a washable marker, particularly if mom has trouble visualizing the head-down position. Others have used the Bladder 56 acupuncture technique, homeopathic pulsatilla, or Webster's Breech-turning Technique.

Babies have rotated anterior in many cases as a result of this positioning: Determine the position (side) of baby's back, and have the mother rest and sleep by lying on the side opposite the baby's back. Have her prop her hip on a pillow, flexing her top leg and bringing it up toward her chest, propping it with a pillow for comfort. Remind her to visualize the baby anterior; have her visualize the baby head down, face down at birth.

- Anne Frye, "Bottoms Up," Midwifery Today Issue 18

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Midwifery Today's Online Forum

I recently had a very traumatic birth as a result of a prolapsed cord. I was also given Cytotec for induction. From what I've read Cytotec can cause a very hard and fast birth and a prolapsed cord could come from a gushing or too hard breaking of the bag of water. I had both of these. Do you think the Cytotec is related to the cord prolapse? If not, could I have more information on prolapsed cords? My doctor told me it is very rare and unpredictable and there is nothing that could've been done to change the outcome. My son was born unresponsive and was not expected to survive. He did and is now home but has brain damage.

- Kristi

Go to our forums to share your thoughts and experience.

Question of the Week (repeated)

Q: When you attend homebirths, what do you keep in your kit ahead of time for those unexpected, middle-of-the-night calls? And what is the most effective way to organize and carry your materials and supplies?

- B.H.


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International Connections

I am a student at the University of Puerto Rico in Humacao and I'm looking for information about birthing centers, the risks involved in using them, the positive and negative experiences of birthing in a center, etc. I had my last baby in a birthing center and feel very strongly about women having more choices available to them. Here in Puerto Rico birthing centers are yet to become legal, so the only place to have a baby is in a hospital. Some hospitals offer birthing rooms, but we still have a long way to go. Efforts have been made to pass a law supporting birthing centers, but twice the petition has been pushed through both houses only to be defeated by the governor, who ignores the petition until the time has passed for either vetoing it or signing it into law.

I want to produce an investigation and write a thesis on the pros and cons to add to the information already existent so there can be another go at pushing the measure through and becoming law. Any suggestions about how to go about doing this will be greatly appreciated.

- Elaine Soto-Martis
Proyecto La Estancia
Calle 8, K-23
Humacao, Puerto Rico 00791


My daughter wrote this a short while ago after watching me nurse her little brother. I think it is too beautiful to keep to myself.

The breast of a woman is beautiful to a tiny baby boy.
It is like a pillow of soft white fur,
he feeds on his Mother's milk and is safe,
and he sleeps beneath her dress and she loves to stroke his bare butt.

- Kimberly Wilson


Students who are confused about the various methods of calculating EDD [Issue 3:47] should be reassured that Wood's method is the same as Naegele's. Naegele's Rule--calculating EDD by subtracting 3 months from LMP and adding 2 weeks--is the SAME as Wood's (adding one year to LMP, and then subtracting 2 months and 14 days.)

Wood recommends adding or subtracting days according to the average length of the woman's individual cycles, but so did Naegele. It's just not often remembered. The only change is Wood's recommendation to use a different calculation for multiparas. This would subtract 4 days from Naegele's dates.

- Gail Hart


In response to Claire Winstone [Issue 3:47]:

Epidurals carry risks. Cesareans carry risks. Breathing carries risks! However, there are very real benefits sometimes from even the most potentially dangerous activities. Opponents of homebirth [sometimes] make misguided statements about the risk of out of hospital birth. They caution families that they are "risking the baby's (or mom's) life" and they tell horror stories, often out of context and unsubstantiated. The burden is on the out of hospital community to demonstrate safety.

It's exciting to have research to back our position. It's sobering and useful to have research to demonstrate the potential risks of routine hospital procedures. I do not believe it benefits providers or clients to present information in an emotionally loaded manner.

I have not encountered any information in my training as a midwife that demonstrates a relationship between epidurals and the negative outcomes described in Claire's letter, e.g., babies exposed to more than an hour's worth of obstetrical medications being more predisposed to become substance abusers, and feeling disconnected from their bodies, fuzzy thinking when under stress, feeling inadequate and incapable of completing things they start, and a whole list of other possible consequences. I strongly believe in giving families accurate information. When I talk to women (and men) about the risks and benefits of a treatment or procedure, I give them documentation. I quote studies and I encourage them to research on their own and share their information with me. I work very hard to ensure that my biases do not become the foundation of my clients' decisions. Giving women information that cannot be independently confirmed is not giving informed choice.

- Melissa Jonas, licensed midwife


This is a profound and extremely negative outcome for any mother to be risking. I decided to do a literature review using PubMed (National Library of Medicine, "PubMed, a service of the National Library of Medicine, provides access to over 11 million MEDLINE citations back to the mid-1960s and additional life science journals," to see if any evidence exists for this distressing outcome. I could find plenty of reasons for women to avoid epidurals, including reduced suckling behavior in neonates and increased risks of malpositioning in the second stage of labor. I found nothing whatsoever to even remotely indicate babies whose mothers have had epidurals are at increased risk for becoming substance abusers or suffering long-term adverse psychological outcomes. I also searched for effects cited by Ms Winstone such as longer breastfeeding in mothers who do not opt for an epidural and found that, on the contrary, there is no difference in breastfeeding length in women who choose epidurals over those who do not (see J Hum Lact. 2000 Feb;16(1):7-12). Further, I find I am at a complete loss to understand how one would "inform an unborn baby of any procedure" or "include the baby in planning and decision making" as promoted by Ms Winstone.

Finally, I found an article that states that 88% of women who request an epidural after planning natural childbirth express being less satisfied with the birthing experience. Their main source of 'loss of satisfaction' arose from concerns about the effects of epidurals on their baby (Reg Anesth Pain Med 2001Sep-Oct;26(5):468-72). Are the concerns that rob women of satisfaction in their labors and deliveries being fostered by apparent misinformation such as "babies of women who choose epidurals are more likely to become substance abusers" being spread among the midwifery community?

When I was pregnant with my first child I got into a disagreement with my physician about episiotomy. He was a proponent of routine episiotomy for all his patients and I was refusing to consent to it. He presented one reason after another for the routine episiotomy, but being well armed after a thorough literature review, I was able to refute all his arguments. He became increasingly impatient with me and he told me if I did not agree to routine episiotomy my husband would not be able to enjoy sex with me because I would be left with a vagina you could drive a truck into and my uterus would fall out at age 40. At that point I decided he was using his position and authority to state things unsupported by research as if they were facts in order to bully me into agreeing to what he felt was in my best interests. I switched doctors and subsequently delivered without an episiotomy, my sex life intact and my uterus still in place nearly two years after the deadline. When I read the letter by Ms Winstone I found myself recalling that experience and feeling a powerful sense of deja vu. I would be very happy to be proven wrong by references to the literature she is citing.

- Natalie K. Bjorklund


In response to Liz Worchester [Issue 3:45]: "Varney´s Midwifery," 3rd edition, 1997, Chapter 28, pp. 521 mentions "third stage hemorrhage is due to partial separation of the placenta, the most common reason for partial separation is mismanagement of the third stage, usually involving uterine massage prior to placental separation..." In the reference section there are five references, of those I believe that the first and the last are the most pertinent to this situation.

- Dombrowski, M.P., et al. Third stage of labor: Analysis of duration and clinical practice. Am. J. Obstet. Gynecol. 172(4,part I):1279-1284 (April) 1995.

- Diagnoses and management of postpartum hemorrhage. ACOG Technical Bulletin Number 143. Jupy 1990.

- Aiyana Gregori, student midwife


Does anyone have information about hypoplasia breast or hypoplastic breast? This is also referred to as an underdeveloped breast and can interfere with milk production. Any information or resources where I could get information would be greatly appreciated.

- Julie


To LaDonna [Issue 3:47, placental abruption]:

Contact a hypnotherapist to reprogram the tapes in your head about your previous births so you don't bring previous experiences to the next birth as expectations. You might also want to attend HypnoBirthing classes to reinforce that your body works perfectly in birth. Hypnosis can tell your placenta to keep doing its job until you're term, or when it's safe for the baby to come. can give you lots of basic info and and can help you find a hypnotherapist with a birthing background.

- J. West, LM, CPM


She should take extra vitamin E (a good natural form) during the last trimester of her pregnancy and be sure that she does not take anything with dong quai (angelica) in it during her pregnancy. Some combinations have it, such as 5W and some herbal cough drops.

- Judy, CPM


Re: separation of abdominal wall [Issue 3:46-47]: The following is from an article by Jennifer Goldberg entitled "Physiology of the Puerperium." The credits were: Principles of Anatomy and Physiology, Nurse-Midwifery (Varney), Myles Textbook for Midwives, Heart and Hands, Maternity and Gynecologic Care, and Holistic Midwifery.

"The abdominal muscles can't retain the abdominal contents for the first few days postpartum (pp). The abdomen protrudes and is relaxed until 2 weeks pp. By 6 weeks pp the abdomen wall is at its nonparous state. The skin regains most of its previous elasticity and some striae (stretch marks) persist. The return of the muscle tone depends on the previous tone, exercise and amount of adipose tissue.

All pp women have some degree of abdominal wall muscle separation, called diastasis recti abdominis. Most women have about half an inch of separation, some very little. With time it becomes less apparent. Severity depends on a number of factors: woman's general condition and muscle tone, if she exercised after previous pregnancies, her parity (regaining complete muscle tone becomes more difficult with increasing parity), whether or not there was time for her to regain tone between pregnancies, overdistended abdomen. Diastasis may or may not occur with or without a large baby. If abdominal tone is not regained, the space between the rectus muscles fills in with fat, peritoneum and fascia. Subsequent pregnancies may not have the necessary muscle support, resulting in a pendulous abdomen.

Have the woman lie down and have her lift her head and shoulders as you place fingertips along the juncture of the abdominal muscles running from the umbilicus to the pubic bone. If you feel some gaping, suggest abdominal exercises. Single leg lifts progressing to sit-ups with knees bent and yoga help. Fajas (belly bands) don't."

- Detrah Hele, CPM


I am looking into becoming a midwife and I have heard that it is harder to become one if you have a degree in nursing. But I have also heard that you have to have a degree in nursing to become a midwife. Please help!

- Heathyrre Henderson
Central California


I've all but given up suggesting the kinds of wholesome remedies for my pregnant "patients" mentioned by Raven in The Art of Midwifery by Raven [Issue 3:47, tips for heartburn]. My "patients" want Tums, they want Zantac, they want what their uncle takes for his heartburn. Call me a cynical CNM.

And I call them patients because that is what they are. They are not clients, although I wish they were.

- Anon.


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Due 4/21/02. VBAC homebirth by CNM is legal in Alaska, but GREATLY discouraged by backup physicians.

Please contact 18811 Sarichef Loop, Eagle River, AK 99577; (907) 753-5708 (W); (907) 694-3728 (H);

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