The Dutch in Old Amsterdam do it .. not to mention the Finns .. The folks in Bergen, Norway, do it .. They’re not even second twins …
This Valentine’s Day over 100 obstetricians, midwives, student doctors and student midwives assembled at Crosshouse Hospital in Kilmarnock to show some love to breech babies.
We were privileged to be joined by Dr Susanne Albrechtsen, Head of Obstetrics at Haukland Hospital in Bergen, Norway, home of Jørgen Løvset. She has written extensively about the practical management of breech presentation and authored several epidemiological articles. Dr Albrechtsen is responsible for the Norwegian breech guidelines, and shares her expert knowledge of breech and operative vaginal deliveries through practical training throughout Scandinavia and beyond (details available through the Norwegian Medical Society). Her hospital in Bergen, which currently enjoys a CS rate of 13%, is a mecca for trainees hoping to improve their hands-on skills. Haukland, with an annual birth rate of 5000, sees 150-200 breech deliveries per year and Dr Albrechtsen herself has attended over 500 breech deliveries.
How do they do it? Dr Albrechtsen tells us: “You just have to decide that it is good for babies to be born vaginally, unless there is clearly a problem, and commit yourself to developing the skills to enable that to happen.” As she explained, a normal vaginal birth is an important programming event with life-long consequences. Evidence is growing about the links between caesarean section and future disease in the child, such as Type 1 diabetes, asthma, allergies, gastroenteritis and obesity (see Ulander et al, 2004). Dr Albrechtsen also presented her epidemiological data, demonstrating the way CS rates and rates of vaginal birth have changed over the last 40 years in Scandinavia. Particularly interesting were the way the Finns have been able to make a dramatic change within a few years, simply by making the decision to do so.
Dr Michele Mohajer, whose unit in Shropshire currently enjoys a 14.3% CS rate, shared with us the work of her breech clinic and her extensive experience with ECV, having performed over 1500 procedures herself, in addition to attending hundreds of breech deliveries in her career. It is reassuring to know that these skills are being maintained by expert practitioners.
Feedback from the day suggested that those attending had concerns about managing an undiagnosed breech birth, and interest in developing skills had been driven by recent experiences. This is a real concern. Approximately 3-4% of babies present breech at term, and 25-30% remain undiagnosed until labour. Consequently, an undiagnosed breech presents in labour approximately 1:100 of all births. It is in everyone’s interests that we do our best to support all women wishing to make the informed choice to labour with their breech babies, putting plans in place so that skills can be developed for when women cannot make a measured decision.
In my view, organising small on-call teams for breech, involving both doctors and midwives, is the best way to accomplish the re-introduction of breech skills. Some research and professional opinion supports this view (Kotaska 2009, Maier et al 2011). Neither all doctors nor all midwives will be confident and keen to attend a breech birth. Ideally all staff involved will be both, but at least one well-prepared and experienced person at every breech birth is essential, for both safety and the reassurance of the woman involved. At the conference, we also reviewed the mechanisms of breech birth, counselling for informed choice, and how to help in a complicated breech birth, particularly when the woman births in an upright position. I’ve noticed more doctors attending these study days each time we do it. One young obstetrician said to me, “I needed you here about a week ago, when I got hauled over the coals for supporting a woman to [successfully] have her breech baby vaginally.” This threatening cultural atmosphere needs to change. We need obstetricians and midwives who are willing to develop the skills to facilitate breech birth in the safest possible way.
Let’s do it .. Let’s fall in love … with breech babies
This study day was organised by Geraldine Butcher, Consultant Midwife for Ayrshire and Arran, and a passionate advocate for the rights of women to make informed decisions about how to have their babies. Feedback from the study day:
“It has been a very fruitful day for me and I will use the presentations and practice to update my own. I will feel more confident in supporting upright breech birth.”
“It gives me more confidence to promote breech delivery and services surrounding breech as an option.”
“Video scenarios were very helpful. Recent undiagnosed breech presentations have encouraged us to review / update knowledge.”