Category Archives: Breech Skills

Bottoms Down Under

‘Into the Breech’ Workshops in Perth and Melbourne, December 2013

Anke Reitter, Danielle Freeth, Rhonda Tombros, Andrew Bisits

This month has seen a small series of Australian workshops, hoping to increase confidence among those already working to modernise breech birth in Australia. The ‘Into the Breech’ conferences were instigated by Dr Rhonda Tombros, an academic lawyer with an interest in human rights and the mother of a breech born baby, and organised by Barbara Glare. The conferences coincided with a six month research fellowship visit by Dr Anke Reitter (FRCOG) of the Frankfurt team, whose MRI research will soon be published, concerning changes in pelvic diameters with maternal position changes.

The Perth workshop, on 3 December, was held in the Perth Zoo and was opened by midwife Danielle Freeth, also the mother of two breech babies. As for obstetricians, it was quality rather than quantity on this occasion. One of the participants, Dr Liza Fower, Head of Obs and Gynea at the Armadale Hospital, gained significant experience facilitating breech birth in South Africa and has been able to continue to offer support. She also contributed to one of our practical workshops with some useful tips.

Anke Reitter frisking Andrew Bisits .. while demonstrating how to release stuck nuchal arms.

Dr Andrew Bisits (FRANZCOG) presented in Perth, on pathways for women and complications. Bisits is one of the Directors of the ALSO (Advanced Life Support in Obstetrics) course in Australia, which will be updated to include emergency manoeuvres when a woman is in an upright position. He and his team, including Midwifery Professor Caroline Homer, have launched an intensive course for professionals in Australia, the BABE (Become a Breech Expert) course. I am very much hoping to bring this course to the UK at some point in the future, and in the meantime will be ensuring that the information presented at the Breech Birth Network study days is in line with the systematic approach they are developing.

Melbourne attracted more consultant obstetricians, GP obstetricians and a lively group of midwives. Many conversations occurred during the break, suggesting a critical mass in this location, likely to move on with a more organised and collaborative approach to supporting women with breech presenting babies. This may require more working together across traditional boundaries if women are to have adequate support for viable choices, especially as breech services are reintroduced among teams with minimal recent experience.

Dr Rhonda Tombros

A highlight of both days was Dr Rhonda Tombros’ presentation on the legal aspects of informed consent and negligence focusing specifically on issues around breech birth. We all hope she writes this up for publication in the near future.

Although I present at these conferences (in this case, on the evidence base and ‘normal for breech’), I find them invaluable to developing my own practice. The two messages I found most interesting with this visit concerned timings and episiotomy.

Timings: Bisits and Reitter gave increased focus to achieving a prompt delivery, suggesting that 3 minutes from the birth of the umbilicus to the birth of the aftercoming head is ideal. “Three minutes is ideal, you are probably okay with five, but after that most babies will experience some sort of compromise.” This aspect has not been previously emphasised at the conferences I have attended, but the intense dialogue which has developed between midwives and obstetricians supporting breech has revealed differences. It seems that timings are almost taken for granted in obstetric training for breech, whereas midwives have a much higher tolerance for a ‘wait and see’ approach, emphasising the ‘hands off the breech’ philosophy. In reviewing the anecdotal experiences where breech is being reintroduced, the current consensus among our small collective of professionals is that, while a ‘wait and see’ approach will often result in a spontaneous resolution, it will also more often result in a severely compromised baby when that spontaneous resolution does not occur. Therefore, following the birth of the umbilicus, if the birth does not continue to progress promptly or you are not confident of the condition of the baby, intervening to facilitate the birth is recommended, using the systematic approach we are advocating:

Try to sweep down the arms in front of the face
If not possible, rotate in the direction of the nuchal arm (modified Lovesets)
Ensure the head is aligned with the body and the mother’s birth canal
Deliver the head using classic or modern techniques to achieve flexion

The skill of an experienced practitioner is in holding back from intervening when the birth is progressing normally, balanced with effective intervention when it is not, and developing this judgement is a key aspect of breech training days.

Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Episiotomy: In Melbourse, Consultant Midwive Michelle Underwood presented data from the Westmead Clinic which she runs with Dr Andrew Pesce in Sydney. While all of their statistics were fascinating – especially demonstrating a reduction in CS for breech from 90% to 63% in the first year of the clinic – I was intrigued by their stats on perineal damage. It seems that, compared to all births, the breech births have the highest rate of episiotomy AND the highest rate of intact perineum. This suggests to me that the majority of perineal damage from vaginal breech births may be iatrogenic, which is not surprising given that cutting a timely episiotomy is an over-emphasised part of some obstetric training for breech (Deering et al 2006), as is the use of forceps.

But is it necessary, or helpful (in most cases)? In his own practise, Bisits avoids episiotomy because he feels the perineum has an active role in encouraging breech babies to remain well flexed throughout the birth. Reitter also discussed her own personal stats – three (3) episiotomies cut in the last 10 years, a period which has included management of over 300 breech births and countless cephalic complications. The episiotomy rate in her unit in Frankfurt is exceptionally low overall. Change was accomplished when the Lead Obstetrician (Prof Frank Louwen) insisted that episiotomies would not be cut unless absolutely necessary, and that each episiotomy would need to be justified personally to him. That’s what leadership can do.

Shawn

A Different Birth

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Brighton Breech Conference, 11 November 2014

Wow! On my way home to Norwich after an amazing day in Brighton.

The day was organised by Jenny Davidson, currently Acting Deputy Head of Midwifery at the Royal Sussex Hospital in Brighton. Jenny is an inspirational midwife, and doing great things to empower both midwives and women with breech babies. She’s nearing the end of a PhD and started the study day off with a research round-up, exploring why the heavily criticised Term Breech Trial has had such an impact on breech practice, and presenting other evidence which widens the discussion and decision-making process for breech. (See Premoda and Toivonen for a start, but Jenny had several pages of references.) The increasing amount of qualitative research revealing women’s experiences of breech pregnancy and childbirth was also discussed. (See Guittier for a start.)

Following this, Benna Waites discussed ‘talking breech’ – how we counsel women with breech-presenting babies. She stressed the importance of recognising that the risks to women of CS are not inconsequential, and of remaining non-judgemental even when women are making decisions which professionals may not feel are the ‘right’ ones. Benna, author of the ‘breech bible’ – Breech Birth – is a Consultant Clinical Psychologist, as well as the mother of a breech-born baby. She brings these important perspectives into her presentations. I hope that well-informed, deeply immersed service user advocates like Benna can in the future participate more fully in discussions around national guidelines, such as those written by NICE and RCOG.

Jane Evans continues to inspire a new generation of midwives presenting her excellent knowledge of the mechanisms of breech birth, and how to assist when help is required, built upon decades of clinical practice. Jane has authored many articles, but her more recent publications in Essentially MIDIRS should be essential reading for professionals seeking to modernise their breech practice.

Today was the first time I have had the opportunity to hear from Dr Michele Mohajer, co-author of this UK-based study) and Consultant Obstetrician at the Royal Shrewsbury Hospital in Shropshire. Michele has run a breech clinic there since 1997, where both breech and ECV have been well supported. Her ECV success rate is excellent, approximately 60%. She shared with us several of her methods for increasing the likelihood of succeeding. There are few things I like more than hearing someone with excellent clinical skills discuss their techniques. I especially admired Dr Mohajer’s discussion of the influence of gaining the woman’s trust and co-operation to her success rates. Her ECV films were excellent and a really useful practice update. I hope Dr Mohajer is also able to reach wider audiences to share her classic obstetric skills. Women who wish to have their babies turned deserve for the practitioners attempting this to have success rates as high as possible.

Hopefully others will share their personal highlights from the day. And (although this study day was sold out), we all look forward to more obstetricians and midwives attending future study days. Please do get involved, share your experiences, develop your services. As several people remarked today, it really does feel like the green shoots of change are growing for breech.

Shawn

Breech updating

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(Another post in response to discussion on the Coalition for Breech Birth Facebook Page.)

Breech births are few and far between, and there are very few ‘experts’ in the world to learn from, so staying updated is a real challenge. Especially if you do not live and work near others who are supporting breech births regularly.

Updating has two purposes: keeping up to date with current evidence and best practice; and reminding yourself how to use skills you use infrequently. Many breech babies, especially those whose mothers are active and upright (e.g. knees/elbows), can be born spontaneously. But those who cannot need calm, considered help in a timely manner. The same applies to external cephalic version – ECV. Both practices benefit from regular performance and knowledge sharing among those who are practicing.

Here are my suggestions on keeping your practice as safe and supportive as possible:

Attend study days. Many individuals offer study days to develop breech skills. Breech Birth Network days concentrate on lots of practical skills, but also have an emphasis on care pathway planning in the UK, aiming to encourage more Trusts to adopt an organised, committed approach to breech.
Share your work. If you are doing research or working with breech and would like to share your experiences, get in touch and present at one of the study days. I am not an expert, but an experienced and passionate believer in the idea that the more we share, the more we talk about it, the more normal it becomes. The best study days have a wide variety of speakers and reflect a wide community dedicated to developing and sharing skills.
Share your experiences. If you learned something at a breech birth you attended that might help us to make our practice safer, share it! Publish it if appropriate, but if you need to share anonymously to protect your client’s and your confidentiality, I can give you space on this blog. It is wonderful and encouraging to hear stories of triumphant breech births where the baby just fell out singing. But we need to hear the stories of doubt and sadness as well, and often these are the ones you learn the most from.
Create your own network. It’s been so valuable to me to have colleagues who I can phone up to debrief the breech births I’ve attended. I learn so much more by doing this. And so valuable to hear their stories, how they have approached certain complications, how they support women, their thoughts on what makes breech birth safe. Keep a record of these sessions and document them; they are part of your professional updating. Write an article about what you have learned together, so that others can respond to it. We need more voices talking about breech skills.
Organise your own study day. Bring the conversation to you. Empower those local to you to share their skills by asking them to present. Inspire your local community to think more about breech.

If you don’t have anyone local to ask questions or debrief with, my number is 07947819122 (in the UK) and I’m always happy to listen. I’m sure most of us are. Good luck!

How much does breech experience matter?

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Some friends of mine at the Coalition for Breech Birth (a consumer advocacy organisation) have been discussing the role of practitioner experience in reducing risk associated with vaginal breech birth. My response is a bit longer than Facebook will permit, so I’m putting it here.

The study I find most useful in this discussion is here:

Su M, McLeod L, Ross S, Willan A, Hannah WJ, Hutton E, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol. 2003 Sep;189(3):740-5. PubMed PMID: 14526305. Epub 2003/10/04. eng.

Overall, the team found very few factors associated with an increase or reduction of risk of adverse perinatal outcome. They did find a dose-reponse relationship between amount of labour and adverse outcome. In other words, a pre-labour CS seemed to afford the most benefit, followed by early labour CS. By the time you are in active labour (>3 cm), there is no longer a statistically significant difference between CS and vaginal birth. So I get particularly annoyed when this study is used to tell women who arrive in advanced labour with an undiagnosed breech that a CS is the safest option.

They also found, contrary to popular belief, that big babies (>3500g) fared no worse than more averaged weight babies, but small babies (<2800g) did. Makes sense to me. Generally but not always, babies who are very small at term may already be slightly compromised; labour may be an additional stress. On the other hand, if a chunky 9-pounder folded in half can fit both his abdomen and his legs through your pelvis, chances are his head is going to fit, especially if you are with someone who knows how to help it into an optimal position.

He also needs to fit without help, because the study also revealed that using augmentation to enhance a labour which is not progressing well enough on its own was associated with over twice the risk of labours which proceeded spontaneously. Similarly, longer second stages increased the risk, so our baby needs to be descending fairly easily in the second stage, without help, or a CS may be the better option.

But the only factor shown to reduce the risk associated with a vaginal breech birth (by over 2/3) is the presence of an experienced clinician at the birth. This person need not be a licensed obstetrician, and the years of experience did not make a difference either – the TBT team specifically looked at these factors. The risk reduction occurred only when ‘an experienced clinician was defined as a clinician who judged him or herself to be skilled at vaginal breech delivery, confirmed by the Head of Department.’ Midwives were among those included in this definition.

Although we do not (yet) have any research (get back to me in a decade or so) which looks at the results of spontaneous breech birth with experienced clinicians at term, this analysis of the TBT suggests that this scenario is significantly less risky than many of the births included in the trial which were responsible for adverse outcomes. Add to that the further benefits we are seeing emerge with upright breech (reduction in need for manoeuvres and the minor injuries these can sometimes cause), and vaginal breech birth is a realistic option for many women.

One further comment on the research: Many are frustrated because the results of retrospective observational studies overwhelmingly indicate similar outcomes for vaginal breech birth and planned CS. These have comparatively little influence on guidelines because they are considered ‘biased.’ However, understanding why they are biased is sometimes useful. Retrospective studies are most often done by experienced practitioners who feel their own results conflict with the lowest common denominator represented by a large multi-centre RCT like the TBT. They present these results to illustrate that a comparatively safe vaginal breech service is possible, despite the fact that breech is often grossly mismanaged in many areas. Retrospective studies do not necessarily represent the ‘norm.’ But they do suggest, along with the TBT’s own data, that if your provider feels confident supporting you to have a vaginal breech birth, you can probably feel pretty confident as well.

Update 2015: A meta-analysis of observational studies indicates significantly better short-term outcomes when CS is planned than when VBB is planned. However, the rate of complications following planned VBB is much less than reported in the Term Breech Trial and similar to the results when a cephalic birth is planned. Read Berhan et al 2015 by clicking the link.

Shawn

Listen to midwives, listen to women

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I always smile when people say, “It’s all well and good to support natural breech birth, but what happens if the head gets stuck?” Those of us who are supporting woman-centred, modern breech birth take an equally realistic view about the need to intervene in a skilled and confident manner when help is needed, although we are probably more realistic about the frequency with which such intervention is required. We also obsess about creating trusting relationships and environments which facilitate more spontaneous, easier births, with the end result that we need to use our skills less often.

However we sometimes rely on these skills to achieve a safe outcome. Therefore we share our experiences with others, for when they might be needed. And we know that supporting others to confidently support more breech births will create new knowledge which will in turn help us to improve our own practice.

Where does this knowledge come from? Hint: not Randomised Controlled Trials. One of the many ways midwives create knowledge about practice is by listening to each other and listening to women. For example, in the training aid linked above, one of the options involves assisting a woman who is on all fours to become straight upright on her knees, and applying suprapubic pressure. This is how my own personal learning about that happened (participants not identified to maintain confidentiality):

The baby’s head was hyperextended at the time of delivery, but not before. Woman on all fours, no progress with the next contraction, no spontaneous movements from the baby to assist his own flexion. Neither the midwife managing nor the Registrar who was supporting could reach the baby’s chin, just what felt like a bird beak (the lower jaw bone) pointed up to the sky, so Mariceau-Cronk was not an option. All present were fairly inexperienced, and no training aids were available, so the decision to get the woman upright was instinctive. The decision to apply suprapubic pressure while doing so was based on RCOG guidelines about how to help when the woman is in lithotomy, transcribed to the current situation. The occiput was felt during suprapubic pressure. Then suddenly the baby’s head dropped into the pelvis, and was immediately born wearing his placenta like a hat. Several minutes of resuscitation were required. Baby recovered quickly and well.

Following on from this story, I returned to the sources I use over and over again. Anne Frye’s Holistic Midwifery described how some midwives get the woman upright (for breech and shoulder dystocia) because this tightens the abdominal muscles, promoting head flexion. So someone else has a theory for how it works. There is also increasing radiological evidence that when upright or prone (e.g. shoulders, pelvis and knees in a straight line), the pelvic inlet is largest, while squatting significantly enlarges the mid-pelvis and pelvic outlet. The strategy of assisting the woman to move into an upright posture and use suprapubic pressure may have resulted in an even better outcome if performed earlier, as soon as the dystocia was identified.

Once you begin to see the patterns, they emerge in the stories you immerse yourself in. Reading Jennie Clegg’s story about her ‘Breech VBAC at home,’ I found this:

The next push I gave it everything I had and rumping happened very quickly followed by the body; the relief of the pressure was immense. Two sharp sensations happened which were the legs releasing, I remember looking through my legs and seeing a little body! Then there were a few sharp uncomfortable movements which were caused by the baby wriggling its arms out. My contractions at this point had stopped.

Debs could see no chin on the chest to examined me and found the head to be extended. An ambulance was called and Debs started manoeuvres to birth the baby. No movement was felt so I was encouraged to change position and Michelle tried nipple stimulation to get contractions coming. Michelle and James helped me to stand, Debs attempted head flexion, movement was felt and I was encouraged to push, baby was born immediately followed by the placenta! (Midwifery Matters, ISSUE 135, Winter 2012)

This scenario was slightly different, but maternal movement was again helpful. Jane Evans, a midwife with many years of breech experience, writes and talks about how her understanding of the physiology of breech birth has been informed by listening to and close observation of women (Evans 2012a, Evans 2012b).

Listen to women. Listen to midwives. Share your stories. Share your skills.

Feel free to share your own stories in the comments below. Community support for breech professionals is available via a Breech Birth Network Facebook group.

References

Michel, S. C., Rake, A., Treiber, K., Seifert, B., Chaoui, R., Huch, R., . . . Kubik-Huch, R. A. (2002). MR obstetric pelvimetry: effect of birthing position on pelvic bony dimensions. AJR Am J Roentgenol, 179(4), 1063-1067. doi: 10.2214/ajr.

Anne Frye’s Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice, Vol II is now available to download as a PDF, you lucky ducks! My father still complains about having to transport the heavy tome across London on the underground when he brought it to me from America one Christmas.

Mechanisms of upright breech birth

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Understanding the physiological process of a breech birth

The following pictures show the way a breech baby wiggles her way through a mother’s pelvis when mum is upright (e.g. kneeling or hands/knees), and the signs a breech birth attendant looks for to tell if this process needs help or not.

Engaging LSA

A breech baby may engage before labour, or may not engage until after her mother’s cervix is fully dilated.

Some midwives feel engagement with the back on one side or another may be ideal. (See Jane Evans‘s ideas on this, on Rixa Freeze’s blog.)

I am happy for the back to be on either side, and these pictures depict the birth of a baby whose legs are extended (frank breech), with her back on her mother’s left.

Descending LST, anterior buttock leading

The breech typically descends with the sacrum transverse, anterior buttock leading. On vaginal examination, this will feel asynclitic – the anal cleft is closest to the maternal sacrum. This is normal for breech.

Maternal movement assists this process in the same way it assists cephalic descent.

The buttocks will be born by lateral spinal flexion (wiggling the bum from side to side).

Anterior buttock rumping

The anterior (maternal front) buttock is born first, followed by the baby’s anus (usually squirting a thick glob of meconium) and the posterior buttock.

The sacrum will soon rotate to sacro-anterior (‘tum to bum’ – the baby’s rear should be in line with the mother’s front). If rotation is tending toward sacro-posterior, this may be an indication for intervention (to gently encourage sacro-anterior rotation).

Birth of the extended fetal legs

Baby’s legs seem to stretch forever, but will be born spontaneously. If there is ‘good descent,’ this will happen with the next big push after the pelvis is born. If there has been any indication of fetal compromise (eg. heart rate abnormalities), assist the legs gently by pushing the knees in towards the abdomen.

If one leg slips down before the other, this may indicate that full internal rotation has not occurred, and help with the arms may be needed.

“If it progresses, wait and see.” – Mary Cronk

Birth of the umbilicus

After baby’s legs flop down, you will have a clear view of the umbilicus and may even be able to see the baby’s heart rate from her chest. Do not touch the umbilicus, but observe: colour, tone, flexion/movement.

Reassuring sign: If you observe cleavage (the sternal crease) on the baby’s chest, you know the arms are in front and should be born with the next contraction or active maternal effort between contractions. If not, you need to help.

Indication for intervention: If full rotation has not occurred by the time the nipple line is visible, or progress stops for >30 seconds at any point, you will need to assist with the birth of the arms.

Rotation to drop the anterior arm below the pubic arch

In most breech births, the arms will be born spontaneously with the baby’s torso in a sacrum-anterior position (‘tum to bum’).

Occasionally, as the head engages, baby rotates slightly to release one arm below the pubic arch, then rotates the other direction to release the other arm.

Birth of the fetal arms

Baby should be ‘tum to bum’ following the birth of the arms, and the head should be aligned in the pelvis in an occipit-anterior position.

Unflexed head obstructed in pelvis

A well-flexed head will pass easily through the pelvis.

Commonly, women experience an urge to lower their bottoms to the surface on which they are kneeling (e.g. bed, floor mat, etc.) This maintains and promotes flexion in the baby’s body and should not be interrupted.

Flexed head passing through pelvis

Babies have often been observed doing a ‘tummy crunch,’ or full body flexion recoil, spontaneously pulling their knees up into a fetal position. This also promotes flexion and helps the head to be born.

Note: A compromised baby will not do this, and you will need to assist more, and sooner.

If progress arrests – no descent with maternal effort – help to flex the head is indicated, especially if baby’s tone and colour are not ideal.

Want to learn more?

Cord prolapse: what do midwives do?

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This post was originally written as a Letter to the Editor, but when I went to submit it, I discovered the on-line journal does not accept any unsolicited writing. All of the articles are ‘commissioned by the Editors from specialists in their field,’ so I guess we should read them as more of a pronouncement than the opening of a dialogue?

I have some concerns about an intervention for cord prolapse described in a recent article on Abnormal Labour (Obstetrics, Gynaecology and Reproductive Medicine, Volume 23, Issue 4, Pages 121-125, April 2013): “Filling the urinary bladder (with 500-750 ml normal saline) helps to elevate the presenting part off the cord – this technique is particularly more suitable to the homebirth or standalone midwifery unit setting where prolonged manual elevation during transfer to an obstetric unit is difficult to maintain. In the hospital setting, filling the urinary bladder offers no increase in survival or improvement in fetal umbilical cord gases over manual elevation alone, although may be a useful adjunct if there is no theatre immediately available.”

As I said, I have some concerns. The authors suggest filling the urinary bladder as a method of preventing cord compression following cord prolapse. They say this technique has not been shown to improve outcomes in a hospital setting, but is ‘particularly more suitable to the homebirth or standalone midwifery unit.’ There are no references provided for the evidence related to use of this technique in either setting. As a midwife who has worked in two countries and the complete range of midwifery-led settings, I have never encountered this technique, nor anyone carrying appropriate equipment to enact it. I am concerned that an unproven, potentially harmful intervention not in widespread use is being presented as best practice, for use by midwives.

I am also concerned that, although the case scenario ended in a vaginal birth, the discussion presents caesarean section as the preferred method of delivery when a cord prolapse is seen, without discussing the importance of determining whether or not delivery is imminent before intervening. Cord prolapse is a common occurrence preceding the birth of a second twin, and during the births of babies with complete (knees flexed) and footling breech presentations. A prolapsed cord at full dilatation may precede a healthy vaginal birth with a delivery interval significantly less than a caesarean section (Gannard-Pechin et al 2012, Huang et al 2012), and when accompanying non-frank breech and twin births is associated with fetal compromise less often than for cephalic singletons (Kouam & Miller 1980, Broche et al 2005). Therefore, giving the impression that the best course of action upon seeing a cord in every situation is to elevate the presenting part manually, effectively preventing descent and spontaneous delivery in preference of a crash section, in many instances will cause more harm than good. This may seem like a matter of course to experienced practitioners, but it won’t be for the inexperienced.

Judging which instances require such emergency measures, and which would benefit from cautious expectant management, is a matter of skill and experience (in theory and practice), to which articles like the one linked above could usefully contribute. Factors to consider include cervical dilatation, type of presentation, signs of fetal distress, and descent with expulsive effort. Additionally, management of breech deliveries with the woman in an all fours position may reduce cord compression (as the cord is above the fetal body rather than below), and can easily be converted to a knees-chest position for more active intervention if delivery does not progress as quickly as expected. This is a strategy midwives are actually using in the community.

Update (December 2014): Those of you who are interested in this topic should read this report from the Netherlands:

M Smit et al, Umbilical cord prolapse in primary care settings in the Netherlands; a case series, Part 2, The Practising Midwife 17 (7); 34-38.

When considering what is recommended and best practice for midwives working in primary care settings, evidence needs to come from those settings. In this study, 2/8 UCP’s were managed with retrograde bladder filling, and these two instances were associated with the poorest Apgars, and the only death reported. While the numbers are small, they suggest that bladder filling in primary care settings may not offer benefits over manual elevation of the presenting part. Additionally, because it is time consuming, especially for a single midwife on her own at home, it may lead to unnecessary delays, compared to outcomes which were conducted in settings where assistance from other staff was immediately available.

What do you think? Are you carrying equipment to inflate women’s bladders if you detect a cord prolapse at home?

Broche, D. E., Riethmuller, D., Vidal, C., Sautiere, J. L., Schaal, J. P., & Maillet, R. (2005). [Obstetric and perinatal outcomes of a disreputable presentation: the nonfrank breech]. J Gynecol Obstet Biol Reprod (Paris), 34(8), 781-788.

Gannard-Pechin, E., Ramanah, R., Cossa, S., Mulin, B., Maillet, R., & Riethmuller, D. (2012). [Umbilical cord prolapse: a case study over 23 years]. J Gynecol Obstet Biol Reprod (Paris), 41(6), 574-583. doi: 10.1016/j.jgyn.2012.06.001

Huang, J. P., Chen, C. P., Chen, C. P., Wang, K. G., & Wang, K. L. (2012). Term pregnancy with umbilical cord prolapse. Taiwan J Obstet Gynecol, 51(3), 375-380. doi: 10.1016/j.tjog.2012.07.010

Kouam, L., & Miller, E. C. (1980). [Prolapse of umbilical cord – new aspects]. Zentralbl Gynakol, 102(13), 724-733.

Heads Up! International Breech Conference

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Washington, DC – November 9-12, 2012

Conference report.

Driven by consumers, sponsored by the Society of Obstetricians and Gynecologists of Canada and attended by obstetricians and midwives from 15 different countries, the third International Breech Conference convened in Washington, DC, from November 9-11.

The highlight of the conference was soon-to-be-published data from observational studies in Frankfurt and Sydney, representing nearly 800 planned vaginal births, presented by obstetricians Andrew Bisits, FRANZCOG, and Anke Reitter, FRCOG, along with Frankfurt team researchers, midwife Betty-Anne Daviss and epidemiologist Ken Johnson. Fellow conference presenter Sophie Alexander (MD, PhD, and co-author of the PREMODA study⁾¹ summarised by pointing out, “These results are consistent with all of the large studies done since the Term Breech Trial. Everyone except Hannah has observed a small increase in low Apgars and non-significant birth injuries for vaginally born breech babies, with no difference in mortality rates or long-term morbidity.”²

The current state of breech research was summarised by Prof Marek Glezerman, MD, Chairman of the team which contributed results from Israeli institutions to the Term Breech Trial, and author of the significant 2006 re-evaluation of the same study which concluded that due to serious flaws in the research and the simplications of standardising its recommendations, the results of the study should be withdrawn.³ Glezerman presented research from further studies, which demonstrate, as Dr Alexander pointed out, that where vaginal breech birth is well supported, it can be a safe option.^4,5 Additionally, Glezerman pointed out that we need to be less precious in our initial evaluation of significant morbidity: “A low Apgar at 1 minute means nothing in 2 hours or 2 years; it only serves to make you alert to the baby.” Bisits also participated in the original TBT and shared Glezerman’s and others’ skepticism about whether the trial design was appropriate to measure what it intended to measure.⁶

Significantly, Anke Reitter, Andrew Bisits and Betty-Anne Daviss are experts in the use of upright techniques for breech delivery, along with Reitter’s Frankfurt colleague Professor Frank Louwen. A majority of the births in each location took place in upright positions, with the woman on hands/knees or a birthing stool. In both settings, they have observed an increased need for manoeuvres or forceps and an increase in birth injuries when the mothers have been in lithotomy position, and these obstetricians are now keen to share their data so that other clinicians can learn safer ways to facilitate vaginal breech births.

This stance was well-received by the many midwives in the audience, many of whom have been advocating upright delivery techniques for vaginal breech birth for some time. One of the foremost breech midwives is Jane Evans, SCM, SRN, a UK Independent Midwife, who presented her recently published descriptions of the mechanisms of a normal breech birth,^7,8 the result of decades of close observation. Although one panel featured a lively debate about whether breech presentation should be viewed as an abnormality or an unusual variation of normal, all agreed that a thorough understanding of the parameters of normal specific to breech birth is a prerequisite for a safe service. Knowing the mechanisms allows a practitioner to understand when progress has deviated from normal and intervention is indicated, and when to refrain from potentially harmful manipulations when these are not required.

The varied conference contributions made two points very clear. Firstly, knowledge about breech birth is evolving far beyond what research done over a decade ago can address, with so much more to learn about how to make breech birth as safe as possible. Secondly, moving breech knowledge forward will require genuine multi-disciplinary openness and skill-sharing, exemplified by the humbleness of the expert obstetricians and midwives who acknowledged the many sources of their knowledge.

Following on from three days of intense discussion, a post-conference practical session on November 12 was dedicated to hands-on, practical learning with simulated breech births, guided by several of the experienced obstetric and midwife practitioners. This included two new manoeuvres, the Louwen Manoeuvre for assisting the birth of fetal arms in an upright delivery through rotation (a variation of Lovset’s), and Frank’s Nudge, used to promote flexion and birth of an extended fetal head. Detailed descriptions of these manoeuvres will be published alongside the Frankfurt data early next year, but they are already being taught in several UK hospitals which incorporate upright techniques into annual mandatory breech updates.

Throughout the three-day conference, we also heard from women who spoke very movingly about their experiences of breech pregnancy and attempts to secure support for their choice of a vaginal breech birth. Evident in these stories was the fear and resistance their providers felt, which prevented them from providing appropriate, woman-centred care, and the long-term effects this had on each woman’s wellbeing. A panel discussion dedicated to this topic included Benna Waites, a UK clinical psychologist whose own experience prompted her to gather the available evidence into her very thorough book, Breech Birth,⁹ essential reading for any breech practitioner. As Waites passionately summarised in her own story: “I was angry, not just scientifically disappointed. Providers need to know: your fear and your ignorance cannot be the reason for our lack of choice.”

The conference was designed to tackle this fear and resistance head-on with expert-led discussions of what is required to change the current situation, in which a caesarean section is either the most often only option when a baby presents breech, or is promoted as the best option due to providers’ lack of familiarity with current breech research since or lack of confidence in their own skills to safely deliver a breech baby. Glezerman argued that to reinstate breech skills, we must standardise assessments of competency with theoretical and practical tests, and while this must be combined with hands-on experience, standardisation cannot be based on numbers alone.¹⁰

This is partially because large numbers of breech births are simply not available to today’s trainee obstetricians and midwives. Recent research into the breech experience of obstetricians training in the UK show remarkably little experience, compared to what obstetric trainees would have experienced a few decades ago.¹¹ The need to measure breech competency independent of birth numbers also results from the influence of personal skill sets on the ability of breech attendants, including confidence and motivation to develop expertise, which requires additional on-call commitments.¹² Several speakers, obstetricians and midwives, spoke movingly of how breech birth attendance is an art, like many aspects of our professions, which some are simply more drawn to than others.

This viewpoint is consistent with the secondary analysis of the TBT results, which demonstrated that a clinician’s own evaluation of his/herself as “skilled and experienced,” when confirmed by their Head of Department, was more strongly associated with good outcomes than when the attendant was defined as a registered obstetrician or by number of years of experience.¹³ It also mirrors the Canadian recommendations that on-call specialist teams be established.¹⁴ In a move which reflects growing institutional support for practitioners who are willing to acquire the necessary experience to support breech birth safely, we heard how one hospital in Canada has recently abolished a mandatory transfer-of-care from midwives to obstetricians when women labouring with breech-presenting babies enter the hospital. It seems likely that, while universal training for doctors and midwives in emergency breech delivery remains required on safety grounds, planned breech births will increasingly be managed by breech specialists. In which case, more of us are needed.

Three days of presentations and discussions ended with a panel dedicated to exploring the legal and ethical dimensions of supporting a woman’s choice to birth her breech baby within today’s risk-adverse and minimally experienced services. As well as legal experts, the panel included obstetricians who facilitated planned breech births, as well as those who were prevented from doing so by their hospital’s policies, which made for an interesting discussion around the ethical dilemma resulting from the professional obligation to respect clients’ informed refusal (eg. of a caesarean section) amidst active obstruction from risk management policies. The discussion made clear that in order to provide the woman-centred service that clients want and many providers want to provide, there are many obstacles which need to be overcome, not all of these are apparent or clearly defined, so they remain difficult to tackle.

Although over the course of the conference we heard from a few American obstetricians who were preserving breech skills in isolated pockets (with positive outcomes, similar to their European counterparts), the medicolegal panel was the only portion of the conference attended by a representative of the ACOG (Dr Constance Bohon), despite repeated invitations. This was a great disappointment to the organisers from the Coalition for Breech Birth, who chose the Washington DC location for this international conference particularly to support the American chapters, who are struggling to open up lines of dialogue between consumers wanting more options and providers and their professional organisations. Listening closely to women’s concerns and extending an olive branch, Bohon suggested, “Perhaps it is time to set up a task force.”

While we in the UK are often not as circumscribed by actual legal constraints limiting woman-centred practice, a well-supported vaginal breech birth is still not easy to come by. The conference organisation team included a UK Coalition for Breech Birth user representative, student midwife Ruth Mace-Tessler, and was attended by several UK midwives and an obstetrician, but again no RCOG representative despite repeated invitations. Maybe the time has come for us to set up a similar task force in the UK?

Shawn

References

1. Goffinet F, Carayol M, Foidart J-M, Alexander S, Uzan S, Subtil D & Bréart G (for the PREMODA Study Group) 2006. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology, 194: 1002-1011. 1. Daviss, B. A., Johnson, K. C. & Lalonde, A. B. 2010. Evolving evidence since the term breech trial: Canadian response, European dissent, and potential solutions. J Obstet Gynaecol Can, 32, 217-24.

2. Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., Willan, A. R. & Term Breech Trial Collaborative, G. 2000. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet, 356, 1375-1383.

3. Glezerman M. 2006. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol, 194, 20-5.

4. Toivonen, E., Palomäki, O., Huhtala, H. & Uotila, J. 2012. Selective vaginal breech delivery at term – still an option. Acta Obstetricia Et Gynecologica Scandinavica, 91, 1177-1183.

5. Hauth, J. C. & Cunningham, F. G. 2002. Vaginal breech delivery is still justified. Obstet Gynecol, 99, 1115-6.

6. Kotaska, A. 2004. Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery. BMJ, 329, 1039-42.

7. Evans, J. 2012a. Understanding physiological breech birth. Essentially MIDIRS, 3, 17-21.

8. Evans, J. 2012b. The final piece of the breech birth jigsaw? Essentially MIDIRS, 3, 46-49.

9. Waites B. 2003. Breech Birth, London, Free Association Books.

10. Glezerman M. 2012. Planned Vaginal Breech Delivery: Current Status and the Need to Reconsider. Expert Review of Obstetrics & Gynecology., 7, 159-166.

11. Dhingra, S. & Raffi, F. 2010. Obstetric trainees’ experience in VBD and ECV in the UK. Journal of Obstetrics and Gynaecology, 30, 10-12.

12. Kotaska, A. 2009. Breech birth can be safe, but is it worth the effort? J Obstet Gynaecol Can, 31, 553-554.

13. Su, M., Mcleod, L., Ross, S., Willan, A., Hannah, W. J., Hutton, E., Hewson, S., Hannah, M. E. & Term Breech Trial Collaborative, G. 2003. Factors associated with adverse perinatal outcome in the Term Breech Trial. American Journal of Obstetrics and Gynecology, 189, 740-745.

14. Daviss, B. A., Johnson, K. C. & Lalonde, A. B. 2010. Evolving evidence since the term breech trial: Canadian response, European dissent, and potential solutions. J Obstet Gynaecol Can, 32, 217-24.

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