Category Archives: Informed Care

Keep an eye on Sydney

Warrnambool Dreaming Weaving Panel, Lightning Ridge

Warrnambool Dreaming Weaving Panel, Lightning Ridge, Boolarng Nangamai Aboriginal Art and Culture Studio — from a previous breech-related trip to Australia

On Sunday, I am heading off to New Zealand (Christchurch & Auckland), where doctors and midwives are keen to learn more about physiological breech birth. From there it’s on to Sydney for the Normal Birth Conference 2016, where I’m excited to be giving an oral presentation about my research into how professionals develop skills to support breech birth. This is my first Normal Birth Conference, and I can’t wait to soak up the influence of so many birth researchers, including the team from Sydney currently publishing some groundbreaking papers about breech (more below). You can follow the conference on Twitter at #NormalBirth16.

I am often asked by students with a budding interest in breech birth and a requirement to write a dissertation, if I can recommend any good/important breech research papers. Why, yes, I can.

  1. The easy and Kuhnian answer to this question is: As it happens, I’ve published a good handful of peer-reviewed research and professional publications concerning breech presentation and breech birth! History may or may not deem them to be important, but if you want to know what I think is important, the reference lists will reveal all.
  2. Read the Term Breech Trial. Read all of it, including all of the follow-up studies written by people who weren’t named Hannah. Critique the research and form your own opinions about if/how it is relevant to contemporary practice. Until you have completed this task, resist the urge to claim publicly that the TBT has been ‘disproven’ or ‘debunked.’ It hasn’t. It is still a powerful force, and in fact contains many relevant lessons. Finally, read the critiques of the TBT.
  3. Now do the same for PREMODA, and if you are reading this in a few months’ time, the Frankfurt studies. At this point it will start to become interesting if you compare the reference lists of the different ‘camps’ of breech thought.
  4. When I was starting my PhD, I did a PubMed search on ‘breech presentation,’ which returned over 4000 results. I read all of the abstracts related to management of breech presentation, and all of the articles where the abstract looked interesting/relevant. It took me about 6 months. My PhD supervisors suggested this strategy might be ‘inefficient.’ Fair point. However, it’s one of the best things I ever did, as I feel confident that I have a broad understanding of research related to breech. However, I’ve muted this suggestion, as it may not fit the time constraints of the pre-registration students. It’s just to say — there is no shortcut if you want to thoroughly understand the research base in your area of practice.
  5. Finally, keep an eye on the group in Sydney who are currently publishing some very important papers. Mixing qualitative and quantitative methods, and focusing on the experiences of women and health care professionals, this team is producing research which complements the observational studies which have predominated in the past 15 years. Although each piece of research contains its own question, underlying them all, the wider questions are lurking: How did we get in such a muddle about breech? And how can we get out of it?
Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Remembering the last visit! Westmead Consultant Midwife Michelle Underwood, Obstetrician Anke Reitter, (me) Shawn Walker, and Lactation Consultant/Conference Organiser Barbara Glare

I will link a few of the Sydney papers below. Looking forward to seeing several members of this team at #NormalBirth16.

Catling, C., Petrovska, K., Watts, N., Bisits, A., Homer, C.S.E., 2015. Barriers and facilitators for vaginal breech births in Australia: Clinician’s experiences. Women Birth 29, 138–143. doi:10.1016/j.wombi.2015.09.004 — A qualitative study of interviews with 9 breech-experienced professionals (midwives and obstetricians) exploring what helped and hindered their ability to provide women with the option of a vaginal breech birth.

Catling, C., Petrovska, K., Watts, N.P., Bisits, A., Homer, C.S.E., 2016. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery 34, 111–116. doi:10.1016/j.midw.2015.12.008 — Additional analysis from the qualitative study above, exploring how these professionals provide care during the decision-making phase, when women are choosing mode of childbirth for a breech-presenting baby.

Homer, C.S.E., Watts, N.P., Petrovska, K., Sjostedt, C.M., Bisits, A., 2015. Women’s experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 15, 1–8. doi:10.1186/s12884-015-0521-4 — A large qualitative study exploring women’s experiences and what women want when planning mode of breech childbirth. Open access too.

Petrovska, K., Watts, N.P., Catling, C., Bisits, A., Homer, C.S.E., 2016. Supporting Women Planning a Vaginal Breech Birth: An International Survey. Birth. doi:10.1111/birt.12249 — An international survey exploring the support women received when planning a breech birth. The researchers found that women were generally happy with their decision to plan a breech birth and would do it again in another pregnancy. However, lack of support from their primary care providers often made this difficult to achieve.

Petrovska, K., Watts, N., Sheehan, A., Bisits, A., Homer, C., 2016. How do social discourses of risk impact on women’s choices for vaginal breech birth? A qualitative study of women’s experiences. Health. Risk Soc. 1–19. doi:10.1080/13698575.2016.1256378

Petrovska, K., Watts, N.P., Catling, C., Bisits, A., Homer, C.S., 2016. “Stress, anger, fear and injustice”: An international qualitative survey of women’s experiences planning a vaginal breech birth. Midwifery 0, 464–469. doi:10.1016/j.midw.2016.11.005

Petrovska, K., Sheehan, A., Homer, C.S.E., 2016. The fact and the fiction: A prospective study of internet forum discussions on vaginal breech birth. Women and Birth. doi:10.1016/j.wombi.2016.09.012

Watts, N.P., Petrovska, K., Bisits, A., Catling, C., Homer, C.S.E., 2016. This baby is not for turning: Women’s experiences of attempted external cephalic version. BMC Pregnancy Childbirth 16, 248. doi:10.1186/s12884-016-1038-1 — Oh, thank goodness for this. The rhetoric around external cephalic version (ECV) is so strong, it almost feels a sacrilege to question it. Despite the Cochrane Review stating clearly that the evidence does not indicate that ECV improves neonatal outcomes, women are constantly told that ECV is ‘best for babies.’ Which says a lot about how reluctant to engage with the option of vaginal breech birth their providers are. This study of women’s experiences is a welcome balance to the dominant view that vaginal breech birth is only something to be considered after ECV has failed. ECV is a good option for many women, and a safe procedure in experienced hands. But it is not for everyone.

Andrew Bisits and Anke Reitter demonstrate breech skills

Andrew Bisits and Anke Reitter demonstrate breech skills

Borbolla Foster, A., Bagust, A., Bisits, A., Holland, M., Welsh, A., 2014. Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study. Aust. N. Z. J. Obstet. Gynaecol. 54, 333–9. doi:10.1111/ajo.12208 — Technically from another team, with one cross-over member, inspirational obstetrician Andrew Bisits. This observational study helps to shed light on the clinical context surrounding these researchers. Although the article makes no mention of use of upright positioning for labour and birth, Dr Bisits is well-known for his use of a birthing stool for breech birth. You can read more about this in a previous blog, Bottoms Down Under.

Andrew Bisits performing a gentle ECV

I may have missed something, or a new study may have been published while I am writing this. (I have updated the post with some recent editions.) Best to keep a look out yourself.

Shawn

RCOG consultation on new breech guideline

A 'normal' breech baby - well-flexed, with lots of room to move

A ‘normal’ breech baby – well-flexed, with lots of room to move

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

Jean-Christophe Lafaille and the HBA3C

Image: http://kylekeeton.com/product/outdoor-mountain-climbing-rock-climbing-protector-mountain-climbing-supplies-downhill-atc-falling-apparatus-free-shipping/

Image: http://kylekeeton.com/

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:

  1. the woman’s decision to birth her baby at home attended by midwives, after having had three previous caesarean sections; and
  2. 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.
Image: http://www.unet.me/free-wallpaper/Fancy-Mountain-Climbing-1920x1408_123814

Image: http://www.unet.me/

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.

Image: http://www.free-picture.net/sports/winter-sports/mountain-climbing.jpg.html

Image: http://www.free-picture.net/

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.

Shawn

(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 PlestedPlested M, Walker S (2014) Building confident ways of working around higher risk birth choicesEssentially MIDIRS 5(9):13-16 – (Archived at City Research Online)

See also the Mama Sherpas film

Can we eliminate all risk for breech babies?

Closer to my heart, by Leah Sandretsky,  www.etsy.com/shop/heartbeatstudio

Closer to my heart, by Leah Sandretsky, www.etsy.com/shop/heartbeatstudio

This week (August 2014), a Dutch research team published the results of a large retrospective cohort study concerning the results of all breech births in the Netherlands. They concluded that an increase in the caesarean section rate following publication of the Term Breech Trial (TBT) has resulted in a significant reduction in perinatal mortality related to breech presentation, and therefore a policy of universal caesarean section for breech would improve outcomes for breech babies even further.

In the year prior to October 2000 (the team does not present data from earlier than 1999; why not?), the perinatal death rate was 1.3/1000 for all breech deliveries (VBB and CS inclusive). Elective sections increased from 24% prior to publication of the TBT to 60% afterwards, and from December 2000-2007, the perinatal mortality rate was 0.7/1000 for all breech deliveries, with an overall VBB rate of 22%. Moreover, the team showed that all of the perinatal deaths occurred during what they called planned breech deliveries (although their understanding of ‘planned breech delivery’ is very different from mine, as I discuss below), so the actual perinatal mortality rate for breech babies born vaginally remained steady at 1.6/1000 during both periods.

A rate of 1.6/1000 is actually quite low compared to the mortality rate of approximately 1/100 reported in the Term Breech Trial. However, the authors propose that the results of this study should replace the information currently given to women in Dutch national guidelines, because according to their calculations, “A policy of elective caesarean section for all term breech deliveries could lower the overall term neonatal mortality in term deliveries by 6.8%, from 172 to 162 per year.”

Unfortunately, it’s not so simple.

Dreaming the impossible dream.

A 'normal' breech baby - well-flexed, with lots of room to move

A ‘normal’ breech baby – well-flexed, with lots of room to move

The first problem with this prediction is that it’s not possible to pursue a policy of elective caesarean section for all term breech deliveries, even if you ‘convinced’ the 40% of women who choose to plan a VBB in the Netherlands to plan a CS. The researchers themselves noted that approximately 1:5 of the perinatal deaths observed occurred when breech presentation was not diagnosed until birth. Without instituting expensive changes to breech screening on a national basis, these outcomes will not necessarily be improved, certainly not without performing many more risky caesarean sections in advanced labour. (When these births were excluded from the analysis, the perinatal mortality rate for VBB’s which were actually planned was 1.3/1000 overall. The Netherlands has a high rate of home birth, so some of these unplanned VBB probably occurred at home with surprised, rather than prepared, midwives.)

Also, the researchers note that they have not performed an intention-to-treat analysis of their data. Multiple studies have noted that approximately 10% of women who plan caesarean sections go into labour unexpectedly before their scheduled operation, and 9.7% of the woman randomised to CS in the TBT gave birth vaginally. The researchers say that those for whom this was the case ‘could not be included in the caesarean section group’ for their study. Why? Were they included in the ‘planned’ vaginal breech birth group? The authors note this category was a ‘composite of vaginal delivery and emergency cesarean.’ Regardless of whether these women actually planned a VBB?

In an intention-to-treat analysis, the outcomes for babies who turn head-down spontaneously would also be included, as the decision to plan a VBB influences whether or not they will. In the Term Breech Trial, twice as many turned when a VBB was planned than when a CS was planned, so that 3.8% of all babies who planned a VBB were born in a cephalic position. Failing to do an intention-to-treat analysis disregards the complexity of breech decision-making and the full range of consequences.

Putting the figures into perspective.

664730The researchers note that 40% of women in the Netherlands choose to plan a vaginal breech birth, in collaboration with their doctors and midwives, and approximately 55% of them achieve this. This results in an overall perinatal mortality rate for breech presenting babies in the Netherlands of 0.7/1000, which happens to be the same perinatal mortality rate for low-risk women giving birth in hospital settings in the Netherlands (de Jong et al 2009; the mortality rate was slightly lower for women who planned a home birth at 0.6/1000). From where I am sitting, this looks like a good example of collaborative decision-making reducing risk while preserving choice.

Earlier this year, another team also led by Vlemmix (2013) published an abstract in the AJOG using further data from the Dutch nationwide perinatal registry from 2000-2007. This demonstrated that in addition to greatly increased maternal morbidity, neonatal mortality in pregnancies which followed an elective CS for breech presentation was 2.5/1000, compared to 1.3/1000 following pregnancies where a VBB was planned (which will be an average of the 2.5/1000 risk following a CS, and substantially lower risk following successful planned VBB’s). How then does this affect the prediction that elective caesarean section for all breech presentations would further significantly reduce the overall national perinatal mortality rate? Only if these women do not have any more children. Seems worth a mention to me, when you are recommending that all breech babies with a neonatal mortality risk of 1.3/1000 be delivered by CS.

Consider statistics given in the RCOG guideline on Birth After Previous Caesarean Birth. They summarise the data relating to term VBACS: “Planned VBAC is associated with a 10/10,000 risk of antepartum stillbirth beyond 39 weeks of gestation and a 4/10,000 risk of delivery related perinatal death (if conducted in a large centre).”

So a woman choosing to await spontaneous labour past 39 weeks and attempt a VBAC has a 1.4/1000 risk of losing her baby, but this is not only perceived as a reasonable decision, it is positively encouraged in most hospitals in the UK. Entire midwifery-led care pathways are set up to support women making this choice, and primiparous women to whom elective section for breech is recommended are proactively counselled that they can feel positively about attempting a VBAC the next time around.

But a woman choosing to birth her breech baby vaginally, knowing that she has a 1.3/1000 chance of losing her baby, is suspect. Does anyone else get the feeling we are robbing Peter to pay Paul?

The researchers identified no sub-classification of women for whom breech birth was more risky, or less risky compared to CS. They did observe that babies with a birth weight of over 3500 g (often excluded from VBB) actually only had a perinatal mortality rate of 0.8/1000. Contrary to what they have concluded, encouraging any woman who plans to have more children and wishes to attempt a VBB (at a relative PMR of 1.3/1000) as opposed to advocating universal elective CS for breech (and exposing subsequent children to double the mortality rate, at 2.5/1000), seems a measured approach.

The team’s representation of morbidity statistics also distorts the picture, as long bone fractures (included in their composite statistic) are common in cephalic births as well. They heal well, and are not generally considered ‘serious morbidity.’ Nonetheless, the morbidity rate of 22/1000 reported in this research was also significantly less than the rate of approximately 1/20 reported in the Term Breech Trial.

Designing research which meets the needs of women and their partners

Descending LST, anterior buttock leading

Descending LST, anterior buttock leading

The researchers have called for the results of their study to replace the information in their national patient information leaflets, which are based on the data from the Term Breech Trial, including the information that outcomes at 2 years of age did not differ between planned VBB and planned CS. One of the authors named in this Vlemmix study has also conducted research into what information matters most to women and their partners (Kok et al 2008).

Kok’s study (2008) demonstrated that women were mostly concerned with the safety of their baby and fear for a handicapped child, and that the 2-year outcome was what mattered most to them. Why then has this team conducted yet another study telling us what we already know – that short-term morbidity and mortality is significantly greater when VBB is planned in most cases – rather than robust research addressing what matters most to the families making these decisions? Whyte’s team (2004) emphasised that the 2-year results surprised them, as the group of children who went on to have handicaps at 2 years of age did not overlap at all with the group of children who experienced severe morbidity in the neonatal period. They were all born apparently healthy, and in the Vlemmix study would have been included in the ‘proof’ that universal CS is a safer policy. Given the numerous studies demonstrating a higher risk of cerebral palsy and other adverse outcomes for breech-presenting babies regardless of mode of delivery (O’Collaghan and MacLennan 2013), the question of whether the babies we save from death in the first 7 days go on to lead full and healthy lives is a fundamental question. And it is the concern which matters most to women.

On the other hand, according to Kok et al (2008) the concern which matters most to women’s partners is the outcomes for women. This study reported only 2 maternal deaths in the 1999-2007 period, despite acknowledging another study already published by the Dutch Maternal Mortality Committee reporting 4 deaths following elective section for term singleton breech in the Netherlands in 2000-2002 alone.

Why are the women disappearing?

If this study does not address the central concerns of women and their partners, why should it take precedence in the information given to aid informed decision-making? If the authors have not performed an intention-to-treat analysis, how can they possibly claim to know that their treatment will have the predicted result? If the study has demonstrated a risk similar to that of planning a VBAC, why are both choices not considered equally reasonable?

These authors are all very much involved with research concerning external cephalic version (ECV) and also feel the results of this research demonstrate the need to use ECV more liberally in order to reduce the incidence of breech presentation at term. While I am a fan of their ECV research and a proponent of ECV as a readily available option for women with breech presenting babies, again we cannot ignore the fact that ECV has not yet been demonstrated to improve neonatal outcomes, possibly for the same reasons the 2 year outcomes for children are not affected. However, ECV does significantly reduce the CS rate for women, particularly in centres where the option of VBB is not well supported. Again, I would like to see this highly experienced and highly influential team turn their attention to answering questions we do not already know the answer to, including whether or not manually turning a breech baby from a breech to a head-down position improves the short- and long-term outcomes for these babies, beyond increasing their chance of being born vaginally.

Shawn

De Jonge, A., van der Goes, B.Y., Ravelli, A.C.J., Amelink-Verburg, M.P., et al. (2009) Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG : an international journal of obstetrics and gynaecology. [Online] 116 (9), 1177–1184. Available from: doi:10.1111/j.1471-0528.2009.02175.x [Accessed: 12 August 2014].

Vlemmix, F., Kazemier, B., Rosman, A., Schaaf, J., et al. (2013) 764: Effect of increased caesarean section rate due to term breech presentation on maternal and fetal outcome in subsequent pregnancies. American Journal of Obstetrics and Gynecology. [Online] 208 (1, Supplement), S321. Available from: doi:http://dx.doi.org/10.1016/j.ajog.2012.10.102.

Vlemmix, F., Bergenhenegouwen, L., Schaaf, J.M., Ensing, S., et al. (2014) Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study. Acta Obstetricia et Gynecologica Scandinavica. [Online] 93 (9), 888–896. Available from: doi:10.1111/aogs.12449 [Accessed: 12 August 2014].

 

Dolichocephaly – understanding ‘breech head’ molding

This post is about dolichocephaly, a form of positional molding which affects some breech babies – how it happens, why it may be important, and how to recognise it.

Everyone is concerned about entrapment of the after coming head in a breech birth. And it seems so unpredictable. Many breech babies, even large ones, seem to just fall out. And then others, not so large, get stuck. RCOG guidelines suggest an estimated fetal weight above 3800 g is ‘unfavourable’ for vaginal breech birth, but goes on to say, “If the baby’s trunk and thighs pass easily through the pelvis simultaneously, cephalopelvic disproportion is unlikely.” (Easily is undefined, but in light of the evidence against augmenting breech labours, I interpret it as occurring spontaneously within about an hour of active pushing.)

Can we predict which babies’ heads are more likely to have difficulty passing through the pelvis? I don’t know, but I feel one phenomenon in particular deserves more attention – dolichocephaly.

Dolichocephaly developing due to positional pressures

Dolichocephaly developing due to positional pressures

Technically, dolichocephaly is a mild cranial deformity in which the head has become disproportionately long and narrow, due to mechanical forces associated with breech positioning in utero (Kasby & Poll 1982, Bronfin 2001Lubusky et al 2007). This change in shape is more commonly associated with primiparity (first babies), larger babies, oligohydramnios, and posterior placentas, all of which result in greater forces applied to the fetal head.

(Note: Like all positional molding which occurs in utero, dolichocephaly does not in itself cause nor indicate abnormal brain development. The head shape is highly likely to return to completely normal in the days and weeks following birth, especially if baby receives lots of holding and cuddles to permit free movement of the head.)

Clinical Importance

Following the birth of the arms in a breech birth, the head will be in the anterior-posterior diameter of the pelvis. When the head shape has become abnormally elongated, the longest diameter of the fetal head will meet the shortest diameter of the maternal pelvis at the inlet. Unless the baby is still on the small side and the pelvic inlet very round, the chin may get stuck on the sacral promontory, preventing head flexion. A very experienced breech provider will have encountered this situation before, and should be able to assist, but it is quite a tricky place to be. The head may need to be rotated into the transverse diameter to safely enter the pelvis. A very elongated head can have difficulty passing through the lower pelvis as well, and can cause damage to the maternal pelvic floor, unless appropriate techniques are used to assist the head to flex.

Effects of abnormal head molding in some breech-positioned babies

Abnormal head molding in some breech babies

Estimation of fetal weight by ultrasound is notoriously inaccurate. However, a lack of proportionality between the head circumference and the biparietal diameter is more obvious to spot (e.g. HC=90th percentile, BPD=60th percentile; or a difference in correlating dates of two weeks or more), and may be a more relevant indication that this baby is too big for this particular woman. Dolichocephaly can be discerned on palpation as well, as the occiput is prominently felt above the fetal back, the head is not ballotable, and may feel unusually wide. I would suggest caution where estimated fetal weight is above 3500 g and a difference in HC and BPD, or careful palpation, indicates abnormal cranial molding has occurred, especially for women who are having their first baby, have a low amniotic fluid index, and/or a high posterior placenta; and in situations where imaging pelvimetry is not used to confirm an ample pelvic inlet.

Counselling Women

Women instinctively do not like weight limits used as ‘selection criteria.’ One woman (Ann, multip, 6’1”) looks at another (Carol, primip, 5’0”) and they both think – We can’t possibly be expected to have similar-sized babies. While Ann may carry a 4000 g baby with no abnormal head molding, and expect a straightforward birth, Carol’s baby may begin to show signs of dolichocephaly at 3300 g, especially if she has low levels of amniotic fluid and a posterior placenta. Carol may still have a successful birth, but it will more likely depend on the skill and experience of her attendant in assisting the aftercoming head to flex, rotate and negotiate the pelvic diameters, and the pelvic diameters themselves.

A 'normal' breech baby - well-flexed, with lots of room to move

A ‘normal’ breech baby – well-flexed, with lots of room to move

We need to move away from the concept of ‘selection criteria,’ which are used by professionals to make decisions for women, and towards an understanding of what is ‘normal for breech.’ We need to understand more about which babies are more likely to experience those beautiful, often-easier-than-cephalic, dancing-into-the-world births, and which babies are truly being put at additional risk by their in utero conditions.

Then we will be able to explain to women the benefits of a caesarean section for pregnancies which have become ‘abnormal.’ Women will be able to approach this intervention with an open heart when they observe professionals are truly supporting ‘normal’ breech births and providing individualised care and screening to those which are not.

I would love to know what others think about this.

Shawn

Breech Birth After Caesarean (BBAC)

Another post responding to maternity service user demand for better information and more individualised care for breech presentation, prompted by a discussion on the Coalition for Breech Birth Facebook group.

In these days of growing awareness of the risks associated with doing too many caesarean sections, women planning an elective section for breech presentation are informed that they can and should be encouraged to try for a vaginal birth after caesarean section (VBAC, or just BAC). Yet how many are informed that she has a 1:10 chance of the breech presentation recurring in the next pregnancy (Coughlan et al 2002, Ford et al 2010)? And that if her second baby is breech there is almost a 1:3 chance that her third will be? That this likelihood is increased if she, her mother or her father were breech (Nordtveit et al 2008)?

‘Breech’ remains an issue for many women throughout their reproductive lives, so much so that some have argued it is ‘physiologically normal’ for some women (Albrechtsen et al 1998). And many women will have spent time between pregnancies considering the information which led them to choose an elective section, and arriving at a very different point of view by the end of their second pregnancy.

The Royal College of Obstetricians and Gynaecologists’ guideline lists a ‘scarred uterus’ (which would include post-CS, as well as other uterine surgery, such as myomectomy) as a contraindication to a vaginal breech birth (VBB). However the guideline also refers to one (small) study which specifically looked at success rates for BBACs:  Ophir et al 1989 had really good outcomes, and a higher rate of successful vaginal birth than many series report. But bigger numbers would be more reassuring, and they need to be compared to results for other VBACs.

(Incidentally, a previous CS is often considered a contraindication for ECV as well, but I found no studies demonstrating an increase in uterine rupture. Burgos et al 2014 looked at this and reported no uterine ruptures in 70 ECVs. Higher numbers would be more reassuring, but this is the problem with breech research – higher numbers are tricky to come by!)

The PREMODA study reported two adverse outcomes for BBACs, which accounted for 2/3 of the deaths they concluded could have been prevented had elective sections been performed at 39 weeks. One woman arrived to the hospital with contractions, but no fetal heart tones. The other woman experienced a spontaneous uterine rupture at 40 weeks, when a VBB was planned. Both complications associated with a pregnancy following a CS in general, not BBAC labours.  Oh, how unfortunate it must have felt – for the families and for the researchers – to have their beautiful breech outcome stats affected by the CSs they were trying to prevent! Understandably, given the current climate which blames any adverse outcome on the breech, they recommended BBACs be avoided.

We talk a lot about risks of labour, but increasing evidence points to risks of not labouring as well. Two obstetricians, Sinha and Bewley (2010) point out in their article, ‘Myth: babies would choose prelabour caesarean section:’

Babies who do not experience labour have significantly increased respiratory and other morbidities that may have profound effects on development, determining immediate and potentially life-long disease. It is thus surprising that obstetricians do not advocate awaiting or inducing labour even in women considering CS. (from the abstract)

Ulander et al al 2004, a Finnish team, draw similar conclusions in their comparison of breech, vertex and caesarean deliveries, ‘Are health expectations of term breech infants unrealistically high?:’

As regards the long-term outcome of the children, the only statistically significant difference was in the number of visits to out-patient departments which were less frequent for breech infants born vaginally than breech infants born through CS (OR 0.70, CI 0.53–0.93) or vertex infants born vaginally (OR 0.58, CI 0.47–0.72) (Table III). The cumulative incidence of long- term morbidity was lower in breech infants born vaginally than in breech infants born by planned CS (OR 0.47, CI 0.28–0.80). (p 83)

Any future research on breech or VBAC should include these long-term outcomes as well. Ulander et al found that the risks of birth trauma were smaller for breech-born babies than for cephalic-born babies, but smallest over all for CS-born babies. Undoubtedly, labour introduces some risks — especially first labours, VBAC labours, breech labours. But like many things in life, sometimes taking those risks results in long-term benefits, which can only be perceived further along down the road. A BBAC is a reasonable choice, which should be supported.

What additional precautions might be in order? A dysfunctional labour is a risk factor for both VBAC and breech labour. Especially if the birth will occur in a unit that does not routinely recommend and promote vaginal breech birth, and thus will not be saturated with experience, inducing or augmenting a BBAC is asking for trouble.

Shawn

Further Research:

  • Bourtembourg, A., Mangin, M., Ramanah, R., Maillet, R., et al. (2013) [Breech delivery and scarred uterus: A special obstetrical situation?]. J Gynecol Obstet Biol Reprod (Paris). 42 (4), 351–358. Conclusion: Vaginal breech delivery in case of a scarred uterus is possible, if each obstetrical situation is correctly studied to authorize a vaginal birth trial after a careful selection of patients and a strict management of labour. Vaginal birth does not seem to increase maternal and neonatal morbidity and mortality in this situation.