Breech Birth

Study Group Module

Breech Birth National Midwifery Institute, Inc. Study Group Coursework Syllabus

Description: This module explores breech which is a normal variation in vaginal birth. It includes recommended reading materials in print and online, and asks students to complete short answer questions for assessment, long answer questions for deeper reflection, and learning activities/projects to deepen your hands-on direct application of key concepts.

Learning Objectives: • Identify the normal range of time in pregnancy when a baby usually turns to a vertex presentation. • Understand the breech presentation to be a variation of normal birth. • Identify the risks of breech birth. • Identify the social/cultural/medical bias that has made vaginal breech birth a rarity. • Demonstrate current understanding of Breech Birth in academic discourse • Identify the landmarks one may detect when palpating a breech baby in late pregnancy. • Identify the steps of an internal exam to confirm suspicion of breech. • Identify ways that a pregnant woman may know her baby is breech or has turned vertex. • Identify the role of ultrasounds to rule out or confirm a suspected breech. • Once a breech is detected, identify ways to encourage the baby to rotate to a vertex position. • Identify the steps of an external version. • Identify the risks of an external version. • Identify potential reasons a baby might be breech. • Develop practice guidelines for external versions in your own practice. • Review the concepts of informed consent. • Identify the mechanisms for vaginal breech birth. • Understand the physiologic emergence of a breech birth, and how to keep the physiology functioning normally • Identify points of intervention in a breech birth, and maneuvers for assisting a breech birth when necessary. • Review newborn resuscitation. • Identify local doctors who are willing to attend vaginal breech births. • Identify the local doctors who are willing to consult with community midwives on breeches. • Identify the local community standard among midwives regarding breech births. © National Midwifery Institute, Inc. Revised 2018

Study Group Module: Breech Birth

Learning Activities: ● Research and read appropriate study sources, seeking out additional study sources where needed ● Complete short answer questions in attached module document for assessment ● Complete long answer questions for deeper reflection in attached module document for assessment ● Complete learning activities listed in attached module document for assessment ○ Write a reflection on the experience of practicing breech delivery ○ Draft practice guidelines for breech ○ Draft practice guidelines for external cephalic version ● Submit work to Study Group Course Coordinator ● Reflect on feedback from Study Group Course Coordinator and re-submit work as needed

Study Sources (print): The following texts are recommended for completion of this module. Use them to cross reference and build a more comprehensive understanding. Using keywords from the Learning Objectives, search the index. Read those pages listed, and read the chapter in which they are found. Establish a context for the information so that you understand how other topics are related. In addition, read the chapter headings in the Table of Contents, and flip through each text to familiarize yourself with the content of chapters. As you work through Study Group modules, you will eventually read each text in its entirety. ● Holistic Midwifery, Vol. I, II, Frye ● Varney’s Midwifery ● Myles Textbook for Midwives ● Human Labor and Birth, Oxorne and Foote ● Assessment and Care of the Well Newborn, Thureen, Deacon, O’Neill, Hernandez ● Birth Emergency Skills Training, Gruenberg

● Optional ● -The Natural Pregnancy Book, Romm ● -Homeopathic Medicines for Pregnancy and Childbirth, Moskowitz ● -Acupuncture in Pregnancy and Childbirth, Betts

Study Sources (online): See NMI website Breech Birth module web resources section for current online study sources for this module.

Related Modules: ● Birth Bag and Setup ● Cesarean and VBAC ● Charting and Practice Guidelines © National Midwifery Institute, Inc. Revised 2018

Study Group Module: Breech Birth

● Embryology and Fetal Development ● Fetal Heart Rate Patterns ● Fetal/Newborn Circulation ● First Stage ● Holistic and Traditional Health and Healing ● Meconium ● Apnea/Hypoxia/Respiratory Distress ● Physical Assessment of the Newborn ● Labwork and other Clinical Assessments ● Second Stage ● Third Stage ● Transporting

Submitting Module for Assessment: Study Group modules are accepted electronically in PDF format only. We encourage you to submit modules as you complete them throughout each quarter of enrollment.

Please e-mail your completed Study Group module to: Study Group Course Work Instructor [email protected]

Once your module has been e-mailed to us, you will receive an e-mail confirmation that we have received it. Study Group modules are reviewed and returned in digital format as PDF documents. Modules can take up to 1 month from submission to be reviewed and returned to you. We will return your module as an e-mail attachment. Each module includes an Evaluation Sheet at the end of the pdf. The module’s page on the student portal also includes a link to a fillable online module evaluation sheet. Please take the time to fill out the module evaluation sheet and return it to us for each module, it helps us to improve our course work.

Please follow these formatting guidelines when submitting modules: ● Your first initial and last name in title of PDF, along with name of module. Example: “ERyanFirstStage.pdf” ● Title of module on the document’s front page ● Your name on the document’s front page ● Provide the text of each question, followed by a blank line and then your thoughtful answer (without the question, you have commentary without context) ● Blank line between the answer for a question and the next question: question, blank line, answer, blank line, question, blank line, answer… ● Please leave margin space for our comments! ● Don’t use script or cursive writing style text ● Font size not smaller than 12 ● Credit sources of direct quotes

Study Group Module: Breech Birth

Completion Requirements and Feedback: In order to complete this module for graduation purposes from National Midwifery Institute you must review all resources, complete the attached short answer questions for assessment, long answer questions for deeper reflection, and learning activities/projects, and submit them as detailed above. Upon return to you, your coursework may have feedback or ask for additional information or exploration on certain topics. Your work will be evaluated n the following Rubric (pasted below). You must achieve a minimum score of 7.5 in order to move on to your next module, though we encourage all students to strive for a 10. Level 1 Level 2 Level 3 Level 3 Student (0 Points) (1 Point) (1.5 points) (2 points) Exceeds Score Not Developing Meets Basic Expectations Adequate Adequacy Expectations

Completion of -Module not -Major -All aspects of -All aspects of module module completed Elements of module elements elements present and prompts and module are present, with answered completely elements missing some minor questions unanswered or missing

Demonstrates - Lack of - Responses - Responses are - Responses are clear, Comprehensi comprehensio are unclear clear and reflect well written, and n and do not basic reflect in-depth on of module reflect basic comprehension comprehension of content and comprehension of module module content and concepts of module content and concepts. Added concepts concepts subpoints and additional reflections demonstrate a deeper knowledge and curiosity. Analysis - Key terms -Inaccurate -Accurate - Accurate definitions not defined definitions of definitions of key of key items key items items -Strong connections -Limited -Connections made between connections made between evidence, subtopics made between evidence, and clinical experience evidence, subtopics and subtopics and clinical clinical experience - experience Incorporation of original ideas and incorporates some clinical experience in responses where possible

Study Group Module: Breech Birth

Level 1 Level 2 Level 3 Level 3 Student (0 Points) (1 Point) (1.5 points) (2 points) Exceeds Score Not Developing Meets Basic Expectations Adequate Adequacy Expectations

Evidence - No research -Research not -Research is -Research is abundant evidence used present but -Research is used -Research not limited compelling and clearly -Research relevant to connected to presented is communities served questions weak or not by midwives asked in relevant to module communities served by midwives Engagement -Evident -Evident study -Evident that -Evident that study with Learning study sources sources were study sources sources were fully were not partially utilized were fully utilized utilized and Resources utilized independent research was undertaken -Full incorporation of original ideas, personal analysis and incorporates relevant clinical experience in all areas possible

Skills Following are excerpts from the NMI forms for assessment of midwifery skills, which include all skills identified and required by NARM. Review the following skills and consider how they each relate to the content of this module. If you are currently working with a preceptor, take this opportunity to focus on these areas. During Supervised Primary Care you will formally evaluate these skills together using the NMI forms Form 52 - Assessment of Student’s Midwifery Skills and Form 53 - Student Self-Assessment of Midwifery Skills. 1. Midwifery Counseling, Education and Communication: A. Provides interactive support and counseling and/or referral services to the mother regarding her relationships with her significant others and other health care providers B. Provides education, support, counseling and/or referral for the possibility of less-than- optimal pregnancy outcomes C. Provides education and counseling based on maternal health/reproductive/family history and on-going risk assessment E. Educates the mother and her family/support unit to share responsibility for optimal pregnancy outcome F. Educates the mother concerning the natural physical and emotional processes of pregnancy, labor, birth and postpartum G. Applies the principles of informed consent H. Provides individualized care I. Advocates for the mother during pregnancy, birth and postpartum J. Provides education, counseling and/or referral, where appropriate for: 8. Complications 2. General Health care Skills:

Study Group Module: Breech Birth

L. Refers for performance of ultrasounds 3. Maternal Health Assessment: D. Assesses fetal weight, size, lie, or lightening F. Performs routine prenatal physical exams, including ongoing assessment of: 1. Maternal psychosocial, emotional health and well-being 17. Fetal position, presentation, lie, and the volume of amniotic fluid 18. Fetal weight 19. Signs of edema 19. Signs of edema 21. Signs of abuse including: a) Maternal substance abuse b) Emotional/physical/sexual abuse to the mother K. Recognizes and responds to potential prenatal complications by 5. Identifying breech presentations 6. Turning breech presentations with: a) Alternative positions (tilt boards, exercises), b) non-allopathic methods 7. Identifying multiple gestation pregnancies L. Establishes and follows emergency contingency plans for mother and/or newborn 4. Labor, Birth and Immediate Postpartum B. Evaluates and supports a laboring mother during the first stage of labor by assessing : 1. Maternal physical and emotional condition based upon assessmnt of: a) vital signs, b) food and fluid intake/output, c) dipstick urinalysis for ketones, d) status of membranes, e) uterine contractions for frequency, duration and intensity with a basic intrapartum examination, f) fetal heart tones, g)fetal lie, presentation, position and descent with: 1) visual observation, 2) abdominal palpation, 3) vaginal examination, h) effacement, dilation of cervix and station of presenting part, i) maternal hydration and/or vomiting by administering 1) fluids by mouth, 2) ice chips, 3) oral herbal/homeopathic remedies, 4) deep immersion in warm water C. Demonstrates the ability to evaluate and support a laboring woman during the second stage of labor by: 11. Demonstrating the ability to recognize and respond to labor and birth complications such as: b) Cord prolapse by: 7) increasing mother’s oxygen supply, 8) facilitating immediate delivery, if birth is imminent, 9) preparing to resuscitate the newborn c)Variations in presentation such as: 1) breech presentation © National Midwifery Institute, Inc. Revised 2018

Study Group Module: Breech Birth

d) Management of meconium stained fluids by: 1) eliciting the mother’s cooperation to deliver head quickly, 2) instructing the mother to stop pushing, 3) wiping out the inside of the baby’s mouth, 4) clearing the airway with suction of mouth and nose, 5) preparing to resuscitate the baby E. Assesses correlation of weeks gestation to fundal height F. Performs routine prenatal physical exams, including ongoing assessment of: 2. Maternal physical health and well-being, by tracking variations and changes in: a) color of mucous membranes, b) General reflexes, c) Elimination/urination patterns, d) Sleep patterns, e) Patterns of sexuality, f)Movement, gait and energy level 4. Vital signs 5. Weight 6. Hemoglobin and hematocrit 7. Glucose level 8. Urine for: a) Appearance, b) Protein, c)Albumin, d)Glucose, e) Ketones, f)pH, g) Leukocytes, h) Nitrites, i) Blood 9. Breast condition 10. Costovertebral angle tenderness (CVAT) 11.Deep tendon reflexes (DTR) of the knee 12. Signs of clonus 13. Fundal height measured with: a) Finger breadths b) Tape measure 14. Evaluation of estimated time of delivery 15. Fetal activity and responsiveness to stimulation 16. Fetal heart rate/tones auscultated with: a) Fetoscope b) Doppler

Introductory and Further Thoughts: Due to laws and regulations many midwives cannot deliver a known breech. This has reduced the skills of many midwives but midwives need to know how to deliver breech in case of a surprise breech as for any global work. There are many resources provided in this module but if you have not attended a vaginal breech, we strongly encourage you to watch multiple breech births online to learn what normal breech looks like.

Study Group Module: Breech Birth

Breech Birth National Midwifery Institute, Inc. Study Group Coursework Short Answer Questions

Short Answer Questions: 1. Define the following: a. breech baby b. breech birth c. surprise breech birth

2. When do you expect a baby to be head down before birth?

3. How often are babies presenting breech at birth?

4. What might you feel when palpating a breech baby? Why might you miss this on palpation?

5. What physical anomalies or birth defects would cause a baby to present breech?

6. What details about the client’s anatomy may influence a baby’s breech position?

7. How does the location of audible fetal heart tones on the client’s abdomen reveal a baby’s presentation? Why might you miss this, or get it upside down?

8. If you are not certain that a baby is head down, what would you do: a. at 32 weeks? b. at 34 weeks? c. at 36 weeks?

9. Your client, Lupe, age 31, G2P1 with a history of an NSVD, has been very healthy during her pregnancy and her baby has been growing well. The baby has clearly been head down since 26 weeks. Today she is 36 weeks. When you are palpating her baby, she has a very tender area on her left side, just below her ribs. You carefully palpate around this tender area, not wanting to hurt her. When you feel at her pelvic brim, you are surprised at how low her baby’s head must be; there is a wide part at her pelvic brim, like maybe shoulders. You palpate her fundus again, taking care to feel beneath the tender place you avoided before. There you feel a hard, ballotable form that floats away from your hands easily. By the time you finish palpating above her pelvic brim again, you are sure that her baby is breech. Once you talk with her about this, she tells you her baby was really moving a few nights ago. Since then, this tenderness beneath her rib area has developed. What will you recommend to her?

Study Group Module: Breech Birth

10. A week passes and Lupe’s baby is still breech. At 37 weeks, she wants to know about her options. She is afraid the baby will come soon and she is worried about attempting a vaginal breech birth in the hospital. What are her options?

11. Discuss External Cephalic Version (ECV) a. what is an ECV? Why are they done? b. what is the optimal timing for an ECV? Why? c. how does a medical external version procedure differ from a midwife performed external version? d. what are the risks and benefits of an ECV? e. why are ECVs typically done under ultrasound guidance in a medical setting?

12. Discuss how the following might be used to help turn a breech baby to cephalic. a. Moxa b. Acupuncture / Acupressure c. Chiropractic / Osteopathy d. Homeopathy e. Hypnotherapy f. (other)

13. What experience do you have / have you had in your apprenticeship with the modalities listed in question 13 in regards to turning breech babies?

14. Why are vaginal breech births especially rare in today’s medical practice?

15. What are the commonly cited concerns about vaginal breech birth?

16. What is the current standard of care or expected delivery method in the hospital for breech babies in your area? Why? What conditions must breech babies meet for vaginal delivery if vaginal delivery is offered?

17. What is the regulation in your area regarding midwives, homebirth, and delivering breech babies?

Even in jurisdictions where attending home breech births is out of legal scope for licensed homebirth midwives, some midwives may find themself attending a surprise or emergency breech birth, or may find themselves working in a different jurisdiction with a different explicit scope of practice in the future. Therefore, we find it critical for all students to demonstrate knowledge on the facilitation of breech birth as primary care providers as a part of their education.

18. Review what you may feel on palpation to determine if a baby is breech. Describe what you might feel to confirm a breech presentation when doing an internal exam. © National Midwifery Institute, Inc. Revised 2018

Study Group Module: Breech Birth

19. During a cervical exam with a breech presentation, what may you mistake for complete effacement and 1cm dilation?

20. What does thick dark meconium mean during second stage of a breech labor?

21. Describe the possible positions a breech baby may assume. What particular consideration for delivery must be taken with each?

22. What positions may clients assume to deliver their breech babies? Which do you prefer and why?

23. Discuss the research on upright breech birth.

24. Should breech babies be delivered in water? Discuss your thoughts.

25. Discuss the “hands off the breech” thought/ideology.

26. Describe “breech extraction”.

27. What signs indicate that all is well in a breech delivery?

28. What signs would show you that you might need to intervene in a breech birth?

29. What maneuvers are indicated for managing breech birth complications? How might they need to adjust depending on the mother’s position?

30. Describe the normal progression of an undisturbed breech birth

31. How long should an uncomplicated breech take from umbilicus to forehead?

32. Under what circumstances would you create a loop of cord during a breech birth?

33. Under what circumstances would you use suprapubic pressure during a breech birth?

34. You have determined that the baby about to be born is breech. This is the second term baby for this mother. She is 9cm dilated, and it feels as though she could likely push past this little bit of remaining cervix. What do you instruct her to do?

35. During a newborn exam following a breech birth, what do you anticipate about the baby?

36. How common might concurrent complications in mother and baby be following a breech delivery?

Study Group Module: Breech Birth

37. How might you learn more about breech birth? Identify Breech learning opportunities around you and online.

Continued………

Study Group Module: Breech Birth

Breech Birth National Midwifery Institute, Inc. Study Group Coursework Long Answer Questions for Deeper Reflection

Questions Requiring Longer, More Thoughtful Answers: (number continued from previous section). 38. Review the research presented on Breech Birth listed in the resources. In your understanding, describe the presentation, impact, and flaws of the Term Breech Trial, later trials that showed different results, and the state of clinical knowledge on breech birth today.

39. Review the Clinical Practice Guideline (in the Online Resources) for attending Breech Births in Canada and New Zealand. What do you agree with and not agree with?

40. Describe how you can continue to serve your client when a breech birth is planned for in the hospital.

41. What experience have you had detecting or confirming breech presentation?

42. Have you been present at breech births? What were your observations?

43. Compile a list of local doctors who are willing to attend vaginal breech births. Additionally, what are their requirements for participation (for example: woman must have IV, epidural, forceps delivery of head, baby must be a certain type of breech...)

44. Compile a list of local doctors who are willing to consult with community midwives regarding breeches.

45. What is the local community standard among midwives regarding detection of breech babies? (What is done by midwives in your community who suspect a client is carrying a breech?)

46. What is the local community standard among midwives regarding breech births?

Continued…..

Study Group Module: Breech Birth

Breech Birth National Midwifery Institute, Inc. Study Group Coursework Projects/Learning Activities

Projects(send completed projects with the rest of your course work for this module) (number continued from previous section). 47. Using a doll and pelvis, practice breech birth maneuvers for midwives (when needed) over and over and over to develop confidence and muscle memory. Practice these in at least two different client positions. Write a paragraph reflecting on the experience of working through a breech delivery.

48. Draft practice guidelines for breech (including footling breech) in your own practice. Include reference to your consultation and referral plan, instructions for clients, informed consent, transport plan in response to cord prolapse, surprise breech in labor, postpartum care, and newborn resuscitation guidelines. Submit this draft and include it later in your Practice Guidelines projects (in the Charting and Practice Guidelines Module.)

49. Draft practice guidelines for external cephalic version in your own practice. Include reference to your consultation and referral plan, informed choice/consent, transport plan in response to complications, and next steps if the ECV is unsuccessful. Submit this draft and include it later in your Practice Guidelines projects (in the Charting and Practice Guidelines Module.)