Category Archives: Conferences

Bottoms Down Under

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

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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.

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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

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:

  • Exif_JPEG_PICTURETry 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

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

Birth Images and conferences: ethics and ownership

Things to think about when sharing photos of births for teaching purposes …

Time to be wise...

I had just finished a conference presentation and feeling somewhat relieved and elated. At the end of the section someone I knew came up and thanked me for the presentation ‘but there is one issue I had’. She proceeded to suggest that one of the pictures I had used of a woman giving birth in a challenging environment abroad that had been taken by a student should not have been used. Had the woman given permission for this?

I thanked her because, of course, she was right. I was, and am, mortified and, of course. I should know better. I consistently warn students and others about the choice of pictures and permissions for them. In fact we had removed one image from our presentation as we had not known the source. And yet, as this had been a student picture, who had given me permission to use in education, I…

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Heads Up! International Breech Conference

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.