This autumn, the OptiBreech Collective will host three webinars to share learning from our on-going research. These webinars are designed for professionals attending planned or unplanned vaginal breech births but are open to all. We will address three common fears and concerns about vaginal breech birth.
Translated caption options will be available.
Three types of cervical head entrapment in vaginal breech births
Thursday, 26 October 2023 from 13:00 to 14:00 GMT
Unpredictable and potentially catastrophic
Which have you encountered? Would you know how to prevent and/or manage if needed?
Human factors when forceps are needed in vaginal breech births
Wednesday, 22 November 2023 from 13:00 to 14:00
When you have been involved in forceps deliveries of the aftercoming head, how has the communication worked? Did everyone know their role? We will share our learning with you about how to optimise communication and attention when there is a tight fit just at the end.
How to resolve complicated arm entrapment in vaginal breech births
Monday, 11 December 2023 from 13:00 to 14:00
When your initial attempt at releasing the arms do not work, what are your options? We will talk you through our strategies and experience.
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 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.
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
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
Breech Birth in Yemen – what I learnt as an MSF Gynaecologist taking physiological breech birth from theory into practice
Dr Sabrina Das
Sabrina is a Consultant Obstetrician & Gynaecologist at Imperial College Healthcare Trust in London. She worked in Yemen as an MSF Gynaecologist from March-July 2021.
In March 2021, I escaped the U.K. to a country where the biggest challenge in healthcare was not COVID-19. I took on a role in Yemen with Doctors Without Borders (MSF), working as an MSF gynaecologist in Taiz governorate. The hospital has been running since 2015, when Taiz City was divided in two by a frontline between the warring parties.
The conflict meant that there was no publicly run maternity hospital in Taiz Houban, as it was not safe for civilians to cross the frontline. Six years into this war (and no end in sight), Taiz Houban Mother and Child Hospital (MCH) is the largest maternity hospital in the region, and the largest MSF project in Yemen. We deliver 400-500 babies per month, and we mainly treat women with risk factors in pregnancy or who develop intrapartum complications. Breech presentation is one such risk factor.
In many high resource countries, breech presentation has become synonymous with Caesarean birth and most mothers opt for this, in spite of no evidence showing any difference in long-term outcome for babies. “Everybody says it is safer to have a Caesarean” is what many women tell me. Thus in London my experience with vaginal breech birth is mostly in the pre-term or second twin scenario. In my time in Yemen, however, I have delivered more vaginal breech babies than I had in my preceding 15-year career.
In Yemen, the word “safer” takes on a completely different meaning and perspective.
The average number of children a woman has is six. Many women get married and start their reproductive journeys in their teenage years, and carry on for the next 20 years. It is not unusual for women to have 12+ pregnancies. The conflict has devastated Yemen’s public healthcare provision, and very few can afford private antenatal care. Even if they could, the war has meant that there is a real shortage of skilled providers even in the private sector. There is no national screening programme. Many women will labour at home. Some labour with a private midwife and practices of private providers are unregulated. It is not uncommon for women to receive oxytocin in the home setting, whilst in labour, to speed things up.
The high fertility rate, lack of easy access to maternity hospitals with facilities for The high fertility rate, lack of easy access to maternity hospitals with facilities for emergency Caesarean, and unregulated practices occurring in the community make the risks of a Caesarean very high. The risks are not so much in the index pregnancy, but in future pregnancies. We have many women with previous Caesarean who attend with ruptured uteri after receiving oxytocin at home, or after labouring for some hours at home. We also have women experiencing the complications of multiple Caesarean births – dense adhesions and surgical issues, but more terrifying is the complication of abnormal placentation from previous Caesarean birth.
We had one woman who we saw in our high-risk clinic with a low lying placenta, and a history of two previous Caesarean births. She also had two previous vaginal births. Only two of her four children were alive. We brought her back to have a planned Caesarean the following day, and on entry, found that the placenta had invaded through the previous uterine scar (a complication called placenta accreta). I delivered the baby and had to perform a hysterectomy. She received six units of blood. She is lucky to be alive. If she had bled at home or gone into labour before finding a hospital to do her Caesarean, she would have died.
We saw another woman who was about 18 years old. She had a 5-month old baby, and got pregnant immediately after her period returned about 2 months prior. She turned out to have an ectopic pregnancy in her Caesarean section scar. It was quite large, about 5cm by 5cm and she bled a lot during the treatment (I evacuated the pregnancy via the cervix). I was seriously afraid she would need a hysterectomy. This is a serious consequence for a young woman in any culture, but my Yemeni colleagues tell me it can be particularly devastating here, where a woman’s status in her husband’s family can be dependent on her potential to have more children. We were lucky this time and she will be back, pregnant, in the not too distant future I expect.
I had to explain the backdrop in Yemen for you to understand that here, Caesarean is not an inconsequential operation. The risks to mothers of complications directly or indirectly related to a Caesarean birth are huge. The relatively small benefit to the baby demonstrated by the Term Breech Trial (2000) do not justify a policy of elective Caesarean breech delivery in this context. Thus, it is common and routine for us to induce women with breech presentation (for all the usual indications), and if a woman presents in labour with a breech baby, we manage them exactly as we would with a head down baby. This includes giving oxytocin to augment labour if needed (especially in first-time mums).
Women here do not have any access to pain relief in labour or continuous monitoring. There isn’t even gas and air!
The lack of regional anaesthetic would make an upright breech vaginal birth an ideal option for women, but the standard practice here is for women to deliver in lithotomy position. Culturally, women in labour tend to lie flat on their beds, usually hooked up to an intravenous drip for some reason. Believe me, every time I do a ward round I sound like a broken record, “Get her up and moving – tell her lying flat is not good for her baby!” And at delivery, I get the women to try going on all fours position. For the breech births, I have had most women (including primiparous women) delivering beautifully on all fours, where nothing more was needed than some verbal encouragement. I was really happy this week, however, when the skills I had learnt from physiological breech training helped with what could otherwise have been a tricky breech birth. .
A mother came in fully dilated, with her second baby in the breech position. Lots of women come to hospital fully dilated and this is not a good thing. The conflict means that women sometimes have to wait until it is safe to travel, or they have trouble accessing transport, or issues like roadblocks and the closure of local services mean they just have really long journeys to get here. Without any idea of what the fetal heart rate has been doing in the preceding hours, without any clue about what medication the woman may have received at home, what has her blood pressure been… I have seen it go wrong far too many times before.
This particular mother was immediately brought to the delivery room, and the midwife explained she had heard a deceleration. We checked the fetal heart and there was definitely a bradycardia going on. I immediately got her onto all fours position and got her to push. The rump advanced to the perineum and I could see the abdomen emerging, and the legs shortly afterwards. I didn’t see the “valley of the cord” as the baby was slightly misaligned so I corrected this with a little rotation. I could hear the mantra “don’t tell the woman to ‘just breathe and wait for the next contraction’”, particularly with the concerns over the fetal heart. So I went ahead and delivered the anterior arm and proceeded confidently with a shoulder press. It worked like magic and the baby was born. Baby started crying after a few minutes on the resuscitaire, and was good as gold by the time we cleaned mum up. The best bit for me was presenting the gorgeous girl to her mother. I told her, “jameel” which means “beautiful”. It is one of the few Arabic words I know. She kissed her hand and touched mine, and without words we shared a moment of connection.
Not all my breech stories are so successful. We had another woman who had four children (all alive) who came in at term with a breech baby in spontaneous labour. She laboured to full dilatation and was pushing for a long time, about two hours. By the time I got involved, she was exhausted and asking for a Caesarean. We persevered for another 30 minutes. She had been in lithotomy, so we got her on the floor. Squatting, kneeling, McRobert’s… we tried all positions possible. The baby’s bum was visible without even parting the labia, but it was not budging. We brought her into theatre and did a Caesarean. On the operating table before starting, I noticed minimal urine in the catheter tubing and what was there was a deep blood-red. Her abdomen was a crescent shape, and looked sunken in on one side. She had the most obstructed labour I had ever seen. The lower segment of her uterus was so distended it looked bruised, almost like a large purple mass. The bladder was extremely oedematous. The baby was not excessively big (3.4kg) but for some reason, the way his bum was fitting in the pelvis, it was malpositioned in some way and there was no way he was coming down. The long second stage in a multiparous women, and all the other outward signs of obstructed labour should have been singing to me.
I saw a similar woman the following day with an intrauterine fetal death at term. We induced her and she was in second stage for about four hours. We were not keen to do a Caesarean for a baby who had already died but in her case it was obstructed. To avoid a ruptured uterus, a Caesarean was the right thing to do for the mum.
So, here’s a summary of what I have learnt about breech birth working alongside my very skilled Yemeni colleagues here in Taiz:
Upright position is fab, as is the lack of regional anaesthetic for a breech birth. That Ferguson’s reflex is a really helpful thing to help the rump deliver. The manoeuvres work a charm once the woman has gotten herself past that point of “no return”. Up to that point, however, you can’t do anything to speed things up apart from verbal encouragement.
If the rump is not delivering, particularly in a multiparous woman, things are not going well and the breech might be malpositioned in some way. Do not start oxytocin in this case (especially if she had been contracting well before). Any sudden cessation of contractions is not a good sign and should prompt an assessment for rupture of the uterus. I would recommend a Caesarean after about two hours of active pushing in second stage for multiparous women.
You can induce or augment a woman with a breech baby just like you can when the baby is cephalic. The same rules apply – look for adequate progress, monitor as you would with a cephalic baby for fetal distress or hyperstimulation, and be wary of augmenting multiparous women who are in spontaneous labour (they are at risk of uterine rupture).
I think that if healthcare professionals follow these simple rules, breech vaginal birth is just as safe as a cephalic vaginal birth in any setting.
Breech Birth Network are pleased to announce the publication of an evaluation of our physiological breech birth training, conducted in eight NHS hospitals across England and Northern Ireland. Click on the image below to read the full evaluation.
Multi-disciplinary training, involving NHS midwives and obstetricians
Only training to have demonstrated an increase, rather than a decrease, in vaginal breech births following delivery of the training package, although this was not statistically significant
Use of upright positions at birth increased significantly
Pilot data: no adverse outcomes among births attended by someone who had completed the training, compared to a background rate of 7%
Pilot data: perineal outcomes similar to cephalic births
Congratulations to midwife Stella Mattiolo, who collected and analysed this data as part of her Masters in Research.
Emma and I frequently receive requests for elective placements from students keen to experience midwifery practice related to breech birth. We wrote this post to provide some guidance into what you can do if you would like to gain more breech exposure.
Elective placements are tricky for a number of reasons:
At the moment, COVID-19.
A lot of administrative paperwork for a short placement.
We need to prioritise students from our local universities.
Direct work with women with a breech-presenting baby is only a small part of what we do.
No guarantee there would be any breech births during this period and/or that permission would be given for you to attend.
You will not be able to gain hands-on experience on an elective placement.
If you would like to spend your elective placement learning more about working with breech presentation, our on-line course is a great place to start. You will gain more exposure to the way breech births work, in a shorter period of time, than most midwives do in their careers. You will gain insight into how women and birthing people can be counselled to ensure informed decision-making. And you will learn how others have implemented change to the way breech works in their local hospitals.
You could structure your own elective placement, including the following:
Working with your local practice development midwives to attend any local training provided to qualified midwives, doctors or medical students, for example mandatory training activities.
Arranging to observe local counselling for breech presentation in your antenatal clinic. This may require you to liaise with the Antenatal Clinic Matron to find out about the local breech care pathway.
Attending presentation scans. You will need to find out where and by whom these are done in your local unit.
Observing external cephalic versions. Where and by whom are these done in your local unit?
Make a video about some aspect of breech management. If we include it in our training, you get lifetime access for free! Think about what women you encounter need more information about. Or what your fellow students need to learn about breech that you have learned through your placement. Practice finding evidence-based answers to the questions posted to these forums.
Writing a commentary article for a midwifery practice journal, such as TPM’s Student Midwife, summarising your self-made elective placement and what you learned.
Finding out the answers to all of these questions and/or completing these activities will give you insight into how the breech care pathway works for the women you care for. In some locations, this care is provided through an organised clinic and the path is clear. In other sites, care is more fragmented, and it may be harder to determine what the pathway is. But this in itself is useful because you will be able to see the work that needs to be done!
Another benefit of crafting your own placement in your local setting is that, when your colleagues know of your interest in breech, you are more likely to be involved in actual breech births. This is called “attracting breeches,” and you can read more about it in this research.
We are very keen to support students but need to be realistic about how we might be able to do that at the moment.
— Shawn and Emma
Image: Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre
We have a number of online and upcoming learning opportunities available for you.
“No more hands off the breech” is published in this month’s The Practising Midwife. In this article, I argue that we need to reconsider the way we use Mary Cronk’s famous phrase, “Hands off the breech!,” along with some other commonly held beliefs that may not be helpful.
I’d love to hear what you think about this and how it relates to your experience.
Consultant Midwife Emma Spillane and I are also speaking at the Northern Maternity and Midwifery Online Festival on Tuesday 23 June. I will be talking about improving the safety of breech birth through research, and Emma will be speaking about implementing a breech birth service.
Finally, our Vimeo channel features a couple new videos created to help student midwives learn about research, through the lens of improving breech safety. I’ve posted them below. The settings enable you to share and embed if you would like.
The first video explains one of the studies published as part of this Trio of Breech Articles, an open-access special issue from the journal Birth: Issues in Perinatal Care.
“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.
We look forward to much debate and discussion! Please share with anyone concerned about safe vaginal breech birth.
Traduit par: Isabelle Brabant et Caroline Daelmans
Dr Anke Reitter and Dr Shawn Walker of the Breech Birth Network will teach together in Barcelona on 23 April at Hospital de la Santa Creu i Sant Pau. Please share with your obstetric and midwifery colleagues. Materials will be translated into Spanish for participants. Click the image below for more information on how to register.
Since the publication of the 2017 RCOG guidelines on the Management of Breech Presentation, mothers have, in theory, been given more choice in their options relating to mode of birth. Unfortunately, anecdotally this does not seem to be the case for all. Many units across the UK do not have dedicated services for mothers found to have a breech presentation at or near term. Therefore, they are potentially missing out on receiving balanced information regarding their choice of mode of birth. Finding out your baby is in a breech presentation at this late stage of pregnancy can be upsetting for some, birth plans have been discussed and made, excitement is building for the new arrival and then suddenly this seems to all be turned upside down. More decisions have to be made, that’s if the choices are offered to parents. Having a dedicated breech clinic, run by those knowledgeable and experienced in breech presentation, can help to allay some of the worries and concerns experienced by parents and ensure all evidence-based options are discussed in a balanced way. The clinic enables a two-way dialect between healthcare practitioner and mother in a supportive environment. In the current financial climate of the NHS it can be difficult to set up new services, however, the mother’s well-being must come first. Additionally, the skill of the practitioner is key to ensuring safety. The RCOG states:
“The presence of a skilled practitioner is essential for safe vaginal breech birth.”
“Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.”
But with the decline in the facilitation of vaginal breech birth over the past two decades how do we ensure as healthcare practitioners that we are skilled to facilitate such births? This post aims to describe one way to increase knowledge, skill and experience in this field and how to set up a breech service within an NHS Trust to ensure mothers really do have all the options open to them for mode of birth with a breech presentation.
The first step to gaining knowledge and experience is to become involved in teaching. This has many benefits including, increasing your comprehension and embedding that information so you can pass it on to others; enables people to recognise you as breech specialist and it helps to build confidence when discussing with colleagues and parents alike. The more you are teaching the greater your understanding and the more people will recognise you within this role as a breech specialist. It is vital to keep your own skills up to date if you are putting yourself forward as a specialist, teaching both locally and assisting with teaching through the Breech Birth Network, CIC will help you keep up to date with the latest evidence and move things forward within your own constabulary. The team at the Breech Birth Network, CIC are very keen to support others to teach on our Physiological Breech Birth courses. You can read the following blog post for more information on the benefits of teaching Physiological Breech Birth with the Breech Birth Network, CIC.
Other ways to get involved with teaching are within the University and to the students coming through the local hospitals, these are the midwives of the future and this is where the biggest change is going to come from. Likewise, speak with the lead Consultant Obstetrician for new doctors starting in your Trust to see if you can teach them a shorter session on their induction days. This enables the new doctors coming into the hospital an awareness of what will be expected of them in terms of offering choice and ensures they have an understanding of both the mechanisms of breech birth and recognising complications. Additionally, setting up a weekly morning teaching session for thirty minutes ideally after handover so those finishing the night shift and those starting the day shift can both attend. This can be done as a case discussion or a scenario using a breech birth video. You could even use a breech birth proforma (if you have one) and ask those attending to complete the proforma whilst watching a video to see if they understand about the timings for a physiological breech birth and when to intervene. Speak to the Practice Development team and ask if you can teach the breech sessions on the mandatory training days too – moral of the story…teach, teach, teach!!
Of course, with all this knowledge and skills you are teaching you need to put it into practice. Put yourself forward at every opportunity to attend breech births both to facilitate them yourself and to support others to gain confidence in facilitating vaginal breech births. Clinical experience is essential. Research has shown, to maintain skills and competence the breech specialist should attend between three to ten breech births every year (Walker, 2017; Walker et al, 2017; Walker et al, 2018). In some smaller units this may be difficult to achieve but by making yourself available to attend births you will have a far better chance at getting these numbers in practice. There is also evidence which suggests that you can create the same complex pattern recognition by watching videos of vaginal breech births, both normal and complicated, as you can by attending breech births in real-life (Walker et al, 2016). Watching videos has the added benefit that you can rewind and re-watch parts of the video to ensure understanding and further analysis.
Setting up a breech birth service would be an excellent next step. Firstly, find a Consultant Obstetrician who is supportive of physiological breech birth and who would help to lead on service development with you. This has to be a multi-disciplinary approach other wise it just won’t be sustainable or safe. The best way to move such services forward is with consultant support and input, don’t try and do it on your own. A breech birth clinic is a good starting point for any service development, this will provide midwife-led and consistent counselling for parents attending the clinic. Depending on the size of the hospital, running the clinic once a week should be adequate initially. Setting up a dedicated email address for all referrals to be sent to is a great way to ensure referrals are not missed and there is a clear pathway set out. The following is an example of such a pathway:
Referrals can be made by any healthcare practitioner, but it is a good idea to link in with the sonographers performing the ultrasound scans. They may be able to send the details of the mother via email immediately following the scan and give the parents an information leaflet. This avoids any delay with the referral being made by another healthcare practitioner and ensures the counselling remains consistent. Moreover, the development of ‘breech teams’ is supported in the literature to ensure there are breech specialist midwives and doctors on every shift, or on-call, to support the wider team to gain their clinical skills to facilitate vaginal breech births and increase safety for mother and baby.
To further develop the service and your own skills you could complete a midwife scanning course. This will enable you to scan mothers referred into the breech service to check presentation before sending for a detailed scan. The advantages of this is that mothers could be referred into the clinic earlier, from thirty-four weeks gestation based on identification on palpation. Research has shown mothers find it difficult making decisions about mode of birth for breech presentation so late in pregnancy and would benefit from earlier referral and discussion. Referrals made at thirty-four weeks gestation with a bedside midwife scan to assess presentation, would enable the counselling to begin sooner giving more time for decision-making. An additional advantage of being able to scan is following mothers up after successful external cephalic version (ECV). Seeing mothers, a week after successful ECV enables you to scan the mother to ensure the baby has remained in a head-down position avoiding unexpected breech births. An adjunct to the scanning course would be to learn to perform ECV’s. This enables a fully midwife-led service and research has indicated comparable rates of success for ECV’s performed by Midwives and those performed by Obstetricians. It is also cheaper for the Trust to have ECV’s performed by Midwives!
Governance and audit are the final steps to take to building the specialist breech midwife role and for service development. This is often seen as the mundane part of the job, but you will benefit greatly by doing this, not just from immersing yourself in all the research but by knowing your service inside and out. Knowing what needs to be changed and what has improved. The first step in governance change is to write the guidelines incorporating physiological breech birth, new evidence relating to breech presentation, service development, the breech clinic, referral pathways and training. An example of a current guideline can be found via this link. Develop an information leaflet to give to parents which contains the latest evidence in relation to breech birth options. It can be given to the mothers either by midwives in the clinic and/or by the sonographers after their ultrasound confirming breech presentation. The following can be used as an example and is editable for use in your organisation.
Finally, audit, audit, audit! Before, after and everything in between! This is your evidence that things need to change and, once the service is developed, the outcomes since you implemented all the aspects of the service. It will also act as evidence of safety which the governance team within the organisation will want to see. Audit rates of planned caesarean, emergency caesarean, planned VBB, successful VBB, neonatal outcomes, maternal outcomes, uptake of ECV, success rate of ECV etc. All before and after the service. It is also a good idea to obtain service user feedback. Developing a simple questionnaire such as this one enables you to easily send and receive feedback regarding the service. Feedback from service users is the most powerful way of moving services forward and supporting change within an organisation, it also enables you to develop the service dependent on the needs of the parents using it. The process of audit and user feedback is continuous throughout the time running the service. However, it is important analyse and present the result at regular opportunities such as at local level with clinical governance days and meetings and at a wider national level at conferences and in journals.
Whilst it can seem daunting and places you in a seemingly vulnerable position, starting your journey as breech specialist is an extremely rewarding one which will enable you to learn and develop new skills not just clinically but operationally and strategically. It will give you a stepping stone into research, audit and teaching, build your confidence as a practitioner and most of all, empower you to provide the best evidence-based care for those families who need that knowledge and support at a crucial time in their pregnancy to help them to make the right decision on mode of birth for them and their breech baby.
Following the implementation of all that has been discussed in this post, the results within the large teaching hospital I work are as follows:
Planned caesarean section increased from 55.8% (n=43) to 62.9% (n=66);
Unplanned caesarean section decreased from 42.9% (n=33) to 24.8% (n=26);
Vaginal breech birth increased from 1.3% (n=1) to 12.3% (n=13)
All results are for those over thirty-six weeks gestation, there were no differences in neonatal mortality or morbidity prior to or following the implementation of the service. This is a positive change and shows how supporting vaginal breech birth in a safe environment can increase the normal birth rate. The results are after a year of implementing the service and will hopefully continue to improve as time goes on and more midwives and doctors become more confident to facilitate breech births.