Tag Archives: breech team

Stockholm and the breech

This weekend, I have been lucky enough to visit Stockholm, Sweden, at the invitation of the Södersjukhuset (BB SÖS), with Dr Andrew Kotaska, author of the 2019 Canadian breech guideline. We delivered training in breech research and practice to obstetricians and midwives from across Stockholm, a contribution to their recent effort to establish city-wide guidelines.

Breech Team Leader Tove Wallström and Breech Midwife Monica Berggren

The day was organised by senior obstetrician Julia Savchenko (pictured with Andrew above). Julia and fellow senior consultant Tove Wallström lead the Labour Ward and the SÖS breech team. These inspirational women presented their local audit results, showing how their vaginal breech births have increased from 9 in 2014 to 50 so far in 2019. Almost all women give birth in an upright position, and all births are attended by a breech-experienced obstetrician and a breech-experienced midwife from the breech team.

Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre

It was exciting to see a ‘Breech Team‘ service working so well in the largest maternity hospital in Stockholm. The team are able to take referrals for women pregnant with a breech-presenting baby at term who wish to give birth at SÖS. They can also provide training for other teams in Sweden who wish to improve the safety and delivery of their own services, using their own resources and presentation materials provided by the Breech Birth Network.

To ask about referral or training, please contact Julia and Tove using the form below.

Typical Swedish post-birth meal — a step up from British tea and toast!

Each family places a pin in the board to celebrate their birth as she leaves SÖS

Busy hospital!

For more information about training outside of Sweden, please see our Booking a Study Day page.

For information about training or referrals for a vaginal breech birth in Sweden, contact Julia and Tove:

Breech Team Lanyard Pins!

We are thrilled at the interest these pins are receiving. We have created them to make it easy to identify people who have attended our Physiological Breech Birth study day and are either on a breech team or working with Breech Birth Network to create a breech team in their work setting. More information below, with the form to request pins at the bottom of this post. We are going to maintain this criteria strictly so that it is meaningful, but we will consider additional designs in the future.

In a few weeks, we will receive our new breech team pins from @madebycooper, based on our Breech Birth Network training booklet cover image by Merlin Strangeway (Drawn to Medicine).

We have created these pins because my research (Walker et al 2018open access version) indicates that the three elements which develop and sustain expertise in breech birth are:

  • affinity
  • visibility
  • relationship

Expertise is generative — it generates comparatively good outcomes, and confidence and competence among colleagues. The role of a breech team is to develop expertise in order to support the entire team to support vaginal breech births safely.

Breech teams enable the development of expertise within organisation because team members  work flexibly to attend breech births when they occur, enabling them to acquire clinical experience. Once new team members develop their own skill and experience, they continue to attend births as an extra layer of support for the wider maternity care team, maintaining their own expertise while promoting confidence and safety.

Walker S, Parker P, Scamell M, 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209. https://doi.org/10.1111/birt.12326

Some Trusts have a specific on-call system. But most find that making their breech team visible is enough to introduce cultural change supporting the development of expertise. One simple way to do this is to designate a breech team (including obstetricians and midwives) and post a list of people and how to contact them in a prominent position on the labour ward. Make it an expectation, backed up by the Trust guideline where possible, that someone from this team is involved in any episode of breech care wherever possible. Sometimes it is not possible. But most of the time it is, even without a rigid on-call system.

A team member should be involved from the moment a term breech is diagnosed, whether antenatally or in labour. Individuals who have developed generative expertise counsel very differently from those who are still developing their skills or are not keen on breech birth. “Facilitating an informed consent discussion that demonstrates respect for maternal intelligence and autonomy, while being realistic about the inability to guarantee a perfect outcome” is also a skill that develops with practice (Walker et al 2016, p11 — open access version).

Walker S, Parker P, Scamell M, 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209. https://doi.org/10.1111/birt.12326

These pins will increase the visibility of breech teams by reminding women that physiological breech births are supported, countering negative portrayals in the media and social discourses of risk, and remind maternity staff that involvement of the breech team is available and expected.

Breech team lanyard pins will be available for FREE from the Breech Birth Network, CIC. To wear the pins:

  • Each member of your team who wears a pin must have attended one of our Physiological Breech Birth study days. If this hasn’t happened yet, you can easily book a study day at your hospital.
  • Your team must contain at least one person who has taught breech skills with us on our Physiological Breech Birth study days (more information on how to do this is on the page). The network pays your expenses to do this, but we need to confirm we are on the same page with the skills and content. Teaching is also one of the mechanisms through which breech expertise develops.

To order pins for your team, contact us using the form below.

Love,

Shawn

 

 

Bruxelles et le siège

Training in Lewisham on November 12 — Book here.

“We believe that we do well what we do often.” – Caroline Daelemans

Drs Caroline Daelemas and Sara Derisbourg

Contact Hōpital Erasme Clinique du Siège on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be.

This month I visited Hōpital Erasme, in Brussels, Belgium. Led by Lead Obstetrician Caroline Daelemans, Erasme began to offer a dedicated Breech Clinic in December 2015. Much of the organisation and development of the clinic has been done by Dr Sara Derisbourg, who continues to research the impact of instituting a dedicated breech service.

I came to Brussels to provide our usual physiological breech study day. The breech team has transitioned to using physiological methods, including upright maternal positions (Louwen et al 2016), after attending training in Norwich in 2017. They now needed the rest of the team to understand the philosophy behind this approach. But the day began with Caroline describing the impact of instituting a dedicated Breech Clinic, and this was particularly exciting for me.

Josephine and Thiago talk about their experience of Ulysse’s breech birth at Erasme

My own research concerning the development of breech competence and expertise, and the recovery of these skills within a service, indicates that developing a core team with significant experience is the most effective method of safely offering a vaginal breech birth service (Walker et al 2016). This skilled and experienced core is more important than the ‘selection criteria’ that are used to predict the likelihood of a good outcome (but in fact are not very predictive). Skill and experience facilitate good outcomes and enable other colleagues to develop competence (Walker et al 2018). The Erasme team even encourage other health care professionals to come with their clients and attend them in labour with their support, to encourage the growth of breech skills.

The need for new ways of organising care has been emphasised in an on-line survey of Dutch gynaecologists just published by Post et al (2018, Does vaginal breech delivery have a future despite low volumes for training?): “Potential suggested alterations in organization are designated gynecologists within one centre, designated teams within one region or centralizing breech birth to hospitals with a regional referral status. Training should then be offered to residents within these settings to make the experience as wide spread as possible.”

Daphne Lagrou of Médecins Sans Frontières demonstrates shoulder press

Daelemans and Derisbourg began with a small team of 5 people. This has gradually expanded and now includes eight members who together provide 24/7 cover for all breech births within the hospital. Women with a breech presentation are referred by colleagues and increasingly by other women. The environment at Erasme is ideal because the hospital has a very positive approach to physiological birth in general, and a 15% overall caesarean section rate in 2017. This compares to 20.2% in Brussels and much higher in many places globally.

Practising collaborative manoeuvres for resolving head extension at the inlet of the pelvis (elevate & rotate)

What has the Breech Clinic changed? Before the introduction of the clinic, the planned vaginal breech birth rate was 7.19%, and in just a few years this has climbed to 42.7% of all breech presentations. Neonatal outcomes have remained stable. Actual vaginal breech births have climbed from 4.2% to 35.96% of all breech presentations within the hospital. The success rate for planned vaginal breech birth is 76.3%, which suggests that within experienced teams, the emergency caesarean section rate is also reduced. (The RCOG guideline suggests about 40% of planned breech births end in CS.)

All of this is very impressive. The message is clear: a physiological approach and an organised care pathway, including a breech clinic and experienced on-call team, can reduce the caesarean section rate significantly without negatively impacting neonatal outcomes. We should all look out for Derisbourg’s papers when they are published.

If you are a woman seeking support for a physiological breech birth, or a health care professional looking to refer a woman to the breech clinic, they can be contacted on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be. Caroline Daelemans will be teaching with me in Lewisham, London, on 12 November.

— Shawn

Breech in Belfast

Consultant Obstetricians Niamh McCabe and Janitha Costa, and Breech Specialist Midwife Jacqui Simpson

The Breech Birth Network visited Belfast this weekend. Dr Anke Reitter FRCOG of the Krankenhaus Sachsenhausen and I taught a day-long physiological breech study day at the Royal Victoria Hospital for over 40 obstetricians and midwives.

The day was organised by Consultant Obstetricians Janitha Costa and Niamh McCabe, enthusiastic upright physiological breech practitioners, and Senior Registrar Shaun McGowan. The team have recently published outcomes associated with their breech clinic (Hickland et al 2017 and Costa 2014).

Our study day increasingly emphasises pattern recognition and decision-making through the use of real breech birth videos, especially videos of complicated births. We watch, deliberate and critique – with compassionate understanding, respect and humble appreciation. These brave health professionals and women have allowed themselves to be vulnerable and exposed in order that others may learn, and we are very grateful.

We have also moved away from using heavy and expensive simulation models and rely instead on doll and pelvis models. These enable us to see what is happening from all angles and embed the theory of the manoeuvres we are teaching. We operate on a see one (the theoretical presentation), do one (hands-on with one of the instructors), teach one (of your colleagues) model. This helps build confidence to carry on teaching the techniques in the local setting.

Our preferred models (it’s a great idea to have some on hand if you are organising a study day or implementing this training in your local setting) are:

Fetal Doll Model; and

Cloth Pelvic Model; or

Female Pelvis Model

Final announcement: Blogging has resumed because … I submitted my PhD a couple weeks ago! Hurrah!

Shawn

Krankenhaus Sachsenhausen is also on Facebook!

“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