This week I am in Amsterdam, attending the First Amsterdam Breech Conference, Teach the Breech! I’ve been tweeting along, with #teachthebreech. If you aren’t on Twitter, you can catch up below. Also check out Rixa Freeze’s blog, Stand and Deliver, for more detailed summaries of the conference activities.
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.
It’s been a historic week.
Last Tuesday, 14th October 2014, obstetricians and midwives from around the world converged in the basement of the Royal College of Obstetricians and Midwives (RCOG) in London for a study day on Management of the Term Breech (#RCOGbreech). The day was originally planned to correspond with the publication of the new RCOG guideline, last published in 2006. However, the re-write has been delayed, understandably. Across the country, more and more units are not only raising the level of support for breech, they are supporting women to birth their breech babies in upright positions, something the current guideline recommends women are advised not to do.
The update authors face some tough choices: 1) continue to advise against an increasingly popular practice, alienating many of the few professionals currently supporting breech births; or 2) turn the current state of affairs upside down by … guess we’ll see when it’s published! The RCOG day was opened by the rather marvellous Mr Lawrence Impey, Oxford Consultant in Obstetrics and Fetal Medicine and co-author (with Justus Hofmeyr) of the 2006 guideline, and Mrs Anita Hedditch, Delivery Suite Senior Midwife and ECV Midwife, also at Oxford. Impey acknowledged the sense of anticipation and slight tension in the room by instructing delegates: “No heckling, and no snorting!”
However, Professor Deirdre Murphy from Dublin created little controversy with her fair and balanced evaluation of the evidence. Although her analysis was much more nuanced, following discussions, the take-home message was: With experienced support, the short-term risks for breech babies (neonatal mortality, serious morbidity) are probably not significantly greater than those for cephalic babies. Both breech and cephalic babies have increased short-term risks compared to a planned caesarean section (CS). For breech babies, the available evidence indicates that by two years of age, no significant difference in primary adverse outcomes (death and neuromotor delay) is apparent between babies born after planned CS and babies born after planned vaginal breech delivery (PVD). But babies born following planned CS face some increased risk of other medical problems.
Murphy was followed by Mich Mohajer of the Royal Shrewsbury, who presented evidence from her telephone survey about what exactly is happening around the UK for breech. ECV appears to be almost universally offered throughout England and Wales at the moment, although she found significant variations in models of care, with some units offering dedicated breech clinics and other units offering an ad hoc service on delivery suite. She found even more variations in levels of support for vaginal breech birth, with only 27% of units in England and Wales supporting VBD. Mohajer also acknowledged the importance of involving midwives with breech skills, as the facilitation of breech births has always been considered part of midwives’ expertise. These two themes: the importance of a specialist approach through dedicated clinics and ‘breech teams,’ and the value of multi-professional collaboration, were echoed frequently throughout the week.
After a brief break, Dr Leonie Penna from King’s in London presented on ‘pitfalls and pearls’ in delivering the vaginal breech. She summarised a number of common errors and helpful hints, bringing the focus onto the real gap in clinical skills which will need to be closed or bridged in order to reintroduce systematic support for planned breech births. Penna was also very upfront in discussing the reluctance of the obstetric profession to shift away from women on their backs, even with strong evidence of how helpful it is. She drew parallels with fetal blood sampling, which it is now recommended to perform with women in left lateral. With Penna’s talk, it became clear that the discussion is finally shifting away from an assumption of vaginal breech DELIVERY and towards and understanding of vaginal breech BIRTH. Finally, Penna as well emphasised the important role midwives have always played in supporting breech births at King’s.
After this, Dr Anke Reitter presented on her experience of being a part of the now-famous breech clinic in Frankfurt, and her MRI data demonstrating how significantly maternal movement affects the dimensions of the bony pelvis. Reitter (@OB_Anke) also discussed how our current understanding of helpful manoeuvres for upright breech birth – especially the first principle of rotation by the shoulder girdle rather than the pelvis – is not new. She showed captivating drawings from historic German and Australian textbooks showing nuchal arms and how to resolve the problem. Thankfully, Reitter will be returning to the UK in June to share her hands-on skills at one of our Breech Birth Network Physiological Breech Study Days.
Visiting speaker Thomas van den Akker, obstetrician and researcher from the Netherlands, reminded the audience of the RCOG’s responsibility to the developing world. In less resource-rich countries, CS presents a much higher risk to women and their future children than it does in the UK. But the world follows the RCOG’s example and demands the highest standard of care, even when it is inappropriate in that context. Van den Akker also presented data from follow-up studies by the Vlemmix team which demonstrate that per 10,000 babies delivered by CS for breech (compared to planned VBD), there were 26 neonates saved in the first pregnancy (19/7442). However, there were 27 neonates (18/6689) lost in subsequent pregnancies in a policy of trial of labour. Can we continue to recommend that first time mothers avoid a vaginal breech birth, while encouraging them to plan a vaginal breech birth after caesarean section (VBAC) in their next pregnancies?
Over lunch, Jane Evans gave a presentation of the mechanisms of breech labour, and strategies to help when help is needed. She brought along her slide show and doll and pelvis, for those who wanted to make the most of every minute available to learn breech skills.
After lunch, the morning speakers engaged in a panel discussion about how the term breech should be managed. The relaxed mood and support for the option of vaginal breech birth was clearly emotive for some. One obstetric delegate stood up and shared how he had become a pariah among his colleagues for continuing to facilitate vaginal breech birth (VBB), and how he hoped the new guideline would be more clear about how important and appropriate it is to support VBB.
This was followed by talks by Impey and Hedditch about the evidence base, practice and their clinical experience of external cephalic version (ECV). Like many other professionals, I have made a pilgrimage to Oxford to visit their renowned clinic and learn from them and their community midwife colleague, Pauline Ellaway. They presented their most recent statistics, which like others’ (see Grootscholten et al, 2008) show a higher rate of interventions and adverse outcomes for post-ECV babies than babies who spontaneously assumed a head-first position (neonatal mortality = 0.9/1000; not significantly different from 1.3/1000, the neonatal mortality for planned VBD in the Netherlands reported in Vlemmix et al). This is a video from a Dutch team which also use a two-person approach.
This then opened up the discussion in the final afternoon panel to a point I had not previously hoped was possible: The genuine suggestion that perhaps dedicated ECV services should become dedicated Breech services, where women’s individual clinical situations are evaluated and those felt to be good candidates are offered a VBB, while those who are not felt to be good candidates are encouraged to consider ECV. (Selection criteria remain controversial, but this openness is a very good start.) The strong message was that women should have access to a high-quality, experienced ECV service, but this should not be the only alternative to CS.
Dr Joris Hemelaar also presented about rates of undiagnosed breech in Oxford, which are over 20% like most places in the UK which do not do routine third trimester scans (which are not recommended by Cochrane. Hemelaar’s point in presenting this information alongside reports on breech/ECV clinics is that we cannot offer women an ECV or detailed counselling about VBB if we do not detect the breech antenatally. However, and my view differs somewhat, as we do not yet have any evidence that the undiagnosed breech is at greater risk in the UK. Most of the available evidence indicates that the undiagnosed breech is far more likely to be born vaginally, at no increased risk. The situation is unlikely to change until more than 27% of UK units support a planned VBB, and until that time, obstetric and midwifery-led units would be wise to put a proactive plan in place so that these births can be managed with a calm, team approach.
As if the RCOG conference was not exciting enough, Senior Midwifery Lecturer Ethel Burns of Oxford Brookes University made the most of international visitors to host a conference on “Breech Birth: Sharing what we know and do, and exploring best practice for the future,” on Saturday, 18th October 2014 (#Oxfordbreech). The day included repeat presentations (for a new audience) from Anke Reitter and Anita Hedditch, and Jane Evans again presented her slides, mechanisms and manoeuvres over lunch; but there were some additions.
- In selected women with high quality care baby mortality is probably little different from cephalic presentation, but is higher than ELCS
- However, there may be a higher risk of obesity, asthma and other serious problems following elective CS
- Maternal mortality and morbidity is dependent on emergency CS rate but unless this is >50% is likely to be increased with a polity of elective CS. This is particularly important in the developing world.
- In the long term, there is a small increase in risk of mortality and morbidity to future babies through unexplained stillbirth and uterine scars.
- Lost skills will mean a higher complication rate for unplanned breech deliveries, be these CS or vaginal
Impey was followed by Ruth Sloman, who has recently completed her Masters in Midwifery at Oxford Brookes. Sloman used focus groups to look at midwives’ knowledge and experience of breech births. I really enjoyed this presentation, and some of Ruth’s themes resonated with my own research, especially the value of video footage in helping professionals to learn when hands-on experience is difficult to come by, and midwives frustration at witnessing vaginal breech deliveries poorly managed and the lack of choice available to many women.
After the break, the conference continued with Dr Andrew Bisits, FRANZCOG of Sydney, Australia. Bisits’ sensitivity to women’s experiences has made him beloved of women and midwives across the globe, and his long-term commitment to supporting vaginal breech births has gained him knowledge and experience exceeding most obstetricians working in 2014. Crucial to Bisits’ talk was a recognition of how important the experience of attempting a vaginal breech birth is to some women. He also encouraged us to recognise that moderate risk-taking confers psychological benefits. Although Bisits’ talk included much more than I can summarise here, a final important point concerned the ‘atomic reaction’ which usually follows adverse outcomes in breech births, and knee-jerk responses usually preclude any genuine learning from these events. If we are to improve the safety of breech birth, it is vitally important that we learn from adverse outcomes by reflecting on them in an open and enquiring, rather than punitive way.
Reitter and Bisits are of course not only two of the most highly experienced breech practitioners in the world, they are passionate advocates for the use of upright positioning. Reitter’s clients birth mostly in all fours/kneeling positions, and Bisits’ clients commonly use a birthing stool. Their view is that it is not so much the position, as the ability of women to move spontaneously and assume the position of her choice, which matters most. The mood of both days indicated that this point has been well and truly made and heard by those writing the new guideline. The question became not so much whether upright positioning would be acknowledged as a legitimate approach, but whether or not it will continue to be considered in any way ‘alternative’ in the new guideline.
Betty-Anne Daviss visited from Ontario, presenting an encapsulated history of the women’s movement in Canada, and how this has influenced the progress they have made with breech birth. She explained the way in which the Canadian-born Coalition for Breech Birth worked with sympathetic doctors and midwives to reintroduce the choice of VBB. Remarkably, Daviss has succeeded in gaining privileges to attend VBBs in her local hospitals, and currently supports approximately 1-3 women per month to achieve their goal.
I also presented my current research concerning how practitioners learn breech skills. We need to accelerate this process if we are going to increase support for planned vaginal breech birth within the current risk-adverse maternity care culture. I’m looking forward to sharing more of this in publications as the research progresses, so watch this space! My presentation also highlighted the standard of care when it comes to maternal birth position for healthy women. NICE’s evidence-based and woman-centred approach is clear:
- Women should be discouraged from lying supine or semi-supine in the second stage of labour and should be encouraged to adopt any other position that they find most comfortable. (1.7.7, current Intrapartum Care guideline)
If policy-makers are now acknowledging that VBB carries a similar risk to cephalic birth in experienced hands, then those who continue to advocate a maternal birth position (lithotomy) which deviates from the current standard of care should present evidence as to why they are doing this, rather than the other way around. Experience alone may be enough to explain it for those who have continued to safely facilitate VBDs, but the next generation and those who have taken a 14-year hiatus would do well to learn the new upright techniques as part of their standard training.
If the authors of the new RCOG guideline walk the walk as well as they have talked the talk in the past week, some major changes are a-foot. But policy changes are only a small part of what happens on the ground, evidenced by the fact that the RCOG has recommended the choice of VBD be offered to women since 2006, something that is clearly not happening universally in the UK. A major cultural shift is required, but these two events suggest that the shifting has indeed begun.
Well done you if you’ve read all the way to end of this post, and join the breech activist club! If you found other aspects of the day important and informative, please do highlight them in the comments below.
The Dutch in Old Amsterdam do it .. not to mention the Finns .. The folks in Bergen, Norway, do it .. They’re not even second twins …
This Valentine’s Day over 100 obstetricians, midwives, student doctors and student midwives assembled at Crosshouse Hospital in Kilmarnock to show some love to breech babies.
We were privileged to be joined by Dr Susanne Albrechtsen, Head of Obstetrics at Haukland Hospital in Bergen, Norway, home of Jørgen Løvset. She has written extensively about the practical management of breech presentation and authored several epidemiological articles. Dr Albrechtsen is responsible for the Norwegian breech guidelines, and shares her expert knowledge of breech and operative vaginal deliveries through practical training throughout Scandinavia and beyond (details available through the Norwegian Medical Society). Her hospital in Bergen, which currently enjoys a CS rate of 13%, is a mecca for trainees hoping to improve their hands-on skills. Haukland, with an annual birth rate of 5000, sees 150-200 breech deliveries per year and Dr Albrechtsen herself has attended over 500 breech deliveries.
How do they do it? Dr Albrechtsen tells us: “You just have to decide that it is good for babies to be born vaginally, unless there is clearly a problem, and commit yourself to developing the skills to enable that to happen.” As she explained, a normal vaginal birth is an important programming event with life-long consequences. Evidence is growing about the links between caesarean section and future disease in the child, such as Type 1 diabetes, asthma, allergies, gastroenteritis and obesity (see Ulander et al, 2004). Dr Albrechtsen also presented her epidemiological data, demonstrating the way CS rates and rates of vaginal birth have changed over the last 40 years in Scandinavia. Particularly interesting were the way the Finns have been able to make a dramatic change within a few years, simply by making the decision to do so.
Dr Michele Mohajer, whose unit in Shropshire currently enjoys a 14.3% CS rate, shared with us the work of her breech clinic and her extensive experience with ECV, having performed over 1500 procedures herself, in addition to attending hundreds of breech deliveries in her career. It is reassuring to know that these skills are being maintained by expert practitioners.
Feedback from the day suggested that those attending had concerns about managing an undiagnosed breech birth, and interest in developing skills had been driven by recent experiences. This is a real concern. Approximately 3-4% of babies present breech at term, and 25-30% remain undiagnosed until labour. Consequently, an undiagnosed breech presents in labour approximately 1:100 of all births. It is in everyone’s interests that we do our best to support all women wishing to make the informed choice to labour with their breech babies, putting plans in place so that skills can be developed for when women cannot make a measured decision.
In my view, organising small on-call teams for breech, involving both doctors and midwives, is the best way to accomplish the re-introduction of breech skills. Some research and professional opinion supports this view (Kotaska 2009, Maier et al 2011). Neither all doctors nor all midwives will be confident and keen to attend a breech birth. Ideally all staff involved will be both, but at least one well-prepared and experienced person at every breech birth is essential, for both safety and the reassurance of the woman involved. At the conference, we also reviewed the mechanisms of breech birth, counselling for informed choice, and how to help in a complicated breech birth, particularly when the woman births in an upright position. I’ve noticed more doctors attending these study days each time we do it. One young obstetrician said to me, “I needed you here about a week ago, when I got hauled over the coals for supporting a woman to [successfully] have her breech baby vaginally.” This threatening cultural atmosphere needs to change. We need obstetricians and midwives who are willing to develop the skills to facilitate breech birth in the safest possible way.
Let’s do it .. Let’s fall in love … with breech babies
This study day was organised by Geraldine Butcher, Consultant Midwife for Ayrshire and Arran, and a passionate advocate for the rights of women to make informed decisions about how to have their babies. Feedback from the study day:
“It has been a very fruitful day for me and I will use the presentations and practice to update my own. I will feel more confident in supporting upright breech birth.”
“It gives me more confidence to promote breech delivery and services surrounding breech as an option.”
“Video scenarios were very helpful. Recent undiagnosed breech presentations have encouraged us to review / update knowledge.”
‘Into the Breech’ Workshops in Perth and Melbourne, December 2013
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.
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.
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:
- Try 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.
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.
Things to think about when sharing photos of births for teaching purposes …
Washington, DC – November 9-12, 2012
Driven by consumers, sponsored by the Society of Obstetricians and Gynecologists of Canada and attended by obstetricians and midwives from 15 different countries, the third International Breech Conference convened in Washington, DC, from November 9-11.
The highlight of the conference was soon-to-be-published data from observational studies in Frankfurt and Sydney, representing nearly 800 planned vaginal births, presented by obstetricians Andrew Bisits, FRANZCOG, and Anke Reitter, FRCOG, along with Frankfurt team researchers, midwife Betty-Anne Daviss and epidemiologist Ken Johnson. Fellow conference presenter Sophie Alexander (MD, PhD, and co-author of the PREMODA study )1 summarised by pointing out, “These results are consistent with all of the large studies done since the Term Breech Trial. Everyone except Hannah has observed a small increase in low Apgars and non-significant birth injuries for vaginally born breech babies, with no difference in mortality rates or long-term morbidity.”2
The current state of breech research was summarised by Prof Marek Glezerman, MD, Chairman of the team which contributed results from Israeli institutions to the Term Breech Trial, and author of the significant 2006 re-evaluation of the same study which concluded that due to serious flaws in the research and the simplications of standardising its recommendations, the results of the study should be withdrawn.3 Glezerman presented research from further studies, which demonstrate, as Dr Alexander pointed out, that where vaginal breech birth is well supported, it can be a safe option.4,5 Additionally, Glezerman pointed out that we need to be less precious in our initial evaluation of significant morbidity: “A low Apgar at 1 minute means nothing in 2 hours or 2 years; it only serves to make you alert to the baby.” Bisits also participated in the original TBT and shared Glezerman’s and others’ skepticism about whether the trial design was appropriate to measure what it intended to measure.6
Significantly, Anke Reitter, Andrew Bisits and Betty-Anne Daviss are experts in the use of upright techniques for breech delivery, along with Reitter’s Frankfurt colleague Professor Frank Louwen. A majority of the births in each location took place in upright positions, with the woman on hands/knees or a birthing stool. In both settings, they have observed an increased need for manoeuvres or forceps and an increase in birth injuries when the mothers have been in lithotomy position, and these obstetricians are now keen to share their data so that other clinicians can learn safer ways to facilitate vaginal breech births.
This stance was well-received by the many midwives in the audience, many of whom have been advocating upright delivery techniques for vaginal breech birth for some time. One of the foremost breech midwives is Jane Evans, SCM, SRN, a UK Independent Midwife, who presented her recently published descriptions of the mechanisms of a normal breech birth,7,8 the result of decades of close observation. Although one panel featured a lively debate about whether breech presentation should be viewed as an abnormality or an unusual variation of normal, all agreed that a thorough understanding of the parameters of normal specific to breech birth is a prerequisite for a safe service. Knowing the mechanisms allows a practitioner to understand when progress has deviated from normal and intervention is indicated, and when to refrain from potentially harmful manipulations when these are not required.
The varied conference contributions made two points very clear. Firstly, knowledge about breech birth is evolving far beyond what research done over a decade ago can address, with so much more to learn about how to make breech birth as safe as possible. Secondly, moving breech knowledge forward will require genuine multi-disciplinary openness and skill-sharing, exemplified by the humbleness of the expert obstetricians and midwives who acknowledged the many sources of their knowledge.
Following on from three days of intense discussion, a post-conference practical session on November 12 was dedicated to hands-on, practical learning with simulated breech births, guided by several of the experienced obstetric and midwife practitioners. This included two new manoeuvres, the Louwen Manoeuvre for assisting the birth of fetal arms in an upright delivery through rotation (a variation of Lovset’s), and Frank’s Nudge, used to promote flexion and birth of an extended fetal head. Detailed descriptions of these manoeuvres will be published alongside the Frankfurt data early next year, but they are already being taught in several UK hospitals which incorporate upright techniques into annual mandatory breech updates.
Throughout the three-day conference, we also heard from women who spoke very movingly about their experiences of breech pregnancy and attempts to secure support for their choice of a vaginal breech birth. Evident in these stories was the fear and resistance their providers felt, which prevented them from providing appropriate, woman-centred care, and the long-term effects this had on each woman’s wellbeing. A panel discussion dedicated to this topic included Benna Waites, a UK clinical psychologist whose own experience prompted her to gather the available evidence into her very thorough book, Breech Birth,9 essential reading for any breech practitioner. As Waites passionately summarised in her own story: “I was angry, not just scientifically disappointed. Providers need to know: your fear and your ignorance cannot be the reason for our lack of choice.”
The conference was designed to tackle this fear and resistance head-on with expert-led discussions of what is required to change the current situation, in which a caesarean section is either the most often only option when a baby presents breech, or is promoted as the best option due to providers’ lack of familiarity with current breech research since or lack of confidence in their own skills to safely deliver a breech baby. Glezerman argued that to reinstate breech skills, we must standardise assessments of competency with theoretical and practical tests, and while this must be combined with hands-on experience, standardisation cannot be based on numbers alone.10
This is partially because large numbers of breech births are simply not available to today’s trainee obstetricians and midwives. Recent research into the breech experience of obstetricians training in the UK show remarkably little experience, compared to what obstetric trainees would have experienced a few decades ago.11 The need to measure breech competency independent of birth numbers also results from the influence of personal skill sets on the ability of breech attendants, including confidence and motivation to develop expertise, which requires additional on-call commitments.12 Several speakers, obstetricians and midwives, spoke movingly of how breech birth attendance is an art, like many aspects of our professions, which some are simply more drawn to than others.
This viewpoint is consistent with the secondary analysis of the TBT results, which demonstrated that a clinician’s own evaluation of his/herself as “skilled and experienced,” when confirmed by their Head of Department, was more strongly associated with good outcomes than when the attendant was defined as a registered obstetrician or by number of years of experience.13 It also mirrors the Canadian recommendations that on-call specialist teams be established.14 In a move which reflects growing institutional support for practitioners who are willing to acquire the necessary experience to support breech birth safely, we heard how one hospital in Canada has recently abolished a mandatory transfer-of-care from midwives to obstetricians when women labouring with breech-presenting babies enter the hospital. It seems likely that, while universal training for doctors and midwives in emergency breech delivery remains required on safety grounds, planned breech births will increasingly be managed by breech specialists. In which case, more of us are needed.
Three days of presentations and discussions ended with a panel dedicated to exploring the legal and ethical dimensions of supporting a woman’s choice to birth her breech baby within today’s risk-adverse and minimally experienced services. As well as legal experts, the panel included obstetricians who facilitated planned breech births, as well as those who were prevented from doing so by their hospital’s policies, which made for an interesting discussion around the ethical dilemma resulting from the professional obligation to respect clients’ informed refusal (eg. of a caesarean section) amidst active obstruction from risk management policies. The discussion made clear that in order to provide the woman-centred service that clients want and many providers want to provide, there are many obstacles which need to be overcome, not all of these are apparent or clearly defined, so they remain difficult to tackle.
Although over the course of the conference we heard from a few American obstetricians who were preserving breech skills in isolated pockets (with positive outcomes, similar to their European counterparts), the medicolegal panel was the only portion of the conference attended by a representative of the ACOG (Dr Constance Bohon), despite repeated invitations. This was a great disappointment to the organisers from the Coalition for Breech Birth, who chose the Washington DC location for this international conference particularly to support the American chapters, who are struggling to open up lines of dialogue between consumers wanting more options and providers and their professional organisations. Listening closely to women’s concerns and extending an olive branch, Bohon suggested, “Perhaps it is time to set up a task force.”
While we in the UK are often not as circumscribed by actual legal constraints limiting woman-centred practice, a well-supported vaginal breech birth is still not easy to come by. The conference organisation team included a UK Coalition for Breech Birth user representative, student midwife Ruth Mace-Tessler, and was attended by several UK midwives and an obstetrician, but again no RCOG representative despite repeated invitations. Maybe the time has come for us to set up a similar task force in the UK?
1. Goffinet F, Carayol M, Foidart J-M, Alexander S, Uzan S, Subtil D & Bréart G (for the PREMODA Study Group) 2006. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology, 194: 1002-1011. 1. Daviss, B. A., Johnson, K. C. & Lalonde, A. B. 2010. Evolving evidence since the term breech trial: Canadian response, European dissent, and potential solutions. J Obstet Gynaecol Can, 32, 217-24.
2. Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., Willan, A. R. & Term Breech Trial Collaborative, G. 2000. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet, 356, 1375-1383.
3. Glezerman M. 2006. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol, 194, 20-5.
4. Toivonen, E., Palomäki, O., Huhtala, H. & Uotila, J. 2012. Selective vaginal breech delivery at term – still an option. Acta Obstetricia Et Gynecologica Scandinavica, 91, 1177-1183.
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