Bottoms Down Under

‘Into the Breech’ Workshops in Perth and Melbourne, December 2013

IMG_0088

Anke Reitter, Danielle Freeth, Rhonda Tombros, Andrew Bisits

This month has seen a small series of Australian workshops, hoping to increase confidence among those already working to modernise breech birth in Australia. The ‘Into the Breech’ conferences were instigated by Dr Rhonda Tombros, an academic lawyer with an interest in human rights and the mother of a breech born baby, and organised by Barbara Glare. The conferences coincided with a six month research fellowship visit by Dr Anke Reitter (FRCOG) of the Frankfurt team, whose MRI research will soon be published, concerning changes in pelvic diameters with maternal position changes.

The Perth workshop, on 3 December, was held in the Perth Zoo and was opened by midwife Danielle Freeth, also the mother of two breech babies. As for obstetricians, it was quality rather than quantity on this occasion. One of the participants, Dr Liza Fower, Head of Obs and Gynea at the Armadale Hospital, gained significant experience facilitating breech birth in South Africa and has been able to continue to offer support. She also contributed to one of our practical workshops with some useful tips.

IMG_0078

Anke Reitter frisking Andrew Bisits .. while demonstrating how to release stuck nuchal arms.

Dr Andrew Bisits (FRANZCOG) presented in Perth, on pathways for women and complications. Bisits is one of the Directors of the ALSO (Advanced Life Support in Obstetrics) course in Australia, which will be updated to include emergency manoeuvres when a woman is in an upright position. He and his team, including Midwifery Professor Caroline Homer, have launched an intensive course for professionals in Australia, the BABE (Become a Breech Expert) course. I am very much hoping to bring this course to the UK at some point in the future, and in the meantime will be ensuring that the information presented at the Breech Birth Network study days is in line with the systematic approach they are developing.

Melbourne attracted more consultant obstetricians, GP obstetricians and a lively group of midwives. Many conversations occurred during the break, suggesting a critical mass in this location, likely to move on with a more organised and collaborative approach to supporting women with breech presenting babies. This may require more working together across traditional boundaries if women are to have adequate support for viable choices, especially as breech services are reintroduced among teams with minimal recent experience.

Dr Rhonda Tombros

Dr Rhonda Tombros

A highlight of both days was Dr Rhonda Tombros’ presentation on the legal aspects of informed consent and negligence focusing specifically on issues around breech birth. We all hope she writes this up for publication in the near future.

Although I present at these conferences (in this case, on the evidence base and ‘normal for breech’), I find them invaluable to developing my own practice. The two messages I found most interesting with this visit concerned timings and episiotomy.

Timings: Bisits and Reitter gave increased focus to achieving a prompt delivery, suggesting that 3 minutes from the birth of the umbilicus to the birth of the aftercoming head is ideal. “Three minutes is ideal, you are probably okay with five, but after that most babies will experience some sort of compromise.” This aspect has not been previously emphasised at the conferences I have attended, but the intense dialogue which has developed between midwives and obstetricians supporting breech has revealed differences. It seems that timings are almost taken for granted in obstetric training for breech, whereas midwives have a much higher tolerance for a ‘wait and see’ approach, emphasising the ‘hands off the breech’ philosophy. In reviewing the anecdotal experiences where breech is being reintroduced, the current consensus among our small collective of professionals is that, while a ‘wait and see’ approach will often result in a spontaneous resolution, it will also more often result in a severely compromised baby when that spontaneous resolution does not occur. Therefore, following the birth of the umbilicus, if the birth does not continue to progress promptly or you are not confident of the condition of the baby, intervening to facilitate the birth is recommended, using the systematic approach we are advocating:

  • Exif_JPEG_PICTURETry to sweep down the arms in front of the face
  • If not possible, rotate in the direction of the nuchal arm (modified Lovesets)
  • Ensure the head is aligned with the body and the mother’s birth canal
  • Deliver the head using classic or modern techniques to achieve flexion

The skill of an experienced practitioner is in holding back from intervening when the birth is progressing normally, balanced with effective intervention when it is not, and developing this judgement is a key aspect of breech training days.

Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Episiotomy: In Melbourse, Consultant Midwive Michelle Underwood presented data from the Westmead Clinic which she runs with Dr Andrew Pesce in Sydney. While all of their statistics were fascinating – especially demonstrating a reduction in CS for breech from 90% to 63% in the first year of the clinic – I was intrigued by their stats on perineal damage. It seems that, compared to all births, the breech births have the highest rate of episiotomy AND the highest rate of intact perineum. This suggests to me that the majority of perineal damage from vaginal breech births may be iatrogenic, which is not surprising given that cutting a timely episiotomy is an over-emphasised part of some obstetric training for breech (Deering et al 2006), as is the use of forceps.

But is it necessary, or helpful (in most cases)? In his own practise, Bisits avoids episiotomy because he feels the perineum has an active role in encouraging breech babies to remain well flexed throughout the birth. Reitter also discussed her own personal stats – three (3) episiotomies cut in the last 10 years, a period which has included management of over 300 breech births and countless cephalic complications. The episiotomy rate in her unit in Frankfurt is exceptionally low overall. Change was accomplished when the Lead Obstetrician (Prof Frank Louwen) insisted that episiotomies would not be cut unless absolutely necessary, and that each episiotomy would need to be justified personally to him. That’s what leadership can do.

Shawn

9 thoughts on “Bottoms Down Under

  1. jimgthornton

    Are you seriously claiming that Dr Reitter has personally delivered 300 vaginal breech births? I don’t know how big her clinic is, but she works in Frankfurt Germany where a hospital delivering 2,000 women a year would be considered large. A 3 percent rate would implie 60 breech babies per year. At least half would be delivered by Caesarean in Germany. Let’s generously say her hospital delivers 30 vaginal breech babies per year. Her web page lists 30 doctors in the clinic. Not all will be delivered by doctors, but I guess Dr Reitter does more than her fair share, although if she finds time to be director of obstetrics and to travel to breech birth conferences in Australia, she surely cannot do much more. Let’s be generous and assume she personally does 5 per year. That would imply that she has been working at that rate for 60 years!

    In my hospital with 6,000 births a year, even before the Term Breech Trial came out, very few individual doctors would have personally delivered more than half a dozen vaginal breech births in a year, and those who did so would have only done it for a relatively short period while they were senior resident on the labour ward.

    Over 34 years (four in Africa) as a trainee and consultant obstetrician, always doing both labour ward sessions and obstetric on call, I doubt I’ve personally delivered more than 50 breech babies vaginally in total. Probably fewer.

    I’m not getting at Dr Ritter. I’m sure she’s very skilfull, and certainly much more skilful than me! But I remain sceptical of casual claims of very large personal vaginal breech experience.

    Reply
  2. midwifeshawn

    Good morning, Dr Thornton! Your vehement scepticism is invigorating, and I have secured a second coffee in order to respond to it. Your scepticism is also reasonable .. I too believe breech experience is sometimes exaggerated.

    But my claim is not casual, nor was hers. At the hospital in which Dr Reitter works in Frankfurt, they began running an organised breech clinic in 2003. They steadily attracted more referrals, serving as a regional centre, and the breech birth rate has climbed to well above 10% of all births per annum. During this time, two consultants (mainly) have put themselves on call for breech births, Prof Frank Louwen and Dr Anke Reitter. Their data, which includes over 400 planned breech births as of 2011, indicates that a small number were not able to have a VBB due to no ‘experienced attendant’ being available, eg. neither of them were able to attend.

    Dr Reitter is currently in Australia on a 6-month research fellowship where she has been finalising some of her own publications and assisting Dr Andrew Bisits with some of his research and teaching activities in Australia. Dr Bisits also puts himself on-call for breech births and has attended a similarly large number. His data has just been accepted for publication, so we’ll be keeping a keen eye out for it.

    I can verify that this is how they do it because as we sat across a table in Perth sharing a couple of very excellent pints of Little Creatures*, Andrew phoned back to Sydney to check which colleague was on-call. One of his breech caseload was ‘in the zone,’ and he wanted to check whether there was someone with sufficient experience on duty should the birth occur before his arrival back at 6am the next morning. Andrew also revealed that some of his best games of tennis have occurred after being called out in the night to a breech birth. He and Anke made the point of how important it is to look after yourself when you are so often on-call looking after others .. by running 10K around the Swan River prior to the conference! Hard core. I and the other more voluptuous speaker went out to breakfast.

    Rather than exemplifying the superiority of German obstetrics, Dr Reitter and the Frankfurt clinic show us what could be possible if anyone actually took any notice of the RCOG recommendation to refer to someone who is experienced enough to support a vaginal breech birth, and specialist breech clinics were recognised as the way forward. It won’t be many obstetricians, or indeed many midwives, who will want to put themselves on-call in order to develop this level of experience. But hopefully we’ll make the most of those who will.

    (For the straight-shooting record, since some people refer to me as an ‘expert’ – a label I’ve never put on myself – I have been involved in over 20 planned vaginal breech births in the 4 years since I have been qualified in the UK, and 9 of these have resulted in actual vaginal breech births. But I’m on call at the moment, so hopefully 10 soon. Nine VBBs does not make me an expert, but it makes me more experienced with VBB than most midwives will be in their careers, and from what I can tell roughly equivalent to a UK-trained Registrar these days.)

    * It was awesome, and highly recommended by Andrew’s son: https://littlecreatures.com.au/

    Reply
  3. midwifeshawn

    I’ve edited the above reply, as after consultation it appears I may have underestimated the amount of experience, rather than overestimated.

    Jim Thornton wrote: “In my hospital with 6,000 births a year, even before the Term Breech Trial came out, very few individual doctors would have personally delivered more than half a dozen vaginal breech births in a year, and those who did so would have only done it for a relatively short period while they were senior resident on the labour ward.”

    If this represents ‘an experienced centre’ in the TBT, the results are clearly not applicable to services where individuals are attending 30 breech births per year. And if as a midwife I can attend half a dozen vaginal breech births in the past year by putting myself on-call, much more can be done to make vaginal breech birth a viable option for women, using a specialist clinic approach.

    Reply
    1. jimgthornton

      Delighted to be corrected, but fear people like Drs Reitter and Bisits are rare in UK. We seem more interested in work/life balance. But maybe that’s just the NHS. Dig! 😉

      Has Dr Reitter published her series? If not, we’d love it in EJOG.

      Reply
      1. midwifeshawn

        I feel sure she will be in touch.

        There are a few wonderfully mad OBs out there putting themselves on-call to drag this thing into a multi-professional team approach. It requires juggling and flexibility, but not as big a burden as most people think, especially if you have a partner system or small team set up.

        I did think of you over the summer. My older boys and I were just about to walk out the door to go canoeing down the road in Beccles, when I got a call a few weeks earlier than I was expecting it. Three hours later her baby was born quickly and easily at the hospital, but the thought flew through my mind: “No wonder they don’t have more breech births in Nottingham! Jim Thornton would never be having this.”

        Reply
  4. Pingback: Emerging evidence for upright breech birth | The midwife, the mother and the breech

  5. Pingback: The breech and the perineum | The midwife, the mother and the breech

What are your thoughts?