Tag Archives: London

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

A craftsman’s job

Two weeks, two inspirational obstetric colleagues, two very welcoming UK cities. So much commitment to improve the system for breech babies and their mothers.

eclipse tweetOn the 20th of March, Dr Elie Azria of the Hôpital Paris Saint Joseph and Descartes University, joined me in Dundee, Scotland, to teach through the eclipse! The French and Belgians have continued to support breech births in the last 15 years, responding to the Term Breech Trial (TBT) with a prospective observational study (PREMODA, 2006) which involved over twice the number of planned breech births (VBB) than the TBT, and demonstrated no statistically significant difference in outcomes between those who planned a VBB and those who planned a caesarean section (CS). Azria was the lead author on a follow-up analysis of the data examining factors associated with adverse perinatal outcomes in the PREMODA data.

AzriaIn our Breech Birth Network study day, Azria presented new research concerning whether breech presentation is an independent risk factor in preterm breech birth, with interesting results which we hope to see published soon. He also gave an inspiring presentation on the “Traps of Evidence Based Medicine,” using the example of term breech delivery, building on his work to reconcile the need for maternal autonomy and medical responsibility in shared decision-making about mode of childbirth.

from http://hustleandgrind.co/

from http://hustleandgrind.co/

I always enjoy teaching with experienced practitioners who come from a different practice culture. Practice constantly improves and evolves from sharing these different ways, if we are open to learning from each other. Azria pointed out that, sadly, even within a culture where support for VBB has remained standard, the use of CS is on the rise. As he described, “Breech delivery is a craftsman’s job,” an art as well as a science. Learning breech skills requires commitment, dedication and practice, which not everyone is willing to offer. Nor are many people keen to take the risk of learning in the current risk-averse climate of maternity care.

Read more about How singleton breech babies are born in France, from the AUDIPOG network (Lansac et al 2015).

Julie Woodman (Queen Alexandra) & Miss Nicola Lack (UCLH)

Julie Woodman (Queen Alexandra) & Miss Nicola Lack (UCLH)

On the 27th March, I was joined by Miss Nicola Lack, Consultant Obstetrician from University College London Hospital NHS Trust. Lack gave a fantastic presentation on the research base for counselling about mode of childbirth with a breech presenting baby. One of the problems with a decimated skills base is that, while we may have a strict set of inclusion criteria for what constitutes ‘normal’ for a VBB, it may be quite difficult to find someone who can actually assess those criteria at a moment’s notice on labour ward, eg. a hyperextended neck on ultrasound. Breech skills are not just the manoeuvres which may be used around the time of birth. Skilled practice also involves the ability to provide detailed individualised counselling and make relevant antenatal assessments, as well as on-going interpretation throughout pregnancy and labour.

Portsmouth

photo by Michelle Ball

Lack’s presentation drew extensively from her own experience of working in the UK and Africa, as well as her understanding of medico-legal issues and constraints caused by a litigious practice culture. She explained how, when counselling, we really need to talk about the potential benefits of VBB as well as the risks. For example, she reflected on how, when she first qualified as an obstetrician in 1999, placenta percreta was relatively rare. Now, she and her colleagues encounter it approximately once a week or fortnight, due to the increase in CS rate. That’s very concerning. Lack also facilitates a postnatal birth reflections clinic, where she has had the opportunity to learn how women feel about breech childbirth experiences, both CS and VBB, after the event.

Midwives Michelle Ball and Shawn Walker

with my Twitter friend @Shelly_RM

My one sadness on both days was that, despite the best efforts of the organisers and the high calibre of the obstetric speakers at the events, so few obstetric colleagues attended the study days. This is a real problem. Midwives are increasingly advocating for women to have the realistic option of a well-supported VBB if that is their informed choice, but this needs to be a collaborative effort. I urge our obstetric colleagues to come to the table to learn and work with us, so that the women and babies we care for, and we as professionals, can benefit from the best possible support of the wider multi-disciplinary team.

Thank you to Consultant Midwife Phyllis Winters of the Montrose Maternity Unit and Julie Woodman of the Queen Alexandra Hospital in Portsmouth for organising the study days.

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