Tag Archives: for L

Jean-Christophe Lafaille and the HBA3C

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This story about a woman’s home birth after 3 caesarean sections (HBA3C) caused a bit of a Twitter storm earlier this year. OB Prof Jim Thornton has written about his involvement here – his post and the comments below it will give you a sense of what the outrage was all about. What they won’t tell you is that a significant number of maternity service users and professional advocates active in the #matexp campaign called for an end to the storm, just as they are calling for an end to disrepectful care and divided professional camps. Their work is very worthy of your attention.

What interests and concerns me is that criticism and debate around this woman’s story seems to centre on:

  1. the woman’s decision to birth her baby at home attended by midwives, after having had three previous caesarean sections; and
  2. the woman’s memory that the midwife “told me I COULD have a natural birth no matter how many sections I’d had!” – and the near universal interpretation that this permission (for lack of a better word) equates to reassuring her that it was somehow the safest or the best option.

Conspicuously absent is discussion about the woman’s description of care leading to her first 3 caesarean sections .. “As I was naive I thought I had to do what they said” .. “I was determined to have my VBAC. Until the doctor told me I was going to kill myself and my baby. So a scheduled CS was made for 38+4.” In my experience of working with women requesting support for what some might call extreme birth choices, disrespectful, coercive and often non-evidence based experiences of maternity care usually precede such apparently extreme decisions. Moderate risk-taking behaviour by a woman keen to collaborate with her care providers has been over-ruled by someone who feels they know best.

Strictly speaking, her midwives were correct: a woman CAN have a natural birth no matter how many sections she has had .. or she can try. This descriptive statement says nothing about the risk/benefit balance of such a choice, which her caregivers would certainly have discussed in detail. Women are supported to choose the mode of birth which is best for them, or they aren’t. Women are supported to choose the location of their birth, or they aren’t. ‘Risking out’ is an entirely different model of decision-making. And supporting women to exercise their own power and autonomy in low- to moderate-risk situations will potentially create fewer high-risk situations further compromised by lack of trust and respect between women and caregivers.

I would like to see more professional discussion around how we counsel women making very complex birth choices. This conversation is often difficult for health professionals because it requires an admission of vulnerability. The nature of complexity means several things could be going on at once, some of which may be new and unfamiliar and thus require more time and consideration for an appropriate response. But the nature of birth is that a crisis can emerge very quickly, and that time may not available. Experience helps. But who has a hefty bulk of experience supporting VBA3Cs?   Experience of complications is particularly valuable in such work – but how many midwives who have actually experienced a uterine rupture at home are still practising? Professionals in these situations are always out on a limb.

Does this mean health professionals should never support women making choices which increase the complexity of caring for them in labour? What should professionals’ attitudes be to such choices? One tweeter opined that the NHS should not support VBAC’s at home, because brain damaged babies cost the NHS a fortune and, “There is a limit to what you can do with other people’s money.” What exactly did the woman in question do with ‘other people’s money,’ except use the minimum required for such a birth? Should a woman be forced to have surgery because otherwise her baby might cost the health system too much? Is this really a route we want to go down as a society?

All of the outrage about women making apparently ‘risky’ birth choices contrasts with societal reactions when men make make similarly risky lifestyle choices. Stories about mountain climbers always send a chill up my spine, and one that particularly affected me was the disappearance of Jean-Christophe Lafaille during his ill-fated winter climb up Makalu in 2006. I casually stumbled upon an article in some large-circulation magazine, containing a haunting photo of his wife and 4-year-old son. I was struck by the look of loss and longing in their eyes, probably because in 2006 I had two sons of my own of a similar age. I often wonder how his wife and son are doing now.

While mountain climbers are not immune to criticism from their own community as well as those outside it, they are also glorified and funded by large companies. They usually climb with teams of people, so it is not just their own lives they are responsible for (although in the case of J-C L it was). The captivating stories of their exploits are used to promote merchandise. Even people who would never dream of scaling Makalu find their tales inspiring. The makers of the film Everest, due to be released this week, are banking on it.

Perhaps Jean-Christophe Lafaille can help shed some light on the essential humanness of risk-taking and some women’s deep desire for contact with their most basic – and essential – self:

“I find it fascinating that our planet still has areas where no modern technology can save you, where you are reduced to your most basic – and essential – self. This natural space creates demanding situations that can lead to suffering and death, but also generate a wild interior richness. Ultimately, there is no way of reconciling these contradictions. All I can do it try to live within their margins, in the narrow boundary between joy and horror. Everything on this earth is a balancing act.” (reference)

While maternity services are about safety, they should never be about enforcing some presumed collective version of what is safe onto everyone, suppressing in the process the inherently creative and often risk-taking human spirit, as well as the potential discovery of benefits in these non-mainstream choices. Nations have mountain rescue services because people will continue to climb mountains. And women will continue to want to birth their babies, sometimes in extreme circumstances. I am comfortable with my role ‘on the ground,’ so to speak, providing the standardised care which institutional systems offer and most women are happy with. I am also comfortable supporting women who metaphorically want to scale a mountain, and I will continue trying to find what sort of equipment, sustenance, maps and guidance will help them be as safe as possible while being boundary-testing humans in all their glory. I hope that maternity services can find a way through which enables more women to ‘be themselves’ in birth, as safely as possible, with an open acceptance by women and health professionals that in some instances, this may in fact come with some greater risk. I hope that maternity services can provide care which meets women’s spiritual as well as physical needs, and that judgements and coercion can recede into the past. Every woman who gives birth – however she does it – is a hero.

Shawn

(Originally written on 12 April 2015. Publication postponed due to professional blizzards.)

Related resources –

You may be interested in this article, co-written with Mariamni Plested. Plested M, Walker S (2014) Building confident ways of working around higher risk birth choices. Essentially MIDIRS 5(9):13-16 – (Archived at City Research Online)

See also the Mama Sherpas film

Record keeping

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IMG_6268 - Version 2

When attending any birth, record keeping is extremely important, both during the birth itself (to facilitate communication) and afterward.

Early this month, I attended a study day organised by IMUK (an organisation of independent midwives in the UK). The day was entitled, “Health Care Records on Trial,” and the purpose was to ensure we are all aware of best practice when it comes to record keeping, as well as some of the pitfalls to avoid ending up in court should all not go to plan. Our host and instructor, Andrew Andrews MBE, was Bond Salon‘s Director of Health & Social Care. And he was fierce! Mr Andrews inspired due diligence through his penetrating glare alone. But the day was far from dreary and fear-mongering, instead offering really clear guidance, based on illustrated examples from Andrews extensive legal experience in health care.

Mr Andrews presentation referred frequently to the NMC’s Principles of good records (2009). While I strive to ensure my records are of the highest possible quality, I am aware I have not always met the highest standard – now even moreso! – but there is always room for improvement. In addition to being a legal duty, maintaining accurate and fit for purpose records helps to ensure safety by facilitating communication between the team.

We were all keen to develop greater understanding about how to document care which falls outside of mainstream guidelines, or when women decline the care on offer. Many women engage an independent midwife when the NHS does not provide the care they have decided is best for them. We discussed in detail the criteria for offering treatment on the NHS (therapeutic effect & reasonable prospect of success) vs private treatment (welfare, well-being & reasonable prospect of success). These subtle differences can make a big difference.

poolside notesMr. Andrews is a big fan of keeping the notes with the woman and documentation by the bedside (or poolside, as I am doing in the picture to the right). The Francis Report indicated that patients should have access to their notes in real time. This ensures that those caring for a woman have immediate access to all relevant information, and she or her loved ones can highlight any errors. Poor record keeping contributes to a discontinuity in care, and this in turn puts patients at risk of harm. Collaborative, bedside record keeping also helps all members of staff to follow the core principles of:

  • Patient’s [sic] autonomy
  • Patient’s right to self-determination
  • Working in partnership with the patient as decision-maker

Care records should be chronological, but not necessarily sequential. In the margin is the time you put pen to paper, in the text is the time you did it. Events should be recorded as close to real time as possible, but must be captured within 24 hours. After 24 hours records are no longer considered ‘contemporaneous.’ No need to use ‘written in retrospect’ at all, and the expression only refers to events recorded after the 24 hour window.

We had a debate about the records also being ‘the woman’s story.’ I have mixed feelings about this. As an independent midwife, I used to give women a copy of their notes and really felt how important this story was to them. However, working in the NHS, where I frequently care for women whose clinical histories I do not already know thoroughly, I often find it tricky to wade through thick narrative notes in order to extract essential information. In my self-designed notes, I used to have three columns: the time I was recording, the clinical highlights, the story. This is my preferred system, combining the best of both purposes. In an NHS context, I may begin to use a continuation sheet for the story, to separate it from clinical information my colleagues may need to know quickly.

Mr Andrews reminded us that the purpose of documentation is to ensure patient safety and continuity of care. They are a reminder of the plan and context of care, and a means of communicating with colleagues. Failure in communication is almost always identified in serious case reviews. Therefore, he recommended records should be:

  • Bullet points
  • Captured in the context of care
  • Written with your colleagues in mind

I am inclined to agree!

You too have an opportunity to be inspired by Mr Andrew’s penetrating glare and brilliant knowledge of health and social care cases, as he will be appearing, along with Sir Robert Francis, QC, at The RCM Legal Birth Conference on Tuesday, 7 July 2015.

– Shawn

The breech and the perineum

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In an active breech birth, we aim to support and encourage the physiological process as long as it appears to be safely unfolding. When practising in this way, we have to understand why some variations occur, when they may threaten the safety of mother or baby, and how clinicians might intervene to safely assist the birth when necessary. 

Breech deliveries are not associated with an increased incidence of severe perineal damage (Jones 2000), and compare favourably to instrumental cephalic deliveries and persistent posterior positions. However, in a lithotomy (supine, legs in stirrups) breech delivery, episiotomies are commonly used to assist with manoeuvres. Manual assistance at some stage is almost always necessary when women are in this position, and an early episiotomy is considered by many to be beneficial. So much so that ‘inappropriate avoidance of episiotomy’ has been identified as a common mistake in breech simulation exercises (Maslovitz et al 2007). However, current RCOG guidelines indicate that episiotomies should not be performed as a matter of course, but according to clinical indication. So what are these indications?

In contrast, active breech births (where women assume upright positions) are associated with lower rates of perineal damage than cephalic births. In a recent study (Bogner et al 2014) comparing a small series of all fours breech births with lithotomy deliveries, serious perineal lacerations occurred only 14.6% of the time when women were in all fours, compared to 58.5% of the time with lithotomy deliveries. A majority in the latter category were due to episiotomies, rather than the mechanical process of birth.

The breech stretches a perineum differently from a head. A well-flexed, round head will displace the fanning perineum more or less evenly, spreading the tissue during the crowning process. In contrast, a bottom is softer and flatter. And other limbs provide irregular pressure.

When might intervention be helpful?

I became interested in this question due to differing information from several experienced clinicians. Mary Cronk MBE, with whom I had the great privilege to teach a few years ago, explained in her inimitable way that she was a bit more ‘scissor-happy’ with breech babies, so there must be good reason. However, other experienced clinicians feel that an intact perineum is important to maintain fetal flexion for as long as possible, and needing to cut an episiotomy should be a very rare occurrence. (See a previous discussion.)

One of Mary’s classic slides includes a birth where she cut an episiotomy because the perineum had become overstretched and was tearing in a button-hole pattern. Especially when nulliparous women give birth to frank breech babies, this overstretching may occur because the perineum does not spread and recede over the comparatively flat bottom in the same way as it does a head.

If the perineum has become abnormally distended and is causing significant delay, consider a 'perineal sweep.' If not successful, an episiotomy is indicated.

If the perineum has become abnormally distended and is causing delay, consider a ‘perineal sweep.’ If not successful, an episiotomy is indicated.

The illustration to the right depicts an abnormally distended and overstretched perineum. The baby’s bitrochanteric diameter (the distance between the outer points of the hips) has already descended past the ischial spines, and we have passed the ‘point of no return’ – the baby will be born vaginally.

The potential risks with an abnormally distended perineum are:

  • Delaying the birth at a point when the umbilicus has already descended into the pelvis and may be compressed. The fetal heart may no longer be reliably auscultated due to descent into the pelvic brim. If this is the case, assistance is warranted.
  • A button-hole tear in the mother’s perineum.

Are there alternatives to episiotomy?

When we recently met up at the RCOG and Oxford Breech Conferences this October, I asked Anke Reitter what she would do if she felt that a tight perineum was holding up a birth at a crucial point. She described to me what might be called a ‘perineal sweep.’ Similar to a cervical sweep, (with consent) the clinician inserts one finger between the breech and the tightly applied perineum, and sweeps around the perimeter, encouraging the border of the perineum to recede over the presenting part and allow the birth to proceed. She explained that this often causes progress to resume without the need to perform an episiotomy.

I found this really helpful to consider as part of my breech midwifery toolkit. As we re-develop our professional cultural knowledge about breech, it is important we continue to talk about what we do and how we do it, even those skills we feel will be rarely needed. While we strive to create the conditions for those 85% of women to give birth to their breech babies over intact perineums without assistance, we also have to be able to recognise the perineum/bottom combination which may occasionally present a problem, and how we might address this for the best possible outcome.

I would love to hear your thoughts and experiences.

Shawn

Breech birth team work

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Introducing more support for planned breech birth in your hospital setting? This post is for you.

The management of breech presentation is undergoing an important transition. In the past twenty years, we’ve gone from:

  1. Management according to the preferences of individual consultants and/or units, tending increasingly toward caesarean section
  2. Blanket caesarean section policy following the publication of the Term Breech Trial
  3. A recognition in more recent guidelines that vaginal breech birth should remain an option for women
  4. Increasing demand from women for more choice and involvement in decision-making around how they birth their breech babies

As a result, health care providers are needing to re-skill in the facilitation of breech birth, and in a way which matches women’s expectations. This requires introducing entirely new skills to manage breech births when the mother is upright and active, as women who choose to birth vaginally usually expect to be.

But transitions can be de-stabilising. Doing things ‘as they are always done’ provides some protection because team members are familiar with their roles. Each professional knows her/his place on the team. They are familiar with the range of events that might happen in this scenario, and they know by repetitive practice exactly how they will need to communicate and respond. The emergency caesarean section for the undiagnosed breech discovered at 9 cm – the team has been here before many times, and swings comfortably into action.

In contrast, a planned breech birth is novel territory. This is even more the case if the woman has planned to be upright and active, as many teams will have rehearsed emergency breech drills with the mannequin in a lithotomy position (legs in stirrups). Therefore, teams supporting this choice will need to employ different strategies to ensure effective teamwork around the time of birth.

Identify your breech birth dream team

(These suggestions apply to a planned breech birth which occurs in a hospital setting, particularly one where a planned breech service is being introduced.)Breech Dream Team

Ideally, the entire second stage and the birth of this breech baby will be primarily supported by three people. These three should be familiar with and aligned with the woman’s birth plan and each other, as any task or relational conflict will compromise decision-making ability (de Wit et al 2013, Puck & Pregernig 2014). They should each have a clear understanding of what their role in the team will be, and they should have rehearsed together the management of some common emergencies. They should have clear eye contact with each other throughout the birth, in order to confirm in an unobtrusive way the on-going evaluation that the birth is going well, or to prepare each other for the possibility that it might not be.

Each team member has a different primary responsibility:

1)   Management – This person is primarily responsible for facilitating the birth, and may be an experienced midwife or an obstetrician. Ideally, this person will be known to the woman and have experience with breech birth in general (and the type of birth the woman has requested). The birth facilitator will be intimately familiar with the woman and her wishes, as well as the mechanics of breech birth, how to anticipate possible problems, and how to assist when required. They are responsible for co-ordinating care and preparing the rest of the team to assist when required.

2)   Support – This person, usually a senior midwife, is responsible for taking over monitoring of the woman’s and baby’s well-being throughout the second stage, frequently relaying this information to the rest of the team and reassuring the woman. Positioned beside the woman, they are an important communication bridge, especially when the woman is in a kneeling position, facing away from the person managing the birth. In this position, the support professional is also placed to assist with applying suprapubic pressure and/or change of maternal position.

3)   Perspective – This person is responsible for documenting the birth and providing a second evaluation of progress. This role requires breech experience because in order to document appropriately and accurately, the person needs to understand what they are seeing. Similarly, in order to assist with the evaluation of progress, this person needs to be familiar with normal progress in a breech birth. Because of their perspective, this person is also an important communication bridge with the rest of the team outside the door (eg calling for further help, alerting paediatricians to possible complications, etc.), and may alert the managing professional to potential problems. Therefore, this role is often taken by the most experienced person in the room, such as the obstetrician or the experienced midwife who is supporting another midwife to develop her skills.

The triangle: nature’s most powerful structure

Most normal births are attended by two midwives, and this is more than adequate. But a breech birth is not an everyday occurrence. Documentation will need to be of a gold star standard. Yet in most hospitals, each person in the room will still be developing their skills with breech and will therefore need to concentrate on the task at hand, making attendance to paperwork tricky. It is also easy to become enthralled with the beauty of an unfolding breech birth.Team Triangle

Therefore, supporting breech births with a primary team of three strengthens a situation made vulnerable by its novelty. A triangle is one of nature’s strongest structures; this mini-team is strengthened, given a base by the addition of perspective. Given the importance of documentation in any higher-risk birth, triangulation of data (eg strengthening the accuracy by using different sources) also makes practical sense. The triangulated team increases everyone’s safety in a novel situation.

Interestingly, many women instinctively form their own triangles, involving two supporters. The third person in this triangle also provides additional support, strength and perspective for both her and her partner.

Continuity: the way forward

Continuity of carer – ensuring a woman knows the professional who will be facilitating her birth, and ideally the entire team – has known, evidenced benefits. Fewer interventions, greater satisfaction. Knowing who else will be in the room, and what their role will be, will also help the woman to feel more relaxed and reassured about the upcoming birth.

Continuity has benefits for providers as well, especially when it comes to facilitating non-standard care. A number of sources have suggested on-call teams for breech births as the way forward (Kotaska 2009, Daviss et al 2010) and on-call midwives are a middle ground. Especially when experience is minimal, preparation is key. Where an on-call team is not available, the entire team who will be attending the birth should be identified when the woman is admitted to hospital, and again at handover if appropriate. This team should have a thorough discussion about roles and responsibilities, and a run-through of the ‘fire drill’ if things do not go as planned, well before second stage requires the additional team members to attend.

The team should meet afterwards to review the birth and identify if any group work issues have been identified that can be improved for future births. This review should involve the obstetric labour lead, a midwifery manager and/or risk management midwife if the breech service is new to the maternity team. A reflective approach in the early stages will pay off in increased safety and a more confident, united team in the long run.

Further information and inspiration for your dream team

Teamwork is crucial to the safety of breech births. Michael West has written extensively about the characteristics of ‘real teams,’ as opposed to ‘pseudo teams.’ Real teams have clear, shared team objectives; role interdependence and role clarity; and they meet regularly to review and improve performance (West, 2014). If we are to successfully change the culture of breech birth, and support women as safely as possible as we develop our skills and experience, we must function as real teams.

West, M.A., & Lyubovnikova, J. (2013). Illusions of Team Working in Health Care. Journal of Health Organization and Management, 27(1), 134-142. (more from West)

You may also be interested in this article: Plested M, Walker S. Building confident ways of working around higher risk birth choices. Essentially MIDIRS 5(9)13-16.

How have you prepared your teams to support planned breech births?

Shawn

Dolichocephaly – understanding ‘breech head’ molding

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This post is about dolichocephaly, a form of positional molding which affects some breech babies – how it happens, why it may be important, and how to recognise it.

If you permanently link to this page, please use the new site: https://breechbirth.org.uk/2014/04/dolichocephaly-understanding-breech-head-molding/

Everyone is concerned about entrapment of the after coming head in a breech birth. And it seems so unpredictable. Many breech babies, even large ones, seem to just fall out. And then others, not so large, get stuck. RCOG guidelines suggest an estimated fetal weight above 3800 g is ‘unfavourable’ for vaginal breech birth, but goes on to say, “If the baby’s trunk and thighs pass easily through the pelvis simultaneously, cephalopelvic disproportion is unlikely.” (Easily is undefined, but in light of the evidence against augmenting breech labours, I interpret it as occurring spontaneously within about an hour of active pushing.)

Can we predict which babies’ heads are more likely to have difficulty passing through the pelvis? I don’t know, but I feel one phenomenon in particular deserves more attention – dolichocephaly.

Dolichocephaly developing due to positional pressures

Dolichocephaly developing due to positional pressures

Technically, dolichocephaly is a mild cranial deformity in which the head has become disproportionately long and narrow, due to mechanical forces associated with breech positioning in utero (Kasby & Poll 1982, Bronfin 2001, Lubusky et al 2007). This change in shape is more commonly associated with primiparity (first babies), larger babies, oligohydramnios, and posterior placentas, all of which result in greater forces applied to the fetal head.

(Note: Like all positional molding which occurs in utero, dolichocephaly does not in itself cause nor indicate abnormal brain development. The head shape is highly likely to return to completely normal in the days and weeks following birth, especially if baby receives lots of holding and cuddles to permit free movement of the head.)

Clinical Importance

Following the birth of the arms in a breech birth, the head will be in the anterior-posterior diameter of the pelvis. When the head shape has become abnormally elongated, the longest diameter of the fetal head will meet the shortest diameter of the maternal pelvis at the inlet. Unless the baby is still on the small side and the pelvic inlet very round, the chin may get stuck on the sacral promontory, preventing head flexion. A very experienced breech provider will have encountered this situation before, and should be able to assist, but it is quite a tricky place to be. The head may need to be rotated into the transverse diameter to safely enter the pelvis. A very elongated head can have difficulty passing through the lower pelvis as well, and can cause damage to the maternal pelvic floor, unless appropriate techniques are used to assist the head to flex.

Effects of abnormal head molding in some breech-positioned babies

Abnormal head molding in some breech babies

Estimation of fetal weight by ultrasound is notoriously inaccurate. However, a lack of proportionality between the head circumference and the biparietal diameter is more obvious to spot (e.g. HC=90th percentile, BPD=60th percentile; or a difference in correlating dates of two weeks or more), and may be a more relevant indication that this baby is too big for this particular woman. Dolichocephaly can be discerned on palpation as well, as the occiput is prominently felt above the fetal back, the head is not ballotable, and may feel unusually wide. I would suggest caution where estimated fetal weight is above 3500 g and a difference in HC and BPD, or careful palpation, indicates abnormal cranial molding has occurred, especially for women who are having their first baby, have a low amniotic fluid index, and/or a high posterior placenta; and in situations where imaging pelvimetry is not used to confirm an ample pelvic inlet.

Counselling Women

Women instinctively do not like weight limits used as ‘selection criteria.’ One woman (Ann, multip, 6’1”) looks at another (Carol, primip, 5’0”) and they both think – We can’t possibly be expected to have similar-sized babies. While Ann may carry a 4000 g baby with no abnormal head molding, and expect a straightforward birth, Carol’s baby may begin to show signs of dolichocephaly at 3300 g, especially if she has low levels of amniotic fluid and a posterior placenta. Carol may still have a successful birth, but it will more likely depend on the skill and experience of her attendant in assisting the aftercoming head to flex, rotate and negotiate the pelvic diameters, and the pelvic diameters themselves.

A 'normal' breech baby - well-flexed, with lots of room to move

A ‘normal’ breech baby – well-flexed, with lots of room to move

We need to move away from the concept of ‘selection criteria,’ which are used by professionals to make decisions for women, and towards an understanding of what is ‘normal for breech.’ We need to understand more about which babies are more likely to experience those beautiful, often-easier-than-cephalic, dancing-into-the-world births, and which babies are truly being put at additional risk by their in utero conditions.

Then we will be able to explain to women the benefits of a caesarean section for pregnancies which have become ‘abnormal.’ Women will be able to approach this intervention with an open heart when they observe professionals are truly supporting ‘normal’ breech births and providing individualised care and screening to those which are not.

I would love to know what others think about this.

Shawn