Category Archives: Research

New RCOG guideline published today!

The new RCOG Management of Breech Presentation guideline has been published today. This guideline substantially revises recommendations in the previous version, published in 2006. If followed, it will undoubtedly improve women’s access to and experience of breech care. Below I will highlight two of the new guideline’s game-changing recommendations, and then raise two key questions concerning areas of on-going exploration.

Reference: Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. BJOG 2017; DOI: 10.1111/1471-0528.14465.

Victoria and Kirin Owal celebrate the healthy birth of their twins (#2 breech) with their NHS Team.

Counselling (Section 4.1)

The guideline offers specific recommendations around counselling, following the summary presented by lead author Mr Lawrence Impey at the RCOG Breech Conference in 2014. When discussing perinatal mortality, rather than focusing on the dichotomy between elective caesarean section at 39 weeks (0.5/1000) and planned breech birth (2.0/1000), the guidelines also recommend women consider these figures in light of those for planned cephalic birth (1.0/1000).

This is important. If we follow the logic that has dominated breech care for the last 17 years – elective CS for all because it reduces perinatal mortality – we would need to apply this to planned cephalic births as well. The truth is always somewhere in between. All childbirth options carry benefits as well as risks, and women should be supported to apply their own values to decision-making, rather than feel obligated to adopt uniform recommendations arising from contemporary risk-focused discourse. This new guideline is much clearer about the obligation of health care professionals to present women with genuine breech childbirth options.

Dr Brad Bootstaylor of SeeBaby, Atlanta Georgia, demonstrating upright breech skills

Maternal birth position (Section 6.7)

The guideline has changed from recommending lithotomy birth position to the following: “Either a semi-recumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant.” This will be joyously welcomed by midwives and obstetricians who have been gradually incorporating upright breech methods into clinical skills training for some time, and the women who have been insisting on the freedom to choose their own birthing position.

But as the explanatory notes indicate, “The principle difficulty with an all-fours position is when manoeuvres are required. Most obstetricians are more familiar with performing these in a difficult breech birth with the woman in the dorsal position.” This begs the question of how we will overcome the difficulty resulting from lack of obstetric familiarity with performing manoeuvres when women are in upright, particularly kneeling positions. Our recently published evaluation of the Breech Birth Network Physiological Breech Birth training days reported that one of the greatest concerns expressed by participants in the workshops was lack of involvement and collaboration from obstetric colleagues, whom they had difficulty convincing to attend the training in order to learn effective manoeuvres. Hopefully changes in our national guideline will prompt more interest.

Tanya Burchill practising manoeuvres with Emma Spillane during a break in Physiological Breech Birth Training

Question #1: What does it mean to be ‘skilled’ in breech birth birth?

The word ‘skilled’ recurs 15 times in the new RCOG breech guideline. Variations include: ‘skilled intrapartum care,’ ‘skilled birth attendant(s),’ ‘skilled supervision,’ ‘skilled attendant(s),’ ‘operator skilled in vaginal breech delivery,’ ‘skilled support,’ ‘skilled personnel.’ Each reference suggests skill is a key ingredient of safe vaginal birth.

What does it mean to be ‘skilled’ in vaginal breech birth? Is it a quality possessed by individuals, or institutions, or both? How is skill assessed? How is it maintained?

The danger with lack of definition regarding breech skill is that by default it will be judged in retrospect. A good outcome occurs = the attendants were skilled. A bad outcome occurs = the attendants lacked skill and were overconfident in assessment of their own competence. A health professional attends four spontaneous breech births which do not require intervention = they are now perceived as ‘skilled.’

The guideline points to evidence from the PREMODA study, in which good outcomes were achieved in a study with senior obstetrician presence in 92.3% of cases. Association is not causation, but we need to take seriously the value the PREMODA researchers placed on this as a key to their success. In a UK context, or elsewhere, does that mean we can (or should?) reasonably expect all senior obstetricians to be ‘skilled’ at vaginal breech birth? What if the senior obstetrician does not feel ‘skilled’ her/himself? What if a midwife is the most experience person available to attend a breech birth?

Claire Reading sharing her skills

The new RCOG guideline further recommends: “Units with limited access to skilled personnel should inform women that vaginal breech birth is likely to be associated with greater risk and offer antenatal referral to a unit where skill levels and experience are greater.” And: “All maternity units must be able to provide skilled supervision for vaginal breech births where a woman is admitted in advanced labour and protocols for this eventuality should be developed.” How will all maternity units be able to provide skilled supervision for undiagnosed breech births, if some of them will also need to be up front about their lack of skill to support planned breech births?

The new guideline recommends that “simulation equipment should be used to rehearse the skills that are needed during vaginal breech birth by all doctors and midwives.” The extent to which such simulation training will result in skill development in settings where skills have become depleted over the last 20-30 years is unclear. Our recent systematic review highlights the lack of evidence regarding the ability of standard training programmes to improve outcomes, and suggests that teaching vaginal breech birth as part of an obstetric emergencies course may actually reduce the chances that providers will actually attend breech births (Walker, Breslin, Scamell and Parker, 2017).

The development of professional competence to facilitate breech births is a complex matter to which institutions may like to pay closer attention as they develop the ‘routine vaginal breech delivery service’ envisioned by the new guideline. Some of this complexity is explored in these two papers involving research with experienced practitioners: Standards for maternity care professionals attending planned upright breech births and Principles of physiological breech birth practice.

Question #2: What is a footling presentation?

Despite the acknowledged paucity of evidence regarding factors that increase the risks of vaginal breech birth, ‘footling presentation’ remains a clinical indication for advising women that the risks associated with vaginal breech birth are likely to be independently increased. Unfortunately, neither the guideline nor generally available breech literature provides a clear definition of what this means, nor is it likely that a similar definition has been used among disparate studies looking at outcomes associated with variations of breech presentation.

The danger with this lack of definition is that in many complete and incomplete breech presentations, where one or both legs are flexed, one or more feet will be palpable on vaginal examination. This is especially the case at advanced dilatation, when legs will often slip further down due to the increased space in the sacral cavity, into which the breech has also descended. And of course in advanced labour, the dangers of performing a caesarean section for a dubious indication are increased. It has never made sense to me to perform a caesarean section at advanced dilatation because one might need to perform a caesarean section! Where skill levels are minimal and practitioners are not taught to locate the sacrum as the denominator, many complete and/or incomplete breech presentations will be labelled ‘footling.’

Dr Susanne Albrechtsen teaching breech skills

In my practice, I follow the nomenclature suggested by Susanne Albrechtsen (unfortunately only available in Norwegian): a footling breech is one in which both feet present first, and the fetal pelvis is disengaged, above the pelvic brim. A fetus whose pelvis is engaged with one or more feet palpable alongside is a flexed breech (complete/incomplete).

We will await more professional debate and actual evidence concerning the definition of ‘footling breech’ and its association with fetal outcomes. Perhaps now that the new RCOG is more supportive of vaginal breech birth, more professionals will feel experienced enough to engage in discussions which will move our knowledge base forward and further increase the safety of breech birth.

Shawn

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

Standards for upright breech birth now on-line

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

SW tweet

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.

Recruiting further participants

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.

http://fluidsurveys.com/surveys/breechmidwife/expression-of-interest-vc2/

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.

— Shawn

A Tale of Two Breech Film Premiers

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.

IMG_6592

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).

IMG_6600On 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.

– Shawn

RCOG and Oxford Breech Conferences, October 2014

Screen Shot 2014-10-19 at 17.09.13Well.

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!

ColleaguesHowever, 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.

Mohajer1Murphy 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.

BiasesAfter 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.

huggingAfter 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.

placentaVisiting 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?

Jane EvansOver 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.

Deirdre Murphy, Anke Reitter, Mich Mohajer, Thomas van den Akker, Leonie Penna

Deirdre Murphy, Anke Reitter, Mich Mohajer, Thomas van den Akker, Leonie Penna

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.

keenThis 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.

ECVDr 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.

Oxford Brookes

Shawn Walker, Ethel Burns, Anita Hedditch, Andrew Bisits, Lawrence Impey, Anke Reitter, Betty-Anne Daviss

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.

Collaborative approachThis day kicked off with Lawrence Impey presenting the evidence base for breech birth, emphasising some of the themes from the previous Tuesday’s conference:

  • 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

heavy handedImpey 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.

nuclearAfter 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.

enablingReitter 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.

getting itBetty-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.

anticipatoryI 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)

Screen Shot 2014-10-19 at 17.09.59If 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.

Screen Shot 2014-10-19 at 15.30.44If 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.

sitting next to youWell 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.

Shawn

Resources and a plug

Posterior arm born, anterior arm high, shoulders in A-P diameter - help is required!

Posterior arm born, anterior arm high, shoulders in A-P diameter – help is required!

In July, Gerhard Bogner of Salzburg presented data at a Breech Birth Network study day.  Although the series is small, the data indicate that when the mother is in all fours position to birth a breech baby, approximately 70% of those births will occur completely spontaneously, eg. without the need to perform assisting manoeuvres at all. Use of upright positioning also reduced the rate of maternal perineal damage from 58.5% to 14.6%, which is actually better than cephalic births!

The reduced need for manoeuvres potentially reduces iatrogenic damage to babies associated with interference at the time of birth, such as birth injuries and inhaled meconium. That’s great for that 70%, but what about the other 30%? The babies born with upright positioning in Bogner’s study had a slightly higher rate of low cord blood gases, indicating hypoxia, although no consequences for the infants or differences in 5 minute Apgar scores were observed.

If a woman is birthing her baby in an upright position, how do we assist the birth confidently and safely when delay is identified? How do upright manoeuvres differ from those performed when the woman is supine? To address a growing need for more practical training in upright breech birth, City University are offering Physiological Breech Birth Workshops in London and taster days around the country. The next one is on 2nd of December at the Whittington in Central London. Lots of hands-on training with a small group of doctors and midwives committed to extending breech skills. We also post conferences and workshops provided by others when we can.

Several people have been in touch to ask about the How and When to Help handout. I disabled the link because it is constantly being updated! Please feel free to download this one and use it in your practice area. But keep in mind understanding in this area is constantly expanding, and this is just one midwife’s current approach. I’m working on research to understand others’ approaches as well, but it will be some time until this is finished.

Look out for two articles appearing this month. In The Practising Midwife, I present a summary of current evidence related to ECV (external cephalic version), with some excellent photos provided by Dr Helen Simpson and Midwife Emma Williams of South Tees Foundation Hospital. In Essentially MIDIRS, Mariamni Plested and I talk about issues in providing innovative care for higher risk birth choices.

Finally, shameless plug: Today (30/9/14) is the last day to vote for my, um, remarkable cousin Jake in the NRS National Model Search. Read all about him here, and then click on the link at the bottom of the article to VOTE FOR JAKE!

Favourite quote from the article: “The funny thing is, some bulls are just like big dogs. They come up to you, put their butt in your face and say, ‘Scratch my butt.’ But as soon as they get that flank rope on them, it’s like, ‘Game on. I’ve got something to do now.'”

Awww. Gotta love a bit of passion, of finding your niche and loving it … We love you, Jake! (Just what every 18 year old boy always wanted, a plug on a breech birth information site. We clearly share a common love of butts.)

Update: He won! Go Jake!

Shawn

Bogner, G., Strobl, M., Schausberger, C., Fischer, T., et al. (2014) Breech delivery in the all fours position: a prospective observational comparative study with classic assistance. Journal of perinatal medicine. [Online] Available from: doi:10.1515/jpm-2014-0048

The longer-term effects of CS for breech in Denmark

Screen Shot 2014-08-15 at 06.30.06Something is rotten …

Well, I suppose a backlash was inevitable. Due to the campaigning of women and the willingness of a significant number of health care providers to provide women with a real choice when it comes to breech childbirth, the argument for re-skilling to better support breech births has been gaining momentum. But this week saw the publication of two studies arguing this is not such a good idea.

First it was a Dutch group (Vlemmix et al 2014) who made the argument that at 1.3/1000 compared to nil, vaginal breech birth (VBB) results in ten times the mortality of planned CS. They overlooked the need to match the word ‘planned’ with an intention-to-treat analysis, and their own research (Vlemmix et al 2013) suggesting that neonatal mortality was doubled in pregnancies following an elective CS compared to those where a VBB was planned in the first pregnancy (2.5/1000 vs 1.3/1000). (Read my response here.)

When baby's head has descended into the pelvis, the pubic bones are directly behind the occiput

When baby’s head has descended into the pelvis, the pubic bones are directly behind the occiput

Now a Danish study asks, “Can Caesarean section improve child and maternal health? The case of breech babies” (Jensen and Wust, 2014). Wait, did I read that right? Are we asking whether CS can improve maternal health? Really?

Unlike their Dutch counterparts, Jensen and Wust have decided: “In our estimation sample, we observe only few infant deaths for breech babies. Thus we do not consider this very rare outcome in the proceeding analysis.” One country decides this outcome is a deal breaker, another feels it is so rare that it is not necessary to consider it.

Jensen and Wust present a lot of beautiful graphs and calculations showing that there was a noticeable improvement in Apgar scores and a reduction in visits to the GP, but no significant change in serious morbidity (ill-health) or hospitalisations in the first three years of life, following the sudden increase in elective CS for breech associated with the publication of the Term Breech Trial in 2000.

Although I am in favour of attempting to calculate the longer-term effects of such sweeping changes, I am concerned about what they did and did not choose to speculate upon.

Their most statistically significant finding was an increase in prolonged maternal hospitalisation following an elective CS. This has noticeable financial implications, which they calculated, but they do not address the increase in costs and risks in future births. The financial blind eye is concerning, but their conclusion that CS does not affect the health of the mother, without considering future births, is even more disconcerting.

On the other hand, they speculate that the additional expenditure for elective CS is balanced by costs savings as a result of significant reductions in cerebral palsy and subsequent care needed. They did not have information on actual rates of CP in this population. Instead, they reference a 2001 study by Krebs, which did NOT note a relationship between CP and mode of delivery, and found in 20,000 breech births a total of 4 serious long-term disabilities and 18 minor disabilities possibly related to low Apgar scores. They ignored Krebs previous research (1999) indicating that an increase in CP for breech-presenting babies was NOT associated with mode of delivery. They also ignored a recent systematic review and meta-analysis (O’Callaghan and MacLennan 2013) demonstrating that CS does NOT reduce the risk of CP for breech-presenting babies.

It’s important to get this right. Low Apgars are definitely associated with increased CP and other problems in head-down babies, possibly because the birth itself less often causes minor asphyxia, and therefore the cause is often an underlying fragility. In Krebs’ work, he found the association was mostly with small for gestational age infants; this corresponds with other breech research which consistently associates smaller babies with poorer outcomes. But because many breech babies have lower Apgars as a consequence of the way they are born, Apgars are not such a clear indicator of future risk in this population. They were not in the Term Breech Trial (Whyte et al 2004), and that is the best evidence we have to go on at the moment.

The main outcomes shown in this research are an increase in overall Apgar scores and a decrease in visits to the GP in the first year, less significantly in the second year, and not significantly different in the third year of life. They found no increase in significant neonatal morbidity or hospitalisations in the first 3 years of life. Although it was not originally one of their primary outcomes, the GP visits could be significant. It could also be that in the wake of a major change in practice suggesting that breech-born babies are at increased risk, everyone’s a bit nervous in the first couple of years? We need more information regarding these babies’ actual health problems to understand and use this data, because it conflicts with a Finnish study which found the opposite was the case at 7 years (Ulander et al 2004).

So Jensen and Wust have given us more research indicating an increase in short-term morbidity (with mortality being rare and insignificant?) but no difference in significant neonatal morbidity and the need for increased medical care after 2 years. This matches the information from the Term Breech Trial. Despite the authors insistence they have uncovered evidence that CS is best for all breech babies, and that it is ultimately cheaper (based on their non-evidence-based speculation on future costs of CP only), it actually adds to the literature confirming no concrete evidence of a difference in long-term outcomes for breech babies. Just goes to show you how you can take a group of statistics and put just about any spin on it you like, especially if your mathematical ability makes your analysis fairly impenetrable to most people. (Good thing I live with an actuary.)

Screen Shot 2014-08-15 at 06.30.06Turning now to the elephant in the room

Being born vaginally may be more risky for some babies than being born by CS. Most of the evidence seems to indicate that, in the short-term at least, using standard lithotomy delivery practices, this is the case. On the other hand, most of the long-term evidence does not indicate lasting effects.

What concerns me about literature like this, which makes predictions about what would be saved or not, financially or physically, with this approach or that – is that women, as long as they are human, will continue to have their own unique approach, and they should. That is what being human is about. Many will want to deliver their breech babies by CS, and they should have access to that care, even if it means a greater financial burden. And many will want to give birth vaginally, even in awareness that the rare outcome of neonatal mortality is more likely to happen to them, even in the awareness that if something goes wrong, they will need to live with it for the rest of their lives. We will always have death, and handicapped children that require our grief, our love and our devotion. This cannot be eradicated. Women deserve to be able to make this very personal decision without being made to feel criminal.

Instead of continuing to do research which tells us what we already know, we should invest in research exploring modern management strategies which are showing promise in reducing risk to babies born vaginally, so that women who live in countries where there ought to be a choice actually have one, and women who live in countries where CS is either inaccessible or a real danger to their health have the best chance of going home with a healthy baby. We should stop trying to have the last word on how breech babies should be born, let women decide how to balance the complex array of risks and benefits in their own lives and families, and develop our skills at being ‘with woman’ and her breech.

Shawn

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].

 

Moxibustion: A Smoke Screen?

Screen Shot 2014-06-13 at 01.38.38Professionals: Concerned about women waving giant sticks of burning wacky weed around their wee toes in a desperate attempt to turn their breech babies?! Take action NOW! Ensure that these women can access support for a vaginal breech birth with an experienced, trusted professional, and you will no longer have to busy yourself trying to root out such madness!

Screen Shot 2014-06-13 at 06.51.12Last week the results of a trial (Coulon et al 2014) were released which appeared to show moxibustion with acupuncture ineffective in causing more babies to turn head-down. The trial had its good points. A reasonable number of women randomised (328) at the appropriate point in pregnancy (33+4 – 35+4) to use moxibustion for maximum effectiveness. This in itself was impressive, as most centres do not bother about breech presentation until 36 weeks, making recruitment for studies during this time period difficult. The team looked at the percentage of babies who remained breech at 37+2, the point when ECV (a procedure to manually try to turn the baby in the uterus to a head-down position) would be offered, and found that 72% who had the treatment were still breech, compared with 63.4% who had the placebo. They reported this was not statistically different, but superficially it looks like the treatment had the opposite of the desired effect.

Screen Shot 2014-06-13 at 01.38.58On the other hand, they appear to have used actual needles, heated with moxibustion, rather than the method most commonly used in UK-based moxibustion practices, which involves using the heated sticks only. Also, the intervention and placebo were applied for only six sessions. Generally, women using moxibustion in the UK are usually taught to home-administer (usually with the help of her partner) and then instructed to follow a ten-day course, applying moxibustion twice a day, and continuing whether the baby turns or not. The ten-day, moxibustion-only practice follows a less treat-to-cure, and more treat-to-nourish philosophy, the idea being that the moxibustion nourishes the energy of the womb and promotes optimal positioning. (No swearing until I’ve finished the article, please!)

Screen Shot 2014-06-13 at 01.39.14I’m a fan of observing responses to research on Twitter. (See this previous discussion on hypnosis for childbirth.) And Twitter did not disappoint. The Green Journal announced the Coulon study, and obstetricians celebrated their vindication for having dismissed the practice years ago. There’s nothing like the joy of scientific confirmation of one’s deeply held beliefs. It was as if somebody walked into a room full of midwives and said, “Hey, guess what? Continuity of carer improves outcomes for everybody!” (By the way, it does.)

Screen Shot 2014-06-13 at 02.12.23But then a woman who had actually experienced a breech pregnancy pointed out the obvious: What are the alternatives? Generally, women are highly motivated to give birth vaginally (Raynes-Greenow et al 2004Guittier et al 2011). They instinctively feel what the research tells us – that  a normal birth, wherever possible, is beneficial for both babies and women. There are many hospitals throughout the Western world, including some in the UK, where women cannot even access an ECV, let alone a vaginal breech birth. I’ve had phone conversations where I’ve asked to speak with the person who performs ECVs and been told, “We don’t do that here for liability reasons.” Folks, it’s 2014.

Screen Shot 2014-06-13 at 01.38.22With evidence-based counselling based on the outcomes of the Term Breech Trial, Kok et al 2008 found at least 35% of women preferred to plan a vaginal breech birth. Evidence-based counselling includes the lack of evidence of any difference between two-year outcomes whether an elective caesarean section or a vaginal breech birth is planned (Whyte et al 2004). We can reasonably conclude that if approximately 1/3 of women are not planning a vaginal breech birth in a given setting, then they are probably being directively counselled towards a caesarean section. This would include feeling forced to choose a caesarean section because no plan will be put in place to ensure attendance at a vaginal breech birth by an experienced and supportive professional.

Screen Shot 2014-06-13 at 01.41.57Women resort to practices such as moxibustion and handstands in the swimming pool because they are constantly given the message that breech presentation is ‘wrong’ and should be corrected, with very few alternatives. Whereas the evidence indicates that turning babies, even with ECV, does not improve outcomes for those babies, though it certainly improves the chances of a vaginal birth in settings with minimal support for vaginal breech birth (Hofmeyr and Kulier, 2012 – Cochrane Review). I am increasingly uncomfortable with the current situation, where women do things they do not actually want to do because they cannot access a vaginal breech birth at all, or will not be supported to choose that option until they have done everything else (especially ECV).

Screen Shot 2014-06-13 at 01.40.36Personally, I have no strong opinion on the use of moxibustion itself, as I generally prefer to leave the use of complementary therapies up to what works for individual women, as long as they do not pose a threat to her or her baby. I have taken training to be able to offer women advice, and I have supported women through the use of moxibustion. (We usually spend the ‘treatment’ time talking through the issues around breech birth.) When I speak publicly about breech management, someone usually asks me why I have not included moxibustion. And I tend to dodge the question, not so much because I am convinced of its efficacy or not, but because I believe it is professionals’ attitudes towards breech presentation and not the breech itself that needs to be ‘corrected.’

Screen Shot 2014-06-13 at 06.19.23Let me propose this radical solution: Why don’t we channel some of that indignation over moxibustion practices into ensuring that breech services improve to a point where women will not need to look elsewhere? Let’s ensure every woman has access to a well-supported vaginal breech birth, an ECV attempted by a highly experienced practitioner, and/or a woman-centred caesarean section as late in her pregnancy as she wishes to plan it, including in early labour. Let’s ensure that women have sympathetic, experienced counselling and continuity from a midwife while they navigate these choices, and the attendance of a highly experienced consultant, ready to step up and be that expert in complications of childbirth, backing up the team at birth.

No Re-tweet, sadly ;-)

No Re-tweet, sadly 😉

While we must always make room for those who choose a different path, I suspect that if we got a bit more comfortable with breech in general, the debate over whether moxibustion has a place in the mainstream or not would fade into the distance. Stop blaming pregnant women for their misled attempts to avoid a caesarean section, and the sympathetic midwives who are desperate to help them, and sort out primary breech services.

Shawn

 

 

 

 

 

Choice 1 Choice 2 Choice 3

 

 

 

[Note: I can only access the abstract to Coulon et al at the moment, as it has been posted ahead-of-print. I’ll update the post when it’s published, if there’s anything more to say.]

 

Emerging evidence for upright breech birth

When I talk about ‘upright breech birth,’ I mean a birth where the woman is encouraged to be upright and active throughout her labour and able to assume the position of her choice for the birth. This is in contrast to the classic lithotomy position, in which the woman is flat on her back, usually with legs in stirrups. Upright includes all fours, kneeling, standing, sitting on a birth stool, lying on her side if her body (and not her attendant) tells her to, etc. Birth position is not a static concept. The defining feature of upright breech birth is the woman’s ability to follow her birthing instincts, to move spontaneously in order to assist the birth. However, many providers have developed preferences, having observed women birth successfully in a variety of positions.

Many advantages have been claimed for upright positioning. But if supporting this ideal is to become a reality, we need two things. Firstly, we need evidence regarding the outcomes for breech births managed in non-lithotomy positions. And we need skills in managing complications which occur when women are in non-lithotomy positions.

A step forward for the evidence occurred this week with the publication of research covering 11 years of experience at a large metropolitan teaching hospital in Australia (Foster et al 2014). This retrospective study, which used an intention-to-treat analysis, found much lower rates of complications than the Term Breech Trial, in line with those achieved by the PREMODA group, concluding that in experienced centres, vaginal breech birth is a reasonable option. For me, the take home message coming from the increasing number of studies which show the same comparatively better results is less about the inherent safety of breech birth, and more about how fundamental the local experience level and organised team approach is to achieving optimal safety levels.

Although the article does not discuss birthing position, the correspondence author, Dr Andrew Bisits, is well known for supporting upright breech births using a birthing stool, and in many of the births in this series, the women would have remained upright and active (see also Kathleen Fahy’s description of spontaneous breech birth). Some evidence indicates that use of a birthing stool may shorten duration of labour (Swedish birth seat trial), and this would certainly be an advantage for a breech birth.

Another advantage to using a birthing stool is that health professionals who are comfortable with lithotomy manoeuvres do not have to make any major adjustments to their practice, aside from a willingness to get closer to the floor. The baby emerges facing the same way, the same signs of descent are observed, very similar manoeuvres are used to resolve a delay in progress. An obstetric bed can also be adjusted to mimic a birthing stool, but women have more ability to stand up and move spontaneously when their feet are planted on the ground.

Active Birth Labour Support Stool

Active Birth Labour Support Stool

A number of birthing stools are available in the UK. Active Birth Pools supply a model which is very similar to the Birthrite seat. A birthing stool is a good investment for a Trust. As one of my former obstetric colleagues put it, “If they are good for breech, they are probably pretty good for cephalic babies as well!” Indeed.

Midwives have long supported women to birth in upright positions (for example, Maggie Banks, Jane Evans and Mary Cronk are well-known midwifery authors about breech), but as the RCOG guidelines (2006) recommend lithotomy, supporting this in hospital settings has been difficult. However, around the world, obstetric departments are increasingly discovering the benefits of enabling women to be upright, especially in all fours, kneeling and standing positions. These include teams in Frankfurt (some statistics, some background), Salzburg, Ecuador (Parto podalico), Brazil (parto natural hospitalar pélvicoParto Pélvico Existe Sim!, and of course various parts of the UK.

Facilitating this type of breech birth requires a change in perspective and an understanding of new manoeuvres to assist in the event of complications or delay. The sooner these alternatives are incorporated into national skills/drills training, the more women with breech babies will be able to follow their instincts to assist with securing the safest possible delivery for their babies.

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.

Why midwives are sceptical

This blog is Part 2 in a discussion about on-going RCTs looking at induction of labour (IOL) at various gestations: Why midwives are sceptical about research on medical interventions

In theory, research like this is done in order to support clinical decision-making and to enable informed consent for proposed interventions. If midwives seem dubious about the merits of research concerning medicalised birth, it is because our experience indicates that truly informed consent is a rare beast. Once an RCT has decided that a certain course of action results in less risk for baby, any woman who wants to take a different course will most likely have a fight on her hands, with most health professionals, family, friends, even her partner.

Because it is socially unacceptable to say – It is okay for a woman to choose an option which appears more risky for her baby. Women are not just baby carriers. They live complex physical and emotional lives in which other factors are important too. – midwives end up in the awkward position of trying to argue with The Truth of big science.

Soon, someone will get funding to do an RCT looking at whether the outcomes for babies are better for low-risk primips who undergo elective CS at 39 weeks, or normal labour. And my guess is CS will come out on top for the Big Ones – reduced morbidity and mortality. And then what? Will all primips be offered a CS at 39 weeks? And those who refuse?

I’d like to think we could use the information from these trials to truly offer women an induction of labour, acknowledging that it will not be right for everyone, but as a midwife I see every day what happens to women who decline the Recommended Treatment. Take for example this recent Tweet:

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Is it really okay for an ‘anaesthesiologist’ and president of MSF-USA (Doctors Without Borders) to publicly discuss this tragic outcome, in a way which implies that a woman who declines a recommended CS is selfish, cold, heartless .. & uninformed (despite having definite, and accurate, reasons for refusing). Putting her own experience ahead of her baby’s life, as if losing a baby is ever a good experience, even for the most ambivalent. Are women who decline medical advice no longer entitled to respect and confidentiality? This so-called professional then used the MSF-USA twitter account to re-tweet this damning judgement to 361,500 followers. Midwives in the UK are struck off for less.

We need more research on how to increase the quality rather than the quantity of birth, and life in general; and the quality of women’s experiences will certainly improve with more compassion and less guilt-tripping. Childbirth is not a trip to Walmart.

I want women to have the choice of an early induction, or a CS, if research indicates it may benefit their baby. If they feel it is the best choice for them, so do I. But I want women who don’t want this to have their choices acknowledged as equally valid and equally supported. And I don’t have a lot of faith that will happen.

Finally, because it’s my blog: For me, going into labour was like falling in love. The agonising wait, wondering when it will happen. The brief period of terror when I realised it had. Followed by succumbing. Followed by a lot of hard work and ultimately, blessedly, joy. For me, it was worth waiting for.

Shawn

How the consent process introduces bias into RCTs

Part 1: Why I remain sceptical of RCTs concerning obstetric interventions in normal labour and birth

Another blog post in response to a Twitter debate .. this time concerning various RCTs currently evaluating IOL vs expectant management. We’ve been discussing three trials:

The questions are valid. We know stillbirth is increased, especially in certain populations, the longer a pregnancy continues. In order to make an informed decision, many women will want to know the most likely outcomes and effects of opting in or out of proposed interventions. RCTs are considered the most unbiased way of settling these issues, unsullied by the biases of women or health professionals.

The problem is, these interventions are eventually applied to a population that is, due to being human, inherently biased. Some women feel a strong preference in one direction, some in another; and some want their doctor to decide for them. Women need to consent to be randomised into RCTs, and women who are most averse to the proposed intervention simply decline consent. Therefore the population recruited becomes slightly biased towards a preference for the intervention being investigated.

Is this important? Does it matter? I don’t know. Recent research by Wu et al suggests that women with a strong preference for vaginal birth were more likely to have a vaginal birth. RCTs cannot tell us the effect of women’s preferences on the outcomes they measure. Yet in theory their results are used to offer women an option they will almost certainly have an opinion about.

If I were contributing to the design of these trials, I would want to collect observational data alongside the main trial data. Things like:

  • Why do women consent or decline to participate in the RCT? Are the women who declined to participate due to a strong preference against induction more or less likely to have a normal birth? Are the outcomes for their babies significantly different than those in either arm of the trial?
  • What are the long-term outcomes? Especially in the over-35 population, an increase stillbirth rate may be due to inherent weaknesses in the baby. Significant long-term differences are often not detectable until 2 years of age.
  • And finally .. would they do the again? Would they recommend it to a friend?

These are questions best answered using quantitative techniques, but women may have different questions or priorities, which we will only discover using qualitative investigations.

See Part 2: Why midwives are sceptical.

Shawn

Dr Susanne Albrechtsen and the Big Breech Picture

Dr Susanne Albrechtsen, obstetrician and epidemiologist from Haukeland University Hospital in Norway, spoke at a Breech Birth Network study day in Kilmarnock on 14 February 2014. Read about the day.

Epidemiology is the study of patterns, causes and effects associated with conditions of disease or health in defined populations. (Information from the BMJ.) For our purposes, epidemiology helps us to understand what happens with breech presentation in large groups, enabling us to ask and answer questions such as:

  • What factors are associated with an increased incidence of breech presentation?
  • What are the characteristics of the hospitals in which breech presentation is most/least likely to be delivered vaginally, or to result in a good outcome?
  • What are the long-term effects associated with of breech presentation, and do they vary by mode of delivery?

Albrechtsen has been researching breech presentation for many years. In a 2004 systematic review, Albrechtsen and her team discussed the literature concerning mode of delivery for breech presentation. The article illustrates well why the external validity of the Term Breech Trial (TBT) is questionable: many centres have demonstrated considerably lower neonatal mortality and morbidity levels associated with vaginal breech birth (VBB) than those the TBT reported. They also discuss the difficulties of repeating the TBT trial design in locations with good results for breech-born babies: the lower your perinatal morbidity and mortality, the more recruits you need in your study to reach statistical significance. In Norway, Albrechtsen’s team calculated each arm of a randomised controlled trial (RCT) would require 10,000 members for two-sided testing. Clearly impractical. This review also raises reasonable questions about the research base behind the practice of external cephalic version (ECV). Although the available research suggests that the practice of ECV reduces the rate of CS for breech, there is no clear evidence that it reduces perinatal mortality. (You can read an earlier systematic review on this point, if you can read Norwegian.) We should be approaching all options – ECV, VBB, and CS – as reasonable. Albrechtsen and co. have also been making the point for some time that caesarean section does not reduce the rates of cerebral palsy (CP) for breech-presenting babies. Sadly, rates of CP among breech-presenting babies are significantly higher than for vertex babies, regardless of the mode of birth. This is because CP is most often the result of an antenatal insult (infection, growth restriction, etc.) rather than the birth itself. This has recently been confirmed in a systematic review and meta-analysis by another team. The excellent national databases kept in Norway enable these kinds of ‘big picture’ views on the outcomes for breech babies. Albrechtsen has also contributed to a significant amount of literature concerning patterns in the occurrence and recurrence of breech presentation. This includes research on the familial predisposition to term breech delivery, demonstrating that  factors influenced by genetic inheritance come from both mothers and fathers. Additionally, she has looked at the effect of having a breech baby on subsequent pregnancies, covering the recurrence of breech presentation (common), rates of subsequent pregnancies and interpregnancy intervals. Understanding that having a breech baby appears to affect a woman’s attitude toward future pregnancies means that we can attempt to provide more supportive counselling in current breech pregnancies. The extensive Norwegian birth registers also enabled her to look at outcomes among siblings, demonstrating that women with recurring breech presentation represent a lower risk of adverse perinatal outcome, whereas a current breech presentation with no previous history of breech presentation is at higher risk.

“Perhaps heterogeneity exists, implying that recurring breech presentation for some women represents a normal condition with no increase in perinatal mortality” (p 775).

This article adds to our understanding about how confounding factors both contribute to breech presentation and to the increase in poor outcomes among breech babies, regardless of mode of delivery:

“The evidence is compelling that fetuses presenting as breech are affected already to a higher extent before delivery because morphologic and functional damage is more common in these fetuses” (p 775).

Routine CS is likely to improve the rate at which this minority of more vulnerable babies survive being born; but it cannot undo what has already been done. This is supported by the long-term outcomes within the TBT. We should be approaching all options – ECV, VBB, and CS – as reasonable. (This is not to say that breech-presenting babies are likely to be abnormal. The vast majority of them are perfectly normal, assuming a breech position due to genetic or accidental factors. But it does explain why, despite a widespread policy of CS for breech, we still see increased adverse outcomes for babies delivered in a breech position. And why becoming comfortable with the fact that this will occur regardless might help us improve outcomes for more women, who can reasonably choose a VBB.) Albrechtsen’s work on Secular trends in peri- and neonatal mortality in breech presentation; Norway 1967-1994 gives us some insight into why breech presentation has been the subject of fierce and passionate position-taking. In 1967-1976, 9.2% of babies delivered in breech presentation after 24 weeks died; that is almost 1:10. This figure declined significantly throughout subsequent decades, even after the CS rate stabilised, probably due to improved obstetric and neonatal care. (Preterm breech babies are at greater risk than term breech babies, born after 37 weeks.) As someone who spends many hours answering women’s questions – such as, “Why is my baby breech?” – I am grateful for Albrechtsen’s work. Some believe the TBT was the last word on the topic of breech delivery. Others continue to believe that we have much more detail to understand in order to support women well through the complex and emotional journey of a breech pregnancy.

Shawn

Breech updating

(Another post in response to discussion on the Coalition for Breech Birth Facebook Page.)

Breech births are few and far between, and there are very few ‘experts’ in the world to learn from, so staying updated is a real challenge. Especially if you do not live and work near others who are supporting breech births regularly.

Updating has two purposes: keeping up to date with current evidence and best practice; and reminding yourself how to use skills you use infrequently. Many breech babies, especially those whose mothers are active and upright (e.g. knees/elbows), can be born spontaneously. But those who cannot need calm, considered help in a timely manner. The same applies to external cephalic version – ECV. Both practices benefit from regular performance and knowledge sharing among those who are practicing.

Here are my suggestions on keeping your practice as safe and supportive as possible:

  1. Attend study days. Many individuals offer study days to develop breech skills. Breech Birth Network days concentrate on lots of practical skills, but also have an emphasis on care pathway planning in the UK, aiming to encourage more Trusts to adopt an organised, committed approach to breech.
  2. Share your work. If you are doing research or working with breech and would like to share your experiences, get in touch and present at one of the study days. I am not an expert, but an experienced and passionate believer in the idea that the more we share, the more we talk about it, the more normal it becomes. The best study days have a wide variety of speakers and reflect a wide community dedicated to developing and sharing skills.
  3. Share your experiences. If you learned something at a breech birth you attended that might help us to make our practice safer, share it! Publish it if appropriate, but if you need to share anonymously to protect your client’s and your confidentiality, I can give you space on this blog. It is wonderful and encouraging to hear stories of triumphant breech births where the baby just fell out singing. But we need to hear the stories of doubt and sadness as well, and often these are the ones you learn the most from.
  4. Create your own network. It’s been so valuable to me to have colleagues who I can phone up to debrief the breech births I’ve attended. I learn so much more by doing this. And so valuable to hear their stories, how they have approached certain complications, how they support women, their thoughts on what makes breech birth safe. Keep a record of these sessions and document them; they are part of your professional updating. Write an article about what you have learned together, so that others can respond to it. We need more voices talking about breech skills.
  5. Organise your own study day. Bring the conversation to you. Empower those local to you to share their skills by asking them to present. Inspire your local community to think more about breech.

If you don’t have anyone local to ask questions or debrief with, my number is 07947819122 (in the UK) and I’m always happy to listen. I’m sure most of us are. Good luck!

How much does breech experience matter?

Some friends of mine at the Coalition for Breech Birth (a consumer advocacy organisation) have been discussing the role of practitioner experience in reducing risk associated with vaginal breech birth. My response is a bit longer than Facebook will permit, so I’m putting it here.

The study I find most useful in this discussion is here:

Su M, McLeod L, Ross S, Willan A, Hannah WJ, Hutton E, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol. 2003 Sep;189(3):740-5. PubMed PMID: 14526305. Epub 2003/10/04. eng.

Overall, the team found very few factors associated with an increase or reduction of risk of adverse perinatal outcome. They did find a dose-reponse relationship between amount of labour and adverse outcome. In other words, a pre-labour CS seemed to afford the most benefit, followed by early labour CS. By the time you are in active labour (>3 cm), there is no longer a statistically significant difference between CS and vaginal birth. So I get particularly annoyed when this study is used to tell women who arrive in advanced labour with an undiagnosed breech that a CS is the safest option.

They also found, contrary to popular belief, that big babies (>3500g) fared no worse than more averaged weight babies, but small babies (<2800g) did. Makes sense to me. Generally but not always, babies who are very small at term may already be slightly compromised; labour may be an additional stress. On the other hand, if a chunky 9-pounder folded in half can fit both his abdomen and his legs through your pelvis, chances are his head is going to fit, especially if you are with someone who knows how to help it into an optimal position.

He also needs to fit without help, because the study also revealed that using augmentation to enhance a labour which is not progressing well enough on its own was associated with over twice the risk of labours which proceeded spontaneously. Similarly, longer second stages increased the risk, so our baby needs to be descending fairly easily in the second stage, without help, or a CS may be the better option.

But the only factor shown to reduce the risk associated with a vaginal breech birth (by over 2/3) is the presence of an experienced clinician at the birth. This person need not be a licensed obstetrician, and the years of experience did not make a difference either – the TBT team specifically looked at these factors. The risk reduction occurred only when ‘an experienced clinician was defined as a clinician who judged him or herself to be skilled at vaginal breech delivery, confirmed by the Head of Department.’ Midwives were among those included in this definition.

Although we do not (yet) have any research (get back to me in a decade or so) which looks at the results of spontaneous breech birth with experienced clinicians at term, this analysis of the TBT suggests that this scenario is significantly less risky than many of the births included in the trial which were responsible for adverse outcomes. Add to that the further benefits we are seeing emerge with upright breech (reduction in need for manoeuvres and the minor injuries these can sometimes cause), and vaginal breech birth is a realistic option for many women.

One further comment on the research: Many are frustrated because the results of retrospective observational studies overwhelmingly indicate similar outcomes for vaginal breech birth and planned CS. These have comparatively little influence on guidelines because they are considered ‘biased.’ However, understanding why they are biased is sometimes useful. Retrospective studies are most often done by experienced practitioners who feel their own results conflict with the lowest common denominator represented by a large multi-centre RCT like the TBT. They present these results to illustrate that a comparatively safe vaginal breech service is possible, despite the fact that breech is often grossly mismanaged in many areas. Retrospective studies do not necessarily represent the ‘norm.’ But they do suggest, along with the TBT’s own data, that if your provider feels confident supporting you to have a vaginal breech birth, you can probably feel pretty confident as well.

Update 2015: A meta-analysis of observational studies indicates significantly better short-term outcomes when CS is planned than when VBB is planned. However, the rate of complications following planned VBB is much less than reported in the Term Breech Trial and similar to the results when a cephalic birth is planned. Read Berhan et al 2015 by clicking the link.

Shawn

Hypnosis for childbirth: medical or social intervention?

fundingI’m feeling slightly bemused again by the obstetric interest in whether hypnosis for childbirth has been shown to ‘work’ via randomised controlled trial (RCT), following the on-line advanced publication of another large RCT in the BJOG (Cyna et al 2013). They’ve flown straight into the hen house again, stirring up a lively Twitter debate, made more timely because the Duchess of Cambridge apparently used hypnobirthing in the successful birth of her first child.

EBM labour coping

But was she following evidence based medicine (EBM)? No, she was not. Women do not follow EBM when it comes to labour coping strategies. They follow social medicine. They look around for women who they feel are ‘like’ themselves, women who share the same philosophy towards birth as they do, women who have experienced birth in the way they hope to. They explore available coping strategies and pick a few which are in tune with the coping strategies they use outside of the microcosmic birth world. And of course, they look to their midwives on the day.

in and out of NHS

Our risk-focused maternity culture is particularly poor at sending the message to women: “Your body was designed to do this. You can do this, you are strong, and you will cope. And if you need help, it will be there.” Instead we give women the message that they will need to ‘do’ something extra in order to be able to birth normally. When it comes to pharmacological pain relief, many would rather have ‘nothing,’ and hypnosis is about as close to nothing as you can get. Apparently the data back me up.

yoga

My major problem with Cyna et al’s study is that it takes what seems to work in a social setting, e.g. a group of women who share similar beliefs and are looking for similar things out of childbirth, and a facilitator who nurtures self-belief and enhances new and familiar coping strategies over a period of time, and they medicalise it. The 3 hypnosis sessions in this study were delivered by a doctor trained in hypnosis, only 50% attended all three sessions, and some allocated to the training even chose to attend a different hypnosis training group outside of the intervention. This suggests to me that the intervention was not very appealing on a social level. Every article published seems to acknowledge that the pared down version used in an RCT isn’t quite like what is practised in today’s hypnobirthing and natal hypnotherapy classes which are so popular with women, where women receive on-going support from their classmates and instructors.

blinding and biasAdditionally, these researchers blinded health professionals involved to group allocation, a fault I have discussed the last time this debate flew up (although in the Cyna study it is difficult to imagine how health professionals remained blinded to allocation when some groups were asked to use a CD in labour and others were not). Again, my issue is with the medicalisation of a social art. Part of my job as a midwife is to facilitate an environment which supports a woman’s natural coping skills. If I do not know what coping strategies she is using, I am much less likely to get that right. Blinding in a trial like this is neither possible nor desirable.

questions

With various types of research trials turning up conflicting information, the pragmatic in me deals with this by imagining how certain conversations might play out.

Woman: Does hypnobirthing work?

Me: It depends on what you mean by ‘work’ (and what you mean by ‘hypnobirthing,’ but that’s more complicated so I’m not going to say it out loud – yet).

If by ‘work,’ you mean you want it to relieve your labour pain, in a general population it has not been shown to be as effective as water or Entonox.

If by ‘work,’ you mean you are hoping to avoid unnecessary interventions such as instrumental or surgical delivery, in a general population hypnobirthing has not been shown to do that. Home birth and continuity have both been shown to do that very effectively. If your Trust is not practising evidence based medicine by ensuring you have access to these, having another woman support you and your partner during labour is also helpful. She need not have special training. Someone just being there the whole time will have the same effect.

If by ‘work,’ you mean you will look back on your childbirth experience and decide that was effective for you, the answer is, “Many women feel hypnobirthing has been effective for them, but whether it will be for you is down to many individual factors. I suggest you follow your instincts on this one.”

*****

Woman: My friend recommended this hypnobirthing class to me, but I don’t really like it. What do you think? I really want a natural birth.

Me: I think you ought to spend the evenings out doing something lovely with your partner instead. Your body was designed to give birth, you will be able to do it when the time comes, and we will do our best to support you. If you need help, we will be here. (See also above suggestions re: ‘working.’)

*****

Woman: I started doing a hypnobirthing class, which I really like, but when I talked about it with my consultant, he said it was quackery. What do you think?

Me: If you can’t be a bit quacky in labour, when can you? He may have never watched someone use hypnobirthing effectively in labour. I think you ought to follow your instincts on this one and do what gives you confidence. We will support you.

*****

Commissioner: Should we fund hypnosis antenatal classes for the women using our maternity services?

Me: No. We should not fund complementary therapies which have not been proven effective, but we should educate midwives in appropriately supporting women who choose to use them. We should also stop funding unnecessary extra ultrasounds which are requested against available evidence of their lack of effectiveness in improving outcomes, and significant effectiveness in increasing unnecessary interventions, incurring further associated costs. We should then channel the money we have saved into a more reliable home birth service (which has been proven to be the least costly option with no change in outcomes for multips, and a significant decrease in interventions) and more continuity services (also proven to improve outcomes), targeted first at those who need them most. Midwives should then use their clinical judgement and experience to support the individual women in their care, rather than referring them all to bare bones antenatal classes.

(Or some such similar argument, depending on which non-evidence-based intervention is currently most overused while many midwives run around like headless chickens trying to provide evidence based one-to-one care, desperately clinging to techniques like hypnosis which might help more women to do it by themselves when midwives cannot be at their sides providing individualised care.)

Upcoming study day: Promoting Normal Birth & Hypnobirthing Conference, 19/6/14

Listen to midwives, listen to women

I always smile when people say, “It’s all well and good to support natural breech birth, but what happens if the head gets stuck?” Those of us who are supporting woman-centred, modern breech birth take an equally realistic view about the need to intervene in a skilled and confident manner when help is needed, although we are probably more realistic about the frequency with which such intervention is required. We also obsess about creating trusting relationships and environments which facilitate more spontaneous, easier births, with the end result that we need to use our skills less often.

However we sometimes rely on these skills to achieve a safe outcome. Therefore we share our experiences with others, for when they might be needed. And we know that supporting others to confidently support more breech births will create new knowledge which will in turn help us to improve our own practice.

Where does this knowledge come from? Hint: not Randomised Controlled Trials. One of the many ways midwives create knowledge about practice is by listening to each other and listening to women. For example, in the training aid linked above, one of the options involves assisting a woman who is on all fours to become straight upright on her knees, and applying suprapubic pressure. This is how my own personal learning about that happened (participants not identified to maintain confidentiality):

The baby’s head was hyperextended at the time of delivery, but not before. Woman on all fours, no progress with the next contraction, no spontaneous movements from the baby to assist his own flexion. Neither the midwife managing nor the Registrar who was supporting could reach the baby’s chin, just what felt like a bird beak (the lower jaw bone) pointed up to the sky, so Mariceau-Cronk was not an option. All present were fairly inexperienced, and no training aids were available, so the decision to get the woman upright was instinctive. The decision to apply suprapubic pressure while doing so was based on RCOG guidelines about how to help when the woman is in lithotomy, transcribed to the current situation. The occiput was felt during suprapubic pressure. Then suddenly the baby’s head dropped into the pelvis, and was immediately born wearing his placenta like a hat. Several minutes of resuscitation were required. Baby recovered quickly and well.

Following on from this story, I returned to the sources I use over and over again. Anne Frye’s Holistic Midwifery described how some midwives get the woman upright (for breech and shoulder dystocia) because this tightens the abdominal muscles, promoting head flexion. So someone else has a theory for how it works. There is also increasing radiological evidence that when upright or prone (e.g. shoulders, pelvis and knees in a straight line), the pelvic inlet is largest, while squatting significantly enlarges the mid-pelvis and pelvic outlet. The strategy of assisting the woman to move into an upright posture and use suprapubic pressure may have resulted in an even better outcome if performed earlier, as soon as the dystocia was identified.

Once you begin to see the patterns, they emerge in the stories you immerse yourself in. Reading Jennie Clegg’s story about her ‘Breech VBAC at home,’ I found this:

The next push I gave it everything I had and rumping happened very quickly followed by the body; the relief of the pressure was immense. Two sharp sensations happened which were the legs releasing, I remember looking through my legs and seeing a little body! Then there were a few sharp uncomfortable movements which were caused by the baby wriggling its arms out. My contractions at this point had stopped.

Debs could see no chin on the chest to examined me and found the head to be extended. An ambulance was called and Debs started manoeuvres to birth the baby. No movement was felt so I was encouraged to change position and Michelle tried nipple stimulation to get contractions coming. Michelle and James helped me to stand, Debs attempted head flexion, movement was felt and I was encouraged to push, baby was born immediately followed by the placenta! (Midwifery Matters, ISSUE 135, Winter 2012)

This scenario was slightly different, but maternal movement was again helpful. Jane Evans, a midwife with many years of breech experience, writes and talks about how her understanding of the physiology of breech birth has been informed by listening to and close observation of women (Evans 2012a, Evans 2012b).

Listen to women. Listen to midwives. Share your stories. Share your skills.

Feel free to share your own stories in the comments below. Community support for breech professionals is available via a Breech Birth Network Facebook group.

References

Michel, S. C., Rake, A., Treiber, K., Seifert, B., Chaoui, R., Huch, R., . . . Kubik-Huch, R. A. (2002). MR obstetric pelvimetry: effect of birthing position on pelvic bony dimensions. AJR Am J Roentgenol, 179(4), 1063-1067. doi: 10.2214/ajr.

Anne Frye’s Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice, Vol II is now available to download as a PDF, you lucky ducks! My father still complains about having to transport the heavy tome across London on the underground when he brought it to me from America one Christmas.