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Seeking your thoughts on new research …

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Illustration by Kate Evans

We are seeking your thoughts on two new pieces of research currently in the development stage. If you have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, or you work with pregnant women in a non-medical capacity (e.g. doula, antenatal teacher, breastfeeding supporter, etc.), we would love to hear from you.

Emma Spillane would like your feedback on an Information Leaflet for people pregnant with breech-presenting babies. The leaflet will be used in research to determine an approximate level of demand for vaginal breech birth, with balanced counselling and adequate support.

elevate&rotate

Talking through elevate and rotate

Shawn Walker is preparing an application for a large grant to fund a pilot randomised controlled trial. No term breech trials have been published since 2000 (Hannah et al). The team around this project would like to gather a Breech Advisory Group composed of people who have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, and non-medical birth workers, such as doulas and antenatal teachers. At this stage, we would like your feedback on the suggested design of the trial, to ensure that the information resulting from the research will be useful to those considering breech options. For those of you who would like to remain with the project if funding is obtained, we will send regular updates with opportunities to provide feedback at stages like final project design, advertising the trial and analysing the results.ShawnPortsmouth

If you are interested in participating in our research in this way, please complete the form below and one of us will be in touch.

Upcoming conferences

You and your colleagues may be interested in these two upcoming conferences, led by obstetricians. First, a two-day breech conference in Denmark featuring a number of internationally known teachers and researchers:

Denmark 2019

And in November, Breech Birth Network will be offering physiological breech training alongside the British Intrapartum Care Society Conference in Leicester.

BICS 2019

 

Breech Birth Training in Ethiopia

Last month I spent ten days in Southern Ethiopia volunteering for a charity, Midwives@Ethiopia (M@E).  The charity provides training for Ethiopian midwives and supports rural health centres to improve their standards.  This involves providing them with much needed essential equipment to help in the quest to improve maternal and neonatal morbidity and mortality.  My main role during the trip was to assist with the week training programme which was designed to teach midwives to safely manage obstetric emergencies in low resourced settings.  I was asked to teach vaginal breech birth and thought that this was the perfect place to run the Breech Birth Network’s Physiological Breech Birth study day, which teaches normal physiology and the skills to resolve complications of a breech birth (Walker et al, 2017).

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Discussing normal mechanism

In rural health centres in Ethiopia, the midwife’s hands are their tools and so what could be more perfect than to teach them a new concept to managing breech births where they could use their ‘tools’ to safely resolve complications should they arise. But also, to teach upright positioning of a breech birth which gives up to a 70% chance of the birth happening spontaneously (Louwen et al, 2017).  I was very nervous about the training, partly because this was such a new concept to the midwives, birthing in upright positions. “Women do not do that,” I was told. They informed me that women were “not cooperative” and therefore they gave birth in lithotomy positions.  I was not sure whether this was the case or if it was more to do with the well-known obstetric phenomenon of there being a bed in the centre of the room, so the person will just get on it because they think that is the right thing to do.  Or a lack of antenatal education on the importance of being mobile in labour.  This made me more nervous because upright breech birth was going to be so far from what they were used to doing and seeing, a bit radical!  The language barrier may also be an issue as well as the cultural differences, but I had nothing to lose and I really wanted to teach something which I believed would undoubtedly make a difference to mothers and their babies as well as to the midwives.

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Second stage birth room in Uddo Health Centre

I started the day talking about the midwives experiences they have had of breech births. Unsurprisingly to me all the midwives in the room had witnessed and facilitated breech births, there is no scanning available and so most breech presentations are
undiagnosed.  There is also limited access to health care for women and s ECV to turn the baby to a head down position is not usually an option.  There were thirty-seven midwives present from different health centres and some from the main hospital in Dilla.  Their experience ranged from eight weeks qualified to seven years qualified however some had very limited clinical experience in this time. Such as Getnet, the head of midwifery at Dilla University, he had six months clinical experience and has been working non-clinically for five years teaching midwives.  I was struck by their stories of how women would walk for miles in labour to access help from a health centre because their labour had been obstructed, the breech presenting baby would be half born and they needed assistance to complete the birth of the baby.  If they called an ambulance it could take hours to reach them, if it arrived at all, and they could then have a two, three, four hour or more transfer time to the nearest hospital for obstetric assistance.  It is no wonder the maternal and neonatal morbidity and mortality rates are so high.  However, the Government is working hard at improving the morbidity and mortality rates with the help from the WHO and other organisations such as M@E and they have met their goal of increasing safety for mothers and babies early which is a fantastic effort and must be recognised.

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Nenko, M@E’s main contact in Ethiopia who works with WHO

Health officers such as Nenko are vital in the quest to improve maternal and child health.  They work very closely with the WHO and charities to bring training and help from other areas to improve safety for mother and child.

After finding out about their experiences I taught the normal mechanisms of a breech birth.  I emphasised how birthing in upright positions will assist with the birth, widening the pelvis by up to 1.9cm (Reitter et al, 2016). I used a flexible pelvis to demonstrate this at every opportunity and referred it to cephalic birth as well, so they could see how women birthing in upright positions can help for all births.  I had the help of two excellent midwifery lecturers, Kiddist and Shimeles.  Kiddist is a lecturer at Awassa University about three hours north of Dilla, she has many years of experience and left Ethiopia briefly to complete her Masters in Amsterdam.  Shimeles has seven years of clinical experience before becoming a lecturer at Dilla University and is now interested in moving into research.  Their English was excellent, so they were able to help with the translation, this was a very new way of teaching breech birth for them to, but they were enthralled listening intently and repeating everything I was saying in Amharic to ensure understanding.

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Kidist and Shimeles, Ethiopian Midwifery Lecturers

Something which I have always found very surprising is the lack of knowledge about the normal mechanism of a breech birth, like I found so many times when teaching in the UK, the Ethiopian Midwives were also unclear about the normal mechanisms prior to the training.  This was evident by their answers to the pre-course training questionnaire which I had asked them to complete prior to starting the training.  Twenty-two of the midwives thought that as the Frank breech passes through the ischial spines of the maternal pelvis, the fetal sacrum is normally anterior.  This is the most common thought, although the actual answer is sacrum transverse.  This is misconception is possibly due to traditional breech training focussing on telling practitioners that the back must be uppermost, however the rotation to sacrum anterior occurs after the birth of the buttocks so the rotation is visible and should be noted as a reassuring sign of progress.

After lunch it was time to teach how to quickly recognise complications and resolve them working with physiology.  During breakfast I had given two other M@E volunteers a crash course on the resolution of complications, so they would be able to assist with the teaching during the day.  When I spoke about and taught a complication I would show the manoeuvre for resolving the complication by teaching Shimeles and then ask him to show the group with me. Shimeles was then able to assist with the teaching which meant we had more time to ensure all participants were able to correctly perform the manoeuvre and had good understanding of what they were doing.  I was pleasantly surprised at how enthusiastic everyone was and how well they picked up these new manoeuvres.  I started with simple shoulder press, I talked through when to use it and how to perform it and showed them videos of the manoeuvres being used.  They found this particularly useful.  They then all took it in turns to come up and perform the manoeuvre with either myself, Haf or Shimeles.  This was a simple manoeuvre for assisting with the birth of the fetal head if it is deflexed at the outlet possibly due to the cord being around the neck or to speed up the birth due to a fetal concern.  It was a manoeuvre they all felt they could use in practice which was easy to perform and very effective.  I then taught shoulder press with ‘rock and roll’ which they thought was very amusing.  Again, I taught Shimeles, he translated and performed the manoeuvre with me and then the group practiced.  Shoulder press with ‘rock and roll’ can be used for a head in the mid-pelvis which has not fully flexed or if simple shoulder press has not been successful.  Many of the midwives preferred this version of shoulder press to the simple shoulder press because they felt more secure holding the baby in this way.

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It was lovely to see such enthusiasm for learning something new and the ‘light-bulb’ moment when they understood how birthing in upright positions can reduce the need for intervention which, for them, working in such low resourced settings and with extremely long transfer times in to an obstetric facility, was so important to have skills which would surely help to successfully assist breech births and potentially reduce harm to mother and baby.  I held onto this enthusiasm as I continued through the course of the afternoon teaching how to recognise and resolve a compound arm by sweeping down the anterior arm.  How to recognise and resolve using rotational manoeuvres with ‘prayer hands’, an anterior nuchal arm or bilateral nuchal arms. This is the complication which they found the hardest to grasp, the manoeuvre requires rotation to sacrum transverse, sweeping down the anterior arm under the pubic bone before rotating back to ‘tum to bum’.  It required much more practice than the other manoeuvres but after a few attempts each they also were able to resolve this complication confidently.

After the arm complications came the head complications.  The most feared of complications by healthcare professionals in any country is an extended head at the pelvic inlet.  This was also true here in Ethiopia, where on the pre-training survey many commented about this complication:

“…delayed engagement of the after-coming head to save both fetal and maternal life.”

It was clear this complication was misunderstood as it is by so many healthcare professionals.  It is due to the lack of knowledge about the physiology of a breech birth that this complication is so feared and difficult to manage.  One of the questions on the pre-training questionnaire asks about how a practitioner would resolve delayed engagement of the aftercoming head, the answers confirmed the lack of knowledge and understanding of the complication.  If this is not taught to healthcare practitioners how are they supposed to resolve the complication?

“after deliver of arm and lower extremities then deliver the head by MSV manoeuvre/procedure”

“…with piper forceps, by doing cervical incision.”

“Apply MSV…manoeuvre to deliver the head if after this manoeuvre still the head is not deliver apply piper forceps.”

“We use MSV manoeuvre and simultaneously apply supra pubic pressure.”

I taught them how to use a manoeuvre called ‘elevate and rotate’ describing the physiology behind why the head does not engage and becomes impacted at the pelvic inlet on the sacral promontory.  Once they understood this, the manoeuvre came easily to them.  They watched it on a video and had many goes at practicing it. This manoeuvre was so important for all of them to learn but in particular those working in rural health centres.  Having heard the stories they shared throughout the day about obstructed breech births and not being able to resolve these complications, I knew that even if a woman had spent hours walking in labour for assistance, it may be too late to save the baby, but these manoeuvres could still help to save the mother.  It really struck me how their challenges were so much different to ours back in the UK, how lucky we were to have obstetric assistance at our finger tips within minutes. It puts everything into perspective and changes your views on many things within midwifery when you hear these stories and challenges which they face every day when they go to work.

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At the end of the day I was given a traditional Ethiopian applause and cheer, I knew at this moment I had taught them all something which they could use, something that would really make a difference to their practice not only with breech birth but quite possibly with cephalic births too.  I hope to return to Ethiopia next year and be able to train more midwives these invaluable skills, so they can help more mothers and babies safely enter this world whatever position they decide to present in!

— Emma Spillane

Bruxelles et le siège

Training in Lewisham on November 12 — Book here.

“We believe that we do well what we do often.” – Caroline Daelemans

Drs Caroline Daelemas and Sara Derisbourg

Contact Hōpital Erasme Clinique du Siège on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be.

This month I visited Hōpital Erasme, in Brussels, Belgium. Led by Lead Obstetrician Caroline Daelemans, Erasme began to offer a dedicated Breech Clinic in December 2015. Much of the organisation and development of the clinic has been done by Dr Sara Derisbourg, who continues to research the impact of instituting a dedicated breech service.

I came to Brussels to provide our usual physiological breech study day. The breech team has transitioned to using physiological methods, including upright maternal positions (Louwen et al 2016), after attending training in Norwich in 2017. They now needed the rest of the team to understand the philosophy behind this approach. But the day began with Caroline describing the impact of instituting a dedicated Breech Clinic, and this was particularly exciting for me.

Josephine and Thiago talk about their experience of Ulysse’s breech birth at Erasme

My own research concerning the development of breech competence and expertise, and the recovery of these skills within a service, indicates that developing a core team with significant experience is the most effective method of safely offering a vaginal breech birth service (Walker et al 2016). This skilled and experienced core is more important than the ‘selection criteria’ that are used to predict the likelihood of a good outcome (but in fact are not very predictive). Skill and experience facilitate good outcomes and enable other colleagues to develop competence (Walker et al 2018). The Erasme team even encourage other health care professionals to come with their clients and attend them in labour with their support, to encourage the growth of breech skills.

The need for new ways of organising care has been emphasised in an on-line survey of Dutch gynaecologists just published by Post et al (2018, Does vaginal breech delivery have a future despite low volumes for training?): “Potential suggested alterations in organization are designated gynecologists within one centre, designated teams within one region or centralizing breech birth to hospitals with a regional referral status. Training should then be offered to residents within these settings to make the experience as wide spread as possible.”

Daphne Lagrou of Médecins Sans Frontières demonstrates shoulder press

Daelemans and Derisbourg began with a small team of 5 people. This has gradually expanded and now includes eight members who together provide 24/7 cover for all breech births within the hospital. Women with a breech presentation are referred by colleagues and increasingly by other women. The environment at Erasme is ideal because the hospital has a very positive approach to physiological birth in general, and a 15% overall caesarean section rate in 2017. This compares to 20.2% in Brussels and much higher in many places globally.

Practising collaborative manoeuvres for resolving head extension at the inlet of the pelvis (elevate & rotate)

What has the Breech Clinic changed? Before the introduction of the clinic, the planned vaginal breech birth rate was 7.19%, and in just a few years this has climbed to 42.7% of all breech presentations. Neonatal outcomes have remained stable. Actual vaginal breech births have climbed from 4.2% to 35.96% of all breech presentations within the hospital. The success rate for planned vaginal breech birth is 76.3%, which suggests that within experienced teams, the emergency caesarean section rate is also reduced. (The RCOG guideline suggests about 40% of planned breech births end in CS.)

All of this is very impressive. The message is clear: a physiological approach and an organised care pathway, including a breech clinic and experienced on-call team, can reduce the caesarean section rate significantly without negatively impacting neonatal outcomes. We should all look out for Derisbourg’s papers when they are published.

If you are a woman seeking support for a physiological breech birth, or a health care professional looking to refer a woman to the breech clinic, they can be contacted on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be. Caroline Daelemans will be teaching with me in Lewisham, London, on 12 November.

— Shawn

India and the breech

Missed our Facebook Live event with Fernandez Hospitals? Watch the recording here:

PMET student Arunarao Pusala receives her training certificate in Karimnagar

 

This month I am in Hyderabad, India, visiting Dr Evita Fernandez and UK Consultant Midwives Indie Kaur and Kate Stringer. Today at 5pm IST (that’s 11.30 GMT), we will be having a Facebook Live discussion on Breech Birth in India. This will be followed by hands-on workshops on the 12th and 19th in Hyderabad.

 

with Senior Midwives Theresa and Jyoti

The Fernandez Hospitals are at the forefront of compassionate maternity care on a large scale in India. The Stork Home facility has been beautifully designed and rivals some of the best midwifery units in the UK. But Dr Evita and her team of doctors and midwives are very ambitious. They want to revive vaginal breech skills so that women can confidently choose this option. How will this work in Hyderabad? Join us for a discussion.

Midwives and doulas support women together in the beautiful Stork Home facility in Hyderabad

From Arunarao: “My special thanks to dr Evita ,lndie mam Kate mam and Shawn mam for the opportunity to participate in BREECH BIRTH WORKSHOP at karimnagar.i am so panic about breech presentation and breech birth before I come to professional midwifery training, know iam very excited to assist the spontaneous and assisted breech birth,because now I came to know breech also has its own mechanism and always always we have to respect those mechanism and iam aware of the manoeuvres to apply whenever it’s needed.thank you all of you mam iam so blessed to have a teaching faculty like you.” Thank you Arunarao — you really got it!

Shawn

Rotational manoeuvre to release breech nuchal arms

flat hands

In June, I spent a week in the Netherlands working with a committed group of lecturers. The midwifery universities of the Netherlands share a common curriculum, and following our meeting last year, they agreed to incorporate physiological breech birth into their training programme. My visit was to support the midwifery lecturers to implement the new skills into standard midwifery training.

While in Amsterdam, I collaborated with Midwifery Lecturer Bahar Goodharzi of Academie Verloskunde Amsterdam Gröningen (AVAG) to create a short series of films demonstrating the rotational arm manoeuvre we teach in Breech Birth Network study days. We agreed that this is a tricky manoeuvre to learn and teach, but it is incredibly effective in practice so worth the effort of learning. I’ve collected our short demonstrations in the film below, along with information about how to recognise that this manoeuvre is required.

Note: If you have difficulty rotating the baby initially, you may have to elevate the baby slightly to a higher station, so that the shoulder girdle rises above the pelvic inlet. It can then rotate to engage in the transverse diameter.

Thank you to Emma Spillane of St George’s Hospital in London, who has helped to refine the way we teach this manoeuvre following her own experiences of successfully using it in practice.

For a poetic description of what it is like to encounter this complication for the first time as a midwife or doctor, read Nicole Morales’ blog, The prose of no rotation and no descent: rotating to free the arms.

You can download the Physiological Breech Birth Algorithm here.

Midwifery Lecturers of the Netherlands, June 2018

— Shawn