Warrnambool Dreaming Weaving Panel, Lightning Ridge, Boolarng Nangamai Aboriginal Art and Culture Studio — from a previous breech-related trip to Australia
On Sunday, I am heading off to New Zealand (Christchurch & Auckland), where doctors and midwives are keen to learn more about physiological breech birth. From there it’s on to Sydney for the Normal Birth Conference 2016, where I’m excited to be giving an oral presentation about my research into how professionals develop skills to support breech birth. This is my first Normal Birth Conference, and I can’t wait to soak up the influence of so many birth researchers, including the team from Sydney currently publishing some groundbreaking papers about breech (more below). You can follow the conference on Twitter at #NormalBirth16.
I am often asked by students with a budding interest in breech birth and a requirement to write a dissertation, if I can recommend any good/important breech research papers. Why, yes, I can.
Read the Term Breech Trial. Read all of it, including all of the follow-up studies written by people who weren’t named Hannah. Critique the research and form your own opinions about if/how it is relevant to contemporary practice. Until you have completed this task, resist the urge to claim publicly that the TBT has been ‘disproven’ or ‘debunked.’ It hasn’t. It is still a powerful force, and in fact contains many relevant lessons. Finally, read the critiques of the TBT.
Now do the same for PREMODA, and if you are reading this in a few months’ time, the Frankfurt studies. At this point it will start to become interesting if you compare the reference lists of the different ‘camps’ of breech thought.
When I was starting my PhD, I did a PubMed search on ‘breech presentation,’ which returned over 4000 results. I read all of the abstracts related to management of breech presentation, and all of the articles where the abstract looked interesting/relevant. It took me about 6 months. My PhD supervisors suggested this strategy might be ‘inefficient.’ Fair point. However, it’s one of the best things I ever did, as I feel confident that I have a broad understanding of research related to breech. However, I’ve muted this suggestion, as it may not fit the time constraints of the pre-registration students. It’s just to say — there is no shortcut if you want to thoroughly understand the research base in your area of practice.
Finally, keep an eye on the group in Sydney who are currently publishing some very important papers. Mixing qualitative and quantitative methods, and focusing on the experiences of women and health care professionals, this team is producing research which complements the observational studies which have predominated in the past 15 years. Although each piece of research contains its own question, underlying them all, the wider questions are lurking: How did we get in such a muddle about breech? And how can we get out of it?
Remembering the last visit! Westmead Consultant Midwife Michelle Underwood, Obstetrician Anke Reitter, (me) Shawn Walker, and Lactation Consultant/Conference Organiser Barbara Glare
I will link a few of the Sydney papers below. Looking forward to seeing several members of this team at #NormalBirth16.
Homer, C.S.E., Watts, N.P., Petrovska, K., Sjostedt, C.M., Bisits, A., 2015. Women’s experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 15, 1–8. doi:10.1186/s12884-015-0521-4 — A large qualitative study exploring women’s experiences and what women want when planning mode of breech childbirth. Open access too.
Petrovska, K., Watts, N.P., Catling, C., Bisits, A., Homer, C.S.E., 2016. Supporting Women Planning a Vaginal Breech Birth: An International Survey. Birth. doi:10.1111/birt.12249 — An international survey exploring the support women received when planning a breech birth. The researchers found that women were generally happy with their decision to plan a breech birth and would do it again in another pregnancy. However, lack of support from their primary care providers often made this difficult to achieve.
Watts, N.P., Petrovska, K., Bisits, A., Catling, C., Homer, C.S.E., 2016. This baby is not for turning: Women’s experiences of attempted external cephalic version. BMC Pregnancy Childbirth 16, 248. doi:10.1186/s12884-016-1038-1 — Oh, thank goodness for this. The rhetoric around external cephalic version (ECV) is so strong, it almost feels a sacrilege to question it. Despite the Cochrane Review stating clearly that the evidence does not indicate that ECV improves neonatal outcomes, women are constantly told that ECV is ‘best for babies.’ Which says a lot about how reluctant to engage with the option of vaginal breech birth their providers are. This study of women’s experiences is a welcome balance to the dominant view that vaginal breech birth is only something to be considered after ECV has failed. ECV is a good option for many women, and a safe procedure in experienced hands. But it is not for everyone.
Andrew Bisits and Anke Reitter demonstrate breech skills
On the evening of Tuesday, 30th of June, 2015, British breech aficionados were spoilt for choice. There were two important premiers of breech-related films, held in two different cities.
I was privileged to attend the Newcastle premier of doctor Rebecca Say’s Breech, the product of an NIHR-funded research project. Audience members were treated to the film, intended to be an educational tool to help women with decision-making when baby presents breech, followed by a discussion about the film, its potential impact and future plans.
The film is embedded as part of a website containing further information for women, incorporating research from many sources. Say’s research indicated women access information on-line well before meeting with health professionals, and finding balanced, useful and unbiased information was difficult. Maintaining the Breech Decisions website will depend on further funding, but it is a useful, up-to-date tool at the moment. You may also be interested in Say’s qualitative research about women’s experiences of ECV (2013).
On the same evening, a group in London assembled to view the Heads Up film with Dr Stuart Fischbein, visiting from Los Angeles. The film is a passionate plea to #reteachbreech – and you can find out more about this project on this Twitter hashtag, or Dr Stu’s Blog.
Last Tuesday, 14th October 2014, obstetricians and midwives from around the world converged in the basement of the Royal College of Obstetricians and Midwives (RCOG) in London for a study day on Management of the Term Breech (#RCOGbreech). The day was originally planned to correspond with the publication of the new RCOG guideline, last published in 2006. However, the re-write has been delayed, understandably. Across the country, more and more units are not only raising the level of support for breech, they are supporting women to birth their breech babies in upright positions, something the current guideline recommends women are advised not to do.
The update authors face some tough choices: 1) continue to advise against an increasingly popular practice, alienating many of the few professionals currently supporting breech births; or 2) turn the current state of affairs upside down by … guess we’ll see when it’s published! The RCOG day was opened by the rather marvellous Mr Lawrence Impey, Oxford Consultant in Obstetrics and Fetal Medicine and co-author (with Justus Hofmeyr) of the 2006 guideline, and Mrs Anita Hedditch, Delivery Suite Senior Midwife and ECV Midwife, also at Oxford. Impey acknowledged the sense of anticipation and slight tension in the room by instructing delegates: “No heckling, and no snorting!”
However, Professor Deirdre Murphy from Dublin created little controversy with her fair and balanced evaluation of the evidence. Although her analysis was much more nuanced, following discussions, the take-home message was: With experienced support, the short-term risks for breech babies (neonatal mortality, serious morbidity) are probably not significantly greater than those for cephalic babies. Both breech and cephalic babies have increased short-term risks compared to a planned caesarean section (CS). For breech babies, the available evidence indicates that by two years of age, no significant difference in primary adverse outcomes (death and neuromotor delay) is apparent between babies born after planned CS and babies born after planned vaginal breech delivery (PVD). But babies born following planned CS face some increased risk of other medical problems.
Murphy was followed by Mich Mohajer of the Royal Shrewsbury, who presented evidence from her telephone survey about what exactly is happening around the UK for breech. ECV appears to be almost universally offered throughout England and Wales at the moment, although she found significant variations in models of care, with some units offering dedicated breech clinics and other units offering an ad hoc service on delivery suite. She found even more variations in levels of support for vaginal breech birth, with only 27% of units in England and Wales supporting VBD. Mohajer also acknowledged the importance of involving midwives with breech skills, as the facilitation of breech births has always been considered part of midwives’ expertise. These two themes: the importance of a specialist approach through dedicated clinics and ‘breech teams,’ and the value of multi-professional collaboration, were echoed frequently throughout the week.
After a brief break, Dr Leonie Penna from King’s in London presented on ‘pitfalls and pearls’ in delivering the vaginal breech. She summarised a number of common errors and helpful hints, bringing the focus onto the real gap in clinical skills which will need to be closed or bridged in order to reintroduce systematic support for planned breech births. Penna was also very upfront in discussing the reluctance of the obstetric profession to shift away from women on their backs, even with strong evidence of how helpful it is. She drew parallels with fetal blood sampling, which it is now recommended to perform with women in left lateral. With Penna’s talk, it became clear that the discussion is finally shifting away from an assumption of vaginal breech DELIVERY and towards and understanding of vaginal breech BIRTH. Finally, Penna as well emphasised the important role midwives have always played in supporting breech births at King’s.
After this, Dr Anke Reitter presented on her experience of being a part of the now-famous breech clinic in Frankfurt, and her MRI data demonstrating how significantly maternal movement affects the dimensions of the bony pelvis. Reitter (@OB_Anke) also discussed how our current understanding of helpful manoeuvres for upright breech birth – especially the first principle of rotation by the shoulder girdle rather than the pelvis – is not new. She showed captivating drawings from historic German and Australian textbooks showing nuchal arms and how to resolve the problem. Thankfully, Reitter will be returning to the UK in June to share her hands-on skills at one of our Breech Birth Network Physiological Breech Study Days.
Visiting speaker Thomas van den Akker, obstetrician and researcher from the Netherlands, reminded the audience of the RCOG’s responsibility to the developing world. In less resource-rich countries, CS presents a much higher risk to women and their future children than it does in the UK. But the world follows the RCOG’s example and demands the highest standard of care, even when it is inappropriate in that context. Van den Akker also presented data from follow-up studies by the Vlemmix team which demonstrate that per 10,000 babies delivered by CS for breech (compared to planned VBD), there were 26 neonates saved in the first pregnancy (19/7442). However, there were 27 neonates (18/6689) lost in subsequent pregnancies in a policy of trial of labour. Can we continue to recommend that first time mothers avoid a vaginal breech birth, while encouraging them to plan a vaginal breech birth after caesarean section (VBAC) in their next pregnancies?
Over lunch, Jane Evans gave a presentation of the mechanisms of breech labour, and strategies to help when help is needed. She brought along her slide show and doll and pelvis, for those who wanted to make the most of every minute available to learn breech skills.
Deirdre Murphy, Anke Reitter, Mich Mohajer, Thomas van den Akker, Leonie Penna
After lunch, the morning speakers engaged in a panel discussion about how the term breech should be managed. The relaxed mood and support for the option of vaginal breech birth was clearly emotive for some. One obstetric delegate stood up and shared how he had become a pariah among his colleagues for continuing to facilitate vaginal breech birth (VBB), and how he hoped the new guideline would be more clear about how important and appropriate it is to support VBB.
This was followed by talks by Impey and Hedditch about the evidence base, practice and their clinical experience of external cephalic version (ECV). Like many other professionals, I have made a pilgrimage to Oxford to visit their renowned clinic and learn from them and their community midwife colleague, Pauline Ellaway. They presented their most recent statistics, which like others’ (see Grootscholten et al, 2008) show a higher rate of interventions and adverse outcomes for post-ECV babies than babies who spontaneously assumed a head-first position (neonatal mortality = 0.9/1000; not significantly different from 1.3/1000, the neonatal mortality for planned VBD in the Netherlands reported in Vlemmix et al). This is a video from a Dutch team which also use a two-person approach.
This then opened up the discussion in the final afternoon panel to a point I had not previously hoped was possible: The genuine suggestion that perhaps dedicated ECV services should become dedicated Breech services, where women’s individual clinical situations are evaluated and those felt to be good candidates are offered a VBB, while those who are not felt to be good candidates are encouraged to consider ECV. (Selection criteria remain controversial, but this openness is a very good start.) The strong message was that women should have access to a high-quality, experienced ECV service, but this should not be the only alternative to CS.
Dr Joris Hemelaar also presented about rates of undiagnosed breech in Oxford, which are over 20% like most places in the UK which do not do routine third trimester scans (which are not recommended by Cochrane. Hemelaar’s point in presenting this information alongside reports on breech/ECV clinics is that we cannot offer women an ECV or detailed counselling about VBB if we do not detect the breech antenatally. However, and my view differs somewhat, as we do not yet have any evidence that the undiagnosed breech is at greater risk in the UK. Most of the available evidence indicates that the undiagnosed breech is far more likely to be born vaginally, at no increased risk. The situation is unlikely to change until more than 27% of UK units support a planned VBB, and until that time, obstetric and midwifery-led units would be wise to put a proactive plan in place so that these births can be managed with a calm, team approach.
Shawn Walker, Ethel Burns, Anita Hedditch, Andrew Bisits, Lawrence Impey, Anke Reitter, Betty-Anne Daviss
As if the RCOG conference was not exciting enough, Senior Midwifery Lecturer Ethel Burns of Oxford Brookes University made the most of international visitors to host a conference on “Breech Birth: Sharing what we know and do, and exploring best practice for the future,” on Saturday, 18th October 2014 (#Oxfordbreech). The day included repeat presentations (for a new audience) from Anke Reitter and Anita Hedditch, and Jane Evans again presented her slides, mechanisms and manoeuvres over lunch; but there were some additions.
This day kicked off with Lawrence Impey presenting the evidence base for breech birth, emphasising some of the themes from the previous Tuesday’s conference:
In selected women with high quality care baby mortality is probably little different from cephalic presentation, but is higher than ELCS
However, there may be a higher risk of obesity, asthma and other serious problems following elective CS
Maternal mortality and morbidity is dependent on emergency CS rate but unless this is >50% is likely to be increased with a polity of elective CS. This is particularly important in the developing world.
In the long term, there is a small increase in risk of mortality and morbidity to future babies through unexplained stillbirth and uterine scars.
Lost skills will mean a higher complication rate for unplanned breech deliveries, be these CS or vaginal
Impey was followed by Ruth Sloman, who has recently completed her Masters in Midwifery at Oxford Brookes. Sloman used focus groups to look at midwives’ knowledge and experience of breech births. I really enjoyed this presentation, and some of Ruth’s themes resonated with my own research, especially the value of video footage in helping professionals to learn when hands-on experience is difficult to come by, and midwives frustration at witnessing vaginal breech deliveries poorly managed and the lack of choice available to many women.
After the break, the conference continued with Dr Andrew Bisits, FRANZCOG of Sydney, Australia. Bisits’ sensitivity to women’s experiences has made him beloved of women and midwives across the globe, and his long-term commitment to supporting vaginal breech births has gained him knowledge and experience exceeding most obstetricians working in 2014. Crucial to Bisits’ talk was a recognition of how important the experience of attempting a vaginal breech birth is to some women. He also encouraged us to recognise that moderate risk-taking confers psychological benefits. Although Bisits’ talk included much more than I can summarise here, a final important point concerned the ‘atomic reaction’ which usually follows adverse outcomes in breech births, and knee-jerk responses usually preclude any genuine learning from these events. If we are to improve the safety of breech birth, it is vitally important that we learn from adverse outcomes by reflecting on them in an open and enquiring, rather than punitive way.
Reitter and Bisits are of course not only two of the most highly experienced breech practitioners in the world, they are passionate advocates for the use of upright positioning. Reitter’s clients birth mostly in all fours/kneeling positions, and Bisits’ clients commonly use a birthing stool. Their view is that it is not so much the position, as the ability of women to move spontaneously and assume the position of her choice, which matters most. The mood of both days indicated that this point has been well and truly made and heard by those writing the new guideline. The question became not so much whether upright positioning would be acknowledged as a legitimate approach, but whether or not it will continue to be considered in any way ‘alternative’ in the new guideline.
Betty-Anne Daviss visited from Ontario, presenting an encapsulated history of the women’s movement in Canada, and how this has influenced the progress they have made with breech birth. She explained the way in which the Canadian-born Coalition for Breech Birth worked with sympathetic doctors and midwives to reintroduce the choice of VBB. Remarkably, Daviss has succeeded in gaining privileges to attend VBBs in her local hospitals, and currently supports approximately 1-3 women per month to achieve their goal.
I also presented my current research concerning how practitioners learn breech skills. We need to accelerate this process if we are going to increase support for planned vaginal breech birth within the current risk-adverse maternity care culture. I’m looking forward to sharing more of this in publications as the research progresses, so watch this space! My presentation also highlighted the standard of care when it comes to maternal birth position for healthy women. NICE’s evidence-based and woman-centred approach is clear:
Women should be discouraged from lying supine or semi-supine in the second stage of labour and should be encouraged to adopt any other position that they find most comfortable. (1.7.7, current Intrapartum Care guideline)
If policy-makers are now acknowledging that VBB carries a similar risk to cephalic birth in experienced hands, then those who continue to advocate a maternal birth position (lithotomy) which deviates from the current standard of care should present evidence as to why they are doing this, rather than the other way around. Experience alone may be enough to explain it for those who have continued to safely facilitate VBDs, but the next generation and those who have taken a 14-year hiatus would do well to learn the new upright techniques as part of their standard training.
If the authors of the new RCOG guideline walk the walk as well as they have talked the talk in the past week, some major changes are a-foot. But policy changes are only a small part of what happens on the ground, evidenced by the fact that the RCOG has recommended the choice of VBD be offered to women since 2006, something that is clearly not happening universally in the UK. A major cultural shift is required, but these two events suggest that the shifting has indeed begun.
Well done you if you’ve read all the way to end of this post, and join the breech activist club! If you found other aspects of the day important and informative, please do highlight them in the comments below.
Professionals: Concerned about women waving giant sticks of burning wacky weed around their wee toes in a desperate attempt to turn their breech babies?! Take action NOW! Ensure that these women can access support for a vaginal breech birth with an experienced, trusted professional, and you will no longer have to busy yourself trying to root out such madness!
Last week the results of a trial (Coulon et al 2014) were released which appeared to show moxibustion with acupuncture ineffective in causing more babies to turn head-down. The trial had its good points. A reasonable number of women randomised (328) at the appropriate point in pregnancy (33+4 – 35+4) to use moxibustion for maximum effectiveness. This in itself was impressive, as most centres do not bother about breech presentation until 36 weeks, making recruitment for studies during this time period difficult. The team looked at the percentage of babies who remained breech at 37+2, the point when ECV (a procedure to manually try to turn the baby in the uterus to a head-down position) would be offered, and found that 72% who had the treatment were still breech, compared with 63.4% who had the placebo. They reported this was not statistically different, but superficially it looks like the treatment had the opposite of the desired effect.
On the other hand, they appear to have used actual needles, heated with moxibustion, rather than the method most commonly used in UK-based moxibustion practices, which involves using the heated sticks only. Also, the intervention and placebo were applied for only six sessions. Generally, women using moxibustion in the UK are usually taught to home-administer (usually with the help of her partner) and then instructed to follow a ten-day course, applying moxibustion twice a day, and continuing whether the baby turns or not. The ten-day, moxibustion-only practice follows a less treat-to-cure, and more treat-to-nourish philosophy, the idea being that the moxibustion nourishes the energy of the womb and promotes optimal positioning. (No swearing until I’ve finished the article, please!)
I’m a fan of observing responses to research on Twitter. (See this previous discussion on hypnosis for childbirth.) And Twitter did not disappoint. The Green Journal announced the Coulon study, and obstetricians celebrated their vindication for having dismissed the practice years ago. There’s nothing like the joy of scientific confirmation of one’s deeply held beliefs. It was as if somebody walked into a room full of midwives and said, “Hey, guess what? Continuity of carer improves outcomes for everybody!” (By the way, it does.)
But then a woman who had actually experienced a breech pregnancy pointed out the obvious: What are the alternatives? Generally, women are highly motivated to give birth vaginally (Raynes-Greenow et al 2004, Guittier et al 2011). They instinctively feel what the research tells us – that a normal birth, wherever possible, is beneficial for both babies and women. There are many hospitals throughout the Western world, including some in the UK, where women cannot even access an ECV, let alone a vaginal breech birth. I’ve had phone conversations where I’ve asked to speak with the person who performs ECVs and been told, “We don’t do that here for liability reasons.” Folks, it’s 2014.
With evidence-based counselling based on the outcomes of the Term Breech Trial, Kok et al 2008 found at least 35% of women preferred to plan a vaginal breech birth. Evidence-based counselling includes the lack of evidence of any difference between two-year outcomes whether an elective caesarean section or a vaginal breech birth is planned (Whyte et al 2004). We can reasonably conclude that if approximately 1/3 of women are not planning a vaginal breech birth in a given setting, then they are probably being directively counselled towards a caesarean section. This would include feeling forced to choose a caesarean section because no plan will be put in place to ensure attendance at a vaginal breech birth by an experienced and supportive professional.
Women resort to practices such as moxibustion and handstands in the swimming pool because they are constantly given the message that breech presentation is ‘wrong’ and should be corrected, with very few alternatives. Whereas the evidence indicates that turning babies, even with ECV, does not improve outcomes for those babies, though it certainly improves the chances of a vaginal birth in settings with minimal support for vaginal breech birth (Hofmeyr and Kulier, 2012 – Cochrane Review). I am increasingly uncomfortable with the current situation, where women do things they do not actually want to do because they cannot access a vaginal breech birth at all, or will not be supported to choose that option until they have done everything else (especially ECV).
Personally, I have no strong opinion on the use of moxibustion itself, as I generally prefer to leave the use of complementary therapies up to what works for individual women, as long as they do not pose a threat to her or her baby. I have taken training to be able to offer women advice, and I have supported women through the use of moxibustion. (We usually spend the ‘treatment’ time talking through the issues around breech birth.) When I speak publicly about breech management, someone usually asks me why I have not included moxibustion. And I tend to dodge the question, not so much because I am convinced of its efficacy or not, but because I believe it is professionals’ attitudes towards breech presentation and not the breech itself that needs to be ‘corrected.’
Let me propose this radical solution: Why don’t we channel some of that indignation over moxibustion practices into ensuring that breech services improve to a point where women will not need to look elsewhere? Let’s ensure every woman has access to a well-supported vaginal breech birth, an ECV attempted by a highly experienced practitioner, and/or a woman-centred caesarean section as late in her pregnancy as she wishes to plan it, including in early labour. Let’s ensure that women have sympathetic, experienced counselling and continuity from a midwife while they navigate these choices, and the attendance of a highly experienced consultant, ready to step up and be that expert in complications of childbirth, backing up the team at birth.
No Re-tweet, sadly 😉
While we must always make room for those who choose a different path, I suspect that if we got a bit more comfortable with breech in general, the debate over whether moxibustion has a place in the mainstream or not would fade into the distance. Stop blaming pregnant women for their misled attempts to avoid a caesarean section, and the sympathetic midwives who are desperate to help them, and sort out primary breech services.
[Note: I can only access the abstract to Coulon et al at the moment, as it has been posted ahead-of-print. I’ll update the post when it’s published, if there’s anything more to say.]
The Dutch in Old Amsterdam do it .. not to mention the Finns .. The folks in Bergen, Norway, do it .. They’re not even second twins …
This Valentine’s Day over 100 obstetricians, midwives, student doctors and student midwives assembled at Crosshouse Hospital in Kilmarnock to show some love to breech babies.
explaining the way ‘prayer hands’ help maintain alignment of the fetal head
We were privileged to be joined by Dr Susanne Albrechtsen, Head of Obstetrics at Haukland Hospital in Bergen, Norway, home of Jørgen Løvset. She has written extensively about the practical management of breech presentation and authored several epidemiological articles. Dr Albrechtsen is responsible for the Norwegian breech guidelines, and shares her expert knowledge of breech and operative vaginal deliveries through practical training throughout Scandinavia and beyond (details available through the Norwegian Medical Society). Her hospital in Bergen, which currently enjoys a CS rate of 13%, is a mecca for trainees hoping to improve their hands-on skills. Haukland, with an annual birth rate of 5000, sees 150-200 breech deliveries per year and Dr Albrechtsen herself has attended over 500 breech deliveries.
How do they do it? Dr Albrechtsen tells us: “You just have to decide that it is good for babies to be born vaginally, unless there is clearly a problem, and commit yourself to developing the skills to enable that to happen.” As she explained, a normal vaginal birth is an important programming event with life-long consequences. Evidence is growing about the links between caesarean section and future disease in the child, such as Type 1 diabetes, asthma, allergies, gastroenteritis and obesity (see Ulander et al, 2004). Dr Albrechtsen also presented her epidemiological data, demonstrating the way CS rates and rates of vaginal birth have changed over the last 40 years in Scandinavia. Particularly interesting were the way the Finns have been able to make a dramatic change within a few years, simply by making the decision to do so.
Dr Michele Mohajer Royal Shrewsbury
Dr Michele Mohajer, whose unit in Shropshire currently enjoys a 14.3% CS rate, shared with us the work of her breech clinic and her extensive experience with ECV, having performed over 1500 procedures herself, in addition to attending hundreds of breech deliveries in her career. It is reassuring to know that these skills are being maintained by expert practitioners.
Feedback from the day suggested that those attending had concerns about managing an undiagnosed breech birth, and interest in developing skills had been driven by recent experiences. This is a real concern. Approximately 3-4% of babies present breech at term, and 25-30% remain undiagnosed until labour. Consequently, an undiagnosed breech presents in labour approximately 1:100 of all births. It is in everyone’s interests that we do our best to support all women wishing to make the informed choice to labour with their breech babies, putting plans in place so that skills can be developed for when women cannot make a measured decision.
working it out together
In my view, organising small on-call teams for breech, involving both doctors and midwives, is the best way to accomplish the re-introduction of breech skills. Some research and professional opinion supports this view (Kotaska 2009, Maier et al 2011). Neither all doctors nor all midwives will be confident and keen to attend a breech birth. Ideally all staff involved will be both, but at least one well-prepared and experienced person at every breech birth is essential, for both safety and the reassurance of the woman involved. At the conference, we also reviewed the mechanisms of breech birth, counselling for informed choice, and how to help in a complicated breech birth, particularly when the woman births in an upright position. I’ve noticed more doctors attending these study days each time we do it. One young obstetrician said to me, “I needed you here about a week ago, when I got hauled over the coals for supporting a woman to [successfully] have her breech baby vaginally.” This threatening cultural atmosphere needs to change. We need obstetricians and midwives who are willing to develop the skills to facilitate breech birth in the safest possible way.
Let’s do it .. Let’s fall in love… with breech babies
This study day was organised by Geraldine Butcher, Consultant Midwife for Ayrshire and Arran, and a passionate advocate for the rights of women to make informed decisions about how to have their babies. Feedback from the study day:
“It has been a very fruitful day for me and I will use the presentations and practice to update my own. I will feel more confident in supporting upright breech birth.”
“It gives me more confidence to promote breech delivery and services surrounding breech as an option.”
“Video scenarios were very helpful. Recent undiagnosed breech presentations have encouraged us to review / update knowledge.”
Dr Susanne Albrechtsen, obstetrician and epidemiologist from Haukeland University Hospital in Norway, spoke at a Breech Birth Network study day in Kilmarnock on 14 February 2014. Read about the day.
Epidemiology is the study of patterns, causes and effects associated with conditions of disease or health in defined populations. (Information from the BMJ.) For our purposes, epidemiology helps us to understand what happens with breech presentation in large groups, enabling us to ask and answer questions such as:
What factors are associated with an increased incidence of breech presentation?
What are the characteristics of the hospitals in which breech presentation is most/least likely to be delivered vaginally, or to result in a good outcome?
What are the long-term effects associated with of breech presentation, and do they vary by mode of delivery?
Albrechtsen has been researching breech presentation for many years. In a 2004 systematic review, Albrechtsen and her team discussed the literature concerning mode of delivery for breech presentation. The article illustrates well why the external validity of the Term Breech Trial (TBT) is questionable: many centres have demonstrated considerably lower neonatal mortality and morbidity levels associated with vaginal breech birth (VBB) than those the TBT reported. They also discuss the difficulties of repeating the TBT trial design in locations with good results for breech-born babies: the lower your perinatal morbidity and mortality, the more recruits you need in your study to reach statistical significance. In Norway, Albrechtsen’s team calculated each arm of a randomised controlled trial (RCT) would require 10,000 members for two-sided testing. Clearly impractical. This review also raises reasonable questions about the research base behind the practice of external cephalic version (ECV). Although the available research suggests that the practice of ECV reduces the rate of CS for breech, there is no clear evidence that it reduces perinatal mortality. (You can read an earlier systematic review on this point, if you can read Norwegian.) We should be approaching all options – ECV, VBB, and CS – as reasonable. Albrechtsen and co. have also been making the point for some time that caesarean section does not reduce the rates of cerebral palsy (CP) for breech-presenting babies. Sadly, rates of CP among breech-presenting babies are significantly higher than for vertex babies, regardless of the mode of birth. This is because CP is most often the result of an antenatal insult (infection, growth restriction, etc.) rather than the birth itself. This has recently been confirmed in a systematic review and meta-analysis by another team. The excellent national databases kept in Norway enable these kinds of ‘big picture’ views on the outcomes for breech babies. Albrechtsen has also contributed to a significant amount of literature concerning patterns in the occurrence and recurrence of breech presentation. This includes research on the familial predisposition to term breech delivery, demonstrating that factors influenced by genetic inheritance come from both mothers and fathers. Additionally, she has looked at the effect of having a breech baby on subsequent pregnancies, covering the recurrence of breech presentation (common), rates of subsequent pregnancies and interpregnancy intervals. Understanding that having a breech baby appears to affect a woman’s attitude toward future pregnancies means that we can attempt to provide more supportive counselling in current breech pregnancies. The extensive Norwegian birth registers also enabled her to look at outcomes among siblings, demonstrating that women with recurring breech presentation represent a lower risk of adverse perinatal outcome, whereas a current breech presentation with no previous history of breech presentation is at higher risk.
“Perhaps heterogeneity exists, implying that recurring breech presentation for some women represents a normal condition with no increase in perinatal mortality” (p 775).
This article adds to our understanding about how confounding factors both contribute to breech presentation and to the increase in poor outcomes among breech babies, regardless of mode of delivery:
“The evidence is compelling that fetuses presenting as breech are affected already to a higher extent before delivery because morphologic and functional damage is more common in these fetuses” (p 775).
Routine CS is likely to improve the rate at which this minority of more vulnerable babies survive being born; but it cannot undo what has already been done. This is supported by the long-term outcomes within the TBT. We should be approaching all options – ECV, VBB, and CS – as reasonable. (This is not to say that breech-presenting babies are likely to be abnormal. The vast majority of them are perfectly normal, assuming a breech position due to genetic or accidental factors. But it does explain why, despite a widespread policy of CS for breech, we still see increased adverse outcomes for babies delivered in a breech position. And why becoming comfortable with the fact that this will occur regardless might help us improve outcomes for more women, who can reasonably choose a VBB.) Albrechtsen’s work on Secular trends in peri- and neonatal mortality in breech presentation; Norway 1967-1994 gives us some insight into why breech presentation has been the subject of fierce and passionate position-taking. In 1967-1976, 9.2% of babies delivered in breech presentation after 24 weeks died; that is almost 1:10. This figure declined significantly throughout subsequent decades, even after the CS rate stabilised, probably due to improved obstetric and neonatal care. (Preterm breech babies are at greater risk than term breech babies, born after 37 weeks.) As someone who spends many hours answering women’s questions – such as, “Why is my baby breech?” – I am grateful for Albrechtsen’s work. Some believe the TBT was the last word on the topic of breech delivery. Others continue to believe that we have much more detail to understand in order to support women well through the complex and emotional journey of a breech pregnancy.
Wow! On my way home to Norwich after an amazing day in Brighton.
The day was organised by Jenny Davidson, currently Acting Deputy Head of Midwifery at the Royal Sussex Hospital in Brighton. Jenny is an inspirational midwife, and doing great things to empower both midwives and women with breech babies. She’s nearing the end of a PhD and started the study day off with a research round-up, exploring why the heavily criticised Term Breech Trial has had such an impact on breech practice, and presenting other evidence which widens the discussion and decision-making process for breech. (See Premoda and Toivonen for a start, but Jenny had several pages of references.) The increasing amount of qualitative research revealing women’s experiences of breech pregnancy and childbirth was also discussed. (See Guittier for a start.)
Following this, Benna Waites discussed ‘talking breech’ – how we counsel women with breech-presenting babies. She stressed the importance of recognising that the risks to women of CS are not inconsequential, and of remaining non-judgemental even when women are making decisions which professionals may not feel are the ‘right’ ones. Benna, author of the ‘breech bible’ – Breech Birth – is a Consultant Clinical Psychologist, as well as the mother of a breech-born baby. She brings these important perspectives into her presentations. I hope that well-informed, deeply immersed service user advocates like Benna can in the future participate more fully in discussions around national guidelines, such as those written by NICE and RCOG.
Jane Evans continues to inspire a new generation of midwives presenting her excellent knowledge of the mechanisms of breech birth, and how to assist when help is required, built upon decades of clinical practice. Jane has authored many articles, but her more recent publications in Essentially MIDIRS should be essential reading for professionals seeking to modernise their breech practice.
Today was the first time I have had the opportunity to hear from Dr Michele Mohajer, co-author of this UK-based study) and Consultant Obstetrician at the Royal Shrewsbury Hospital in Shropshire. Michele has run a breech clinic there since 1997, where both breech and ECV have been well supported. Her ECV success rate is excellent, approximately 60%. She shared with us several of her methods for increasing the likelihood of succeeding. There are few things I like more than hearing someone with excellent clinical skills discuss their techniques. I especially admired Dr Mohajer’s discussion of the influence of gaining the woman’s trust and co-operation to her success rates. Her ECV films were excellent and a really useful practice update. I hope Dr Mohajer is also able to reach wider audiences to share her classic obstetric skills. Women who wish to have their babies turned deserve for the practitioners attempting this to have success rates as high as possible.
Hopefully others will share their personal highlights from the day. And (although this study day was sold out), we all look forward to more obstetricians and midwives attending future study days. Please do get involved, share your experiences, develop your services. As several people remarked today, it really does feel like the green shoots of change are growing for breech.