Tag Archives: all fours

Bottoms Down Under

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

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Anke Reitter, Danielle Freeth, Rhonda Tombros, Andrew Bisits

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

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

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

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

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

Dr Rhonda Tombros

Dr Rhonda Tombros

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

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

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

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

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

Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

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

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

Shawn

Breech updating

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

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

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

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

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

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

Cord prolapse: what do midwives do?

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

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

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

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

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

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

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

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

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

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

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

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

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