In today’s blog, I am not exploring the lack of accessibility to options for vaginal breech birth or about the ethics and spectrum of experiences with ECV. This blog is just about the practical nature of breech restriction from my experience as a midwife.
You might be reading this blog because you are in a difficult position at the end of pregnancy with a breech baby that is deep in the pelvis. This is different than a baby that isn’t engaged and whose head has restrictions under a rib or impacted by the respiratory diaphragm. What are some things you or those helping you can do or at least explore?
As a midwife seeing pregnancies presenting breech, I find that one of the difficulties that can prevent the baby from turning head down can be that the baby can be quite deep in the pelvis. This can also be a problem for those seeking an External Cephalic Version (ECV) as that restriction presents as a challenge for providers. For me, as I work with families, it can be frustrating that in their session with me we are able to completely disengage the breech from the pelvis, but at the ECV the following day they are unable to do the same. When working with such presentations, I follow the principles of Spinning Babies™of balance, gravity, and movement. These principles give an advantage not just prior but even during an ECV. I also have the advantage of time and pacing not just for the pregnant nervous system but also for meeting the pacing for soft tissues release.
A deeply engaged breech can be identified by palpation, and sometimes the baby is so low that it can be mistaken for a head down baby. This is most likely to occur with a frank breech. A frank breech is more likely to get wedged lower due to the smaller diameter of the presenting part (as compared to a complete or incomplete) and the movements of the feet and hands are more towards the top of the uterus. An anterior placenta can also mask the perceptions of movement in the pregnancy. The heartbeat with a fetoscope will also be located just above the pubic bone or slightly higher and the waist of the baby can feel like a neck. The provider might be thinking that head must be deeply engaged.
A baby’s bum that is deep in the pelvis may or may not have restrictions preventing it from releasing. I believe some of the time the baby gets deep and grows and the soft tissues surrounding it restricts it from releasing to go head down. What soft tissues might be involved in this restriction? The fascia, round ligaments, the broad ligament, the psoas, the QL, and the inguinal ligament are all directly part of the surrounding area. There are more soft tissues involved with fetal positioning, but I’m not going to address an entire session here. Releasing these soft tissues can promote balance but also contribute to pelvic stability and assist with alleviating possible pain.
Creating space for a baby to find space to move also can happen by alleviating single sided compression patterns. These patterns can occur due to activities of everyday life (carrying toddlers, driving, sitting on couches, work) as well as from scar tissue or injuries from surgeries or accidents. We can balance the space with bodywork and then we can employ measures for using gravity and movement.
Releasing the bum is easier when the surrounding tissue is softened and released. It is also easier if the pregnant parent has trust for those assisting them. Connecting to the baby can also be encouraged. I usually finish bodywork with activities that assist in accessing different parts of the brain so that the person can go internally and slow down and be present. This ratcheting down the nervous systems is an important element in this work. I tend to favor light fascia therapy over the abdomen, a standing sacral release and manteada of the buttocks and belly before we work with gravity. The forward leaning inversion may be all that is needed for some people, but with those with babies that are deeply engaged, we will employ more strategies.
The Forward Leaning Inversion (FLI) is used for balancing the uterus and addressing possible nonphysiological twists in the uterus. Don’t forget that the contraindications for an FLI include hypertension, glaucoma, not wanting to do it, a large diastasis rectii, and threatened preterm labor. If a baby is deeply engaged and our parent is physically stable, I will add the manteada of the buttocks using the rebozo during the FLI. Finally, I bring out the slant board and demonstrate how to get up on it. Once on the slant board, we can add extra help with an abdominal release, a rocking motion or continuing to release the round ligaments or fasciatherapy.
For a pregnant parent at home, they can go ahead stretch, soften and open. They can also do 10 FLI a day (be safe and have support) spread out throughout the day as well as 3 breech tilts on the slant board for 10 minutes each time. I believe this is useful to do right before an ECV as well. The spectrum of ease for the ECV can range from simple massage with a few fingers to two providers putting full weight on the belly. These experiences in pregnancy are nothing alike, but we want to release soft tissues before such force may be employed.
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