Tag Archives: breech clinics

Breech in Belfast

Consultant Obstetricians Niamh McCabe and Janitha Costa, and Breech Specialist Midwife Jacqui Simpson

The Breech Birth Network visited Belfast this weekend. Dr Anke Reitter FRCOG of the Krankenhaus Sachsenhausen and I taught a day-long physiological breech study day at the Royal Victoria Hospital for over 40 obstetricians and midwives.

The day was organised by Consultant Obstetricians Janitha Costa and Niamh McCabe, enthusiastic upright physiological breech practitioners, and Senior Registrar Shaun McGowan. The team have recently published outcomes associated with their breech clinic (Hickland et al 2017 and Costa 2014).

Our study day increasingly emphasises pattern recognition and decision-making through the use of real breech birth videos, especially videos of complicated births. We watch, deliberate and critique – with compassionate understanding, respect and humble appreciation. These brave health professionals and women have allowed themselves to be vulnerable and exposed in order that others may learn, and we are very grateful.

We have also moved away from using heavy and expensive simulation models and rely instead on doll and pelvis models. These enable us to see what is happening from all angles and embed the theory of the manoeuvres we are teaching. We operate on a see one (the theoretical presentation), do one (hands-on with one of the instructors), teach one (of your colleagues) model. This helps build confidence to carry on teaching the techniques in the local setting.

Our preferred models (it’s a great idea to have some on hand if you are organising a study day or implementing this training in your local setting) are:

Fetal Doll Model; and

Cloth Pelvic Model; or

Female Pelvis Model

Final announcement: Blogging has resumed because … I submitted my PhD a couple weeks ago! Hurrah!

Shawn

Krankenhaus Sachsenhausen is also on Facebook!

“No time to put a plan in place”

Thinking through the practicalities of breech advocacy.

Midwives and obstetricians who would like give women with breech presenting babies more support to plan a vaginal breech birth (VBB) need to think through the wider picture of how this happens in order to become effective advocates. In my experience of doing breech advocacy throughout the post-Term Breech Trial era, women often get in touch after 38 or 39 weeks to try to organise support for a VBB. Achieving this requires quite a bit of discussion and negotiation in quite a short period of time.

This post makes visible some ‘common experiences’ in women’s vaginal breech birth journeys. Services differ in every area, so it won’t be every woman’s experience. And increasingly, forward-thinking NHS Trusts are working with advocacy organisations (such as the Coalition for Breech Birth, Breech Birth UK and BBANZ) to develop woman-centred care pathways which meet women’s needs rather than restrict their choices, like this team in Sheffield.

Common experienceOther possibilities
33 weeksAntenatal clinic visit. Midwife or woman suspects breech. Woman told not to worry, most babies will turn.Informed about / referred for moxibustion treatment. Not associated with risk of harm. Shown to reduce breech and CS when used with acupuncture. Shown to reduce use of syntocinon before and during labour regardless of presentation. (Coyle et al, Cochrane Review, 2012)
36 weeksPalpation in antenatal clinic. Midwife suspects breech and refers for USS. Woman receives counselling re: ECV, to return at a later date. Is told discussion re: mode of birth will occur after unsuccessful ECV.One-stop shop breech clinic. Scan, counselling and ECV performed by a midwife or doctor with specialist training. If unsuccessful/declined, mode of birth preference documented. To return for further counselling.
37 weeksCounselling repeated by a different professional, who may have different personal preferences. External cephalic version attempted. If unsuccessful, asked to return for counselling re: mode of birth in consultant clinic.Returns to breech clinic for second attempt at ECV. Sees same practitioner, who is also part of the breech birth team. After unsuccessful/declined second attempt, confirms choice of mode of birth. Wider team made aware of planned VBB.
38 weeksReturns to antenatal clinic and sees another consultant or registrar. Majority of UK hospitals reluctant to support planned VBB. Advised to have CS. In some cases, a managed breech delivery in lithotomy is offered.Woman and her birth partner prepare for the up-coming birth.
39 weeks +After a return visit to antenatal clinic to attempt to negotiate support for an active VBB, meeting yet another consultant, and lots of research on the internet, woman seeks out external sources of support for VBB. Advocate (Supervisor of Midwives, doula, independent midwife) attempts to liaise with hospital staff, who ask, “Why do they all leave it to the last minute? There’s no time to put a plan in place now!Returns to breech clinic at 41 weeks to revisit choice of mode of birth, taking factors such as fetal growth and length of pregnancy into consideration. Talks to the same or another experienced member of the breech team.

Questions for reflection:

  • Consider your current work setting. If a woman tells you she would like to consider a VBB but is not receiving support to plan one, what can you do?
  • Who needs to be involved in her plan?
  • Who will support you to support her? To what extent are you comfortable being involved?
  • How can you build a local breech team, who can be ready to meet this need when it arises?
  • Consider working with your team to develop an informational resource for women, like this leaflet from King’s College Hospital.

Please share your positive experiences and good examples of breech teams in the comments.

Shawn

References:

Beuckens, A., Rijnders, M., Verburgt-Doeleman, G., Rijninks-van Driel, G., Thorpe, J., Hutton, E., 2016. An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives. BJOG An Int. J. Obstet. Gynaecol. 123, 415–423. doi:10.1111/1471-0528.13234

Catling, C., Petrovska, K., Watts, N.P., Bisits, A., Homer, C.S.E., 2015. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery. doi:10.1016/j.midw.2015.12.008

Coyle ME  Peat B, S.C.A., 2012. Cephalic version by moxibustion for breech presentation (Review). Cochrane Database Syst. Rev. doi:10.1002/14651858.CD003928.pub3

Walker, S., Perilakalathil, P., Moore, J., Gibbs, C.L., Reavell, K., Crozier, K., 2015. Standards for midwife practitioners of external cephalic version: A Delphi study. Midwifery 31, e79–e86. doi:10.1016/j.midw.2015.01.004