Tag Archives: breech birth

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.

How ‘evidence-based’ is your Algorithm?

1 Reply

Vaginal breech birth (VBB) is a controversial area of research, in an area of high obstetric litigation. Understandably, people are wary of introducing changes in practice that could expose them, mothers or babies to additional risks. Our research team responds frequently to questions and challenges about our approach, how it aligns with national guidance, and the evidence base.

Recently, a colleague became concerned after reading that the Health Services Investigation Board (HSIB) had presented evidence in Parliament in 2020 about the use of an algorithm to assist a baby’s birth.

The report did not indicate which algorithm was used in this instance, and there are many in circulation. Neither Breech Birth Network nor the OptiBreech Collaborative have ever produced an algorithm for use by maternity triage teams to support breech births at home, nor have we ever promoted the use of our algorithm for this purpose. We have not been informed by any sites in the south-east of England that have been using our algorithm that they have been instructed by the HSIB to stop using it.

How does the OptiBreech Algorithm align with national guidance?

The Physiological Breech Birth Algorithm (OptiBreech Algorithm) is designed to guide clinical decision-making during simulation training, to develop these skills for use in practice. The Vaginal Breech Birth training is delivered via the Royal College of Obstetricians and Gynaecologists (RCOG). The 2023 course was attended by 105 obstetricians and midwives from across the UK, and international visitors.

The description of manoeuvres in our algorithm is fully compliant with RCOG Management of Breech Presentation guidance, which states that, “If the operator has the skills of undertaking the manoeuvres with the mother in a forward position these should be performed without delay.”

In the RCOG guideline, all evidence relating to management of active second stage is based on ‘expert opinion.’ This guidance states that, “[I]ntervention to expediate breech birth is required if there is evidence of poor fetal condition or if there is a delay of more than 5 minutes from delivery of the buttocks to the head, or of more than 3 minutes from the umbilicus to the head.”

How does the OptiBreech Algorithm differ from national guidance?

Our Algorithm and OptiBreech guideline recommend that the birth should be complete within (including time for manoeuvres): 7 minutes from rumping (both buttocks and anus visible on the perineum), 5 minutes from the birth of the pelvis, and/or 3 minutes from the birth of the umbilicus. This is more conservative than the RCOG guideline and, in principle, less likely to contribute to delay in a baby’s birth – unless earlier intervention actually causes complications (see below).

The RCOG guidance was published in 2017 and is intended to be updated every three years. It has not since been updated, but that does not mean that the evidence base has not moved on.

What evidence is the OptiBreech Algorithm based on?

First version

The first version of the Physiological Breech Birth Algorithm was used in Breech Birth Network training in 2017. It was based on video evidence conducted with Dr Anke Reitter. This structured study of video evidence measured median and range interval times for a series of upright breech birth videos. We also recorded the observable mechanisms (position changes) of the breech baby as they journeyed out of the maternal pelvis, and how these related to whether attendants used interventions to facilitate the birth. From this data, we produced an algorithm, including indications that assistance is needed and which interventions were indicated.

Prior to this, training had been based on a combination of instructing attendants to remain “Hands off the breech,” or to perform a set of routine manoeuvres, each of which are only appropriate to supine positions. This was clearly causing confusion and delay.

Refinements

Midwife Emma Spillane then further tested the time intervals with a case-control design and found similar results. While head and arm entrapment only occurred once each, when interventions were used, attendants to ‘case’ births (neonatal admissions or death) waited almost twice as long to intervene as those at ‘control’ births (no neonatal admission).

How has the OptiBreech Algorithm been tested in practice?

Currently, the OptiBreech Algorithm guides vaginal breech birth management within all OptiBreech research, alongside a more detailed OptiBreech Practice Guideline. These materials are reviewed regularly within the OptiBreech Collaborative, based on reviews of their use in practice and our continually evolving evidence base. We follow a Community of Practice approach and host frequent webinars focused on developments in practice.

There are more outcome data associated with use of the OptiBreech Algorithm than any other breech algorithm we can identify. To date, we have evaluated the effects of training and service delivery based on the OptiBreech Algorithm in three prospective studies:

The training evaluation

In our 2016-2019 evaluation, obstetricians and midwives received training in ‘physiological breech birth’ based on the OptiBreech Algorithm. We compared clinical outcomes for births attended by someone who had completed the training with those not attended by someone who had completed the training. We prospectively recorded 0/21 (0%) severe neonatal outcomes when VBBs were attended by someone who had completed the OptiBreech training, compared to 5/69 (7.2%) where no clinicians present had completed the training.

The implementation evaluation

We evaluated how well thirteen National Health Service (NHS) hospitals were able to implement breech intrapartum teams and provide OptiBreech-trained professionals for VBBs, planned or unplanned. This study observed one neonatal SAE among 82 planned (1.2%) and 40 actual VBBs (2.5%). In the birth where the SAE occurred, the woman was positioned in a supine position, had spinal anaesthesia prior to the start of second stage, and Loveset’s and Mauriceau-Smellie-Veit (M-S-V) were used as instructed in the PROMPT flowchart.

Among VBBs, 34/39 (87.2%) were complete within 5 minutes of the birth of the pelvis. One was born very quickly, without an attendant, so the data is missing.

The prospective observational cohort (In Press)

Our prospective observational cohort study collects outcomes for women who receive OptiBreech collaborative care for a planned or unplanned VBB, currently across 10 NHS sites. Management of labour is based on the OptiBreech Algorithm and Practice Guideline.

In our latest analysis of data received to 8 September 2023, the database records 97 planned and 42 actual VBBs. None of them involved a neonatal SAE. Two babies had an Apgar <7 at 5 minutes (2.1%). We have interval data available for 30 of these births, and 27 of them (90%) were completed within 5 minutes of the birth of the pelvis.

Total prospective VBBs

These studies include a total of 200 prospectively observed* and 103 actual OptiBreech VBBs, with one neonatal SAE. This corresponds to a rate of 0.5% for planned VBB and 1.0% for actual VBBs to date.

(* The training evaluation did not include planned VBBs that ended in caesarean birth. These rates could change as we accumulate further data.)

How does this compare to other vaginal breech birth research?

To measure neonatal severe adverse events (SAEs), we use a composite measure, that is made up of: neonatal mortality (death, neonatal admission to SCBU/NICU for >4 days, Apgar <4 at 5 minutes, HIE Grade 3, Intubation / ventilation >24 hours, parenteral or tube feeding >24 hours, seizures or convulsions > 24 hours, peripheral nerve / brachial plexus injury present at discharge, skull fracture, spinal cord injury). This measure is based on a similar composite used in the Term Breech Trial and PREMODA studies.

In the Term Breech Trial, the neonatal SAE rate for planned VBB was 52/1039 (5.0%) overall and 29/511 (5.7%) in countries with a low overall perinatal mortality rate, such as the UK.

In PREMODA, the neonatal SAE rate for planned VBB was 40/2502 (1.6%).

In the largest study of VBB in the UK this centur y, Pradhan et al reported a low Apgar (<7 at 5 minutes) rate of 52/882 (5.9%).

Does immediate assistance result in more complications?

Among the 103 actual VBBs we have evaluated, 88.4% were completed within five minutes of the birth of the pelvis, and the neonatal SAE rate was 1%. A rate of 88.4% under 5 minutes is NOT achievable without actively encouraging or assisting the birth. Our guidance is clearly not resulting in an increase in serious complications. In our next analysis, we will look at rates of assistance and minor complications.

Who are the OptiBreech Collaborative? And what is the basis for their claims of expertise?

The OptiBreech Collaborative consists of the Principal Investigators for our research at various sites across the UK, including breech specialist midwives and obstetricians. We all support planned (and unplanned), term, singleton VBBs regularly. Names are acknowledged in our recent publications. The Collaborative is led by Dr Shawn Walker, a consultant midwife and the chief investigator of the OptiBreech studies.

The RCOG guidance states, “Guidance for the case selection and management of vaginal breech birth should be developed in each department by the healthcare professionals who supervise such births.”

You would be hard pressed to identify a lead obstetrician in the UK who has clinically led a team that has supported 200 planned, term, singleton VBBs over the past six years. That is essentially what we have done — during a pandemic, in severely stretched NHS hospitals, without the backup of clear national guidance, and often in the face of extraordinary resistance to our efforts.

We are not even certain the authors of the RCOG guidance, who are eminent, experienced and well-respected obstetricians, are regularly supervising planned, term, singleton VBBs. We certainly know that a majority of consultant obstetricians in the UK are not regularly supervising planned, term, singleton VBBs. If women are to be believed, many professionals are actively discouraging planned VBB by providing only inaccurate and/or biased information.

The RCOG guidance points to ‘an article by Evans’ (not publicly available) to describe the technique and manoeuvres to be used for VBBs in an ‘all fours’ position. We absolutely credit Jane Evans and Mary Cronk with introducing VBB in an ‘all fours’ position to UK practice with the first ever training provided, and their training was our starting point. Mary Cronk (who attended a total of 25 VBBs in her career) introduced the phrase, “Hands off the breech.” This has been widely adopted by the RCOG and other guidelines. But neither Evans nor Cronk has ever shared any outcome data. The OptiBreech effort has transparently reported 200 prospectively observed VBBs.

While we eagerly began with Evans-Cronk methods, our own experience and research has simply taught us that we get better outcomes when we assist the birth sooner rather than later, using our physiology-based, responsive approach rather than a routine set of manoeuvres. That is what we practice, that is what we evaluate, and that is what we teach.

We never expected that we would end up recommending more active intervention and liberal use of episiotomy with any delay on the perineum (after other methods are used). But there is no point in doing research if you do not believe the results and allow it to guide your practice.

What is the evidence for other algorithms currently in use?

We cannot identify a single study that has compared outcomes for VBBs before and after training based on a different breech algorithm with actual clinical outcome data that improved, other than ours.

We have identified one study (Hardy et al 2 020), which evaluated training based on the ‘appropriate manoeuvres,’ Lovesets and M-S-V. The pre-training low Apgar rate was 0/56 and post-training it was 7/80 (8.8%, p=0.041). Special care nursery admissions also increased. In our view, these methods should not continue to be taught unless someone can produce any evidence at all that teaching them improves clinical outcomes.

In 2021, we escalated our concerns to the then President of the RCOG and the Chief Executive of the RCM, who have promised us a review of current guidance. We hope, for the sake of breech babies and their parents, that this review begins soon.

We would be happy to be corrected. Please do direct us to any available empirical evidence underpinning other breech training or algorithms currently in use across the UK or elsewhere.

— Shawn

Breech-first twins

1 Reply

Women with breech presentation at term should now be offered the choice of a vaginal or caesarean birth, benefits and risks of both for her individually, and the implications for future pregnancies (RCOG, 2017). Vaginal breech birth and vaginal twin birth are both made safer by the attendance of specialist, skilled practitioners (Su et al, 2003; Barrett et al, 2013). When it comes to the combination of vaginal breech and twin births, there remains a lack of professional consensus on the safety of vaginal birth compared to planned caesarean. This is particularly true of breech presenting twins, where the first twin is breech at term, compared to twins in a vertex-breech order, which has been subject to more research.

RCOG breech guidance (2017) recommends planned caesarean in cases where the first twin is breech, but not in the case of twins where the second twin is breech. This recommendation is influenced by the Hogle et al paper (2003), which found lower Apgar scores at five minutes for breech-first twins born vaginally. However, the paper did not find any other significant negative outcomes for these babies, such as neonatal unit admissions, need for resuscitation or increased mortality. Women considering a vaginal breech birth are now routinely informed that following a vaginal breech birth, babies are more likely to have lower Apgar scores, but that this does not translate into severe illness or long-term health consequences. Therefore, breech lead twins behave similarly to singleton breech babies who are born vaginally, meaning they should also be suitable for vaginal birth depending on maternal choice.

As with many areas of breech, research studies are mostly retrospective and often reporting on small numbers. Nonetheless, evidence dating from 1998-2022 suggests no significant difference in neonatal morbidity or mortality for lead breech twins born vaginally or by caesarean, or any difference in outcomes for breech lead twins compared to cephalic lead twins (Grisaru et al, 2000). In 2020, Korb et al published their secondary analysis of the JUMODA twin study, which concluded that planned vaginal birth with a breech twin first is not associated with higher neonatal mortality or morbidity for either twin. In their systematic review, Steins Bisschop et al (2012) found no difference in neonatal outcomes between vaginal or caesarean birth for breech first or second twin. Several authors stress the value of practitioners and centres having exposure to and skills in facilitating vaginal breech and vaginal twin birth.

Where caesarean is recommended (Nassar et al, 2005; Hogle et al, 2003), these papers appear to generalize the singleton findings of the Term Breach Trial (Hannah et al, 2000), which have since been called into question. Bourtembourg et al (2012) recommend caesarean for nulliparous clients, but this is based on likelihood of vaginal birth, rather than negative impact on mother or baby. The RCOG breech guideline (2017) mentions the risk of interlocking when the first twin is breech, but the only available evidence on this is from Cohen et al in 1965; none of the studies analysed in this review cited interlocking of twins to be a significant labour complication.

The impact on maternal health was not included in many of these studies, but where this was considered, findings suggest either no difference to maternal morbidity (Bats et al, 2006); a greater incidence of postpartum haemorrhage following planned caesarean (Ghesquière, 2022); or an increased incidence of deep vein thrombosis and pulmonary embolism (Sentilhes, 2007) following planned caesarean. These findings should be incorporated into consultations on the benefits and risks of modes of birth.

According to the evidence reviewed, planning a vaginal birth with breech-presenting twins is a reasonable choice and should be approached in a similar way to singleton breech birth. However, the birth must be facilitated in a unit with staff skilled and experienced in vaginal breech and vaginal twin birth.

Are there any additional considerations?

Estimated fetal weight should be considered. Blickstein et al (2000) found benefits from planned caesarean in cases when the breech twin weighed less than 1500g. As is often the case in breech, babies weighing over 3800g were recommended for caesarean section in many studies, which means they are omitted from the current evidence base.

Jacana Bresson

New year, new course, new password, new opportunities

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Happy new year, breech advocates! We’ve got nearly 10 hours of evidence-packed, video-rich, detail-loving breech birth training content waiting for you.

Our fully updated 2022 course is now on-line. To help you reach your new year’s resolution of developing some beautiful breech skills, the course will be available at a discounted price of £50 for the first two weeks of January. No code needed; access is for one year.

Along with a new course, our Vimeo library has a NEW PASSWORD. This is available from the “Resources for Teaching and Implementation” section of any course you are enrolled in, along with our amazing Dropbox of guidelines and training resources. Registered users have permission to use the content for non-profit teaching purposes — because learning together is the safest, most effective way to do it.

More about why we change this on an annual basis.

All of our online courses also come with free access to our Online Webinars. These are one-hour discussions on topics that have arisen during the course of our practice or others’, where we share learning and reflection with each other.

https://twitter.com/MHollander2628/status/1477589281967378435?s=20

If you have previously completed any of our on-line courses, you are eligible to register for the Refresher course for only £10/year. This is exactly the same as the main course, but for a nominal cost to help us keep our platforms online. You can review the course, or just complete the assessment to obtain a new certificate for your portfolio.

Anyone organising or attending one of our face-to-face courses will be given free access to the on-line course for one year. Due to the on-going pandemic and need for social distancing, we rarely have external places to offer as we did pre-2020, but you can still host a study day for yourself and your colleagues.

If your site is participating in the OptiBreech Trial, your free online training package has already been updated.

What if I have attended an in-person course in the past? Access to the Refresher Course is only available to those who have purchased and completed one of our on-line courses, beginning in 2021. All of our previous courses have been advertised with one year’s access to our Vimeo Library. Content is updated regularly, so our recent courses are significantly expanded, based on current research, compared to those of previous years. If you have completed the main course, the system will automatically consider you eligible to take the Refresher. If you use our videos for teaching within your institution, we encourage you to ask your employer to reimburse your training so you can continue to maintain access.

Opportunities

Finally, some opportunities to become more involved in Breech Birth Network. We would really like some help with the following, and if you are willing to make a regular commitment and develop the skills necessary, we can also pay you! Emma and I developed the skills to do all this because that is what was necessary, and we know others can too.

Ideally, we would like to involve people who are supporting breech births professionally in some way, so that the learning that occurs in these roles also spills over into developing your own practice. That’s what makes it worthwhile for us. And obvs, we expect that you would have completed our training to know what you are getting into and that your approach to breech birth aligns with ours.

Online Webinatrix. We do our online webinar series ad hoc at the moment, but we’d like it to happen regularly.
Video Master. We have a large Vimeo library, but in order to make the most of it, it needs to be organised — edited, tagged, consent forms stored securely, etc.
Online education Diva. In addition to developing new content based upon new evidence or learning from practice in our communities, we have a need to develop translated versions of our courses to make them more accessible to a wider audience. We use Articulate 360 and WordPress, and although we don’t expect you to come in with those skills, we need someone who is willing to develop them to get the job done.
Accounting Guru. This doesn’t necessarily need to be a birth professional. We use Xero, and our amazing admin assistant Charlie has been doing this for us for a few years, but now needs to hand over due to other exciting things happening in her life.

If you are interested in any of these roles and prepared to make a commitment to helping our small, not-for-profit enterprise grow, please get in touch using the form below.

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.

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:

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

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

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!

NICE Guideline consultation on Induction of Labour

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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

Video Library Access

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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

I Jornada de Atención Integral al Parto de Nalgas, 23 de Abril 2020

Dr Anke Reitter and Dr Shawn Walker of the Breech Birth Network will teach together in Barcelona on 23 April at Hospital de la Santa Creu i Sant Pau. Please share with your obstetric and midwifery colleagues. Materials will be translated into Spanish for participants. Click the image below for more information on how to register.

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