Category Archives: Risk Management

Avoiding ‘us versus them’ when breech births go wrong

This week, BBC News Northern Ireland reported on a coroner’s inquest concerning a breech birth:

“Baby death inquest hears breech delivery method very unusual practice.”
11 April 2024, Kelly Bonner, BBC News N I

In this blog, I reflect on how this inquest has been reported. I do so with the understanding that not everything that is reported is 100% accurate. But once it is in print, we must deal with it.

I acknowledge the significant grief and devastation the parents of Troy Brady have experienced; they deserve justice and clarity. I also acknowledge the trauma Dr Sharma and colleagues have experienced, as their undoubtedly best intentions fell short of the desired outcome. I will offer some alternative ways we can learn from this tragic event, in the hope that our professions can prevent similar avoidable harm in the future.

Claim: Upright maternal positions are ‘very unusual practice’ for breech births.

The article’s headline caption is that, “The delivery position used by a doctor for a baby boy who was in a breech position was a ‘very unusual practice’, an expert [consultant obstetrician] has told an inquest.” The obstetric consultant expert who made this claim also testified that she has ‘delivered 30 breeched [sic] babies in her career and does not consider herself experienced in breech delivery.’ Another consultant obstetrician, from Scotland, further testified: “Breech delivery on all fours isn’t something we do in Scotland. It’s simply not something we’re experienced in. We would normally deliver the baby in lithotomy position.”

Unusual practice for whom?

These witnesses have made a classic type II error – when one assumes that something does not exist or is uncommon simply because one has not encountered it. One only needs to do a basic literature search to uncover the evidence for how ‘usual’ or ‘unusual’ upright maternal positions are for vaginal breech births.

In fact, almost all (if not all) UK primary researc h concerning how to improve the safety of vaginal breech birth is being done by people who regularly practice upright breech birth. Research about caesarean section is NOT research about how to improve the safety of actual vaginal breech births. Research about identifying breech babies or trying to turn them head-down in pregnancy (external cephalic version) is NOT research about how to improve the safety of actual vaginal breech births.

PubMed Search: ((vaginal breech birth) AND (safety)) AND (UK)

Breech Birth Network’s Physiological Breech Birth training is the only training that has been evaluated in NHS hospitals that has demonstrated a change in knowledge and behaviour following training (2 017 & 202 1). The training includes how to safety assist upright breech births. Upright maternal position is taught as a “tool and not a rule” in a clinician’s vaginal breech birth skillset. Nonetheless, among a sample of clinicians who have experience facilitating vaginal breech births in BOTH supine/lithotomy and upright positions, the outcomes demonstrate a clear preference for upright positions once clinicians have received this training, with good outcomes compared to those who have not.

In 2022, Deputy Director of Midwifery Emma Spillane published her case control study covering eight years of vaginal breech births in a London teaching hospital (2012 – 2020). Neither she nor I worked at this site during the study period. In this sample of 45 births, 43% occurred in upright maternal birthing positions, and 56% were facilitated by midwives.

The OptiBreech feasibility studies and pilot trial are the only prospective observational studies of vaginal breech births to be conducted in the UK since the Term Breech Trial was published in 2000. Over 70% of OptiBreech births occurred in upright positions, when the births were attended by clinicians who had appropriate training to support women to birth in the birthing position of their choice. In qualitative studies with women, they also reported more balanced counsellin g, detailing the risks and benefits of all options, from breech specialist midwives working in OptiBreech clinics. (This was another concern in the Brady case.)

Who is ‘we’? And who decides what ‘we do’ in Scotland?

While no research has reported maternal birth positions for vaginal breech births in Scotland, it is categorically wrong to say that it is ‘not done’ in Scotland, let alone in Northern Ireland. The OptiBreech team recently published a birth stor y from a woman very keen to share her experience, specifically to raise awareness of the need to ensure more maternity care providers in Scotland have training in upright breech birth.

Within the past two years, Breech Birth Network has been commissioned to deliver the Physiological Breech Birth Study Da y in Kilmarnock, Glasgow and Dumfries. Within our training, we use videos provided by women who have given birth in upright positions in Scotland. Every time we do teach, we ask attendants about their prior experience. Upright breech birth experience is invariably reported in Scotland, as it is at all English, Welsh and Northern Irish hospitals where we teach. Multiple members of our teaching team are based in Scotland, where they practice – you guessed it! – upright breech birth.

From our training in Kilmarnock:

What was the most useful part of this training?
Excellent explanation of mechanisms of breech birth and the manoeuvres to assist if needed.
All content was excellent, including new videos not available on online course. But most useful part was tapping into [the instructor's] first hand experience, both of clinical VBB and of establishing breech service with shared expertise.
What is one thing you intend to change about your practice based on this training?
Knowing that breech babies need to be born quickly and not waiting hands off the breech if there isn't clear descent.
How would you like to see this training influence practice in your organisation?
We are already using some of content/resources in modified way to introduce physiological breech birth. I hope we can have formal in house study days and support to adopt the algorithm in our guideline in coming years.
Feedback from Breech Birth Network Physiological Breech Birth Study Day in Kilmarnock, 2023

It is true than many providers in Scotland, such as those that supported Sandy MacMillan’s birth, do not have formal training in upright breech birth. Despite clear demand from women for this option, upright breech-experienced clinicians who wish to introduce the fully-evaluated, evidence-based training available face resistance from decision-makers who keep repeating: “Breech delivery on all fours isn’t something we do in Scotland. It’s simply not something we’re experienced in. We would normally deliver the baby in lithotomy position.” And it becomes a self-fulfilling prophecy …

Upright breech-experienced providers who have been safely attending vaginal breech births over the past seven years have been writing to me over the past few days to ask for help in addressing the extraordinary resistance they are experiencing due to this sensationalised media, based on a statement made by a self-described non-breech-experienced obstetrician, about a birth that occurred in 2016. Let’s take a deep breath before a fear-driven reaction distracts from the very real issues raised in this case.

What does ‘slow and delayed’ mean?

Jane Brady told the inquest during her evidence that Troy was delivered up to his neck in the all-fours position and was “hanging there, just hanging there”.

Her husband John Brady described the labour as “shocking”.

“I was waiting for someone to step in and save the day. It seemed as if no-one knew what they were doing,” he said.
quoted in 11 April 2024, BBC News NI

The harrowing events described by Troy Brady’s parents are the most consequential issue in this case. We (Breech Birth Network and the OptiBreech Collaborative) have been raising awareness of the dangers of delay in vaginal breech birth s to the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives for a few years now.

*Impey L, Murphy D, Griffiths M, Penna L, on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation (Green-Top Guideline 20b). 2017*

It is important to remember that this birth occurred in 2016. While many providers of vaginal breech education had been teaching upright breech methods by that point, the majority of teaching focused heavily on a ‘Hands Off the Breech’ approach. In the early 2000’s, upright maternal positioning was taught almost as a panacea. Based on the belief that it was safer to avoid touching the baby, proponents advocating putting the woman in an all fours position so that gravity could help the baby be born without the need for hands-on manoeuvres. As result, many people tried this, and discovered that in fact, hands-on manoeuvres are often needed.

The RCOG first introduced guidance on timings in the 2017 update of their guidance, based on professional opinion. Prior to this, the approach emphasised ‘Hands Off the Breech,’ but with no guidance on indications to intervene, how to intervene in upright births, or optimal time intervals.

Our mutual observation that reluctance to intervene was resulting in avoidable adverse outcomes prompted Dr Anke Reitter and I to undertake our first video study. This attempted to accurately describe, for the first time, the ‘normal’ parameters for vaginal breech births, based on evidence rather than professional opinion. During the process of conducting this study, I systematised the approach we were then teaching into the first Physiological Breech Birth Algorithm, focusing on our recommendation that the birth should be complete within 7 minutes of rumping (both buttocks and anus visible on the perineum), 5 minutes of the birth of the fetal pelvis, and/or 3 minutes of the birth of the umbilicus.

“In my reading of the case, delivery was slow and delayed,” she said.

“Manoeuvres were not deployed by Dr Sharma and that made me feel that he didn’t have an awful lot of experience in this type of birth.

“When things went wrong it was obvious that Dr Sharma hadn’t been trained on how to manoeuvre the baby and there was a delay.”
Dr Alyson Hunter, quoted in 11 April 2024, BBC News N I

We first taught using the Physiological Breech Birth Algorithm at a study day in Belfast, Northern Ireland, in October 2017. This was the first study day in the world to introduce this algorithmic approach. Yes, we also introduced upright birthing positions and what manoeuvres are effective when using these positions. But after 14 years of doing research in this area, my strong opinion is this: While upright birthing positions are often preferred by the women and clinicians who use them, the biggest impact on the safety of vaginal breech birth comes from improvements to our understanding of what constitutes ‘normal’ progress, especially the normal time frames of emergence.

This sensationalised journalism will potentially result in a backlash against all those who have been using and teaching physiological breech birth methods. The most tragic outcome if this occurs is that women like Sandy MacMilla n will continue to request support for upright breech births, and well-intentioned clinicians like Dr Sharma will continue to support their reasonable request, but without access to high-quality training about how and when to intervene in these types of births. As a result, we will continue to have inquests that include testimony like that above. The solution to an adverse outcome based on lack of appropriate training in a widely used practice is NOT to restrict training and practice.

What about the placenta?

The paediatric pathologist and neonatologist expert in this inquest also described problems with the placenta that likely impacted this birth:

During the inquest hearing, experts told the court that Troy had a “smaller than usual” placenta and that it was not “operating as it should be”.

Dr Caroline Gannon, a paediatric and perinatal pathologist, said it is known that “placenta infection and placenta deficiency can cause brain damage”.

Consultant neonatologist Dr David Sweet told the inquest Troy’s reduced reserves meant he was “less able to deal with vaginal delivery”.

However, he said there was “no clue” there was a risk to Troy.

“No one could have known he had a deficient placenta,” he added.

“Having half a placenta is like having one lung instead of two – he’s going to get into difficulty quicker,” he said.
Baby death inquest hears breech delivery method very unusual practice, BBC News NI, 11 April 2024

I am absolutely in agreement with the neonatologist. Some breech babies are breech because there is an underlying problem, and unfortunately, we cannot always identify when this is the case. But it is MUCH more likely when a baby is premature, born at 33 weeks rather than about 40 weeks. In OptiBreech physiological breech birth practice, we teach that, exactly as the neonatologists describes, smaller babies are more likely to get into difficulty quicker. And therefore, attendants must be even more swift to assist the birth.

Again, the issue is not with the maternal position – all of us who practice upright breech birth regularly have attended multiple successful upright preterm breech births.

What is expertise, and who is an expert?

The obstetric consultant expert who made the headline claim also testified that she has ‘delivered 30 breeched [sic] babies in her career and does not consider herself experienced in breech delivery.’

My own credentials / expertise to comment are:

*Search conducted Sunday, 14 April 2024. To make it easy, I’ve circled the links to my work. The other two links are work by close colleagues.*

I am one of the most experienced vaginal breech birth attendants in the UK. I have attended well over 50 vaginal breech births (I stopped counting). I have also contributed to the safe care of at least double that number, because for many, an in-labour caesarean birth is the safest option when a deviation from normal occurs. Knowing how to identify this is part of the skill of an experienced vaginal breech birth attendant.
My experience includes management of complicated breech births (eg. needing to use hands-on manoeuvres to deliver the baby) where the woman is in an upright position, as well as those where the woman is in a supine position. To me personally, neither is ‘very unusual practice.’
I am the only clinician in the country who has led multi-centre studies of planned vaginal breech births. My OptiBreec h work included 13 NHS sites in England and Wales, 199 planned vaginal breech births, and 96 actual vaginal breech births.
I teach vaginal breech birth skills personally to over 1000 experienced maternity care providers each year, through a training course developed out of research and thoroughly evaluated. I lead a team of similarly experienced clinicians who help teach this course, and it is constantly developing based on our frequent reflections and the research.
I lead an international community of practice. My visibility in this arena means that I frequently debrief clinicians and women who have experienced poor outcomes with vaginal breech births. While this is one of the saddest and most difficult aspects of my role as a public expert, it also enables me to identify patterns across a wide range of practice cultures. This in turn helps me to focus my research on the areas most likely to impact safety if we improve them.
My PhD was titled, “Competence and Expertise in Physiological Breech Birt h,” giving me some confidence in my ability to identify this.
Finally, I continue to research the ‘problem’ of how to make vaginal breech birt h as safe as possible from a variety of perspectives, using multiple scientific methods. If you search ‘vaginal breech birth’ on any research database, you will find my work among the top 10 primary research publications. If you search ‘upright breech birth’ on ANY search engine, it would be impossible to miss my work in this area.

But I am a midwife. I am rarely called upon to provide formal ‘expert witness’ nationally or even locally, in risk management activities. This is likely due to what Diehl and Dzubinski describe as ‘Role Incredulity.’ People expect consultant obstetricians to be experts in vaginal breech birth, even when they are giving testimony that they are not. Whereas, due to the rarity with which midwives are perceived as clinical experts in complex births, a midwife who is an actual expert in vaginal breech birth will frequently face doubts about her capacity. This is my daily lived experience.

ROLE INCREDULITY

In a male-privileged culture, people may assume women are not in charge. Outsiders may mistake women in a stereotypically make role – leader, engineer, tech support, lawyer, physician – for a stereotypically female role, such as administrative support, court reporter, nurse, or wife. This mistaken assumption is called role incredulity, and even when others learn the woman’s actual role, the effects may linger in doubts about her capacity. (p 18)

What should we focus on?

In my expert opinion, focusing on the following information is most likely to impact the safety of future vaginal breech births, regardless of the maternal birthing position:

“In my reading of the case, delivery was slow and delayed,” she said.

“Manoeuvres were not deployed by Dr Sharma and that made me feel that he didn’t have an awful lot of experience in this type of birth.

“When things went wrong it was obvious that Dr Sharma hadn’t been trained on how to manoeuvre the baby and there was a delay.”
Dr Alyson Hunter, quoted in 11 April 2024, BBC News N I

Continuing to focus on the upright birthing position, with antagonism directed against those who support women’s choice to use this position, is a distraction from the real safety issue. That is, the continuing dogmatic, non-evidence-based belief that ‘hands off the breech’ until at least 5 minutes have passed from the birth of the pelvis (RCOG, 2017) will result in a ‘safer’ delivery. This is simply false, ignored by most experts, and dangerous when novices blindly follow it. But it continues to be taught, along with the promotion of lithotomy birthing positions, usually with much confidence and shroud-waving by people who have actually attended very few, if any, vaginal breech births.

Secondary analysis SPSS means table, 14 April 2024, of Spillane’s Optimal Time Intervals for Vaginal Breech Births dataset.

The table above was created from our archived dataset of Spillane’s Optimal Time Intervals for Vaginal Breech Births study. It demonstrates that in control cases (good outcomes), assistance is provided in all cases well before the 3 minutes from the umbilicus recommended in current RCOG guidance. There is less difference, and less ability to modify this difference, in the length of time taken to perform manoeuvres. Swifter intervention is a modifiable behavioural factor.

This is directly relevant to John Brady’s description of his baby being born up to the neck and then “hanging there, just hanging there.” Even an untrained parent can see that there is something very, very wrong with this approach. Please, listen to him!

For a cross-cultural comparison, the Danish national guideline has now eliminated the instruction to ‘let the baby hang’ after the birth of the arms, regardless of the position the mother is in. This is not helpful, as it does not result in head flexion. Only manual assistance can help flex the aftercoming head, and delaying this is potentially harmful.

While there is evidence to suggest swifter intervention results in better outcomes, especially when attendants are novices and less likely to perform manoeuvres confidently, this teaching continues to be attacked, disbelieved and dismissed in favour of ‘us versus them’-style debates about maternal birthing position. This is a hardship for those of us who are continually striving to improve the safety of vaginal breech birth and respect women’s right to give birth as they choose.

Meanwhile, babies are needlessly dying.

— Shawn

Secondary analysis SPSS means table, 14 April 2024, of Spillane’s Optimal Time Intervals for Vaginal Breech Births dataset. Compared to the differences between controls and cases (good and adverse outcomes), less obvious differences exist in time-to-intervention intervals between supine and upright births.

Webinar 30 August 5PM: Testicular complications of vaginal breech birth

Why use more retrospective data and modelling to support universal third trimester scanning when prospective data suggests the implementation of specialist vaginal breech birth teams is equally likely to impact outcomes? — The OptiBreech Project

OptiBreech position on home breech birth

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Dr Shawn Walker, Consultant Midwife and Chief Investigator, explains the OptiBreech position on planned vaginal breech birth at home.
OptiBreech position on home breech birth — The OptiBreech Project

Induction of labour and … everyone

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This week, I ventured into a Twitter discussion around routine induction of labour for everyone at 39 weeks, initiated by obstetrician Ed Prosser-Snelling with this tweet, if you want to check out the thread:

Somebody remind me about the argument against routine induction of labour at 39 weeks?

National Maternity Ambition.

Patient Safety.

@SagefemmeSB @ThatMidwife @MCR_SB_Research @OBSevidence https://t.co/7vCL5clpP2 pic.twitter.com/bDxPyByauZ

— Ed Prosser-Snelling🏴󠁧󠁢󠁷󠁬󠁳󠁿 (@ProsserSnelling) July 7, 2019

Because this is the place I collect my controversial thoughts, and because this obviously affects the extremely narrow window of possibility for vaginal breech birth, here are my thoughts:

Is induction of labour a reasonable option for breech presentation? Secondary analysis of PREMODA data says it is … https://t.co/DFgAutHBw6

— Dr Shawn Walker (@SisterShawnRM) June 26, 2019

I actually think it’s not a bad idea to enable women who want it to have access to elective IOL from 39 weeks, regardless of their risk level (or indeed fetal presentation). The research is pretty clear that it does not increase CS rates. It appears to reduce perinatal mortality but increase neonatal admissions (Stocks et al 2012). My main, deep and passionate commitment is for women to be in control of their mode of birth and birth experiences as much as possible.

If we induced everyone at 40 weeks (which would also seem reasonable) then you would eradicate late term stillbirth.

I take your point about 37-39 weeks, that might extrapolate into 39+, but even as Alex suggested a shift to 40 weeks would see a fall. 250k additional inductions?

— Ed Prosser-Snelling🏴󠁧󠁢󠁷󠁬󠁳󠁿 (@ProsserSnelling) July 7, 2019

My biggest concern about committing services to making more medical options more easily accessible is that, at the moment, accessing the most evidence-based care for optimal physiological birth is not easy. Providing more medical interventions will divert resources and attention from achieving this. Not every woman has continuity of midwifery care, an intervention backed up by multiple systematic reviews, which also reduces preterm birth, total fetal loss and neonatal death (see Sands statement on Continuity of Carer). Midwifery CoC is a government-backed, national priority (see Better Births) and is requiring major reorganisation of services everywhere. Sometimes, to do things properly, concentrating on one big change at a time does help. It also helps when trying to determine which intervention is responsible for any observed changes.

All that is process and can be managed.

What is the priority? Reducing stillbirth or the inconvenience of reorganising services?

— Ed Prosser-Snelling🏴󠁧󠁢󠁷󠁬󠁳󠁿 (@ProsserSnelling) July 8, 2019

Similarly, women who would like to plan a vaginal breech birth are not provided with care that the evidence base says will give them the best chance of a good outcome — an experienced attendant — effectively making this choice unavailable in most locations. And women who would like to await spontaneous labour past the locally decided date for routine IOL face judgement and resistance — not from all health care professionals, but from many.

And all of the other observational data such as Sarah Stocks paper in the BMJ in 2012? And conversely women now older, higher BMI, less healthy would work effect in the opposite direction.

— Alexander Heazell (@MCR_SB_Research) July 7, 2019

I spend a good deal of my professional life supporting women who are actively seeking help to plan a birth that clearly involves more risk than awaiting spontaneous labour after 39 weeks. I know plenty of women are prepared to accept some element of increased neonatal risk in their holistic assessment of what is right for them, but that they are easily shamed into changing their minds. (If anyone is asking themselves why they don’t meet them, bear in mind most of them will stop talking about what they really want when they pick up on judgmental attitudes about their choices. Then they will seek support elsewhere, or just accept what’s on offer. It is emotionally exhausting for them and for those midwives and obstetricians who try to help them pick up the pieces.)

I’ve many experiences of childbirth, personal and professional. Little else provokes such deep or extreme emotions. It’s sometimes joyous and sometimes deeply tragic. I do “get” it. I don’t presume to speak for colleagues.

— Ed Prosser-Snelling🏴󠁧󠁢󠁷󠁬󠁳󠁿 (@ProsserSnelling) July 8, 2019

Midwives everywhere will also be worrying about the ever-narrowing window of normality during childbirth. What exactly will be a midwife’s sphere of practice in a world of routine induction at 39 weeks? Most guidelines indicate we’re not supposed to perform a cervical sweep on a nullip until after 40 weeks and a multip after 41? Who will give birth in midwife-led units? Home birth? Will it be reasonable to plan anything other than an OU birth? Midwives will also be concerned about hidden costs they can’t quite put into words (or a cost-utility analysis), things like the time spent scheduling and rescheduling IOL, time spent counselling women who are upset about ‘having to be induced,’ time spent scheduling additional appointments with consultant midwives or consultant obstetricians for women who have declined induction, time spent debriefing women who feel traumatised by an IOL process that felt out of control, etc.

Personally, no, but I do think we should have an informed conversation with all women. Many women do not know why IOL offered for prolonged pregnancy, speaking to mums whose babies die after 41 weeks they don't understand why no one told them that SB increase after 40 wks.

— Alexander Heazell (@MCR_SB_Research) July 7, 2019

Expanding the offer of IOL to 39 weeks requires careful, multi-professional collaboration because it has massive implications for women, the service, and the role of the midwife. What women need to have a satisfying induction (Coates et al 2019) is not something that can be provided for all women currently undergoing induction now — how will we provide it for more? The history of obstetrics is replete with well-meaning people implementing plausibly beneficent interventions ASAP, but also many instances in which unanticipated harms are discovered as consequences late in the day. I want world in which birthing families have more options, not less. But I would like to take things slowly, carefully so that we:

Research the effects of implementing this policy thoroughly. Let’s do thorough PPI work to ensure all of the outcomes that all stakeholders are worried about are eventually accounted for. Let’s ensure midwives are part of the team that designs rather than just delivers the research, so they can take an equal part in confidently implementing & disseminating it. Ten years later, let’s look back and be able to confidently say, “Look what we’ve done!” with one tone of voice or another …
Co-design an information and consent process with women who have had positive and negative experiences of IOL. Women would be informed at 37 weeks that the risk of stillbirth increases from 39 weeks with clear, consistent information, including infographics. They would be offered a scheduled induction, and if they decline, neither them nor their midwife (if otherwise low-risk) would be required to justify this decision.
Co-design services which give women maximum control over the timing of their induction. Have some ‘scheduled’ slots for women who prefer that and some for arising medical indications. And tell everyone else that they can put themselves on the waiting list for medical induction whenever they want to after 39 weeks, to be seen on a first-come-first-serve basis. If we have capacity to do this many IOL, we ought to have capacity to offer greater flexibility. One of the things women regret losing with scheduled IOL is the ability to trust their instincts as they are becoming parents. Ensure at each visit women know how to access IOL if they want it, but don’t hound women who choose not to join this queue.
See this as a ‘choice’ issue and not a stillbirth reduction ‘target.’ Targets which require everyone accept the intervention in order to achieve the target outcome will reduce, rather than expand, choice.

Maybe around 160 fewer stillbirths per year. You judge dramatic or not.

Wait, wait, wait to understand the problem – why not act now with interventions we know about?

Of course morbidity matters, nobody ever suggested it doesn’t.

— Ed Prosser-Snelling🏴󠁧󠁢󠁷󠁬󠁳󠁿 (@ProsserSnelling) July 8, 2019

Finally, I feel that midwives need to lead on research that contributes to our knowledge about IOL, rather than seeing it as ‘the realm of the abnormal,’ and thus obstetric territory. If we are offering IOL closer and closer to 39 weeks, this is more ‘normal’ than ‘abnormal,’ especially as we know outcomes for live babies are best after 39 weeks. For example, we have Cochrane Reviews on cervical sweeps and nipple stimulation (see Evidence-Based Birth blogs on membrane sweeps and breast stimulation to stimulate labour).

Yes – a complex policy solution. I agree.

If we are going for that though, I would actually go for poverty.

Which solution has the best chance of implementation. Poverty reduction, improvement of antenatal care or changing the date of routine induction of labour?

— Ed Prosser-Snelling🏴󠁧󠁢󠁷󠁬󠁳󠁿 (@ProsserSnelling) July 7, 2019

Many women would like the ability to request a sweep earlier than 40 weeks, and they certainly will want this if induction at 39 weeks is routine. Might this help, or harm, or are there trade-offs? Might pumping breast milk after 38 weeks improve spontaneous birth and breastfeeding rates? Might these traditional midwifery approaches have potential to help women retain more control over initiation of their labour and consequently their choice of birth setting? Researching and changing midwifery practice related to cervical ripening for women at term who wish this would, in my opinion, be a more manageable and likely more widely acceptable first step than scheduling more hospital-based inductions. It would also dovetail nicely if a policy of offering induction at 39 or 40 weeks does become routine.

Would you really balance those hypothetical risks against a clear option to now take action to prevent further morbidity?

Even in your worst case scenario we are exchanging mortality for morbidity.

— Ed Prosser-Snelling🏴󠁧󠁢󠁷󠁬󠁳󠁿 (@ProsserSnelling) July 7, 2019

Shawn

Consultation: Rapid resolution and redress scheme for severe birth injury

New RCOG guideline published today!

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The new RCOG Management of Breech Presentation guideline has been published today. This guideline substantially revises recommendations in the previous version, published in 2006. If followed, it will undoubtedly improve women’s access to and experience of breech care. Below I will highlight two of the new guideline’s game-changing recommendations, and then raise two key questions concerning areas of on-going exploration.

Reference: Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. BJOG 2017; DOI: 10.1111/1471-0528.14465.

Victoria and Kirin Owal celebrate the healthy birth of their twins (#2 breech) with their NHS Team.

Counselling (Section 4.1)

The guideline offers specific recommendations around counselling, following the summary presented by lead author Mr Lawrence Impey at the RCOG Breech Conference in 2014. When discussing perinatal mortality, rather than focusing on the dichotomy between elective caesarean section at 39 weeks (0.5/1000) and planned breech birth (2.0/1000), the guidelines also recommend women consider these figures in light of those for planned cephalic birth (1.0/1000).

@SisterShawnRM “Women near or in active 2nd stage of labour should not be routinely offered caesarean section [New 2017]” #breech @RCObsGyn

— Oli Silverwood-Cope (@olvindaRM) March 17, 2017

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This is important. If we follow the logic that has dominated breech care for the last 17 years – elective CS for all because it reduces perinatal mortality – we would need to apply this to planned cephalic births as well. The truth is always somewhere in between. All childbirth options carry benefits as well as risks, and women should be supported to apply their own values to decision-making, rather than feel obligated to adopt uniform recommendations arising from contemporary risk-focused discourse. This new guideline is much clearer about the obligation of health care professionals to present women with genuine breech childbirth options.

Maternal birth position (Section 6.7)

The guideline has changed from recommending lithotomy birth position to the following: “Either a semi-recumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant.” This will be joyously welcomed by midwives and obstetricians who have been gradually incorporating upright breech methods into clinical skills training for some time, and the women who have been insisting on the freedom to choose their own birthing position.

Shame Louwen and Reitter’s paper on #breech in upright position wasn’t reviewed for @RCObsGyn #breechGreentop https://t.co/W1nMdodrET

— Oli Silverwood-Cope (@olvindaRM) March 18, 2017

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But as the explanatory notes indicate, “The principle difficulty with an all-fours position is when manoeuvres are required. Most obstetricians are more familiar with performing these in a difficult breech birth with the woman in the dorsal position.” This begs the question of how we will overcome the difficulty resulting from lack of obstetric familiarity with performing manoeuvres when women are in upright, particularly kneeling positions. Our recently published evaluation of the Breech Birth Network Physiological Breech Birth training days reported that one of the greatest concerns expressed by participants in the workshops was lack of involvement and collaboration from obstetric colleagues, whom they had difficulty convincing to attend the training in order to learn effective manoeuvres. Hopefully changes in our national guideline will prompt more interest.

Question #1: What does it mean to be ‘skilled’ in breech birth birth?

The word ‘skilled’ recurs 15 times in the new RCOG breech guideline. Variations include: ‘skilled intrapartum care,’ ‘skilled birth attendant(s),’ ‘skilled supervision,’ ‘skilled attendant(s),’ ‘operator skilled in vaginal breech delivery,’ ‘skilled support,’ ‘skilled personnel.’ Each reference suggests skill is a key ingredient of safe vaginal birth.

What does it mean to be ‘skilled’ in vaginal breech birth? Is it a quality possessed by individuals, or institutions, or both? How is skill assessed? How is it maintained?

The danger with lack of definition regarding breech skill is that by default it will be judged in retrospect. A good outcome occurs = the attendants were skilled. A bad outcome occurs = the attendants lacked skill and were overconfident in assessment of their own competence. A health professional attends four spontaneous breech births which do not require intervention = they are now perceived as ‘skilled.’

The guideline points to evidence from the PREMODA study, in which good outcomes were achieved in a study with senior obstetrician presence in 92.3% of cases. Association is not causation, but we need to take seriously the value the PREMODA researchers placed on this as a key to their success. In a UK context, or elsewhere, does that mean we can (or should?) reasonably expect all senior obstetricians to be ‘skilled’ at vaginal breech birth? What if the senior obstetrician does not feel ‘skilled’ her/himself? What if a midwife is the most experience person available to attend a breech birth?

The new RCOG guideline further recommends: “Units with limited access to skilled personnel should inform women that vaginal breech birth is likely to be associated with greater risk and offer antenatal referral to a unit where skill levels and experience are greater.” And: “All maternity units must be able to provide skilled supervision for vaginal breech births where a woman is admitted in advanced labour and protocols for this eventuality should be developed.” How will all maternity units be able to provide skilled supervision for undiagnosed breech births, if some of them will also need to be up front about their lack of skill to support planned breech births?

The new guideline recommends that “simulation equipment should be used to rehearse the skills that are needed during vaginal breech birth by all doctors and midwives.” The extent to which such simulation training will result in skill development in settings where skills have become depleted over the last 20-30 years is unclear. Our recent systematic review highlights the lack of evidence regarding the ability of standard training programmes to improve outcomes, and suggests that teaching vaginal breech birth as part of an obstetric emergencies course may actually reduce the chances that providers will actually attend breech births (Walker, Breslin, Scamell and Parker, 2017).

Value of midwifery #breech knowledge and skills, and continuous support acknowledged in @RCObsGyn #BreechGreentop pic.twitter.com/lChFVNxMVN

— Oli Silverwood-Cope (@olvindaRM) March 18, 2017

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The development of professional competence to facilitate breech births is a complex matter to which institutions may like to pay closer attention as they develop the ‘routine vaginal breech delivery service’ envisioned by the new guideline. Some of this complexity is explored in these two papers involving research with experienced practitioners: Standards for maternity care professionals attending planned upright breech births and Principles of physiological breech birth practice.

Question #2: What is a footling presentation?

Despite the acknowledged paucity of evidence regarding factors that increase the risks of vaginal breech birth, ‘footling presentation’ remains a clinical indication for advising women that the risks associated with vaginal breech birth are likely to be independently increased. Unfortunately, neither the guideline nor generally available breech literature provides a clear definition of what this means, nor is it likely that a similar definition has been used among disparate studies looking at outcomes associated with variations of breech presentation.

The danger with this lack of definition is that in many complete and incomplete breech presentations, where one or both legs are flexed, one or more feet will be palpable on vaginal examination. This is especially the case at advanced dilatation, when legs will often slip further down due to the increased space in the sacral cavity, into which the breech has also descended. And of course in advanced labour, the dangers of performing a caesarean section for a dubious indication are increased. It has never made sense to me to perform a caesarean section at advanced dilatation because one might need to perform a caesarean section! Where skill levels are minimal and practitioners are not taught to locate the sacrum as the denominator, many complete and/or incomplete breech presentations will be labelled ‘footling.’

Dr Susanne Albrechtsen teaching breech skills

In my practice, I follow the nomenclature suggested by Susanne Albrechtsen (unfortunately only available in Norwegian): a footling breech is one in which both feet present first, and the fetal pelvis is disengaged, above the pelvic brim. A fetus whose pelvis is engaged with one or more feet palpable alongside is a flexed breech (complete/incomplete).

We will await more professional debate and actual evidence concerning the definition of ‘footling breech’ and its association with fetal outcomes. Perhaps now that the new RCOG is more supportive of vaginal breech birth, more professionals will feel experienced enough to engage in discussions which will move our knowledge base forward and further increase the safety of breech birth.

Shawn

The breech and the perineum

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In an active breech birth, we aim to support and encourage the physiological process as long as it appears to be safely unfolding. When practising in this way, we have to understand why some variations occur, when they may threaten the safety of mother or baby, and how clinicians might intervene to safely assist the birth when necessary.

Breech deliveries are not associated with an increased incidence of severe perineal damage (Jones 2000), and compare favourably to instrumental cephalic deliveries and persistent posterior positions. However, in a lithotomy (supine, legs in stirrups) breech delivery, episiotomies are commonly used to assist with manoeuvres. Manual assistance at some stage is almost always necessary when women are in this position, and an early episiotomy is considered by many to be beneficial. So much so that ‘inappropriate avoidance of episiotomy’ has been identified as a common mistake in breech simulation exercises (Maslovitz et al 2007). However, current RCOG guidelines indicate that episiotomies should not be performed as a matter of course, but according to clinical indication. So what are these indications?

In contrast, active breech births (where women assume upright positions) are associated with lower rates of perineal damage than cephalic births. In a recent study (Bogner et al 2014) comparing a small series of all fours breech births with lithotomy deliveries, serious perineal lacerations occurred only 14.6% of the time when women were in all fours, compared to 58.5% of the time with lithotomy deliveries. A majority in the latter category were due to episiotomies, rather than the mechanical process of birth.

The breech stretches a perineum differently from a head. A well-flexed, round head will displace the fanning perineum more or less evenly, spreading the tissue during the crowning process. In contrast, a bottom is softer and flatter. And other limbs provide irregular pressure.

When might intervention be helpful?

I became interested in this question due to differing information from several experienced clinicians. Mary Cronk MBE, with whom I had the great privilege to teach a few years ago, explained in her inimitable way that she was a bit more ‘scissor-happy’ with breech babies, so there must be good reason. However, other experienced clinicians feel that an intact perineum is important to maintain fetal flexion for as long as possible, and needing to cut an episiotomy should be a very rare occurrence. (See a previous discussion.)

One of Mary’s classic slides includes a birth where she cut an episiotomy because the perineum had become overstretched and was tearing in a button-hole pattern. Especially when nulliparous women give birth to frank breech babies, this overstretching may occur because the perineum does not spread and recede over the comparatively flat bottom in the same way as it does a head.

If the perineum has become abnormally distended and is causing significant delay, consider a 'perineal sweep.' If not successful, an episiotomy is indicated.

If the perineum has become abnormally distended and is causing delay, consider a ‘perineal sweep.’ If not successful, an episiotomy is indicated.

The illustration to the right depicts an abnormally distended and overstretched perineum. The baby’s bitrochanteric diameter (the distance between the outer points of the hips) has already descended past the ischial spines, and we have passed the ‘point of no return’ – the baby will be born vaginally.

The potential risks with an abnormally distended perineum are:

Delaying the birth at a point when the umbilicus has already descended into the pelvis and may be compressed. The fetal heart may no longer be reliably auscultated due to descent into the pelvic brim. If this is the case, assistance is warranted.

A button-hole tear in the mother’s perineum.

Are there alternatives to episiotomy?

When we recently met up at the RCOG and Oxford Breech Conferences this October, I asked Anke Reitter what she would do if she felt that a tight perineum was holding up a birth at a crucial point. She described to me what might be called a ‘perineal sweep.’ Similar to a cervical sweep, (with consent) the clinician inserts one finger between the breech and the tightly applied perineum, and sweeps around the perimeter, encouraging the border of the perineum to recede over the presenting part and allow the birth to proceed. She explained that this often causes progress to resume without the need to perform an episiotomy.

I found this really helpful to consider as part of my breech midwifery toolkit. As we re-develop our professional cultural knowledge about breech, it is important we continue to talk about what we do and how we do it, even those skills we feel will be rarely needed. While we strive to create the conditions for those 85% of women to give birth to their breech babies over intact perineums without assistance, we also have to be able to recognise the perineum/bottom combination which may occasionally present a problem, and how we might address this for the best possible outcome.

I would love to hear your thoughts and experiences.

Shawn

Breech birth team work

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Introducing more support for planned breech birth in your hospital setting? This post is for you.

The management of breech presentation is undergoing an important transition. In the past twenty years, we’ve gone from:

Management according to the preferences of individual consultants and/or units, tending increasingly toward caesarean section
Blanket caesarean section policy following the publication of the Term Breech Trial
A recognition in more recent guidelines that vaginal breech birth should remain an option for women
Increasing demand from women for more choice and involvement in decision-making around how they birth their breech babies

As a result, health care providers are needing to re-skill in the facilitation of breech birth, and in a way which matches women’s expectations. This requires introducing entirely new skills to manage breech births when the mother is upright and active, as women who choose to birth vaginally usually expect to be.

But transitions can be de-stabilising. Doing things ‘as they are always done’ provides some protection because team members are familiar with their roles. Each professional knows her/his place on the team. They are familiar with the range of events that might happen in this scenario, and they know by repetitive practice exactly how they will need to communicate and respond. The emergency caesarean section for the undiagnosed breech discovered at 9 cm – the team has been here before many times, and swings comfortably into action.

In contrast, a planned breech birth is novel territory. This is even more the case if the woman has planned to be upright and active, as many teams will have rehearsed emergency breech drills with the mannequin in a lithotomy position (legs in stirrups). Therefore, teams supporting this choice will need to employ different strategies to ensure effective teamwork around the time of birth.

Identify your breech birth dream team

(These suggestions apply to a planned breech birth which occurs in a hospital setting, particularly one where a planned breech service is being introduced.)

Ideally, the entire second stage and the birth of this breech baby will be primarily supported by three people. These three should be familiar with and aligned with the woman’s birth plan and each other, as any task or relational conflict will compromise decision-making ability (de Wit et al 2013, Puck & Pregernig 2014). They should each have a clear understanding of what their role in the team will be, and they should have rehearsed together the management of some common emergencies. They should have clear eye contact with each other throughout the birth, in order to confirm in an unobtrusive way the on-going evaluation that the birth is going well, or to prepare each other for the possibility that it might not be.

Each team member has a different primary responsibility:

1) Management – This person is primarily responsible for facilitating the birth, and may be an experienced midwife or an obstetrician. Ideally, this person will be known to the woman and have experience with breech birth in general (and the type of birth the woman has requested). The birth facilitator will be intimately familiar with the woman and her wishes, as well as the mechanics of breech birth, how to anticipate possible problems, and how to assist when required. They are responsible for co-ordinating care and preparing the rest of the team to assist when required.

2) Support – This person, usually a senior midwife, is responsible for taking over monitoring of the woman’s and baby’s well-being throughout the second stage, frequently relaying this information to the rest of the team and reassuring the woman. Positioned beside the woman, they are an important communication bridge, especially when the woman is in a kneeling position, facing away from the person managing the birth. In this position, the support professional is also placed to assist with applying suprapubic pressure and/or change of maternal position.

3) Perspective – This person is responsible for documenting the birth and providing a second evaluation of progress. This role requires breech experience because in order to document appropriately and accurately, the person needs to understand what they are seeing. Similarly, in order to assist with the evaluation of progress, this person needs to be familiar with normal progress in a breech birth. Because of their perspective, this person is also an important communication bridge with the rest of the team outside the door (eg calling for further help, alerting paediatricians to possible complications, etc.), and may alert the managing professional to potential problems. Therefore, this role is often taken by the most experienced person in the room, such as the obstetrician or the experienced midwife who is supporting another midwife to develop her skills.

The triangle: nature’s most powerful structure

Most normal births are attended by two midwives, and this is more than adequate. But a breech birth is not an everyday occurrence. Documentation will need to be of a gold star standard. Yet in most hospitals, each person in the room will still be developing their skills with breech and will therefore need to concentrate on the task at hand, making attendance to paperwork tricky. It is also easy to become enthralled with the beauty of an unfolding breech birth.

Therefore, supporting breech births with a primary team of three strengthens a situation made vulnerable by its novelty. A triangle is one of nature’s strongest structures; this mini-team is strengthened, given a base by the addition of perspective. Given the importance of documentation in any higher-risk birth, triangulation of data (eg strengthening the accuracy by using different sources) also makes practical sense. The triangulated team increases everyone’s safety in a novel situation.

Interestingly, many women instinctively form their own triangles, involving two supporters. The third person in this triangle also provides additional support, strength and perspective for both her and her partner.

Continuity: the way forward

Continuity of carer – ensuring a woman knows the professional who will be facilitating her birth, and ideally the entire team – has known, evidenced benefits. Fewer interventions, greater satisfaction. Knowing who else will be in the room, and what their role will be, will also help the woman to feel more relaxed and reassured about the upcoming birth.

Continuity has benefits for providers as well, especially when it comes to facilitating non-standard care. A number of sources have suggested on-call teams for breech births as the way forward (Kotaska 2009, Daviss et al 2010) and on-call midwives are a middle ground. Especially when experience is minimal, preparation is key. Where an on-call team is not available, the entire team who will be attending the birth should be identified when the woman is admitted to hospital, and again at handover if appropriate. This team should have a thorough discussion about roles and responsibilities, and a run-through of the ‘fire drill’ if things do not go as planned, well before second stage requires the additional team members to attend.

The team should meet afterwards to review the birth and identify if any group work issues have been identified that can be improved for future births. This review should involve the obstetric labour lead, a midwifery manager and/or risk management midwife if the breech service is new to the maternity team. A reflective approach in the early stages will pay off in increased safety and a more confident, united team in the long run.

Further information and inspiration for your dream team

Teamwork is crucial to the safety of breech births. Michael West has written extensively about the characteristics of ‘real teams,’ as opposed to ‘pseudo teams.’ Real teams have clear, shared team objectives; role interdependence and role clarity; and they meet regularly to review and improve performance (West, 2014). If we are to successfully change the culture of breech birth, and support women as safely as possible as we develop our skills and experience, we must function as real teams.

West, M.A., & Lyubovnikova, J. (2013). Illusions of Team Working in Health Care. Journal of Health Organization and Management, 27(1), 134-142. (more from West)

You may also be interested in this article: Plested M, Walker S. Building confident ways of working around higher risk birth choices. Essentially MIDIRS 5(9)13-16.

How have you prepared your teams to support planned breech births?

Shawn

Dolichocephaly – understanding ‘breech head’ molding

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This post is about dolichocephaly, a form of positional molding which affects some breech babies – how it happens, why it may be important, and how to recognise it.

If you permanently link to this page, please use the new site: https://breechbirth.org.uk/2014/04/dolichocephaly-understanding-breech-head-molding/

Everyone is concerned about entrapment of the after coming head in a breech birth. And it seems so unpredictable. Many breech babies, even large ones, seem to just fall out. And then others, not so large, get stuck. RCOG guidelines suggest an estimated fetal weight above 3800 g is ‘unfavourable’ for vaginal breech birth, but goes on to say, “If the baby’s trunk and thighs pass easily through the pelvis simultaneously, cephalopelvic disproportion is unlikely.” (Easily is undefined, but in light of the evidence against augmenting breech labours, I interpret it as occurring spontaneously within about an hour of active pushing.)

Can we predict which babies’ heads are more likely to have difficulty passing through the pelvis? I don’t know, but I feel one phenomenon in particular deserves more attention – dolichocephaly.

Dolichocephaly developing due to positional pressures

Technically, dolichocephaly is a mild cranial deformity in which the head has become disproportionately long and narrow, due to mechanical forces associated with breech positioning in utero (Kasby & Poll 1982, Bronfin 2001, Lubusky et al 2007). This change in shape is more commonly associated with primiparity (first babies), larger babies, oligohydramnios, and posterior placentas, all of which result in greater forces applied to the fetal head.

(Note: Like all positional molding which occurs in utero, dolichocephaly does not in itself cause nor indicate abnormal brain development. The head shape is highly likely to return to completely normal in the days and weeks following birth, especially if baby receives lots of holding and cuddles to permit free movement of the head.)

Clinical Importance

Following the birth of the arms in a breech birth, the head will be in the anterior-posterior diameter of the pelvis. When the head shape has become abnormally elongated, the longest diameter of the fetal head will meet the shortest diameter of the maternal pelvis at the inlet. Unless the baby is still on the small side and the pelvic inlet very round, the chin may get stuck on the sacral promontory, preventing head flexion. A very experienced breech provider will have encountered this situation before, and should be able to assist, but it is quite a tricky place to be. The head may need to be rotated into the transverse diameter to safely enter the pelvis. A very elongated head can have difficulty passing through the lower pelvis as well, and can cause damage to the maternal pelvic floor, unless appropriate techniques are used to assist the head to flex.

Effects of abnormal head molding in some breech-positioned babies

Abnormal head molding in some breech babies

Estimation of fetal weight by ultrasound is notoriously inaccurate. However, a lack of proportionality between the head circumference and the biparietal diameter is more obvious to spot (e.g. HC=90th percentile, BPD=60th percentile; or a difference in correlating dates of two weeks or more), and may be a more relevant indication that this baby is too big for this particular woman. Dolichocephaly can be discerned on palpation as well, as the occiput is prominently felt above the fetal back, the head is not ballotable, and may feel unusually wide. I would suggest caution where estimated fetal weight is above 3500 g and a difference in HC and BPD, or careful palpation, indicates abnormal cranial molding has occurred, especially for women who are having their first baby, have a low amniotic fluid index, and/or a high posterior placenta; and in situations where imaging pelvimetry is not used to confirm an ample pelvic inlet.

Counselling Women

Women instinctively do not like weight limits used as ‘selection criteria.’ One woman (Ann, multip, 6’1”) looks at another (Carol, primip, 5’0”) and they both think – We can’t possibly be expected to have similar-sized babies. While Ann may carry a 4000 g baby with no abnormal head molding, and expect a straightforward birth, Carol’s baby may begin to show signs of dolichocephaly at 3300 g, especially if she has low levels of amniotic fluid and a posterior placenta. Carol may still have a successful birth, but it will more likely depend on the skill and experience of her attendant in assisting the aftercoming head to flex, rotate and negotiate the pelvic diameters, and the pelvic diameters themselves.

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

We need to move away from the concept of ‘selection criteria,’ which are used by professionals to make decisions for women, and towards an understanding of what is ‘normal for breech.’ We need to understand more about which babies are more likely to experience those beautiful, often-easier-than-cephalic, dancing-into-the-world births, and which babies are truly being put at additional risk by their in utero conditions.

Then we will be able to explain to women the benefits of a caesarean section for pregnancies which have become ‘abnormal.’ Women will be able to approach this intervention with an open heart when they observe professionals are truly supporting ‘normal’ breech births and providing individualised care and screening to those which are not.

I would love to know what others think about this.

Shawn

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