When watching the birth of a breech baby we know that baby will actively participate in their own birth.  Midwife Jane Evans wrote about “The Tummy Scrunch” as being a missing link of the cardinal movements for breech birth.  In looking at breech birth we see things that we don’t see the same way with head down babies.  There is such respect for the movements of the baby as they help themselves be born.  There is such respect for the movements of the birth giver as they find just the right position to help the baby be born. We also recognize that repeated movements by either one of them along with them not facilitating descent can be a call for help.  How might this manifest in a head down birth where we don’t see baby on the outside but recognize that same relationship?

I remember laboring as a breech mother.  As my daughter was emerging, I could feel this shaking beneath me and thought just for a moment, “who is down there doing that?”  It was her.  No one was touching me besides her, and she was helping herself be born.  Rock, rock, rock and a build up of pressure as her burrito-looking bum continued to emerge.  I pushed to meet the pressure and then… release.  Her legs were born.  Rock, rock, rock, and the build up again of pressure and I pushed and both her elbows were born.  Rock, rock, rock, and a build up of pressure and her arms were born.  It was that moment, when her head was still inside, I felt I was done.

As breech practitioners, we know that breech babies will help themselves be born.  They may even rock themselves back and forth attempting to move off of where they may be caught.  Yet when this is attempted repeatedly, and there is no change in rotation or descent, we recognize it as a call to help.  We can see the efforts and if we wait too long to help them do what they sometimes are already trying to do, their efforts stop as fetal well-being decreases along with tone and flexion.  Delaying help may result in a greater need for resuscitation efforts.  

With vertex (head down) babies we don’t visually see babies working to be born.  In fact, I think there might be assumptions that little happens internally due to reduced space and the baby magically changes its consciousness upon emergence.  But if you’ve paid deeper attention, you hear or experience the reports of birth givers feeling baby push off of the top of the uterus. Some people can feel the baby moving its head back and forth finding their way.  Babies are helping themselves be born as best they can.  We just don’t visually see the same details.  

For both vertex and breech, birthing individuals also move to help birth their baby.  If one watches closely you can see maternal movements responding to what is happening internally and in relationship between their baby and their body.  

Returning to me giving birth to my breech baby, once her body was out I felt like I was done.   I instinctually moved from standing and leaning forward to leaning back into a slightly sitting position. At this point my husband had reached up to support the body of my baby so she wouldn’t fall out, yet nothing was happening.  (Yes, many of us know that nothing is in the uterus now and that continuing to push instead of wait may be advised) We waited and it was during these moments that my husband just let go of her and her feet touched the floor.  She suddenly lifted her feet, bending her knees, and threw forward her hands in clenched fists.  The pressure increased and her head was born. We had called what she had done a sign that she was going to be pretty bad ass but now we also know it in the breech world as a reflex called “the tummy scrunch.”  She was throwing herself forward flexing her head. I had also reacted to the lack of pressure and shifted my positioning.

With a head down baby we, too, can see that maternal movement is responding to pressures and fetal positioning from within their own body.  When a shoulder or an arm is on top of the pubic bone in an instinctual birth setting, you will see the birth giver move into positions due to the pressure of the obstruction.  We may know that the baby is low and begin asking ourselves, “Why is this person moving towards positions that make room to open the inlet?” Or “Isn’t this baby already engaged?”  We must dig deeper.

Sometimes birth workers  who know that baby is low may purposefully try to guide a parent into positions that open the outlet.  In some cases this can be useful, and they find their way towards birth.  However, when a person consistently returns to particular positions that open a certain level of the pelvis, they are giving us signs that they are trying to do something.  This is us seeing individualized anatomy and its response to the position of the descending baby.  As practitioners, our heads may think they should be in an outlet position.  Yet when we see the instinctual movements and responses to pain and intensity, we may be guided to use our knowledge of positioning to see what kind of help is needed.  We look at the bigger picture or the whole body of the baby that is unseen inside the person giving birth.

I remember watching a first time mother pushing for her breech baby on a deBy birth stool. As baby came closer and closer to rumping, I had expected to see internal rotation of her femurs to open the outlet.  This was not at all what this mother chose to do.  In fact, she asked for more support for her foot to be able to lunge out and externally rotate her leg on one side.  I realized then, and in watching other subsequent breech births, that this is part of the pattern in making way for the head to enter the pelvis at this time.

Now I am a firm believer in having patience for people to do the work that needs to be done to birth their baby. Sometimes we stand back and honor the process unfolding before us even when it is uncomfortable while the birth giver figures it out with their own pacing.  This is sacred work being done with their nervous system. There is a time where someone knows what they need to do to birth their baby, and yet they wait for the right moment to say “yes” (as Anna Mara Rossetti would say).

Yet, there comes a time when the repeated positions of the birth giver are similar (although over a longer period of time) to a breech baby continually trying to come off of the inlet of the pelvis.  We can put the puzzle pieces together as a sign of what needs to happen to be able to help that baby be freed before exhaustion, transfer, or shoulder dystocia.  

Honestly, we have trained for these situations.  We can see their efforts are not bringing change.  We can understand that both the baby and the birthing parent are doing the best that they can. This is when we can use a combination of following our instinct, tracking their attempts at solutions while trying to resolve pain, and using knowledge of pelvic anatomy and positioning to free whatever may be impacted.  

We can use inlet opening positions or even shift the position of baby off of the bones or reduce the presenting diameter using a Forward Leaning Inversion and / or Abdominal Lift and Tuck.  We can also use other inlet methods.

Birth attendants for vertex and breech gain knowledge with anatomy, physiology, and restoration of the mechanisms of birth.  Midwives attending breech learn to look up higher as to what might be happening above that we cannot see, as these details are life saving.  We know to look to the baby and birth giver as to what they are trying to do to help and that too informs us to help . It is time that this same deep listening can be applied to all births for when and how help may be needed.

References:

Breech Without Borders: https://www.breechwithoutborders.org/videos/  “Upright complete breech grand multip” 

Evans, Jane.  “The final piece of the breech birth jigsaw?” Essentially MIDIRS. 3(3):46–49, MARCH 2012.  (About the reflex of the tummy scrunch)

Evans, Jane. “Understanding Physiological Breech Birth”  http://www.breechbirth.net/uploads/1/2/7/8/12786795/essentially-midirs-feb-2012.pdf pg 17-21.

Rossetti, Anna Maria. Italian midwife and Approved Spinning Babies® Trainer.  

Tully, Gail. Spinning Babies® https://www.spinningbabies.com/optimal-maternal-postions-at-the-levels-of-the-pelvis/ 

Tully, Gail.  “Solutions for Dystocia in the Levels of the Pelvis.” June 14, 2019.