The Royal College of Obstetricians and Gynaecologists is consulting the public on the proposed new breech guideline, until 2 May, which is Monday. Read the guideline: Here. They accept one peer review per organisation, so I will collate any comments sent to me personally or posted here on Monday afternoon, and submit them for Breech Birth Network. – Shawn
It’s not every day you get to watch a sea otter pup come into the world! But when a pregnant wild otter took shelter in our Great Tide Pool Saturday, we had a unique opportunity to see it happen. Sea otters can give birth in water or on land. You’ll notice that mom starts grooming her pup right away to help it stay warm and buoyant—a well-groomed sea otter pup is so buoyant it’s practically unsinkable! For more video of the birth (spoiler alert: the miracle of life is graphic!) check out our YouTube channel: http://mbayaq.co/1R0v6oD . Besides keeping the pup afloat, grooming also helps get the blood flowing and other internal systems revved up for a career of chomping on invertebrates and keeping nearshore ecosystems, like the kelp forests in Monterey Bay, and the eel grass at Elkhorn Slough, healthy.Our sea otter researchers have been watching wild otters for years and have never seen a birth close up like this. We’re amazed and awed to have had a chance to witness this Monterey Bay conservation success story first hand in our own backyard. Welcome to the world, little otter!
Posted by Monterey Bay Aquarium on Sunday, 6 March 2016
This Tuesday, 1 March 2016, Breech Birth Network travelled to Portsmouth again. The guest speaker was lovely doctor Ms Arti Matah, who spoke about an obstetrician’s view of vaginal breech birth, and led a lively discussion around whether the breech team / care pathway model might work for Portsmouth. Watch this space! I am incredibly impressed with the commitment Portsmouth midwives have shown to developing sound breech skills to support women who choose to birth their breech babies actively.
The skill which captured the group’s imagination most was how to resolve a situation where the head is extended and impacted at the inlet of the pelvis. My research suggests that identification of optimal mechanisms is a core skill for practitioners attending breech births. Therefore our approach to teaching this skill is:
- Identification of optimal mechanism — The aftercoming fetal head normally rotates to the oblique/transverse diameter as it enters the pelvic brim, just like the cephalic-presentation head does when engaging.
- Identification of deviation from optimal mechanism — In this complication, the fetal head is pinned in the anterior-posterior diameter, with occiput anterior, over the maternal symphysis publis, and chin or brow on the sacral promontory. The bottom of the fetal chin is felt like a ‘bird beak,’ pointing towards the sacrum. The maxilla bones are difficult/impossible to reach, so flexing the head using the usual techniques will be a challenge.
- Restore the mechanism — See below.
The RCOG guideline suggests delayed engagement in the pelvis of the aftercoming head should be managed using one or both of the following techniques:
Suprapubic pressure by an assistant should be used to assist flexion of the head. Given our understanding of the head as impacted at the pelvic brim and our goal of restoring the mechanism by rotating the head to assist engagement, we suggest that the goal of suprapubic pressure should initially be to encourage this rotation. This mirrors the understanding we have of suprapubic pressure to resolve a shoulder dystocia by rotating the impacted shoulder off the symphysis pubis. Forcible pressure on an impacted fetal head is unlikely to be beneficial for the baby.
The Mauriceau-Smellie-Veit manoeuvre should be considered, if necessary, displacing the head upwards and rotating to the oblique to facilitate engagement. We use a doll and pelvis to explore why this elevation and rotation prior to re-attempting flexion is necessary. Watch the video below to see this demonstrated.
When a woman is birthing her breech baby actively, we facilitate the head to enter the pelvis using the same principles. Watch the video below, where Midwife Olivia Armshaw is teaching how to intervene in the case of an extended head at the inlet, when the woman is birthing on hands/knees. In this video, the midwives are discussing how maternal movement – in this case, the woman shuffling her bottom back towards the midwife slightly – helps to elevate the head off the pelvic inlet to facilitate engagement, a technique we learned from the midwives of Sheffield. The principles – elevate, rotate & flex the head – are the same.
Thank you to the Practice Development Team at Portsmouth for organising the day. And thanks to the following midwives for assisting with the day:
- Claire Reading, midwife in Somerset, who shared her breech experience gained working abroad, and facilitated one of the hands-on stations
- Olivia Armshaw, midwife from Gloucester, who facilitated one of the learning station and presented on the process of developing a breech team in her local area
- Tess McLeish, midwife from Lewisham who helped the day run smoothly
Our one sadness on this study day was that we were not joined by any of Portsmouth’s obstetric staff, aside from Ms Arti Matah, who needed to leave early because she was good enough to present at the study day following a night on-call. Across the UK, midwives are trying to engage their obstetric colleagues in a discussion about how to improve things for breech babies and their mothers, and we really need more doctors to come to the table for that discussion to result in a service which is as safe as possible.
BONUS was meeting and relaxing with Midwife Jenny Hall in Portsmouth after the study day!
Feedback from the Study Day:
“the group work was excellent Overall I thought the day was was a good balance of theory to practical”
“very interactive. realistic rather than textbook. real life experiences.”
“perfect study day. Interesting and kept my attention all day!!!”
“visual with the film clips and hands on with the doll and pelvis. Was very good to see normal and abnormal films and great discussion with colleagues to share experiences and what to do in that situation.”
“I also thought Shawn’s attitude to breech was very refreshing. I half expected it to be a bit like “you can have a vaginal breech no matter what”. this was not the case. She had a very safe and sensible approach.”
“Unless you are a breech baby, you are not born lucky, but you become so if you invest your resources in nourishing the forces that support the world.”
from the abstract to Melania Calestani’s ethnographic study on how folk from El Alto acquire a sense of well-being, ‘SUERTE’ (Luck): Spirituality and Well-Being in El Alto, Bolivia
In her study, people were helped to achieve well-being by Yatiri, meaning ‘the one who knows.’ These wise women or men were usually elected to the position of yatiri by supernatural events, one of which is being born breech.
This post builds on my primary research, Standards for maternity care professionals attending planned upright breech births: A Delphi study. The research reports an experienced panel’s consensus on the skills required for midwives and obstetricians supporting physiological breech births. The practical content of the article is my personal application of one of the findings to clinical teaching.
“Health professionals attending upright breech births should be competent [to assist] rotation of the fetal back to anterior (when the mechanism has deviated from normal)” (p 5). 77% of the panel agreed that this is an important skill. This standard of competence combines two skills: 1) recognising deviation from normal mechanisms; and 2) assisting by restoring the mechanism to normal.
- Recognising deviation from normal mechanisms
Within the past two weeks, two people have discussed with me concerns about an incorrect understanding of the correct position for the fetal back when a woman is in a hands/knees position. First, a Practice Development Midwife (PDM) says she advocates teaching breech in ‘only one way’ (eg. lithotomy) because people get confused. A midwife attending training advocated for hands/knees positioning, but when questioned about where the fetal back should be, replied, “The fetal back remains uppermost.” Similarly, a student I am mentoring in practice attended sessions on breech at university. Her lecturer suggested hands/knees may be a more advantageous positioning, but later she is told, even in hands/knees, “The fetal back remains uppermost.” The student had worked out that this couldn’t be correct and sought more information. Excellent critical thinking, Charlotte!
These are signs of a practice in transition, and the PDM and Charlotte are right to be concerned. Rotating the fetal back uppermost in a hand/knees position is a dangerous but not uncommon mistake. Even in textbooks, such as this German textbook for midwives (Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Göbel & Hildebrandt, 2007), the woman’s position is changed, but the professional is still following the rule of, “The fetal back remains uppermost.” (Just to reassure you, once the arms are born, they advocate rotating the fetal body 180° so that the head is born occiput-anterior.)
A physiology-based understanding of the normal mechanisms comes from closely observing spontaneous births which are not interrupted. In a spontaneous breech birth, the most common and most optimal (a.k.a. ‘normal’) rotation of the fetal back is to anterior after the sacrum is born, regardless of the position of the mother.
The simplest way for teaching this aspect of the mechanisms I learned from midwife Jenny Davidson. The baby should rotate “tum to bum.” In other words, the baby’s tummy (stomach/front torso) should be facing the mother’s bum (bottom/posterior), no matter what position the mother is in. If those teaching breech can adopt this language to describe mechanisms and positioning, fewer dangerous misunderstandings, and more flexible thinking mayoccur. Teaching breech as a set of rote manoeuvres leads to automatic behaviours, which are sometimes counter-productive. In my research, I am observing that the path to acquiring breech competence and expertise involves learning to problem-solve in complex, unique clinical situations, often un-learning ‘rules’ that one was taught in skills/drills — because the rules don’t always work (eg. ‘the fetal back remains uppermost’ does not apply in every situation). Experienced professionals replace inflexible rules with more flexible understandings and principles, over a period of time, and through much reflection with peers and mentors. Perhaps teaching should be about patterns and principles, rather than prescriptions?
2. Assisting rotation of the fetal back to anterior — restoring the mechanisms to normal
You should rarely have to do this, but if you do, this principle may be helpful: “Rotation, not traction.” You can assist rotation with your fingers on the bony prominences of the baby’s pelvic girdle, as for any breech manoeuvre. Consider as you do what is happening at the inlet of the pelvis – have the shoulders already engaged, or are they just beginning to enter the pelvic brim?
Safe facilitation of physiological breech births depends on the ability to determine when intervention will be beneficial, and when it is unnecessary and potentially harmful. A breech baby will normally rotate spontaneously, with the back to the anterior (“tum to bum”), as the shoulders engage in the transverse diameter of the pelvic inlet. Pulling or manipulating prior to this spontaneous rotation could cause problems. But if the rotation is to the posterior, it may be beneficial for attendants to intervene at this point rather than rotate an occiput-posterior head mid-pelvis. Or at least 77% of an experienced panel think so …
Gibes E & Hildebrandt S (2007) Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Thieme
Questions for reflection:
- Watch the videos in this collection. Identify the normal mechanisms, beginning with descent of the sacrum transverse (to the mother’s side). As you are watching, identify which way you will expect the rotation to occur, anticipating the normal rotation. Did the baby rotate as you expected?
- Imagine you are attending one of the births in the videos and quietly communicating with a colleague who has no previous breech experience, about what you are expecting to see, and what to document during the birth. What do you whisper to your colleague? Do this simultaneously with your colleague/fellow student as you both watch the video
Watch this obstetrician (Diego Alarcon) facilitate a complete breech birth. He is touching more than is advocated by physiological breech-experienced providers – the mechanism has not yet deviated from normal – but his hands tell you what he is thinking. The baby’s right foot is behind the left, indicating that rotation is tending in this direction – sacral anterior, good. However, he is closely guarding this. Watch when he puts the forefinger of his right hand on the baby’s right hip bone to ensure that the rotation will occur in a counter-clockwise direction when the contraction begins. His actions are gentle, not forceful, and they work with the mother’s expulsive efforts.
In this birth, as the sacrum is born, it is mostly transverse (normal), but somewhat posterior, to the mother’s left. The baby does not rotate to sacrum anterior, as we would expect as the arms enter the pelvis to be born. The obstetrician (Michel Odent) recognises that the mechanism has deviated from normal and immediately intervenes to restore the mechanism by sweeping down the anterior arm under the symphysis pubis, across the baby’s face.
This video is much more hands-on than a physiological approach, but it provides a good example of a normal mechanism of sacral rotation following rumping when the mother is in a supine position — and how to assist, because the midwife’s (Renata Hillman) hands are positioned to assist rotation using the bony prominences of the fetal pelvis.
Thinking through the practicalities of breech advocacy.
Midwives and obstetricians who would like give women with breech presenting babies more support to plan a vaginal breech birth (VBB) need to think through the wider picture of how this happens in order to become effective advocates. In my experience of doing breech advocacy throughout the post-Term Breech Trial era, women often get in touch after 38 or 39 weeks to try to organise support for a VBB. Achieving this requires quite a bit of discussion and negotiation in quite a short period of time.
This post makes visible some ‘common experiences’ in women’s vaginal breech birth journeys. Services differ in every area, so it won’t be every woman’s experience. And increasingly, forward-thinking NHS Trusts are working with advocacy organisations (such as the Coalition for Breech Birth, Breech Birth UK and BBANZ) to develop woman-centred care pathways which meet women’s needs rather than restrict their choices, like this team in Sheffield.
|Common experience||Other possibilities|
|33 weeks||Antenatal clinic visit. Midwife or woman suspects breech. Woman told not to worry, most babies will turn.||Informed about / referred for moxibustion treatment. Not associated with risk of harm. Shown to reduce breech and CS when used with acupuncture. Shown to reduce use of syntocinon before and during labour regardless of presentation. (Coyle et al, Cochrane Review, 2012)|
|36 weeks||Palpation in antenatal clinic. Midwife suspects breech and refers for USS. Woman receives counselling re: ECV, to return at a later date. Is told discussion re: mode of birth will occur after unsuccessful ECV.||One-stop shop breech clinic. Scan, counselling and ECV performed by a midwife or doctor with specialist training. If unsuccessful/declined, mode of birth preference documented. To return for further counselling.|
|37 weeks||Counselling repeated by a different professional, who may have different personal preferences. External cephalic version attempted. If unsuccessful, asked to return for counselling re: mode of birth in consultant clinic.||Returns to breech clinic for second attempt at ECV. Sees same practitioner, who is also part of the breech birth team. After unsuccessful/declined second attempt, confirms choice of mode of birth. Wider team made aware of planned VBB.|
|38 weeks||Returns to antenatal clinic and sees another consultant or registrar. Majority of UK hospitals reluctant to support planned VBB. Advised to have CS. In some cases, a managed breech delivery in lithotomy is offered.||Woman and her birth partner prepare for the up-coming birth.|
|39 weeks +||After a return visit to antenatal clinic to attempt to negotiate support for an active VBB, meeting yet another consultant, and lots of research on the internet, woman seeks out external sources of support for VBB. Advocate (Supervisor of Midwives, doula, independent midwife) attempts to liaise with hospital staff, who ask, “Why do they all leave it to the last minute? There’s no time to put a plan in place now!”||Returns to breech clinic at 41 weeks to revisit choice of mode of birth, taking factors such as fetal growth and length of pregnancy into consideration. Talks to the same or another experienced member of the breech team.|
Questions for reflection:
- Consider your current work setting. If a woman tells you she would like to consider a VBB but is not receiving support to plan one, what can you do?
- Who needs to be involved in her plan?
- Who will support you to support her? To what extent are you comfortable being involved?
- How can you build a local breech team, who can be ready to meet this need when it arises?
- Consider working with your team to develop an informational resource for women, like this leaflet from King’s College Hospital.
Please share your positive experiences and good examples of breech teams in the comments.
Beuckens, A., Rijnders, M., Verburgt-Doeleman, G., Rijninks-van Driel, G., Thorpe, J., Hutton, E., 2016. An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives. BJOG An Int. J. Obstet. Gynaecol. 123, 415–423. doi:10.1111/1471-0528.13234
Catling, C., Petrovska, K., Watts, N.P., Bisits, A., Homer, C.S.E., 2015. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery. doi:10.1016/j.midw.2015.12.008
Coyle ME Peat B, S.C.A., 2012. Cephalic version by moxibustion for breech presentation (Review). Cochrane Database Syst. Rev. doi:10.1002/14651858.CD003928.pub3
Walker, S., Perilakalathil, P., Moore, J., Gibbs, C.L., Reavell, K., Crozier, K., 2015. Standards for midwife practitioners of external cephalic version: A Delphi study. Midwifery 31, e79–e86. doi:10.1016/j.midw.2015.01.004
I’m pleased to share with you that the first paper resulting from my PhD research has been published on-line in Midwifery. This is the accepted manuscript version only: http://www.midwiferyjournal.com/article/S0266-6138(16)00025-5/abstract
When the final PDF version is available, I’ll write a fuller post, including a link for a free download, for those who do not have institutional access. – Shawn
P.S. I will be on the east coast of the US from 17-30 May this year, after presenting a video on upright breech birth at the ACOG conference with Dr Annette Fineberg & Brigid Maher of Mama Sherpas. If anyone would like to host a study day, I’d love to share this research with you so that more professionals can learn from the wisdom of the experienced panellists who contributed.
Tonight, I met with some students from the local midwifery school who are preparing for their final OSCE. How exciting! They wanted to review mechanisms and manoeuvres so that they feel confident performing for their exams.
The students will be expected to demonstrate their knowledge of supine/lithotomy skills, so we created a new video to help them remember what we practised.
For those wanting to review the mechanisms when a woman is in a supine position, this video, filmed with midwifery students at the University of Salford last year, may also be helpful.
The next study group, for professionals, students or women in and around Norwich, will be on Monday, the 8th of February, from 10am – 1pm. For more resources to prepare for OSCE’s, click on the OSCE tag.
You may also find this video helpful, made by Joy James, a midwifery lecturer at the University of Glamorgan:
And from Maternity Training International:
Thank you for your interest in my work.
I would be grateful if you would share this link to an Expression of Interest form with your professional networks, so that I can reach as many breech-experienced professionals as possible.
My research has progressed to the next stage, and I am currently recruiting doctors and midwives who have attended between 3-20 upright breech births, who are willing to be interviewed about their experiences. All interview data will be anonymised, and I am particularly keen to interview obstetricians, although still need to interview more midwives as well.
This round of interviews follows on from an initial set of interviews I did with 5 midwives and 4 obstetricians, concerning how they developed experience with upright breech birth. I analysed the data from the initial interviews using grounded theory methods and developed a theoretical framework. These next interviews will serve to probe and explore the categories in this framework to build up a credible theory about how practitioners gain and develop breech skills.
This week, the NHS Trust where I work is honouring the great work of our Maternity Services with a day-long celebration. This includes a bake-off. I have never participated in a bake-off in my life. I don’t really bake much at all. But Victoria Cochrane and I were inspired.
In addition to our wonderful colleagues, we also had celebrations of our own. To begin with, amazing Matron Victoria recently managed to secure funding to purchase mobile ultrasound scanners — for use by the same Community Group Practices which have just been shortlisted for an RCM Better Births award! These scanners in the community will make it easier for women to find out if their baby is breech without having to journey to the hospital, and help minimise the number of women who find out their baby is breech in labour. This will mean more women have the opportunity to consider an external cephalic version (ECV), and/or have a choice of mode of delivery for their breech baby.
Victoria and I have also co-authored an article in The Practising Midwife this month, where we advocate that midwives adopt a ‘plan or scan’ policy to reduce the potentially negative impact of unexpected breech in labour. By this we mean, either inform women antenatally that there is a risk (approximately 1:100-1:150) of an unexpected breech in labour, and encourage them to think about what they would do in that situation, or consider adopting a policy of third trimester presentations scans for low-risk women. We also advocate identifying a group of obstetricians and midwives willing to be called upon to attend a breech birth — a breech team. No need for a 24-hour rota; just identifying a team and involving one of them wherever possible will begin to make a difference. We could do with more research on women’s experiences of unexpected breech in labour as well.
So, the cake:
Maybe it will make it into the hospital newsletter!
Congratulations also to the Sheffield Breech Birth Service, which has also been shortlisted for an RCM Award for Excellence in Maternity Care. The team have been providing continuity and a realist option for women wishing to plan a vaginal breech birth for years, and are a model of what can be achieved when midwives and obstetricians work together to deliver a high quality, safe and respectful service.
Breech advocacy work is a long-term commitment. Things don’t change overnight. Sometimes, we just continue to keep breech on the agenda, reminding ourselves and others that breech does not equal an automatic CS. Midwives and obstetricians continue to stand up for the right of women to choose their mode of birth after balanced counselling and a realistic offer of support for all options.
Thinking about doing a PhD in London? Need an academic to evaluate your programme? Then come to the Centre for Maternal and Child Health Annual Research Partnership Event, on Wednesday 11 November, at City University London. I’ll be speaking about my PhD research, to give a flavour of what it’s like to do a PhD at City. Follow @City_CMCHR. Hope to see you there. — Shawn
This blog will discuss how to recognise the need to intervene to deliver the arms in a vaginal breech birth which has been physiological up until that point. Descriptions are provided as if the woman is in an upright kneeling position, facing away from the attendant midwife or obstetrician. I have been somewhat prescriptive about how delay and dystocia can be evaluated. Experienced practitioners will have their own comfort levels. My intention is to stimulate discussion among modestly experienced practitioners, to help distinguish patterns calling for intervention from those which do not. Once the umbilicus is born, depending on the condition of the baby, unnecessary delay in identifying dystocia could be dangerous.
Recognising what is normal …
Midwives and obstetricians attending vaginal breech births need to learn to ‘read’ what is visible (eg. outside the vagina), as it provides clues about what might be happening at higher levels in the pelvis. In the normal breech mechanisms, the breech descends sacrum transverse, with the fetal back to one side or the other. A rotation occurs as the shoulders engage in the pelvis in the transverse diameter, just as they do in a cephalic birth. The fetal torso fully rotates, finishing fully facing the attendant — “tum to bum.” When this rotation is observed externally, it provides reassurance that the birth is progressing internally. Once the umbilicus is born, there will be a short pause (usually less than 30 seconds) before gravity will begin to pull the unimpeded fetal body down further in the pelvis.
When the shoulders reach the pelvic floor, restitution will occur, just as it does in a cephalic birth. Simultaneously, internally, the aftercoming head is rotating to enter the pelvis in the transverse/oblique diameter, just as it does in a cephalic birth. Externally, this is observed as a slight rotation, in which the anterior fetal arm is released under the pubic arch. Almost immediately (usually less than 30 seconds), another rotation occurs in the opposite direction, and the posterior arm is released under the perineum. This coincides with the final internal rotation of the head, as it realigns to an occipito-anterior position ready to be born, just as it does in a cephalic birth.
A thorough understanding of what is ‘normal’ in a vaginal breech births helps attendants to be aware of when deviations from expected patterns may indicate a threat to fetal well-being. The video below repeats the above information, so that you can recreate it with a doll and pelvis in order to thoroughly understand why this mechanism unfolds in the way that it does.
… and what is not normal.
A deviation from the mechanism described above may indicate a problem, if it is accompanied by a delay. In some cases, when women give birth in upright positions, the combination of a roomy pelvis and the effects of gravity creates a situation in which the fetus can tumble through almost all at once, and the mechanism remains unobserved or seemingly irrelevant to this baby and this mother. If the birth is proceeding rapidly, and the baby is in good condition, there is no need to intervene unless progress stops. Just prepare to break the baby’s fall.
The signal to intervene is an observed variation in the mechanisms, accompanied by a delay (> 30 seconds), unresponsive to spontaneous maternal movement — or any occasion in which the fetus appears compromised. In other words, you observe that descent has stopped and encourage the mother to wiggle, lift a leg, shift her torso, or some other gentle method of shifting the limb which is stuck – but it remains stuck. Some variations suggesting intervention may be necessary include:
The baby has been born to the umbilicus. However, the torso has not completely rotated to face the attendant; the shoulders appear to be in the oblique or A-P diameter of the pelvis. You may need to restore the mechanism. Remember: the shoulders engage in the pelvic inlet in the transverse diameter, visible externally as a complete rotation to face the attendant. If the rotation is not complete, and progress does not resume with spontaneous maternal movement, assume one or both arms are caught up on the pelvic inlet. You can encourage rotation with your hands on the bony prominences of the pelvis (much like Løvset’s), but if this is not easily effective, do not risk twisting the fetal spine. Instead, use ‘prayer hands,’ with your fingertips against the bony prominences of the shoulder girdle, palms flat to avoid fetal organ damage. Elevate slightly to disimpact, and rotate the fetal torso so that the shoulders are in the transverse diameter. Descent should resume following this rotation. Once you have started to intervene, continue to assist the head to be born by manually flexing the head and controlling the delivery, or using shoulder press.
Posterior arm born first
This is not always a problem, but it often happens because the anterior arm is nuchal, eg. raised beside the head. Again, not always a problem. Sometimes an arm in front of the face helps to keep the head flexed, and they can be born simultaneously. If descent and rotation continues, and the baby appears to be in good condition, watch and wait. However, if the posterior arm (closest to the attendant) is born first and there is a delay (> 30 seconds) before the birth of the anterior arm (nearest the symphysis pubis), intervention is likely required. Suspect a nuchal arm, raised alongside the head. Insert your hand behind the fetal back on the side of the arm which needs to be released. Sweep down, in front of the fetal face, and out. This will restore the mechanism and enable the head to descend to the pelvic outlet. If the arm is positioned behind the head and cannot be swept down, rotational manoeuvres may be required, using prayer hands.
One arm born with shoulders in the anterior-posterior (A-P) diameter
Sometimes, the posterior arm is born and the fetus has not rotated at all; the shoulders appear to be in the A-P diameter, with the posterior shoulder visible under the perineum. This is because the anterior arm is nuchal, stretched alongside the fetal head, and prohibiting further descent. It has become wedged tightly against the symphysis pubis, and it is not possible to sweep down in front of the fetal face. This situation will not respond to subtle maternal movements and requires immediate and assertive intervention, in the form of elevation and rotation. In my own experience of using rotational manoeuvres in this situation, I have used ‘prayer hands’ to rotate the fetus into an occipito-posterior position, where it becomes possible to sweep the nuchal arm down in front of the face and out under the pubic arch. The head should be kept in alignment and rotated back to an occipito-anterior position, where shoulder press or manual flexion can be used to deliver the head without delay.
A pause after the birth of the anterior arm, lasting >30 seconds
After the birth of the anterior arm, most of the baby is out. Gravity will usually do its magic, continuing to bring about steady but gradual descent. As the head is rotating into A-P alignment internally, ready to be born, the second arm will release under the perineum. If this process does not resume soon (< 30 seconds) after the birth of the anterior arm, and progress promptly, it suggests two possible problems. Either the posterior arm is blocking the head from descending and rotating, in which case sweeping the second arm down in front of the fetal face should result in both the delivery of the arm and alignment of the head. Or the head has not completely descended into the pelvis. In which case, delivery of the second arm will enable you to get on with assisting the head to be born.
Mechanisms appear normal, complete rotation, umbilicus born, with no further descent for >30 seconds, and especially after the onset of the next contraction
This is when apparent problems with the arms are not actually problems with the arms. The arms are under the sacrum, ready to be born, but they have not been born yet because the head has not entered the pelvis. Although it is possible to sweep them down, this will not solve the underlying problem that the head is extended at the inlet and impacted in the A-P diameter. As described above, the head needs to rotate into the oblique/transverse diameter to enter the pelvis. Begin by lifting the fetal torso to elevate the head off the pelvic inlet slightly. Then rotate to release the arms and enable the head to engage. As you have started to intervene, continue to assist the head to be born, flexing the head manually or using shoulder press once the head has entered the pelvis.
Thank you to Joy Horner, for sharing the photo on which the sketch above is based. And to Mary Cronk, who shared her slides and experience of managing a nuchal arm with me before I encountered it myself, enabling me to resolve it successfully. I am very grateful for the sharing of midwifery knowledge, so I am doing my own sharing in the hope that it will be helpful to another midwife or doctor in a tricky birth.
In this video, the posterior arm is born first, and the obstetrician (Diego Alarcon) gently assists the anterior arm by sweeping it down across the baby’s face.
In this video, the baby is born with the sacrum to the mother’s left and slightly posterior, it looks like due to the positioning of the feet. When the normal rotation to sacral anterior does not occur, the obstetrician (Michel Odent) immediately recognises that the mechanism has deviated from normal and intervenes. He assists the anterior arm to be born by sweeping it down across the baby’s face, restoring the mechanism.
Today is my first son’s birthday. I’ve decorated the cake, packed the basketball tournament lunch, gathered the little presents. Ely’s birth set me on a path, and the love I have felt from the moment he was born knows no other. So I’m celebrating by posting a poem I wrote about giving birth. This birth was Waldo’s, my second son. Birth is life.
for Waldo Myles Capability
we are what gets written –
we are what blooms
you move and I echo
the story written in my body
to tell over again with twists and groans –
the story written in your body to seek out –
memory, the river which threatens and feeds
you move and I echo
my body uncurling from the pain of release –
your body uncurling from the pressure of flight
you move and I echo
we who risk failure
and lunge into our song
you move and I echo
my own primary call
The story of you emerges
wearing its caul
of tea and toast
and breast and boast
in the ecstasy of our achievement.
Each time the shell of me breaks
I am larger and louder –
more full of wind
and song and thanks –
for the day you were born.
I’m pleased to introduce a new co-ordinator for the Breech Birth Network study days: Laura Latina, MSc, RM. Laura is now taking the lead on organising study days, and if you would like to make an enquiry, you can contact her on the form below. Read more about Laura in her own words below.
I love being a midwife. I believe midwifery is an art; the art of empowering women in discovering their capacity of giving birth.
I work at St Thomas hospital as a caseload midwife. I advocate and believe in normal births. I like working closely together with women. My relationship with women and her partner is based on respect and trust. Empowering her and the partner to make their informed choice is also important for me. In my work I prioritise continuity of care; this means I look after women since the beginning of the pregnancy, during birth and post-natal. Pregnancy and birth are a journey; accompanying women and being part of this journey it’s amazing!
I have worked in all settings: midwife led unit, consultant led unit, home and as independent midwife. I encourage women to believe in their bodies and in their babies and I feel full of oxytocin when they have a positive birth experience.
My interest in vaginal breech births has started from my work in developing countries. I have been in many countries of Africa and Afghanistan where I assisted, supervised and taught to more than 30 vaginal breech births also in upright positions.
I love teaching too; I have participated to trainings as facilitator and as ALSO instructor.
My experience in Africa encouraged me to deepen my knowledge in developing countries, for this reason I own a MSc in Reproductive & Sexual Health Research at London School of Hygiene and Tropical Medicine.
I love reading and teaching and I am also interested in research.
I love spending long time chatting in front of a coffee and I go often to walk in a park!
Read more about Breech Birth Network study days on the pages below:
This story about a woman’s home birth after 3 caesarean sections (HBA3C) caused a bit of a Twitter storm earlier this year. OB Prof Jim Thornton has written about his involvement here – his post and the comments below it will give you a sense of what the outrage was all about. What they won’t tell you is that a significant number of maternity service users and professional advocates active in the #matexp campaign called for an end to the storm, just as they are calling for an end to disrepectful care and divided professional camps. Their work is very worthy of your attention.
What interests and concerns me is that criticism and debate around this woman’s story seems to centre on:
- the woman’s decision to birth her baby at home attended by midwives, after having had three previous caesarean sections; and
- the woman’s memory that the midwife “told me I COULD have a natural birth no matter how many sections I’d had!” – and the near universal interpretation that this permission (for lack of a better word) equates to reassuring her that it was somehow the safest or the best option.
Conspicuously absent is discussion about the woman’s description of care leading to her first 3 caesarean sections .. “As I was naive I thought I had to do what they said” .. “I was determined to have my VBAC. Until the doctor told me I was going to kill myself and my baby. So a scheduled CS was made for 38+4.” In my experience of working with women requesting support for what some might call extreme birth choices, disrespectful, coercive and often non-evidence based experiences of maternity care usually precede such apparently extreme decisions. Moderate risk-taking behaviour by a woman keen to collaborate with her care providers has been over-ruled by someone who feels they know best.
Strictly speaking, her midwives were correct: a woman CAN have a natural birth no matter how many sections she has had .. or she can try. This descriptive statement says nothing about the risk/benefit balance of such a choice, which her caregivers would certainly have discussed in detail. Women are supported to choose the mode of birth which is best for them, or they aren’t. Women are supported to choose the location of their birth, or they aren’t. ‘Risking out’ is an entirely different model of decision-making. And supporting women to exercise their own power and autonomy in low- to moderate-risk situations will potentially create fewer high-risk situations further compromised by lack of trust and respect between women and caregivers.
I would like to see more professional discussion around how we counsel women making very complex birth choices. This conversation is often difficult for health professionals because it requires an admission of vulnerability. The nature of complexity means several things could be going on at once, some of which may be new and unfamiliar and thus require more time and consideration for an appropriate response. But the nature of birth is that a crisis can emerge very quickly, and that time may not available. Experience helps. But who has a hefty bulk of experience supporting VBA3Cs? Experience of complications is particularly valuable in such work – but how many midwives who have actually experienced a uterine rupture at home are still practising? Professionals in these situations are always out on a limb.
Does this mean health professionals should never support women making choices which increase the complexity of caring for them in labour? What should professionals’ attitudes be to such choices? One tweeter opined that the NHS should not support VBAC’s at home, because brain damaged babies cost the NHS a fortune and, “There is a limit to what you can do with other people’s money.” What exactly did the woman in question do with ‘other people’s money,’ except use the minimum required for such a birth? Should a woman be forced to have surgery because otherwise her baby might cost the health system too much? Is this really a route we want to go down as a society?
All of the outrage about women making apparently ‘risky’ birth choices contrasts with societal reactions when men make make similarly risky lifestyle choices. Stories about mountain climbers always send a chill up my spine, and one that particularly affected me was the disappearance of Jean-Christophe Lafaille during his ill-fated winter climb up Makalu in 2006. I casually stumbled upon an article in some large-circulation magazine, containing a haunting photo of his wife and 4-year-old son. I was struck by the look of loss and longing in their eyes, probably because in 2006 I had two sons of my own of a similar age. I often wonder how his wife and son are doing now.
While mountain climbers are not immune to criticism from their own community as well as those outside it, they are also glorified and funded by large companies. They usually climb with teams of people, so it is not just their own lives they are responsible for (although in the case of J-C L it was). The captivating stories of their exploits are used to promote merchandise. Even people who would never dream of scaling Makalu find their tales inspiring. The makers of the film Everest, due to be released this week, are banking on it.
Perhaps Jean-Christophe Lafaille can help shed some light on the essential humanness of risk-taking and some women’s deep desire for contact with their most basic – and essential – self:
“I find it fascinating that our planet still has areas where no modern technology can save you, where you are reduced to your most basic – and essential – self. This natural space creates demanding situations that can lead to suffering and death, but also generate a wild interior richness. Ultimately, there is no way of reconciling these contradictions. All I can do it try to live within their margins, in the narrow boundary between joy and horror. Everything on this earth is a balancing act.” (reference)
While maternity services are about safety, they should never be about enforcing some presumed collective version of what is safe onto everyone, suppressing in the process the inherently creative and often risk-taking human spirit, as well as the potential discovery of benefits in these non-mainstream choices. Nations have mountain rescue services because people will continue to climb mountains. And women will continue to want to birth their babies, sometimes in extreme circumstances. I am comfortable with my role ‘on the ground,’ so to speak, providing the standardised care which institutional systems offer and most women are happy with. I am also comfortable supporting women who metaphorically want to scale a mountain, and I will continue trying to find what sort of equipment, sustenance, maps and guidance will help them be as safe as possible while being boundary-testing humans in all their glory. I hope that maternity services can find a way through which enables more women to ‘be themselves’ in birth, as safely as possible, with an open acceptance by women and health professionals that in some instances, this may in fact come with some greater risk. I hope that maternity services can provide care which meets women’s spiritual as well as physical needs, and that judgements and coercion can recede into the past. Every woman who gives birth – however she does it – is a hero.
(Originally written on 12 April 2015. Publication postponed due to professional blizzards.)
Related resources –
You may be interested in this article, co-written with Mariamni Plested. Plested M, Walker S (2014) Building confident ways of working around higher risk birth choices. Essentially MIDIRS 5(9):13-16 – (Archived at City Research Online)
See also the Mama Sherpas film
On the evening of Tuesday, 30th of June, 2015, British breech aficionados were spoilt for choice. There were two important premiers of breech-related films, held in two different cities.
I was privileged to attend the Newcastle premier of doctor Rebecca Say’s Breech, the product of an NIHR-funded research project. Audience members were treated to the film, intended to be an educational tool to help women with decision-making when baby presents breech, followed by a discussion about the film, its potential impact and future plans.
You can view the animation HERE, and the link can be shared freely with women and health professionals: http://research.ncl.ac.uk/breech-decisions/animation.html
The film is embedded as part of a website containing further information for women, incorporating research from many sources. Say’s research indicated women access information on-line well before meeting with health professionals, and finding balanced, useful and unbiased information was difficult. Maintaining the Breech Decisions website will depend on further funding, but it is a useful, up-to-date tool at the moment. You may also be interested in Say’s qualitative research about women’s experiences of ECV (2013).
On the same evening, a group in London assembled to view the Heads Up film with Dr Stuart Fischbein, visiting from Los Angeles. The film is a passionate plea to #reteachbreech – and you can find out more about this project on this Twitter hashtag, or Dr Stu’s Blog.
Fischbein has also recently published his statistics – “Home Birth” with an Obstetrician: A Series of 135 Out of Hospital Births.
Two weeks, two inspirational obstetric colleagues, two very welcoming UK cities. So much commitment to improve the system for breech babies and their mothers.
On the 20th of March, Dr Elie Azria of the Hôpital Paris Saint Joseph and Descartes University, joined me in Dundee, Scotland, to teach through the eclipse! The French and Belgians have continued to support breech births in the last 15 years, responding to the Term Breech Trial (TBT) with a prospective observational study (PREMODA, 2006) which involved over twice the number of planned breech births (VBB) than the TBT, and demonstrated no statistically significant difference in outcomes between those who planned a VBB and those who planned a caesarean section (CS). Azria was the lead author on a follow-up analysis of the data examining factors associated with adverse perinatal outcomes in the PREMODA data.
In our Breech Birth Network study day, Azria presented new research concerning whether breech presentation is an independent risk factor in preterm breech birth, with interesting results which we hope to see published soon. He also gave an inspiring presentation on the “Traps of Evidence Based Medicine,” using the example of term breech delivery, building on his work to reconcile the need for maternal autonomy and medical responsibility in shared decision-making about mode of childbirth.
I always enjoy teaching with experienced practitioners who come from a different practice culture. Practice constantly improves and evolves from sharing these different ways, if we are open to learning from each other. Azria pointed out that, sadly, even within a culture where support for VBB has remained standard, the use of CS is on the rise. As he described, “Breech delivery is a craftsman’s job,” an art as well as a science. Learning breech skills requires commitment, dedication and practice, which not everyone is willing to offer. Nor are many people keen to take the risk of learning in the current risk-averse climate of maternity care.
Read more about How singleton breech babies are born in France, from the AUDIPOG network (Lansac et al 2015).
On the 27th March, I was joined by Miss Nicola Lack, Consultant Obstetrician from University College London Hospital NHS Trust. Lack gave a fantastic presentation on the research base for counselling about mode of childbirth with a breech presenting baby. One of the problems with a decimated skills base is that, while we may have a strict set of inclusion criteria for what constitutes ‘normal’ for a VBB, it may be quite difficult to find someone who can actually assess those criteria at a moment’s notice on labour ward, eg. a hyperextended neck on ultrasound. Breech skills are not just the manoeuvres which may be used around the time of birth. Skilled practice also involves the ability to provide detailed individualised counselling and make relevant antenatal assessments, as well as on-going interpretation throughout pregnancy and labour.
Lack’s presentation drew extensively from her own experience of working in the UK and Africa, as well as her understanding of medico-legal issues and constraints caused by a litigious practice culture. She explained how, when counselling, we really need to talk about the potential benefits of VBB as well as the risks. For example, she reflected on how, when she first qualified as an obstetrician in 1999, placenta percreta was relatively rare. Now, she and her colleagues encounter it approximately once a week or fortnight, due to the increase in CS rate. That’s very concerning. Lack also facilitates a postnatal birth reflections clinic, where she has had the opportunity to learn how women feel about breech childbirth experiences, both CS and VBB, after the event.
My one sadness on both days was that, despite the best efforts of the organisers and the high calibre of the obstetric speakers at the events, so few obstetric colleagues attended the study days. This is a real problem. Midwives are increasingly advocating for women to have the realistic option of a well-supported VBB if that is their informed choice, but this needs to be a collaborative effort. I urge our obstetric colleagues to come to the table to learn and work with us, so that the women and babies we care for, and we as professionals, can benefit from the best possible support of the wider multi-disciplinary team.
Thank you to Consultant Midwife Phyllis Winters of the Montrose Maternity Unit and Julie Woodman of the Queen Alexandra Hospital in Portsmouth for organising the study days.
When attending any birth, record keeping is extremely important, both during the birth itself (to facilitate communication) and afterward.
Early this month, I attended a study day organised by IMUK (an organisation of independent midwives in the UK). The day was entitled, “Health Care Records on Trial,” and the purpose was to ensure we are all aware of best practice when it comes to record keeping, as well as some of the pitfalls to avoid ending up in court should all not go to plan. Our host and instructor, Andrew Andrews MBE, was Bond Salon‘s Director of Health & Social Care. And he was fierce! Mr Andrews inspired due diligence through his penetrating glare alone. But the day was far from dreary and fear-mongering, instead offering really clear guidance, based on illustrated examples from Andrews extensive legal experience in health care.
Mr Andrews presentation referred frequently to the NMC’s Principles of good records (2009). While I strive to ensure my records are of the highest possible quality, I am aware I have not always met the highest standard – now even moreso! – but there is always room for improvement. In addition to being a legal duty, maintaining accurate and fit for purpose records helps to ensure safety by facilitating communication between the team.
We were all keen to develop greater understanding about how to document care which falls outside of mainstream guidelines, or when women decline the care on offer. Many women engage an independent midwife when the NHS does not provide the care they have decided is best for them. We discussed in detail the criteria for offering treatment on the NHS (therapeutic effect & reasonable prospect of success) vs private treatment (welfare, well-being & reasonable prospect of success). These subtle differences can make a big difference.
Mr. Andrews is a big fan of keeping the notes with the woman and documentation by the bedside (or poolside, as I am doing in the picture to the right). The Francis Report indicated that patients should have access to their notes in real time. This ensures that those caring for a woman have immediate access to all relevant information, and she or her loved ones can highlight any errors. Poor record keeping contributes to a discontinuity in care, and this in turn puts patients at risk of harm. Collaborative, bedside record keeping also helps all members of staff to follow the core principles of:
- Patient’s [sic] autonomy
- Patient’s right to self-determination
- Working in partnership with the patient as decision-maker
Care records should be chronological, but not necessarily sequential. In the margin is the time you put pen to paper, in the text is the time you did it. Events should be recorded as close to real time as possible, but must be captured within 24 hours. After 24 hours records are no longer considered ‘contemporaneous.’ No need to use ‘written in retrospect’ at all, and the expression only refers to events recorded after the 24 hour window.
We had a debate about the records also being ‘the woman’s story.’ I have mixed feelings about this. As an independent midwife, I used to give women a copy of their notes and really felt how important this story was to them. However, working in the NHS, where I frequently care for women whose clinical histories I do not already know thoroughly, I often find it tricky to wade through thick narrative notes in order to extract essential information. In my self-designed notes, I used to have three columns: the time I was recording, the clinical highlights, the story. This is my preferred system, combining the best of both purposes. In an NHS context, I may begin to use a continuation sheet for the story, to separate it from clinical information my colleagues may need to know quickly.
Mr Andrews reminded us that the purpose of documentation is to ensure patient safety and continuity of care. They are a reminder of the plan and context of care, and a means of communicating with colleagues. Failure in communication is almost always identified in serious case reviews. Therefore, he recommended records should be:
- Bullet points
- Captured in the context of care
- Written with your colleagues in mind
I am inclined to agree!
You too have an opportunity to be inspired by Mr Andrew’s penetrating glare and brilliant knowledge of health and social care cases, as he will be appearing, along with Sir Robert Francis, QC, at The RCM Legal Birth Conference on Tuesday, 7 July 2015.
This is an excellent course at a world-renowned centre, popular with obstetricians all over the world who travel to Bergen to gain practical skills in breech childbirth and operative delivery. The Norwegians have carried on safely supporting breech births over the past 15 years, and the course is acknowledged by the Norwegian Medical Association. This year, the course will include a session on ‘alternative birth positions in breech delivery.’ It will be taught in English.
For more information and to book, contact Consultant Jørg Kessler on the e-mail listed on the poster. View the programme here: Practical skills in advanced operative obstetrics.