Training in Lewisham on November 12 — Book here.
“We believe that we do well what we do often.” – Caroline Daelemans
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.
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.”
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.
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.