Investing in staff and their skill development will achieve the same, if not better, results and should be the priority.
This a response to a recently published report in PLOS Medicine suggesting that implementation of universal third trimester ultrasound scanning in pregnancy improves outcomes for babies and mothers.
This will be of particular interest to obstetric specialty trainees, many of whom will be able to use study leave and have course fees paid (50%) through educational budgets because the course is hosted by the RCOG.
We look forward to supporting more obstetricians, midwives and paramedics to feel confident in their ability to support vaginal breech births, and to provide appropriate hands-on assistance when indicated.
This Monday, we held a training day at St. Mary’s Hospital in Paddington, London, to support the Imperial OptiBreech Team, led by Consultant Obstetrician Sabrina Das.
OptiBreech Just Giving Page
We will be donating 10% of any revenue obtained from this and all future study days to the OptiBreech Just Giving page, which is raising money to provide sites with extra support so that team members can continue to be on-call for women planning a vaginal breech birth.
We would be incredibly grateful if you would join us in this support by donating if you can and sharing the link with your social networks.
Below is some recent research to demonstrate how we are helping to make breech services better and safer for all families:
First OptiBreech results poster! Walker, S., Dasgupta, T., Hunter, S., Reid, S., Shennan, A., Sandall, J., Davies, S., 2022. Preparing for the OptiBreech Trial: a mixed methods implementation and feasibility study. BJOG An Int. J. Obstet. Gynaecol. 129, 70. https://epostersonline.com/rcog2022/node/4909
Spillane E, Walker S, McCourt C, 2022. Optimal time intervals for vaginal breech births: a case-control study. NIHR Open Res. 2, 45.https://doi.org/10.3310/nihropenres.13297.1
Walker S, Dasgupta T, Halliday A, Reitter A, 2021. Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS): A systematic review on variations in outcome reporting. Eur. J. Obstet. Gynecol. Reprod. Biol. 263, 117–126. https://doi.org/10.1016/j.ejogrb.2021.06.021
Shawn Walker, RM PhD, King’s College London and Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex Hospital Sabrina Das, MB ChB, MRCOG, Imperial College Healthcare NHS Foundation Trust, Queen Charlottes & Chelsea Hospital Emma Spillane, RM MSc, Kingston Hospital NHS Foundation Trust Amy Meadowcroft, RM, Northern Care Alliance NHS Foundation Trust Background In the […]Continuous cyclic pushing: a non-invasive approach to optimising descent in vaginal breech births — The OptiBreech Project
Happy new year, breech advocates! We’ve got nearly 10 hours of evidence-packed, video-rich, detail-loving breech birth training content waiting for you.
Our fully updated 2022 course is now on-line. To help you reach your new year’s resolution of developing some beautiful breech skills, the course will be available at a discounted price of £50 for the first two weeks of January. No code needed; access is for one year.
Image by Katherine Gilmartin
Along with a new course, our Vimeo library has a NEW PASSWORD. This is available from the “Resources for Teaching and Implementation” section of any course you are enrolled in, along with our amazing Dropbox of guidelines and training resources. Registered users have permission to use the content for non-profit teaching purposes — because learning together is the safest, most effective way to do it.
All of our online courses also come with free access to our Online Webinars. These are one-hour discussions on topics that have arisen during the course of our practice or others’, where we share learning and reflection with each other.
If you have previously completed any of our on-line courses, you are eligible to register for the Refresher course for only £10/year. This is exactly the same as the main course, but for a nominal cost to help us keep our platforms online. You can review the course, or just complete the assessment to obtain a new certificate for your portfolio.
Image by Katherine Gilmartin
Anyone organising or attending one of our face-to-face courses will be given free access to the on-line course for one year. Due to the on-going pandemic and need for social distancing, we rarely have external places to offer as we did pre-2020, but you can still host a study day for yourself and your colleagues.
If your site is participating in the OptiBreech Trial, your free online training package has already been updated.
What if I have attended an in-person course in the past? Access to the Refresher Course is only available to those who have purchased and completed one of our on-line courses, beginning in 2021. All of our previous courses have been advertised with one year’s access to our Vimeo Library. Content is updated regularly, so our recent courses are significantly expanded, based on current research, compared to those of previous years. If you have completed the main course, the system will automatically consider you eligible to take the Refresher. If you use our videos for teaching within your institution, we encourage you to ask your employer to reimburse your training so you can continue to maintain access.
Opportunities
Finally, some opportunities to become more involved in Breech Birth Network. We would really like some help with the following, and if you are willing to make a regular commitment and develop the skills necessary, we can also pay you! Emma and I developed the skills to do all this because that is what was necessary, and we know others can too.
Ideally, we would like to involve people who are supporting breech births professionally in some way, so that the learning that occurs in these roles also spills over into developing your own practice. That’s what makes it worthwhile for us. And obvs, we expect that you would have completed our training to know what you are getting into and that your approach to breech birth aligns with ours.
Online Webinatrix. We do our online webinar series ad hoc at the moment, but we’d like it to happen regularly.
Video Master. We have a large Vimeo library, but in order to make the most of it, it needs to be organised — edited, tagged, consent forms stored securely, etc.
Online education Diva. In addition to developing new content based upon new evidence or learning from practice in our communities, we have a need to develop translated versions of our courses to make them more accessible to a wider audience. We use Articulate 360 and WordPress, and although we don’t expect you to come in with those skills, we need someone who is willing to develop them to get the job done.
Accounting Guru. This doesn’t necessarily need to be a birth professional. We use Xero, and our amazing admin assistant Charlie has been doing this for us for a few years, but now needs to hand over due to other exciting things happening in her life.
If you are interested in any of these roles and prepared to make a commitment to helping our small, not-for-profit enterprise grow, please get in touch using the form below.
Should we screen for nuchal cord using ultrasound when a woman is planning a vaginal breech birth? and
What should we do with the information if we do identify a nuchal cord on ultrasound?
‘Nuchal cord’ means that one or more loops of umbilical cord are wrapped around the baby’s neck, during pregnancy or birth. Checking for nuchal cord prior to external cephalic version (ECV) or during risk assessment prior to a vaginal breech birth (VBB) is both common and controversial.
cord-leg entanglement, image: Dr Pricilla Ribeiro-Huguet
What is known:
Nuchal cords are common, especially for breech presentation. For example, in this study (Wong & Ludmir, 2006), where someone specifically looked for a nuchal cord prior to an attempt at ECV, 34/75 (45.3%) babies were spotted wearing their cord as a necklace. They attempted the ECVs without this information. More babies with nuchal cords had transient (temporary) heart rate abnormalities, and their ECVs were less likely to be successful. But none of them had an emergency caesarean birth because of the way their heart rate was affected by attempting ECV.
It may cause problems in some pregnancies and/or births, but visual assessment by ultrasound does NOT help us to predict which ones. (… in general. Unless, as in this paper by Hinkson et al 2019, there are 6 loops of nuchal cord visible. Wow!)
double nuchal cord, image: Shawn Walker
What is not known: Does a nuchal cord increase the risk associated with an ECV or vaginal breech birth? We just don’t know if, or by how much, presence of a nuchal cord increases the risk. This is one reason neither of the RCOG guidelines (ECV, Management of Breech) indicate nuchal cord should be identified, or used as an exclusion criteria, for either of these. In fact, they don’t mention ‘nuchal cord’ or ‘cord around the neck’ at all.
When there is clinical uncertainty, we just say … there is clinical uncertainty. We can’t guarantee it won’t be a problem, but we have no clear evidence that it is likely to cause a problem.
Other guidelines often do say something like, “exclude nuchal cord.” This means, “Look for it with ultrasound to make sure it isn’t there.” But it’s not clear what one is supposed to do if you identify it IS there. And if a clinician has not looked for it, or has not spotted it, and it ends up being there and causing a problem during birth, have they been negligent? It’s a slippery slope.
cord-leg entanglement, image: Dr Anke Reitter
In my own clinical experience, breech babies born vaginally quite often have one or sometimes two loops of nuchal cord around their neck at birth. My gut feeling is that these babies more often needed help to flex the head, for example with a shoulder press, but that this was not more difficult than when the cord is not there.
I also checked our video study (Reitter, Halliday & Walker 2020) database of 42 breech births with ‘good’ outcomes. Among these, 8/42 (19%) had a cord wrapped at least once around the neck. Among these 8, 5/8 had help with the arms, and 6/8 had help to flex the head. This was slightly higher than the overall averages in the whole dataset. In the dataset, there were also 2 cases of leg entanglement, 1 case of arm entanglement, and 1 cord prolapse, where the cord comes out first.
It seems plausible that cord entanglement, whether around the neck or another body part, could interfere with the normal mechanisms of a vaginal breech birth. These babies may then require more assistance to be born safely, which is not itself a problem, as long as that assistance is provided in a timely fashion. It also seems plausible that in some case, a tight or short cord entanglement could cause problems that would put the baby at risk. But the kind of potential problems Peesay describes are all very likely to be picked up with the kind of close monitoring (growth scans, fetal heart rate monitoring, etc.) that every known breech baby received antenatally and/or in labour.
I’ve also added a ‘cord’ tag to several videos in our video library. If you’ve taken our Physiological Breech Birth course, you can search the library to watch several videos where cord entanglements feature and are resolved.
In summary, these are my recommendations:
Don’t routinely go looking for a nuchal cord in otherwise uncomplicated pregnancies.
If you do spot a nuchal cord, explain the clinical uncertainty with regard to its implications.
Offer and attempt ECV if the person chooses this.
Offer and support a VBB if the person chooses this.
When attending a VBB with a known/suspected nuchal cord in labour:
interpret fetal heart monitoring in light of this;
interpret descent in light of this;
anticipate the cord could interfere with the mechanisms, which may require your assistance; and
review all of your tools for assisting the head to flex.
I’d love to know others’ thoughts and experiences?
Shawn
This is really interesting. My breechy had the cord x3 round her neck then looped under her arm. Straight forward home birth. When chatting to midwife after we thought if she'd been cephalic the length of cord left may not have allowed her to descend, as bum first fine! Anecdata!
The team at Sygehus Sønderjylland, the University Hospital of Southern Denmark, has created a wonderful new series of training videos for upright breech birth. We are thrilled to be able to share them with you!
The creation of the videos was led by obstetrician Kamilla Gerhard-Nielsen, who also led the implementation of the upright breech concept in the hospital and its introduction in Denmark.
They also host a FaceBook page. Image: Obstetricians Katrin Loeser and Kamilla Gerhard-Nielsen
“Practical insight into upright breech birth from birth videos: a structured analysis” is now available on-line! (Reitter, Halliday and Walker, 2020, Birth – https://doi.org/10.1111/birt.12480) This paper represents a few years of hard work by Anke Reitter, me and our Research Assistant, Alexandra Halliday. It contains insights into birth timings and the mechanisms as observed in upright breech birth videos. The Physiological Breech Birth Algorithm is also included.
Download Algorithm
We look forward to much debate and discussion! Please share with anyone concerned about safe vaginal breech birth.
Love,
Shawn
Traduit par: Isabelle Brabant et Caroline Daelmans
Next month, I will be a Visiting Scholar at the University of British Columbia. This will include a workshop on my research and physiological breech birth practice, delivered alongside Andrew Kotaska, lead author of the Canadian breech guideline, and a highly respected obstetric and midwifery faculty.
Please share this information with any Canadian OBs and Residents who want to extend their skills to facilitate safe vaginal breech births. The course is accredited for MOC 3. Bookings can be made on-line.
The team at Sygehus Sønderjylland, the University Hospital of Southern Denmark, has created a wonderful 
