Category Archives: Research

A Tale of Two Breech Film Premiers

On the evening of Tuesday, 30th of June, 2015, British breech aficionados were spoilt for choice. There were two important premiers of breech-related films, held in two different cities.

I was privileged to attend the Newcastle premier of doctor Rebecca Say’s Breech, the product of an NIHR-funded research project. Audience members were treated to the film, intended to be an educational tool to help women with decision-making when baby presents breech, followed by a discussion about the film, its potential impact and future plans.

IMG_6592

You can view the animation HERE, and the link can be shared freely with women and health professionals: http://research.ncl.ac.uk/breech-decisions/animation.html

The film is embedded as part of a website containing further information for women, incorporating research from many sources. Say’s research indicated women access information on-line well before meeting with health professionals, and finding balanced, useful and unbiased information was difficult. Maintaining the Breech Decisions website will depend on further funding, but it is a useful, up-to-date tool at the moment. You may also be interested in Say’s qualitative research about women’s experiences of ECV (2013).

IMG_6600On the same evening, a group in London assembled to view the Heads Up film with Dr Stuart Fischbein, visiting from Los Angeles. The film is a passionate plea to #reteachbreech – and you can find out more about this project on this Twitter hashtag, or Dr Stu’s Blog.

Fischbein has also recently published his statistics – “Home Birth” with an Obstetrician: A Series of 135 Out of Hospital Births.

– Shawn

RCOG and Oxford Breech Conferences, October 2014

Screen Shot 2014-10-19 at 17.09.13Well.

It’s been a historic week.

Last Tuesday, 14th October 2014, obstetricians and midwives from around the world converged in the basement of the Royal College of Obstetricians and Midwives (RCOG) in London for a study day on Management of the Term Breech (#RCOGbreech). The day was originally planned to correspond with the publication of the new RCOG guideline, last published in 2006. However, the re-write has been delayed, understandably. Across the country, more and more units are not only raising the level of support for breech, they are supporting women to birth their breech babies in upright positions, something the current guideline recommends women are advised not to do.

The update authors face some tough choices: 1) continue to advise against an increasingly popular practice, alienating many of the few professionals currently supporting breech births; or 2) turn the current state of affairs upside down by … guess we’ll see when it’s published! The RCOG day was opened by the rather marvellous Mr Lawrence Impey, Oxford Consultant in Obstetrics and Fetal Medicine and co-author (with Justus  Hofmeyr) of the 2006 guideline, and Mrs Anita Hedditch, Delivery Suite Senior Midwife and ECV Midwife, also at Oxford. Impey acknowledged the sense of anticipation and slight tension in the room by instructing delegates: “No heckling, and no snorting!

ColleaguesHowever, Professor Deirdre Murphy from Dublin created little controversy with her fair and balanced evaluation of the evidence. Although her analysis was much more nuanced, following discussions, the take-home message was: With experienced support, the short-term risks for breech babies (neonatal mortality, serious morbidity) are probably not significantly greater than those for cephalic babies. Both breech and cephalic babies have increased short-term risks compared to a planned caesarean section (CS). For breech babies, the available evidence indicates that by two years of age, no significant difference in primary adverse outcomes (death and neuromotor delay) is apparent between babies born after planned CS and babies born after planned vaginal breech delivery (PVD). But babies born following planned CS face some increased risk of other medical problems.

Mohajer1Murphy was followed by Mich Mohajer of the Royal Shrewsbury, who presented evidence from her telephone survey about what exactly is happening around the UK for breech. ECV appears to be almost universally offered throughout England and Wales at the moment, although she found significant variations in models of care, with some units offering dedicated breech clinics and other units offering an ad hoc service on delivery suite. She found even more variations in levels of support for vaginal breech birth, with only 27% of units in England and Wales supporting VBD. Mohajer also acknowledged the importance of involving midwives with breech skills, as the facilitation of breech births has always been considered part of midwives’ expertise. These two themes: the importance of a specialist approach through dedicated clinics and ‘breech teams,’ and the value of multi-professional collaboration, were echoed frequently throughout the week.

BiasesAfter a brief break, Dr Leonie Penna from King’s in London presented on ‘pitfalls and pearls’ in delivering the vaginal breech. She summarised a number of common errors and helpful hints, bringing the focus onto the real gap in clinical skills which will need to be closed or bridged in order to reintroduce systematic support for planned breech births. Penna was also very upfront in discussing the reluctance of the obstetric profession to shift away from women on their backs, even with strong evidence of how helpful it is. She drew parallels with fetal blood sampling, which it is now recommended to perform with women in left lateral. With Penna’s talk, it became clear that the discussion is finally shifting away from an assumption of vaginal breech DELIVERY and towards and understanding of vaginal breech BIRTH. Finally, Penna as well emphasised the important role midwives have always played in supporting breech births at King’s.

huggingAfter this, Dr Anke Reitter presented on her experience of being a part of the now-famous breech clinic in Frankfurt, and her MRI data demonstrating how significantly maternal movement affects the dimensions of the bony pelvis. Reitter (@OB_Anke) also discussed how our current understanding of helpful manoeuvres for upright breech birth – especially the first principle of rotation by the shoulder girdle rather than the pelvis – is not new. She showed captivating drawings from historic German and Australian textbooks showing nuchal arms and how to resolve the problem. Thankfully, Reitter will be returning to the UK in June to share her hands-on skills at one of our Breech Birth Network Physiological Breech Study Days.

placentaVisiting speaker Thomas van den Akker, obstetrician and researcher from the Netherlands,  reminded the audience of the RCOG’s responsibility to the developing world. In less resource-rich countries, CS presents a much higher risk to women and their future children than it does in the UK. But the world follows the RCOG’s example and demands the highest standard of care, even when it is inappropriate in that context. Van den Akker also presented data from follow-up studies by the Vlemmix team which demonstrate that per 10,000 babies delivered by CS for breech (compared to planned VBD), there were 26 neonates saved in the first pregnancy (19/7442). However, there were 27 neonates (18/6689) lost in subsequent pregnancies in a policy of trial of labour. Can we continue to recommend that first time mothers avoid a vaginal breech birth, while encouraging them to plan a vaginal breech birth after caesarean section (VBAC) in their next pregnancies?

Jane EvansOver lunch, Jane Evans gave a presentation of the mechanisms of breech labour, and strategies to help when help is needed. She brought along her slide show and doll and pelvis, for those who wanted to make the most of every minute available to learn breech skills.

Deirdre Murphy, Anke Reitter, Mich Mohajer, Thomas van den Akker, Leonie Penna

Deirdre Murphy, Anke Reitter, Mich Mohajer, Thomas van den Akker, Leonie Penna

After lunch, the morning speakers engaged in a panel discussion about how the term breech should be managed. The relaxed mood and support for the option of vaginal breech birth was clearly emotive for some. One obstetric delegate stood up and shared how he had become a pariah among his colleagues for continuing to facilitate vaginal breech birth (VBB), and how he hoped the new guideline would be more clear about how important and appropriate it is to support VBB.

This was followed by talks by Impey and Hedditch about the evidence base, practice and their clinical experience of external cephalic version (ECV). Like many other professionals, I have made a pilgrimage to Oxford to visit their renowned clinic and learn from them and their community midwife colleague, Pauline Ellaway. They presented their most recent statistics, which like others’ (see Grootscholten et al, 2008) show a higher rate of interventions and adverse outcomes for post-ECV babies than babies who spontaneously assumed a head-first position (neonatal mortality = 0.9/1000; not significantly different from 1.3/1000, the neonatal mortality for planned VBD in the Netherlands reported in Vlemmix et al). This is a video from a Dutch team which also use a two-person approach.

keenThis then opened up the discussion in the final afternoon panel to a point I had not previously hoped was possible: The genuine suggestion that perhaps dedicated ECV services should become dedicated Breech services, where women’s individual clinical situations are evaluated and those felt to be good candidates are offered a VBB, while those who are not felt to be good candidates are encouraged to consider ECV. (Selection criteria remain controversial, but this openness is a very good start.) The strong message was that women should have access to a high-quality, experienced ECV service, but this should not be the only alternative to CS.

ECVDr Joris Hemelaar also presented about rates of undiagnosed breech in Oxford, which are over 20% like most places in the UK which do not do routine third trimester scans (which are not recommended by Cochrane. Hemelaar’s point in presenting this information alongside reports on breech/ECV clinics is that we cannot offer women an ECV or detailed counselling about VBB if we do not detect the breech antenatally. However, and my view differs somewhat, as we do not yet have any evidence that the undiagnosed breech is at greater risk in the UK. Most of the available evidence indicates that the undiagnosed breech is far more likely to be born vaginally, at no increased risk. The situation is unlikely to change until more than 27% of UK units support a planned VBB, and until that time, obstetric and midwifery-led units would be wise to put a proactive plan in place so that these births can be managed with a calm, team approach.

Oxford Brookes

Shawn Walker, Ethel Burns, Anita Hedditch, Andrew Bisits, Lawrence Impey, Anke Reitter, Betty-Anne Daviss

As if the RCOG conference was not exciting enough, Senior Midwifery Lecturer Ethel Burns of Oxford Brookes University made the most of international visitors to host a conference on “Breech Birth: Sharing what we know and do, and exploring best practice for the future,” on Saturday, 18th October 2014 (#Oxfordbreech). The day included repeat presentations (for a new audience) from Anke Reitter and Anita Hedditch, and Jane Evans again presented her slides, mechanisms and manoeuvres over lunch; but there were some additions.

Collaborative approachThis day kicked off with Lawrence Impey presenting the evidence base for breech birth, emphasising some of the themes from the previous Tuesday’s conference:

  • In selected women with high quality care baby mortality is probably little different from cephalic presentation, but is higher than ELCS
  • However, there may be a higher risk of obesity, asthma and other serious problems following elective CS
  • Maternal mortality and morbidity is dependent on emergency CS rate but unless this is >50% is likely to be increased with a polity of elective CS. This is particularly important in the developing world.
  • In the long term, there is a small increase in risk of mortality and morbidity to future babies through unexplained stillbirth and uterine scars.
  • Lost skills will mean a higher complication rate for unplanned breech deliveries, be these CS or vaginal

heavy handedImpey was followed by Ruth Sloman, who has recently completed her Masters in Midwifery at Oxford Brookes. Sloman used focus groups to look at midwives’ knowledge and experience of breech births. I really enjoyed this presentation, and some of Ruth’s themes resonated with my own research, especially the value of video footage in helping professionals to learn when hands-on experience is difficult to come by, and midwives frustration at witnessing vaginal breech deliveries poorly managed and the lack of choice available to many women.

nuclearAfter the break, the conference continued with Dr Andrew Bisits, FRANZCOG of Sydney, Australia. Bisits’ sensitivity to women’s experiences has made him beloved of women and midwives across the globe, and his long-term commitment to supporting vaginal breech births has gained him knowledge and experience exceeding most obstetricians working in 2014. Crucial to Bisits’ talk was a recognition of how important the experience of attempting a vaginal breech birth is to some women. He also encouraged us to recognise that moderate risk-taking confers psychological benefits. Although Bisits’ talk included much more than I can summarise here, a final important point concerned the ‘atomic reaction’ which usually follows adverse outcomes in breech births, and knee-jerk responses usually preclude any genuine learning from these events. If we are to improve the safety of breech birth, it is vitally important that we learn from adverse outcomes by reflecting on them in an open and enquiring, rather than punitive way.

enablingReitter and Bisits are of course not only two of the most highly experienced breech practitioners in the world, they are passionate advocates for the use of upright positioning. Reitter’s clients birth mostly in all fours/kneeling positions, and Bisits’ clients commonly use a birthing stool. Their view is that it is not so much the position, as the ability of women to move spontaneously and assume the position of her choice, which matters most. The mood of both days indicated that this point has been well and truly made and heard by those writing the new guideline. The question became not so much whether upright positioning would be acknowledged as a legitimate approach, but whether or not it will continue to be considered in any way ‘alternative’ in the new guideline.

getting itBetty-Anne Daviss visited from Ontario, presenting an encapsulated history of the women’s movement in Canada, and how this has influenced the progress they have made with breech birth. She explained the way in which the Canadian-born Coalition for Breech Birth worked with sympathetic doctors and midwives to reintroduce the choice of VBB. Remarkably, Daviss has succeeded in gaining privileges to attend VBBs in her local hospitals, and currently supports approximately 1-3 women per month to achieve their goal.

anticipatoryI also presented my current research concerning how practitioners learn breech skills. We need to accelerate this process if we are going to increase support for planned vaginal breech birth within the current risk-adverse maternity care culture. I’m looking forward to sharing more of this in publications as the research progresses, so watch this space! My presentation also highlighted the standard of care when it comes to maternal birth position for healthy women. NICE’s evidence-based and woman-centred approach is clear:

  • Women should be discouraged from lying supine or semi-supine in the second stage of labour and should be encouraged to adopt any other position that they find most comfortable. (1.7.7, current Intrapartum Care guideline)

Screen Shot 2014-10-19 at 17.09.59If policy-makers are now acknowledging that VBB carries a similar risk to cephalic birth in experienced hands, then those who continue to advocate a maternal birth position (lithotomy) which deviates from the current standard of care should present evidence as to why they are doing this, rather than the other way around. Experience alone may be enough to explain it for those who have continued to safely facilitate VBDs, but the next generation and those who have taken a 14-year hiatus would do well to learn the new upright techniques as part of their standard training.

Screen Shot 2014-10-19 at 15.30.44If the authors of the new RCOG guideline walk the walk as well as they have talked the talk in the past week, some major changes are a-foot. But policy changes are only a small part of what happens on the ground, evidenced by the fact that the RCOG has recommended  the choice of VBD be offered to women since 2006, something that is clearly not happening universally in the UK. A major cultural shift is required, but these two events suggest that the shifting has indeed begun.

sitting next to youWell done you if you’ve read all the way to end of this post, and join the breech activist club! If you found other aspects of the day important and informative, please do highlight them in the comments below.

Shawn

Resources and a plug

Posterior arm born, anterior arm high, shoulders in A-P diameter - help is required!

Posterior arm born, anterior arm high, shoulders in A-P diameter – help is required!

In July, Gerhard Bogner of Salzburg presented data at a Breech Birth Network study day.  Although the series is small, the data indicate that when the mother is in all fours position to birth a breech baby, approximately 70% of those births will occur completely spontaneously, eg. without the need to perform assisting manoeuvres at all. Use of upright positioning also reduced the rate of maternal perineal damage from 58.5% to 14.6%, which is actually better than cephalic births!

The reduced need for manoeuvres potentially reduces iatrogenic damage to babies associated with interference at the time of birth, such as birth injuries and inhaled meconium. That’s great for that 70%, but what about the other 30%? The babies born with upright positioning in Bogner’s study had a slightly higher rate of low cord blood gases, indicating hypoxia, although no consequences for the infants or differences in 5 minute Apgar scores were observed.

If a woman is birthing her baby in an upright position, how do we assist the birth confidently and safely when delay is identified? How do upright manoeuvres differ from those performed when the woman is supine? To address a growing need for more practical training in upright breech birth, City University are offering Physiological Breech Birth Workshops in London and taster days around the country. The next one is on 2nd of December at the Whittington in Central London. Lots of hands-on training with a small group of doctors and midwives committed to extending breech skills. We also post conferences and workshops provided by others when we can.

Several people have been in touch to ask about the How and When to Help handout. I disabled the link because it is constantly being updated! Please feel free to download this one and use it in your practice area. But keep in mind understanding in this area is constantly expanding, and this is just one midwife’s current approach. I’m working on research to understand others’ approaches as well, but it will be some time until this is finished.

Look out for two articles appearing this month. In The Practising Midwife, I present a summary of current evidence related to ECV (external cephalic version), with some excellent photos provided by Dr Helen Simpson and Midwife Emma Williams of South Tees Foundation Hospital. In Essentially MIDIRS, Mariamni Plested and I talk about issues in providing innovative care for higher risk birth choices.

Finally, shameless plug: Today (30/9/14) is the last day to vote for my, um, remarkable cousin Jake in the NRS National Model Search. Read all about him here, and then click on the link at the bottom of the article to VOTE FOR JAKE!

Favourite quote from the article: “The funny thing is, some bulls are just like big dogs. They come up to you, put their butt in your face and say, ‘Scratch my butt.’ But as soon as they get that flank rope on them, it’s like, ‘Game on. I’ve got something to do now.'”

Awww. Gotta love a bit of passion, of finding your niche and loving it … We love you, Jake! (Just what every 18 year old boy always wanted, a plug on a breech birth information site. We clearly share a common love of butts.)

Update: He won! Go Jake!

Shawn

Bogner, G., Strobl, M., Schausberger, C., Fischer, T., et al. (2014) Breech delivery in the all fours position: a prospective observational comparative study with classic assistance. Journal of perinatal medicine. [Online] Available from: doi:10.1515/jpm-2014-0048

The longer-term effects of CS for breech in Denmark

Screen Shot 2014-08-15 at 06.30.06Something is rotten …

Well, I suppose a backlash was inevitable. Due to the campaigning of women and the willingness of a significant number of health care providers to provide women with a real choice when it comes to breech childbirth, the argument for re-skilling to better support breech births has been gaining momentum. But this week saw the publication of two studies arguing this is not such a good idea.

First it was a Dutch group (Vlemmix et al 2014) who made the argument that at 1.3/1000 compared to nil, vaginal breech birth (VBB) results in ten times the mortality of planned CS. They overlooked the need to match the word ‘planned’ with an intention-to-treat analysis, and their own research (Vlemmix et al 2013) suggesting that neonatal mortality was doubled in pregnancies following an elective CS compared to those where a VBB was planned in the first pregnancy (2.5/1000 vs 1.3/1000). (Read my response here.)

When baby's head has descended into the pelvis, the pubic bones are directly behind the occiput

When baby’s head has descended into the pelvis, the pubic bones are directly behind the occiput

Now a Danish study asks, “Can Caesarean section improve child and maternal health? The case of breech babies” (Jensen and Wust, 2014). Wait, did I read that right? Are we asking whether CS can improve maternal health? Really?

Unlike their Dutch counterparts, Jensen and Wust have decided: “In our estimation sample, we observe only few infant deaths for breech babies. Thus we do not consider this very rare outcome in the proceeding analysis.” One country decides this outcome is a deal breaker, another feels it is so rare that it is not necessary to consider it.

Jensen and Wust present a lot of beautiful graphs and calculations showing that there was a noticeable improvement in Apgar scores and a reduction in visits to the GP, but no significant change in serious morbidity (ill-health) or hospitalisations in the first three years of life, following the sudden increase in elective CS for breech associated with the publication of the Term Breech Trial in 2000.

Although I am in favour of attempting to calculate the longer-term effects of such sweeping changes, I am concerned about what they did and did not choose to speculate upon.

Their most statistically significant finding was an increase in prolonged maternal hospitalisation following an elective CS. This has noticeable financial implications, which they calculated, but they do not address the increase in costs and risks in future births. The financial blind eye is concerning, but their conclusion that CS does not affect the health of the mother, without considering future births, is even more disconcerting.

On the other hand, they speculate that the additional expenditure for elective CS is balanced by costs savings as a result of significant reductions in cerebral palsy and subsequent care needed. They did not have information on actual rates of CP in this population. Instead, they reference a 2001 study by Krebs, which did NOT note a relationship between CP and mode of delivery, and found in 20,000 breech births a total of 4 serious long-term disabilities and 18 minor disabilities possibly related to low Apgar scores. They ignored Krebs previous research (1999) indicating that an increase in CP for breech-presenting babies was NOT associated with mode of delivery. They also ignored a recent systematic review and meta-analysis (O’Callaghan and MacLennan 2013) demonstrating that CS does NOT reduce the risk of CP for breech-presenting babies.

It’s important to get this right. Low Apgars are definitely associated with increased CP and other problems in head-down babies, possibly because the birth itself less often causes minor asphyxia, and therefore the cause is often an underlying fragility. In Krebs’ work, he found the association was mostly with small for gestational age infants; this corresponds with other breech research which consistently associates smaller babies with poorer outcomes. But because many breech babies have lower Apgars as a consequence of the way they are born, Apgars are not such a clear indicator of future risk in this population. They were not in the Term Breech Trial (Whyte et al 2004), and that is the best evidence we have to go on at the moment.

The main outcomes shown in this research are an increase in overall Apgar scores and a decrease in visits to the GP in the first year, less significantly in the second year, and not significantly different in the third year of life. They found no increase in significant neonatal morbidity or hospitalisations in the first 3 years of life. Although it was not originally one of their primary outcomes, the GP visits could be significant. It could also be that in the wake of a major change in practice suggesting that breech-born babies are at increased risk, everyone’s a bit nervous in the first couple of years? We need more information regarding these babies’ actual health problems to understand and use this data, because it conflicts with a Finnish study which found the opposite was the case at 7 years (Ulander et al 2004).

So Jensen and Wust have given us more research indicating an increase in short-term morbidity (with mortality being rare and insignificant?) but no difference in significant neonatal morbidity and the need for increased medical care after 2 years. This matches the information from the Term Breech Trial. Despite the authors insistence they have uncovered evidence that CS is best for all breech babies, and that it is ultimately cheaper (based on their non-evidence-based speculation on future costs of CP only), it actually adds to the literature confirming no concrete evidence of a difference in long-term outcomes for breech babies. Just goes to show you how you can take a group of statistics and put just about any spin on it you like, especially if your mathematical ability makes your analysis fairly impenetrable to most people. (Good thing I live with an actuary.)

Screen Shot 2014-08-15 at 06.30.06Turning now to the elephant in the room

Being born vaginally may be more risky for some babies than being born by CS. Most of the evidence seems to indicate that, in the short-term at least, using standard lithotomy delivery practices, this is the case. On the other hand, most of the long-term evidence does not indicate lasting effects.

What concerns me about literature like this, which makes predictions about what would be saved or not, financially or physically, with this approach or that – is that women, as long as they are human, will continue to have their own unique approach, and they should. That is what being human is about. Many will want to deliver their breech babies by CS, and they should have access to that care, even if it means a greater financial burden. And many will want to give birth vaginally, even in awareness that the rare outcome of neonatal mortality is more likely to happen to them, even in the awareness that if something goes wrong, they will need to live with it for the rest of their lives. We will always have death, and handicapped children that require our grief, our love and our devotion. This cannot be eradicated. Women deserve to be able to make this very personal decision without being made to feel criminal.

Instead of continuing to do research which tells us what we already know, we should invest in research exploring modern management strategies which are showing promise in reducing risk to babies born vaginally, so that women who live in countries where there ought to be a choice actually have one, and women who live in countries where CS is either inaccessible or a real danger to their health have the best chance of going home with a healthy baby. We should stop trying to have the last word on how breech babies should be born, let women decide how to balance the complex array of risks and benefits in their own lives and families, and develop our skills at being ‘with woman’ and her breech.

Shawn

Can we eliminate all risk for breech babies?

Closer to my heart, by Leah Sandretsky,  www.etsy.com/shop/heartbeatstudio

Closer to my heart, by Leah Sandretsky, http://www.etsy.com/shop/heartbeatstudio

This week (August 2014), a Dutch research team published the results of a large retrospective cohort study concerning the results of all breech births in the Netherlands. They concluded that an increase in the caesarean section rate following publication of the Term Breech Trial (TBT) has resulted in a significant reduction in perinatal mortality related to breech presentation, and therefore a policy of universal caesarean section for breech would improve outcomes for breech babies even further.

In the year prior to October 2000 (the team does not present data from earlier than 1999; why not?), the perinatal death rate was 1.3/1000 for all breech deliveries (VBB and CS inclusive). Elective sections increased from 24% prior to publication of the TBT to 60% afterwards, and from December 2000-2007, the perinatal mortality rate was 0.7/1000 for all breech deliveries, with an overall VBB rate of 22%. Moreover, the team showed that all of the perinatal deaths occurred during what they called planned breech deliveries (although their understanding of ‘planned breech delivery’ is very different from mine, as I discuss below), so the actual perinatal mortality rate for breech babies born vaginally remained steady at 1.6/1000 during both periods.

A rate of 1.6/1000 is actually quite low compared to the mortality rate of approximately 1/100 reported in the Term Breech Trial. However, the authors propose that the results of this study should replace the information currently given to women in Dutch national guidelines, because according to their calculations, “A policy of elective caesarean section for all term breech deliveries could lower the overall term neonatal mortality in term deliveries by 6.8%, from 172 to 162 per year.”

Unfortunately, it’s not so simple.

Dreaming the impossible dream.

A 'normal' breech baby - well-flexed, with lots of room to move

A ‘normal’ breech baby – well-flexed, with lots of room to move

The first problem with this prediction is that it’s not possible to pursue a policy of elective caesarean section for all term breech deliveries, even if you ‘convinced’ the 40% of women who choose to plan a VBB in the Netherlands to plan a CS. The researchers themselves noted that approximately 1:5 of the perinatal deaths observed occurred when breech presentation was not diagnosed until birth. Without instituting expensive changes to breech screening on a national basis, these outcomes will not necessarily be improved, certainly not without performing many more risky caesarean sections in advanced labour. (When these births were excluded from the analysis, the perinatal mortality rate for VBB’s which were actually planned was 1.3/1000 overall. The Netherlands has a high rate of home birth, so some of these unplanned VBB probably occurred at home with surprised, rather than prepared, midwives.)

Also, the researchers note that they have not performed an intention-to-treat analysis of their data. Multiple studies have noted that approximately 10% of women who plan caesarean sections go into labour unexpectedly before their scheduled operation, and 9.7% of the woman randomised to CS in the TBT gave birth vaginally. The researchers say that those for whom this was the case ‘could not be included in the caesarean section group’ for their study. Why? Were they included in the ‘planned’ vaginal breech birth group? The authors note this category was a ‘composite of vaginal delivery and emergency cesarean.’ Regardless of whether these women actually planned a VBB?

In an intention-to-treat analysis, the outcomes for babies who turn head-down spontaneously would also be included, as the decision to plan a VBB influences whether or not they will. In the Term Breech Trial, twice as many turned when a VBB was planned than when a CS was planned, so that 3.8% of all babies who planned a VBB were born in a cephalic position. Failing to do an intention-to-treat analysis disregards the complexity of breech decision-making and the full range of consequences.

Putting the figures into perspective.

664730The researchers note that 40% of women in the Netherlands choose to plan a vaginal breech birth, in collaboration with their doctors and midwives, and approximately 55% of them achieve this. This results in an overall perinatal mortality rate for breech presenting babies in the Netherlands of 0.7/1000, which happens to be the same perinatal mortality rate for low-risk women giving birth in hospital settings in the Netherlands (de Jong et al 2009; the mortality rate was slightly lower for women who planned a home birth at 0.6/1000). From where I am sitting, this looks like a good example of collaborative decision-making reducing risk while preserving choice.

Earlier this year, another team also led by Vlemmix (2013) published an abstract in the AJOG using further data from the Dutch nationwide perinatal registry from 2000-2007. This demonstrated that in addition to greatly increased maternal morbidity, neonatal mortality in pregnancies which followed an elective CS for breech presentation was 2.5/1000, compared to 1.3/1000 following pregnancies where a VBB was planned (which will be an average of the 2.5/1000 risk following a CS, and substantially lower risk following successful planned VBB’s). How then does this affect the prediction that elective caesarean section for all breech presentations would further significantly reduce the overall national perinatal mortality rate? Only if these women do not have any more children. Seems worth a mention to me, when you are recommending that all breech babies with a neonatal mortality risk of 1.3/1000 be delivered by CS.

Consider statistics given in the RCOG guideline on Birth After Previous Caesarean Birth. They summarise the data relating to term VBACS: “Planned VBAC is associated with a 10/10,000 risk of antepartum stillbirth beyond 39 weeks of gestation and a 4/10,000 risk of delivery related perinatal death (if conducted in a large centre).”

So a woman choosing to await spontaneous labour past 39 weeks and attempt a VBAC has a 1.4/1000 risk of losing her baby, but this is not only perceived as a reasonable decision, it is positively encouraged in most hospitals in the UK. Entire midwifery-led care pathways are set up to support women making this choice, and primiparous women to whom elective section for breech is recommended are proactively counselled that they can feel positively about attempting a VBAC the next time around.

But a woman choosing to birth her breech baby vaginally, knowing that she has a 1.3/1000 chance of losing her baby, is suspect. Does anyone else get the feeling we are robbing Peter to pay Paul?

The researchers identified no sub-classification of women for whom breech birth was more risky, or less risky compared to CS. They did observe that babies with a birth weight of over 3500 g (often excluded from VBB) actually only had a perinatal mortality rate of 0.8/1000. Contrary to what they have concluded, encouraging any woman who plans to have more children and wishes to attempt a VBB (at a relative PMR of 1.3/1000) as opposed to advocating universal elective CS for breech (and exposing subsequent children to double the mortality rate, at 2.5/1000), seems a measured approach.

The team’s representation of morbidity statistics also distorts the picture, as long bone fractures (included in their composite statistic) are common in cephalic births as well. They heal well, and are not generally considered ‘serious morbidity.’ Nonetheless, the morbidity rate of 22/1000 reported in this research was also significantly less than the rate of approximately 1/20 reported in the Term Breech Trial.

Designing research which meets the needs of women and their partners

Descending LST, anterior buttock leading

Descending LST, anterior buttock leading

The researchers have called for the results of their study to replace the information in their national patient information leaflets, which are based on the data from the Term Breech Trial, including the information that outcomes at 2 years of age did not differ between planned VBB and planned CS. One of the authors named in this Vlemmix study has also conducted research into what information matters most to women and their partners (Kok et al 2008).

Kok’s study (2008) demonstrated that women were mostly concerned with the safety of their baby and fear for a handicapped child, and that the 2-year outcome was what mattered most to them. Why then has this team conducted yet another study telling us what we already know – that short-term morbidity and mortality is significantly greater when VBB is planned in most cases – rather than robust research addressing what matters most to the families making these decisions? Whyte’s team (2004) emphasised that the 2-year results surprised them, as the group of children who went on to have handicaps at 2 years of age did not overlap at all with the group of children who experienced severe morbidity in the neonatal period. They were all born apparently healthy, and in the Vlemmix study would have been included in the ‘proof’ that universal CS is a safer policy. Given the numerous studies demonstrating a higher risk of cerebral palsy and other adverse outcomes for breech-presenting babies regardless of mode of delivery (O’Collaghan and MacLennan 2013), the question of whether the babies we save from death in the first 7 days go on to lead full and healthy lives is a fundamental question. And it is the concern which matters most to women.

On the other hand, according to Kok et al (2008) the concern which matters most to women’s partners is the outcomes for women. This study reported only 2 maternal deaths in the 1999-2007 period, despite acknowledging another study already published by the Dutch Maternal Mortality Committee reporting 4 deaths following elective section for term singleton breech in the Netherlands in 2000-2002 alone.

Why are the women disappearing?

If this study does not address the central concerns of women and their partners, why should it take precedence in the information given to aid informed decision-making? If the authors have not performed an intention-to-treat analysis, how can they possibly claim to know that their treatment will have the predicted result? If the study has demonstrated a risk similar to that of planning a VBAC, why are both choices not considered equally reasonable?

These authors are all very much involved with research concerning external cephalic version (ECV) and also feel the results of this research demonstrate the need to use ECV more liberally in order to reduce the incidence of breech presentation at term. While I am a fan of their ECV research and a proponent of ECV as a readily available option for women with breech presenting babies, again we cannot ignore the fact that ECV has not yet been demonstrated to improve neonatal outcomes, possibly for the same reasons the 2 year outcomes for children are not affected. However, ECV does significantly reduce the CS rate for women, particularly in centres where the option of VBB is not well supported. Again, I would like to see this highly experienced and highly influential team turn their attention to answering questions we do not already know the answer to, including whether or not manually turning a breech baby from a breech to a head-down position improves the short- and long-term outcomes for these babies, beyond increasing their chance of being born vaginally.

Shawn

De Jonge, A., van der Goes, B.Y., Ravelli, A.C.J., Amelink-Verburg, M.P., et al. (2009) Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG : an international journal of obstetrics and gynaecology. [Online] 116 (9), 1177–1184. Available from: doi:10.1111/j.1471-0528.2009.02175.x [Accessed: 12 August 2014].

Vlemmix, F., Kazemier, B., Rosman, A., Schaaf, J., et al. (2013) 764: Effect of increased caesarean section rate due to term breech presentation on maternal and fetal outcome in subsequent pregnancies. American Journal of Obstetrics and Gynecology. [Online] 208 (1, Supplement), S321. Available from: doi:http://dx.doi.org/10.1016/j.ajog.2012.10.102.

Vlemmix, F., Bergenhenegouwen, L., Schaaf, J.M., Ensing, S., et al. (2014) Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study. Acta Obstetricia et Gynecologica Scandinavica. [Online] 93 (9), 888–896. Available from: doi:10.1111/aogs.12449 [Accessed: 12 August 2014].

 

Moxibustion: A Smoke Screen?

Screen Shot 2014-06-13 at 01.38.38Professionals: Concerned about women waving giant sticks of burning wacky weed around their wee toes in a desperate attempt to turn their breech babies?! Take action NOW! Ensure that these women can access support for a vaginal breech birth with an experienced, trusted professional, and you will no longer have to busy yourself trying to root out such madness!

Screen Shot 2014-06-13 at 06.51.12Last week the results of a trial (Coulon et al 2014) were released which appeared to show moxibustion with acupuncture ineffective in causing more babies to turn head-down. The trial had its good points. A reasonable number of women randomised (328) at the appropriate point in pregnancy (33+4 – 35+4) to use moxibustion for maximum effectiveness. This in itself was impressive, as most centres do not bother about breech presentation until 36 weeks, making recruitment for studies during this time period difficult. The team looked at the percentage of babies who remained breech at 37+2, the point when ECV (a procedure to manually try to turn the baby in the uterus to a head-down position) would be offered, and found that 72% who had the treatment were still breech, compared with 63.4% who had the placebo. They reported this was not statistically different, but superficially it looks like the treatment had the opposite of the desired effect.

Screen Shot 2014-06-13 at 01.38.58On the other hand, they appear to have used actual needles, heated with moxibustion, rather than the method most commonly used in UK-based moxibustion practices, which involves using the heated sticks only. Also, the intervention and placebo were applied for only six sessions. Generally, women using moxibustion in the UK are usually taught to home-administer (usually with the help of her partner) and then instructed to follow a ten-day course, applying moxibustion twice a day, and continuing whether the baby turns or not. The ten-day, moxibustion-only practice follows a less treat-to-cure, and more treat-to-nourish philosophy, the idea being that the moxibustion nourishes the energy of the womb and promotes optimal positioning. (No swearing until I’ve finished the article, please!)

Screen Shot 2014-06-13 at 01.39.14I’m a fan of observing responses to research on Twitter. (See this previous discussion on hypnosis for childbirth.) And Twitter did not disappoint. The Green Journal announced the Coulon study, and obstetricians celebrated their vindication for having dismissed the practice years ago. There’s nothing like the joy of scientific confirmation of one’s deeply held beliefs. It was as if somebody walked into a room full of midwives and said, “Hey, guess what? Continuity of carer improves outcomes for everybody!” (By the way, it does.)

Screen Shot 2014-06-13 at 02.12.23But then a woman who had actually experienced a breech pregnancy pointed out the obvious: What are the alternatives? Generally, women are highly motivated to give birth vaginally (Raynes-Greenow et al 2004Guittier et al 2011). They instinctively feel what the research tells us – that  a normal birth, wherever possible, is beneficial for both babies and women. There are many hospitals throughout the Western world, including some in the UK, where women cannot even access an ECV, let alone a vaginal breech birth. I’ve had phone conversations where I’ve asked to speak with the person who performs ECVs and been told, “We don’t do that here for liability reasons.” Folks, it’s 2014.

Screen Shot 2014-06-13 at 01.38.22With evidence-based counselling based on the outcomes of the Term Breech Trial, Kok et al 2008 found at least 35% of women preferred to plan a vaginal breech birth. Evidence-based counselling includes the lack of evidence of any difference between two-year outcomes whether an elective caesarean section or a vaginal breech birth is planned (Whyte et al 2004). We can reasonably conclude that if approximately 1/3 of women are not planning a vaginal breech birth in a given setting, then they are probably being directively counselled towards a caesarean section. This would include feeling forced to choose a caesarean section because no plan will be put in place to ensure attendance at a vaginal breech birth by an experienced and supportive professional.

Screen Shot 2014-06-13 at 01.41.57Women resort to practices such as moxibustion and handstands in the swimming pool because they are constantly given the message that breech presentation is ‘wrong’ and should be corrected, with very few alternatives. Whereas the evidence indicates that turning babies, even with ECV, does not improve outcomes for those babies, though it certainly improves the chances of a vaginal birth in settings with minimal support for vaginal breech birth (Hofmeyr and Kulier, 2012 – Cochrane Review). I am increasingly uncomfortable with the current situation, where women do things they do not actually want to do because they cannot access a vaginal breech birth at all, or will not be supported to choose that option until they have done everything else (especially ECV).

Screen Shot 2014-06-13 at 01.40.36Personally, I have no strong opinion on the use of moxibustion itself, as I generally prefer to leave the use of complementary therapies up to what works for individual women, as long as they do not pose a threat to her or her baby. I have taken training to be able to offer women advice, and I have supported women through the use of moxibustion. (We usually spend the ‘treatment’ time talking through the issues around breech birth.) When I speak publicly about breech management, someone usually asks me why I have not included moxibustion. And I tend to dodge the question, not so much because I am convinced of its efficacy or not, but because I believe it is professionals’ attitudes towards breech presentation and not the breech itself that needs to be ‘corrected.’

Screen Shot 2014-06-13 at 06.19.23Let me propose this radical solution: Why don’t we channel some of that indignation over moxibustion practices into ensuring that breech services improve to a point where women will not need to look elsewhere? Let’s ensure every woman has access to a well-supported vaginal breech birth, an ECV attempted by a highly experienced practitioner, and/or a woman-centred caesarean section as late in her pregnancy as she wishes to plan it, including in early labour. Let’s ensure that women have sympathetic, experienced counselling and continuity from a midwife while they navigate these choices, and the attendance of a highly experienced consultant, ready to step up and be that expert in complications of childbirth, backing up the team at birth.

No Re-tweet, sadly ;-)

No Re-tweet, sadly 😉

While we must always make room for those who choose a different path, I suspect that if we got a bit more comfortable with breech in general, the debate over whether moxibustion has a place in the mainstream or not would fade into the distance. Stop blaming pregnant women for their misled attempts to avoid a caesarean section, and the sympathetic midwives who are desperate to help them, and sort out primary breech services.

Shawn

 

 

 

 

 

Choice 1 Choice 2 Choice 3

 

 

 

[Note: I can only access the abstract to Coulon et al at the moment, as it has been posted ahead-of-print. I’ll update the post when it’s published, if there’s anything more to say.]

 

Emerging evidence for upright breech birth

When I talk about ‘upright breech birth,’ I mean a birth where the woman is encouraged to be upright and active throughout her labour and able to assume the position of her choice for the birth. This is in contrast to the classic lithotomy position, in which the woman is flat on her back, usually with legs in stirrups. Upright includes all fours, kneeling, standing, sitting on a birth stool, lying on her side if her body (and not her attendant) tells her to, etc. Birth position is not a static concept. The defining feature of upright breech birth is the woman’s ability to follow her birthing instincts, to move spontaneously in order to assist the birth. However, many providers have developed preferences, having observed women birth successfully in a variety of positions.

Many advantages have been claimed for upright positioning. But if supporting this ideal is to become a reality, we need two things. Firstly, we need evidence regarding the outcomes for breech births managed in non-lithotomy positions. And we need skills in managing complications which occur when women are in non-lithotomy positions.

A step forward for the evidence occurred this week with the publication of research covering 11 years of experience at a large metropolitan teaching hospital in Australia (Foster et al 2014). This retrospective study, which used an intention-to-treat analysis, found much lower rates of complications than the Term Breech Trial, in line with those achieved by the PREMODA group, concluding that in experienced centres, vaginal breech birth is a reasonable option. For me, the take home message coming from the increasing number of studies which show the same comparatively better results is less about the inherent safety of breech birth, and more about how fundamental the local experience level and organised team approach is to achieving optimal safety levels.

Although the article does not discuss birthing position, the correspondence author, Dr Andrew Bisits, is well known for supporting upright breech births using a birthing stool, and in many of the births in this series, the women would have remained upright and active (see also Kathleen Fahy’s description of spontaneous breech birth). Some evidence indicates that use of a birthing stool may shorten duration of labour (Swedish birth seat trial), and this would certainly be an advantage for a breech birth.

Another advantage to using a birthing stool is that health professionals who are comfortable with lithotomy manoeuvres do not have to make any major adjustments to their practice, aside from a willingness to get closer to the floor. The baby emerges facing the same way, the same signs of descent are observed, very similar manoeuvres are used to resolve a delay in progress. An obstetric bed can also be adjusted to mimic a birthing stool, but women have more ability to stand up and move spontaneously when their feet are planted on the ground.

Active Birth Labour Support Stool

Active Birth Labour Support Stool

A number of birthing stools are available in the UK. Active Birth Pools supply a model which is very similar to the Birthrite seat. A birthing stool is a good investment for a Trust. As one of my former obstetric colleagues put it, “If they are good for breech, they are probably pretty good for cephalic babies as well!” Indeed.

Midwives have long supported women to birth in upright positions (for example, Maggie Banks, Jane Evans and Mary Cronk are well-known midwifery authors about breech), but as the RCOG guidelines (2006) recommend lithotomy, supporting this in hospital settings has been difficult. However, around the world, obstetric departments are increasingly discovering the benefits of enabling women to be upright, especially in all fours, kneeling and standing positions. These include teams in Frankfurt (some statistics, some background), Salzburg, Ecuador (Parto podalico), Brazil (parto natural hospitalar pélvicoParto Pélvico Existe Sim!, and of course various parts of the UK.

Facilitating this type of breech birth requires a change in perspective and an understanding of new manoeuvres to assist in the event of complications or delay. The sooner these alternatives are incorporated into national skills/drills training, the more women with breech babies will be able to follow their instincts to assist with securing the safest possible delivery for their babies.

Shawn