Tag Archives: breech birth

Breech Birth in Yemen

Breech Birth in Yemen – what I learnt as an MSF Gynaecologist taking physiological breech birth from theory into practice

Dr Sabrina Das

Sabrina is a Consultant Obstetrician & Gynaecologist at Imperial College Healthcare Trust in London.  She worked in Yemen as an MSF Gynaecologist from March-July 2021.

Dr Sabrina Das
Breech Birth In Yemen

In March 2021, I escaped the U.K. to a country where the biggest challenge in healthcare was not COVID-19.  I took on a role in Yemen with Doctors Without Borders (MSF), working as an MSF gynaecologist in Taiz governorate.  The hospital has been running since 2015, when Taiz City was divided in two by a frontline between the warring parties. 

The conflict meant that there was no publicly run maternity hospital in Taiz Houban, as it was not safe for civilians to cross the frontline.  Six years into this war (and no end in sight), Taiz Houban Mother and Child Hospital (MCH) is the largest maternity hospital in the region, and the largest MSF project in Yemen.  We deliver 400-500 babies per month, and we mainly treat women with risk factors in pregnancy or who develop intrapartum complications.  Breech presentation is one such risk factor.

In many high resource countries, breech presentation has become synonymous with Caesarean birth and most mothers opt for this, in spite of no evidence showing any difference in long-term outcome for babies. “Everybody says it is safer to have a Caesarean” is what many women tell me.  Thus in London my experience with vaginal breech birth is mostly in the pre-term or second twin scenario.  In my time in Yemen, however, I have delivered more vaginal breech babies than I had in my preceding 15-year career.

picture of concrete area. Doctors without borders, Breech Birth in Yemen.

In Yemen, the word “safer” takes on a completely different meaning and perspective.

The average number of children a woman has is six.  Many women get married and start their reproductive journeys in their teenage years, and carry on for the next 20 years.  It is not unusual for women to have 12+ pregnancies.  The conflict has devastated Yemen’s public healthcare provision, and very few can afford private antenatal care. Even if they could, the war has meant that there is a real shortage of skilled providers even in the private sector.  There is no national screening programme.  Many women will labour at home.  Some labour with a private midwife and practices of private providers are unregulated.  It is not uncommon for women to receive oxytocin in the home setting, whilst in labour, to speed things up. 

The high fertility rate, lack of easy access to maternity hospitals with facilities for The high fertility rate, lack of easy access to maternity hospitals with facilities for emergency Caesarean, and unregulated practices occurring in the community make the risks of a Caesarean very high.  The risks are not so much in the index pregnancy, but in future pregnancies.  We have many women with previous Caesarean who attend with ruptured uteri after receiving oxytocin at home, or after labouring for some hours at home.  We also have women experiencing the complications of multiple Caesarean births – dense adhesions and surgical issues, but more terrifying is the complication of abnormal placentation from previous Caesarean birth.

We had one woman who we saw in our high-risk clinic with a low lying placenta, and a history of two previous Caesarean births.  She also had two previous vaginal births.  Only two of her four children were alive.  We brought her back to have a planned Caesarean the following day, and on entry, found that the placenta had invaded through the previous uterine scar (a complication called placenta accreta).  I delivered the baby and had to perform a hysterectomy.  She received six units of blood.  She is lucky to be alive.  If she had bled at home or gone into labour before finding a hospital to do her Caesarean, she would have died.

We saw another woman who was about 18 years old.  She had a 5-month old baby, and got pregnant immediately after her period returned about 2 months prior.  She turned out to have an ectopic pregnancy in her Caesarean section scar.  It was quite large, about 5cm by 5cm and she bled a lot during the treatment (I evacuated the pregnancy via the cervix).  I was seriously afraid she would need a hysterectomy. This is a serious consequence for a young woman in any culture, but my Yemeni colleagues tell me it can be particularly devastating here, where a woman’s status in her husband’s family can be dependent on her potential to have more children.  We were lucky this time and she will be back, pregnant, in the not too distant future I expect.

I had to explain the backdrop in Yemen for you to understand that here, Caesarean is not an inconsequential operation.  The risks to mothers of complications directly or indirectly related to a Caesarean birth are huge.  The relatively small benefit to the baby demonstrated by the Term Breech Trial (2000) do not justify a policy of elective Caesarean breech delivery in this context.  Thus, it is common and routine for us to induce women with breech presentation (for all the usual indications), and if a woman presents in labour with a breech baby, we manage them exactly as we would with a head down baby.  This includes giving oxytocin to augment labour if needed (especially in first-time mums).

Hospital beds in a Yemeni hospital, Breech Birth in Yemen

Women here do not have any access to pain relief in labour or continuous monitoring.  There isn’t even gas and air! 

The lack of regional anaesthetic would make an upright breech vaginal birth an ideal option for women, but the standard practice here is for women to deliver in lithotomy position.  Culturally, women in labour tend to lie flat on their beds, usually hooked up to an intravenous drip for some reason.  Believe me, every time I do a ward round I sound like a broken record, “Get her up and moving – tell her lying flat is not good for her baby!”  And at delivery, I get the women to try going on all fours position.  For the breech births, I have had most women (including primiparous women) delivering beautifully on all fours, where nothing more was needed than some verbal encouragement. I was really happy this week, however, when the skills I had learnt from physiological breech training helped with what could otherwise have been a tricky breech birth.  .

A mother came in fully dilated, with her second baby in the breech position.  Lots of women come to hospital fully dilated and this is not a good thing.  The conflict means that women sometimes have to wait until it is safe to travel, or they have trouble accessing transport, or issues like roadblocks and the closure of local services mean they just have really long journeys to get here.  Without any idea of what the fetal heart rate has been doing in the preceding hours, without any clue about what medication the woman may have received at home, what has her blood pressure been… I have seen it go wrong far too many times before.

This particular mother was immediately brought to the delivery room, and the midwife explained she had heard a deceleration.  We checked the fetal heart and there was definitely a bradycardia going on.  I immediately got her onto all fours position and got her to push.  The rump advanced to the perineum and I could see the abdomen emerging, and the legs shortly afterwards.  I didn’t see the “valley of the cord” as the baby was slightly misaligned so I corrected this with a little rotation.  I could hear the mantra “don’t tell the woman to ‘just breathe and wait for the next contraction’”, particularly with the concerns over the fetal heart.  So I went ahead and delivered the anterior arm and proceeded confidently with a shoulder press.  It worked like magic and the baby was born.  Baby started crying after a few minutes on the resuscitaire, and was good as gold by the time we cleaned mum up.  The best bit for me was presenting the gorgeous girl to her mother.  I told her, “jameel” which means “beautiful”.  It is one of the few Arabic words I know.  She kissed her hand and touched mine, and without words we shared a moment of connection.

Not all my breech stories are so successful.  We had another woman who had four children (all alive) who came in at term with a breech baby in spontaneous labour.  She laboured to full dilatation and was pushing for a long time, about two hours.  By the time I got involved, she was exhausted and asking for a Caesarean.  We persevered for another 30 minutes.  She had been in lithotomy, so we got her on the floor.  Squatting, kneeling, McRobert’s… we tried all positions possible.  The baby’s bum was visible without even parting the labia, but it was not budging.  We brought her into theatre and did a Caesarean.  On the operating table before starting, I noticed minimal urine in the catheter tubing and what was there was a deep blood-red.  Her abdomen was a crescent shape, and looked sunken in on one side.  She had the most obstructed labour I had ever seen.  The lower segment of her uterus was so distended it looked bruised, almost like a large purple mass.  The bladder was extremely oedematous.  The baby was not excessively big (3.4kg) but for some reason, the way his bum was fitting in the pelvis, it was malpositioned in some way and there was no way he was coming down.  The long second stage in a multiparous women, and all the other outward signs of obstructed labour should have been singing to me. 

I saw a similar woman the following day with an intrauterine fetal death at term.  We induced her and she was in second stage for about four hours.  We were not keen to do a Caesarean for a baby who had already died but in her case it was obstructed.  To avoid a ruptured uterus, a Caesarean was the right thing to do for the mum.

So, here’s a summary of what I have learnt about breech birth working alongside my very skilled Yemeni colleagues here in Taiz:

  1. Upright position is fab, as is the lack of regional anaesthetic for a breech birth.  That Ferguson’s reflex is a really helpful thing to help the rump deliver.  The manoeuvres work a charm once the woman has gotten herself past that point of “no return”.  Up to that point, however, you can’t do anything to speed things up apart from verbal encouragement.
  2. If the rump is not delivering, particularly in a multiparous woman, things are not going well and the breech might be malpositioned in some way.  Do not start oxytocin in this case (especially if she had been contracting well before).  Any sudden cessation of contractions is not a good sign and should prompt an assessment for rupture of the uterus.  I would recommend a Caesarean after about two hours of active pushing in second stage for multiparous women.
  3. You can induce or augment a woman with a breech baby just like you can when the baby is cephalic.  The same rules apply – look for adequate progress, monitor as you would with a cephalic baby for fetal distress or hyperstimulation, and be wary of augmenting multiparous women who are in spontaneous labour (they are at risk of uterine rupture). 

I think that if healthcare professionals follow these simple rules, breech vaginal birth is just as safe as a cephalic vaginal birth in any setting. 

If you would like to make a contribution to MSF’s work in Yemen, please visit https://msf.org.uk/pain-motherhood-yemen-different-scale

Attend A Virtual Seminar!

Breech Birth Network virtual seminars are open to all those who have attended our on-line or face-to-face courses this year.  Upcoming seminars include:

25th June 1.30pm – The ‘Dropped Foot’ Baby in Labour

2nd July 1.30pm – Nuchal cords and vaginal breech births

14th July 6.30pm – ‘Buttock Lift’ for the birth of the fetal buttocks


To join one of the seminars listed above or any other which will be run over the course of the year, please see open the course in which you are enrolled. 

Breech Birth Network, CIC is dedicated to training Midwives and Obstetricians of all levels in physiological breech birth and developing research exploring key breech birth issues. As well as running full days face-to-face training on physiological breech birth, our well attended and evaluated course is now available online. The course has been developed directly from research about physiological breech birth and can be accessed via this link

To support the learning and development following completion of the online course, Breech Birth Network, CIC are now running live reflective sessions with an instructor.  These group sessions will be run virtually and provide an opportunity to discuss important issues and clinical situations related to physiological breech birth. The sessions will be held on Zoom and facilitated by Dr Shawn Walker and Emma Spillane.  The seminars are a chance for those who have attended the Breech Birth Network online training course to discuss issues related to practice, further understand some more unique scenarios and how to manage these in practice. 

The seminars are an opportunity for healthcare professionals to come together and discuss all things breech!  Each seminar will have a main topic or theme, but the conversation will be led by those attending.  You can ask questions; discuss births you have attended and reflect on scenarios in practice. 

We look forward to you joining us.

Shawn and Emma

NICE Guideline consultation on Induction of Labour

Another NICE Guideline that mentions care for breech presentation has been put out for comment. This time it is Inducing Labour. Many fine colleagues are collating responses to the guideline in general, but I would like views on the specific section related to induction of labour in breech presentation.

I have prepared a response, based on previous feedback from women and birthing people. Please let us know how you feel about this, and whether you would word anything differently.

Induction of labour is controversial, and even more controversial for breech presentation. I have tried to word the response in such a way that reflects the need for more informed choice, rather than more induction per se.

Some other resources:

Response to Draft Guideline:

p.10, line 6 “Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]” Cannot locate evidence for this recommendation in evidence review. This statement is vague. Not generally recommended by who? Why? Induction of labour for breech presentation is common outside of the UK. 

p.10, line 14 “Discuss the possible risks of induction with the woman.” Also vague. What are the risks? A systematic review has been done, so women can be offered evidence-based information rather than general reluctance. https://www.ejog.org/article/S0301-2115(17)30578-X/fulltext

p.10, line 5 Suggest the section on ‘Breech Presentation’ is re-written to reflect the ethos of informed choice and discussion, in a similar manner to the section on ‘Previous caesarean birth.’ Otherwise, the service is inequitable. A guideline on IOL with breech presentation is only applicable to women who have chosen to plan a vaginal breech birth. The guideline should reflect and respect this, using neutral, non-judgemental language.

For example:

1.2.19 Advise women with a baby in the breech position, who have chosen to plan a vaginal breech birth, that:

  • induction of labour could lead to an increased risk of emergency caesarean birth, compared to spontaneous breech labour
  • induction of labour could lead to an increased risk of neonatal intensive care unit admission for the baby, compared to spontaneous breech labour
  • the methods used for induction of labour will be guided by the need to reduce these risks. See the recommendations on Methods for inducing labour.

1.2.20 If delivery is indicated, offer women who have a baby in the breech position a choice of:

  • an attempt at external cephalic version, immediately followed by induction of labour if successful
  • caesarean birth or
  • induction of labour in breech presentation

Take into account the woman’s circumstances and preferences. Advise women that they are entitled to decline the offer of treatment such as external cephalic version, induction of labour or caesarean birth, even when it MAY benefit their or their baby’s heath.

Current wording in Draft Guideline is:

Breech presentation

1.2.19 Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]

1.2.20 Consider induction of labour for babies in the breech position if:

  • delivery is indicated and
  • external cephalic version is unsuccessful, declined or contraindicated and
  • the woman chooses not to have an elective caesarean birth.

Discuss the possible risks associated with induction with the woman. [2008, amended 2021]

PhD Fellowship Opportunity

This week, the NIHR (UK based) announced a PhD Fellowship opportunity. A Fellowship is designed to support a researcher to gain experience and training in doing research, and to support the research itself. It’s a great opportunity. Advertisement pasted below.

If you are reading this after any of these calls have closed, the same organisations may have a more recent call.

NIHR-Wellbeing of Women Doctoral Fellowships (Round 6)

Provide the opportunity to undertake exciting and impactful research that will underpin a researcher’s development as an independent future leader. The Doctoral Fellowship funds researchers to undertake a PhD

Wellbeing of Women is delighted to have partnered with the National Institute for Health Research (NIHR) to jointly fund one Charity Partnership Doctoral Fellowship.

All NIHR Fellowships provide the opportunity to undertake exciting and impactful research that will underpin a researcher’s development as an independent future leader. The Doctoral Fellowship funds researchers to undertake a PhD.

NIHR Charity Partnership Fellowships offer researchers the opportunity to be part of an active and supportive community, drawing on the enormous benefits and opportunities of cross-sector working.

For more details please see: https://www.wellbeingofwomen.org.uk/funding-opportunities/nihr-wellbeing-of-women-doctoral-fellowships

Update: Here’s another

HEE/NIHR ICA Clinical Doctoral Research Fellowship

The Clinical Doctoral Research Fellowship (CDRF) funds health and social care professionals to undertake a PhD and professional development in parallel, alongside continued professional practice.

The scheme is part of the HEE/NIHR Integrated Clinical Academic (ICA) Programme.

CDRFs are available to health and social care professionals (excluding doctors or dentists) who are registered with an ICA eligible regulatory body.

For more details please see: https://www.nihr.ac.uk/funding/heenihr-ica-clinical-doctoral-research-fellowship/27181?source=chainmail

If you are considering training to be a researcher and/or clinical academic who does breech research, we would love to hear from you. There are many challenges in breech research. For example, variations in when the breech is diagnosed make recruitment challenging. Sometimes dramatic variations exist between centres in external cephalic version success rates, vaginal breech birth experience and whether or not breech presentation has a dedicated care pathway. This can make recruiting sites difficult, and it is difficult to reach an adequate sample size within single-centre studies. But we have experience in navigating some of these challenges and are keen to collaborate with others.

For example, in the OptiBreech Project, we are building a database designed to support a large, multi-site observational cohort study with multiple embedded trials along the breech care pathway. Some of the questions women or potential researchers have told us would be useful to answer include:

  • Does moxibustion work in a UK context, and what does it cost? This could be tested as a trial within the cohort.
  • Rebozo sifting / positional exercises / homeopathy / hypnosis — do they influence the rate at which babies turn head-down, or the success rate of external cephalic version? This could be tested as a trial within the cohort.
  • Does provision of an ECV service by a Breech Specialist Midwife change the outcomes of the service? And what does it cost compared to an obstetric service? This could be tested as a trial within the cohort.
  • Should we offer cervical sweeps to women with breech-presenting babies? Are they helpful? Safe? From when should we offer them? This could be tested as a trial within the cohort.
  • Does offering induction of labour for women with a breech-presenting baby who desire a vaginal breech birth affect modes of birth and/or outcomes? This could be tested as a trial within the cohort

If you’d like to consider applying for this or another source of funding for breech research, you are welcome to be in touch to discuss!

Shawn

Video Library Access

From 1 May 2021, access to the Physiological Breech Birth video library on Vimeo, hosted by Breech Birth Network, will only be available through our on-line training programme.

Although we’ve always offered a year’s access with training, we’ve never changed the password. But it’s been over a year since we have been able to deliver any in-person study days.

If you have purchased the on-line training, you will have access to the complete training for a year, as well as the Vimeo video library. The password to the library will be posted within the training programme, so you can continue to access the videos you use in training. If you attend an in-person training, you will be given access to the on-line training for one year.

If your organisation uses our videos, someone from your organisation will need to be enrolled onto our on-line course. Institutional rates are available if you would like all of your staff to have access to the course and the video library.

Thank you for making such good use of the training materials we’ve worked hard to create. May the breech babies find you and be safe in your hands.

Shawn

International Maternity Expo Award Nominees

The Breech Birth Network are delighted to announce both Shawn and Emma have been shortlisted for awards at the International Maternity Expo Awards. We are both very honoured to have been shortlisted in the following categories:

Dr Shawn Walker – shortlisted for the Research Innovation Award and the Improving Safety Award

 

Dr Shawn Walker has been shortlisted for both the Research Innovation Award and the Improving Safety Award for her work in improving the knowledge, skills and training around Physiological Breech Birth. Shawn has published a number of research articles highlighting the importance of effective training, the development of experienced breech teams and pracical insights into upright breech birth. Shawn is currenty writing proposals for further essential research into Physiological Breech Birth to further improve safety and choice for mothers and their babies as well as practiotioners facilitating such births.

 

Emma Spillane – shortlisted for the Practice Innovation Award

Emma has been shortlisted for the Practice Innovation Award for her work in setting up a breech birth service in the large London teaching hospital she works in. The service supports mothers in their choices regarding mode of birth for breech presentation at term. Emma is also completing her Masters research in Breech Childbirth Preferences of Parents to further support service provision and support for parents choices.

We would both like to thank those who nominated us. It is a privilege and an honour to have been recognised for the work we are both doing.

Shawn and Emma

Seeking your thoughts on further research…

Image by Kate Evans

Emma Spillane is seeking your thoughts on a new piece of research prior to its submission for ethics approval. If you have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, or you work with pregnant women in a non-medical capacity (e.g. doula, antenatal teacher, breastfeeding supporter, etc.), I would love to hear from you.

I am conducting research as part of my Masters exploring breech childbirth preferences of expectant parents to understand if there is demand for breech birth services within the NHS and explore the factors which influence parents decision-making. At this stage, I would like your feedback on the suggested design of the trial, to ensure that the information resulting from the research will be useful to those considering breech options. For those of you who would like to remain with the project I am forming a Breech Advisory Group provide feedback at further stages in the project such as analysing the results.

If you are interested in participating in my research in this way, please read the plain text summary of the project below and complete a short survey by following the link after the research summary.

Discussing breech birth in Ethiopia

STUDY SUMMARY

Approximately 3-4% of babies at term present in the breech position (bottom or feet first) (Impey et al. 2017). The Royal College of Obstetricians and Gynaecologists’ (RCOG) most recent clinical guideline on Management of Breech Presentation recommends that pregnant women should be offered choice on mode of birth for breech presentation at term(after 37 weeks’ gestation) (Impey et al, 2017).  Despite this recommendation, only 0.4% of all breech babies in the UK are born vaginally (Hospital Episode Statistics, 2017), and this figure includes pre-term breech births where breech presentation is more common (Impey et al. 2017).  These statistics suggest that either the demand for vaginal breech birth is low, or the choice of mode of birth is not being consistently offered.  This study aims to explore this enigma by providing empirical evidence necessary to inform maternity services on the requirement of breech birth services. 

Current evaluations of demand for vaginal breech birth services have been limited by the quality and impartiality of information parents are able to access via their maternity services.    For example, research has shown that women have difficulties finding information to support their choices and are pressured into making the decision based upon practitioner preference (Petrovska et al, 2016).  An investigation carried out in the Netherlands, found that one third of parents would prefer to have their babies born vaginally (Kok, 2008).   However, little is currently known about parents’ preferences in England.  

This research will evaluate the extent of expectant parents’ preferences for vaginal breech birth prior to counselling, and the factors that influence these preferences, using personal interview surveys (Bhattacherjee, 2012).  All women presenting with suspected breech presentation at a large London based teaching hospital – St George’s University Hospital NHS Foundation Trust – will be given information about this study along with their Trust approved mode of birth information leaflet during their routine antenatal appointment at 36 weeks of pregnancy.  As per Trust clinical protocol, women with suspected breech presentation will be offered a referral for an Obstetric Ultrasound Scan (OUSS) for confirmation of fetal presentation.  During this routine OUSS appointment, either prior to or following the scan taking place, parents will be approached by the researcher and invited to take part in an interview on their preferred mode of birth and the reasons behind these preferences. Both parents, if present, will be interviewed separately.  Parents will already have been given information about the study in the form of a Participant Information Sheet PIS) by the clinician referring them for an OUSS. The timing of the interview has been chosen because it fits with the participating Trusts usual pathway of care. Parents are informed there may be long waiting times due to OUSS being arranged at short notice.

The findings from this research will provide evidence on the following:

  1. the demand for a vaginal breech birth service, based on written information prior to individualised counselling;
  2. the factors influencing this demand, which can be used to improve shared decision-making training and taken into account when planning future research; and
  3. a predicted service planning model for a fully integrated breech continuity team within the host Trust.

Data on parents’ preferences for mode of birth will be reported descriptively as a percentage. Qualitative data regarding parents’ reasons for their preferences of mode of birth will be analysed thematically.

https://www.surveymonkey.co.uk/r/8VR9J2K

Emma

India and the breech

Missed our Facebook Live event with Fernandez Hospitals? Watch the recording here:

PMET student Arunarao Pusala receives her training certificate in Karimnagar

This month I am in Hyderabad, India, visiting Dr Evita Fernandez and UK Consultant Midwives Indie Kaur and Kate Stringer. Today at 5pm IST (that’s 11.30 GMT), we will be having a Facebook Live discussion on Breech Birth in India. This will be followed by hands-on workshops on the 12th and 19th in Hyderabad.

with Senior Midwives Theresa and Jyoti

The Fernandez Hospitals are at the forefront of compassionate maternity care on a large scale in India. The Stork Home facility has been beautifully designed and rivals some of the best midwifery units in the UK. But Dr Evita and her team of doctors and midwives are very ambitious. They want to revive vaginal breech skills so that women can confidently choose this option. How will this work in Hyderabad? Join us for a discussion.

Midwives and doulas support women together in the beautiful Stork Home facility in Hyderabad

From Arunarao: “My special thanks to dr Evita ,lndie mam Kate mam and Shawn mam for the opportunity to participate in BREECH BIRTH WORKSHOP at karimnagar.i am so panic about breech presentation and breech birth before I come to professional midwifery training, know iam very excited to assist the spontaneous and assisted breech birth,because now I came to know breech also has its own mechanism and always always we have to respect those mechanism and iam aware of the manoeuvres to apply whenever it’s needed.thank you all of you mam iam so blessed to have a teaching faculty like you.” Thank you Arunarao — you really got it!

Shawn

“No time to put a plan in place”

Thinking through the practicalities of breech advocacy.

Midwives and obstetricians who would like give women with breech presenting babies more support to plan a vaginal breech birth (VBB) need to think through the wider picture of how this happens in order to become effective advocates. In my experience of doing breech advocacy throughout the post-Term Breech Trial era, women often get in touch after 38 or 39 weeks to try to organise support for a VBB. Achieving this requires quite a bit of discussion and negotiation in quite a short period of time.

This post makes visible some ‘common experiences’ in women’s vaginal breech birth journeys. Services differ in every area, so it won’t be every woman’s experience. And increasingly, forward-thinking NHS Trusts are working with advocacy organisations (such as the Coalition for Breech Birth, Breech Birth UK and BBANZ) to develop woman-centred care pathways which meet women’s needs rather than restrict their choices, like this team in Sheffield.

Common experience Other possibilities
33 weeks Antenatal clinic visit. Midwife or woman suspects breech. Woman told not to worry, most babies will turn. Informed about / referred for moxibustion treatment. Not associated with risk of harm. Shown to reduce breech and CS when used with acupuncture. Shown to reduce use of syntocinon before and during labour regardless of presentation. (Coyle et al, Cochrane Review, 2012)
36 weeks Palpation in antenatal clinic. Midwife suspects breech and refers for USS. Woman receives counselling re: ECV, to return at a later date. Is told discussion re: mode of birth will occur after unsuccessful ECV. One-stop shop breech clinic. Scan, counselling and ECV performed by a midwife or doctor with specialist training. If unsuccessful/declined, mode of birth preference documented. To return for further counselling.
37 weeks Counselling repeated by a different professional, who may have different personal preferences. External cephalic version attempted. If unsuccessful, asked to return for counselling re: mode of birth in consultant clinic. Returns to breech clinic for second attempt at ECV. Sees same practitioner, who is also part of the breech birth team. After unsuccessful/declined second attempt, confirms choice of mode of birth. Wider team made aware of planned VBB.
38 weeks Returns to antenatal clinic and sees another consultant or registrar. Majority of UK hospitals reluctant to support planned VBB. Advised to have CS. In some cases, a managed breech delivery in lithotomy is offered. Woman and her birth partner prepare for the up-coming birth.
39 weeks + After a return visit to antenatal clinic to attempt to negotiate support for an active VBB, meeting yet another consultant, and lots of research on the internet, woman seeks out external sources of support for VBB. Advocate (Supervisor of Midwives, doula, independent midwife) attempts to liaise with hospital staff, who ask, “Why do they all leave it to the last minute? There’s no time to put a plan in place now! Returns to breech clinic at 41 weeks to revisit choice of mode of birth, taking factors such as fetal growth and length of pregnancy into consideration. Talks to the same or another experienced member of the breech team.

Questions for reflection:

  • Consider your current work setting. If a woman tells you she would like to consider a VBB but is not receiving support to plan one, what can you do?
  • Who needs to be involved in her plan?
  • Who will support you to support her? To what extent are you comfortable being involved?
  • How can you build a local breech team, who can be ready to meet this need when it arises?
  • Consider working with your team to develop an informational resource for women, like this leaflet from King’s College Hospital.

Please share your positive experiences and good examples of breech teams in the comments.

Shawn

References:

Beuckens, A., Rijnders, M., Verburgt-Doeleman, G., Rijninks-van Driel, G., Thorpe, J., Hutton, E., 2016. An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives. BJOG An Int. J. Obstet. Gynaecol. 123, 415–423. doi:10.1111/1471-0528.13234

Catling, C., Petrovska, K., Watts, N.P., Bisits, A., Homer, C.S.E., 2015. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery. doi:10.1016/j.midw.2015.12.008

Coyle ME  Peat B, S.C.A., 2012. Cephalic version by moxibustion for breech presentation (Review). Cochrane Database Syst. Rev. doi:10.1002/14651858.CD003928.pub3

Walker, S., Perilakalathil, P., Moore, J., Gibbs, C.L., Reavell, K., Crozier, K., 2015. Standards for midwife practitioners of external cephalic version: A Delphi study. Midwifery 31, e79–e86. doi:10.1016/j.midw.2015.01.004