Tag Archives: upright

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!

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

Haukeland University Hospital: Practical skills in advanced operative obstetrics

Bergen poster

Book on-line!

This is an excellent course at a world-renowned centre, popular with obstetricians all over the world who travel to Bergen to gain practical skills in breech childbirth and operative delivery. The Norwegians have carried on safely supporting breech births over the past 15 years, and the course is acknowledged by the Norwegian Medical Association. This year, the course will include a session on ‘alternative birth positions in breech delivery.’ It will be taught in English.

For more information and to book, contact Consultant Jørg Kessler on the e-mail listed on the poster. View the programme here: Practical skills in advanced operative obstetrics.

Turning breech upside down

February 2015

Yesterday, approximately 50 midwives and obstetricians shared some love for breech babies in Preston by hosting a Physiological Breech Study day!

prayer handsThe day was organised by inspirational Consultant Midwife Tracey Cooper, with the help of midwives Emma Ashton and Emma Gornall, and we felt so welcome! Collaborating with their obstetric colleagues, these midwives have led changes in Preston, where guidelines now advise midwives to use hands and knees maternal positioning for all undiagnosed breech births occurring outside the obstetric unit, including the MLBU and home births. In these settings, obstetric beds are not usually available. Adverse outcomes have occurred across the UK because midwives who have only been trained in lithotomy manoeuvres, following guidelines mandating the lithotomy position, have instructed women to lie on the floor, either to perform a hasty and unnecessary vaginal examination, or to ‘manage’ the birth in the way that feels most familiar. As a result, women have then abandoned the most physiologically advantageous forward kneeling position in order to accommodate health professionals. When a woman is supine on a flat surface, the baby’s body cannot hang the way it does in true lithotomy position, and this may cause difficulties with the birth and/or delivery of the head.

Learning to negotiate nuchal arms when women are upright

Learning to negotiate nuchal arms when women are upright

I have been encouraging midwifery leaders to address this problem for some time, after becoming aware of such troubling events occurring not infrequently. In addition, I performed an audit covering a 20-month period in my previous practice setting, and the results indicated that 80% of the breech presentations diagnosed for the first time in labour occurred among otherwise low-risk women under midwifery-led care. This population does not routinely receive a third trimester scan in the UK, and the research does not necessarily indicate that doing routine scans would improve outcomes. However, it does suggest that each midwifery-led setting should have a plan in place to ensure all midwives have setting-appropriate training for managing unanticipated breech births, and that women have access to skilled and supportive counselling and care when this occurs. As more births are occurring in midwifery-led settings following the recommendations of the 2014 NICE Intrapartum Care guidelines, this forward planning will be more and more important, to promote safe physical and psychological outcomes for women and babies.

If you would like to read more about undiagnosed breech or antenatal detection of breech presentation, click on the links.

Emma Ashton, Gerhard Bogner, Olivia Armshaw, Tracey Cooper & Shawn Walker

Emma Ashton, Gerhard Bogner, Olivia Armshaw, Tracey Cooper & Shawn Walker

We were privileged to be joined by Dr Gerhard Bogner of Paracelsus Medical University in Salzburg, Austria. Bogner shared his experience of trailblazing for breech in Austria by introducing the practice of all fours (im Vierfüßer) breech births, which he has been studying in singletons and twins, with good outcomes. We look forward to the publication of Bogner’s twin data, later in the year. (Read more about Bogner’s work on ResearchGate or Pubmed.)

Breech101These international gatherings always prompt discussions about differences in practices. Some audience members were surprised to find that midwives in Austria perform a vaginal examination every hour! Therefore, the evaluation of ‘second stage’ is determined by dilatation. In contrast, visitors from Sheffield – Midwife Helen Dresner-Barnes and Consultant Obstetrician Julia Bodle – explained how in Sheffield, vaginal examinations are not routinely performed during breech labours. Progress is evaluated by observing the woman’s spontaneous expulsive effort, and if she is bearing down for some time without any noticeable descent, this would be considered an arrest in the second stage of labour necessitating a caesarean section. Such differences raise interesting discussions around why we do what we do – for safety? for measurement? for documentation? for protection in case of litigation? And what effects such seemingly neutral interventions may have – interfering with physiology? lowering the threshold for CS with or without benefit? reassuring or undermining the woman and her health professionals? We may not have all the answers, but at least we are beginning to ask the questions.

Thanks also to Lisa Walton of Blackpool and Oli Armshaw of the University of Western England for helping make the day a success.

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

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