Tag Archives: informed choice

Webinar 30 August 5PM: Testicular complications of vaginal breech birth

OptiBreech position on home breech birth

Dr Shawn Walker, Consultant Midwife and Chief Investigator, explains the OptiBreech position on planned vaginal breech birth at home.
OptiBreech position on home breech birth — The OptiBreech Project

Becoming a Breech Specialist and Setting up a Breech Service within the NHS

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Since the publication of the 2017 RCOG guidelines on the Management of Breech Presentation, mothers have, in theory, been given more choice in their options relating to mode of birth. Unfortunately, anecdotally this does not seem to be the case for all. Many units across the UK do not have dedicated services for mothers found to have a breech presentation at or near term. Therefore, they are potentially missing out on receiving balanced information regarding their choice of mode of birth. Finding out your baby is in a breech presentation at this late stage of pregnancy can be upsetting for some, birth plans have been discussed and made, excitement is building for the new arrival and then suddenly this seems to all be turned upside down. More decisions have to be made, that’s if the choices are offered to parents. Having a dedicated breech clinic, run by those knowledgeable and experienced in breech presentation, can help to allay some of the worries and concerns experienced by parents and ensure all evidence-based options are discussed in a balanced way. The clinic enables a two-way dialect between healthcare practitioner and mother in a supportive environment. In the current financial climate of the NHS it can be difficult to set up new services, however, the mother’s well-being must come first. Additionally, the skill of the practitioner is key to ensuring safety. The RCOG states:

“The presence of a skilled practitioner is essential for safe vaginal breech birth.”

And

“Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.”

But with the decline in the facilitation of vaginal breech birth over the past two decades how do we ensure as healthcare practitioners that we are skilled to facilitate such births? This post aims to describe one way to increase knowledge, skill and experience in this field and how to set up a breech service within an NHS Trust to ensure mothers really do have all the options open to them for mode of birth with a breech presentation.

Teaching physiological breech birth at City, University of London

The first step to gaining knowledge and experience is to become involved in teaching. This has many benefits including, increasing your comprehension and embedding that information so you can pass it on to others; enables people to recognise you as breech specialist and it helps to build confidence when discussing with colleagues and parents alike. The more you are teaching the greater your understanding and the more people will recognise you within this role as a breech specialist. It is vital to keep your own skills up to date if you are putting yourself forward as a specialist, teaching both locally and assisting with teaching through the Breech Birth Network, CIC will help you keep up to date with the latest evidence and move things forward within your own constabulary. The team at the Breech Birth Network, CIC are very keen to support others to teach on our Physiological Breech Birth courses. You can read the following blog post for more information on the benefits of teaching Physiological Breech Birth with the Breech Birth Network, CIC.

Other ways to get involved with teaching are within the University and to the students coming through the local hospitals, these are the midwives of the future and this is where the biggest change is going to come from. Likewise, speak with the lead Consultant Obstetrician for new doctors starting in your Trust to see if you can teach them a shorter session on their induction days. This enables the new doctors coming into the hospital an awareness of what will be expected of them in terms of offering choice and ensures they have an understanding of both the mechanisms of breech birth and recognising complications. Additionally, setting up a weekly morning teaching session for thirty minutes ideally after handover so those finishing the night shift and those starting the day shift can both attend. This can be done as a case discussion or a scenario using a breech birth video. You could even use a breech birth proforma (if you have one) and ask those attending to complete the proforma whilst watching a video to see if they understand about the timings for a physiological breech birth and when to intervene. Speak to the Practice Development team and ask if you can teach the breech sessions on the mandatory training days too – moral of the story…teach, teach, teach!!

Of course, with all this knowledge and skills you are teaching you need to put it into practice. Put yourself forward at every opportunity to attend breech births both to facilitate them yourself and to support others to gain confidence in facilitating vaginal breech births. Clinical experience is essential. Research has shown, to maintain skills and competence the breech specialist should attend between three to ten breech births every year (Walker, 2017; Walker et al, 2017; Walker et al, 2018). In some smaller units this may be difficult to achieve but by making yourself available to attend births you will have a far better chance at getting these numbers in practice. There is also evidence which suggests that you can create the same complex pattern recognition by watching videos of vaginal breech births, both normal and complicated, as you can by attending breech births in real-life (Walker et al, 2016). Watching videos has the added benefit that you can rewind and re-watch parts of the video to ensure understanding and further analysis.

Setting up a breech birth service would be an excellent next step. Firstly, find a Consultant Obstetrician who is supportive of physiological breech birth and who would help to lead on service development with you. This has to be a multi-disciplinary approach other wise it just won’t be sustainable or safe. The best way to move such services forward is with consultant support and input, don’t try and do it on your own. A breech birth clinic is a good starting point for any service development, this will provide midwife-led and consistent counselling for parents attending the clinic. Depending on the size of the hospital, running the clinic once a week should be adequate initially. Setting up a dedicated email address for all referrals to be sent to is a great way to ensure referrals are not missed and there is a clear pathway set out. The following is an example of such a pathway:

Breech service referral process at St George’s University Hospital NHS Foundation Trust

Referrals can be made by any healthcare practitioner, but it is a good idea to link in with the sonographers performing the ultrasound scans. They may be able to send the details of the mother via email immediately following the scan and give the parents an information leaflet. This avoids any delay with the referral being made by another healthcare practitioner and ensures the counselling remains consistent. Moreover, the development of ‘breech teams’ is supported in the literature to ensure there are breech specialist midwives and doctors on every shift, or on-call, to support the wider team to gain their clinical skills to facilitate vaginal breech births and increase safety for mother and baby.

To further develop the service and your own skills you could complete a midwife scanning course. This will enable you to scan mothers referred into the breech service to check presentation before sending for a detailed scan. The advantages of this is that mothers could be referred into the clinic earlier, from thirty-four weeks gestation based on identification on palpation. Research has shown mothers find it difficult making decisions about mode of birth for breech presentation so late in pregnancy and would benefit from earlier referral and discussion. Referrals made at thirty-four weeks gestation with a bedside midwife scan to assess presentation, would enable the counselling to begin sooner giving more time for decision-making. An additional advantage of being able to scan is following mothers up after successful external cephalic version (ECV). Seeing mothers, a week after successful ECV enables you to scan the mother to ensure the baby has remained in a head-down position avoiding unexpected breech births. An adjunct to the scanning course would be to learn to perform ECV’s. This enables a fully midwife-led service and research has indicated comparable rates of success for ECV’s performed by Midwives and those performed by Obstetricians. It is also cheaper for the Trust to have ECV’s performed by Midwives!

Governance and audit are the final steps to take to building the specialist breech midwife role and for service development. This is often seen as the mundane part of the job, but you will benefit greatly by doing this, not just from immersing yourself in all the research but by knowing your service inside and out. Knowing what needs to be changed and what has improved. The first step in governance change is to write the guidelines incorporating physiological breech birth, new evidence relating to breech presentation, service development, the breech clinic, referral pathways and training. An example of a current guideline can be found via this link. Develop an information leaflet to give to parents which contains the latest evidence in relation to breech birth options. It can be given to the mothers either by midwives in the clinic and/or by the sonographers after their ultrasound confirming breech presentation. The following can be used as an example and is editable for use in your organisation.

Breech information leaflet developed by the Breech Birth Network, CIC

Finally, audit, audit, audit! Before, after and everything in between! This is your evidence that things need to change and, once the service is developed, the outcomes since you implemented all the aspects of the service. It will also act as evidence of safety which the governance team within the organisation will want to see. Audit rates of planned caesarean, emergency caesarean, planned VBB, successful VBB, neonatal outcomes, maternal outcomes, uptake of ECV, success rate of ECV etc. All before and after the service. It is also a good idea to obtain service user feedback. Developing a simple questionnaire such as this one enables you to easily send and receive feedback regarding the service. Feedback from service users is the most powerful way of moving services forward and supporting change within an organisation, it also enables you to develop the service dependent on the needs of the parents using it. The process of audit and user feedback is continuous throughout the time running the service. However, it is important analyse and present the result at regular opportunities such as at local level with clinical governance days and meetings and at a wider national level at conferences and in journals.

Whilst it can seem daunting and places you in a seemingly vulnerable position, starting your journey as breech specialist is an extremely rewarding one which will enable you to learn and develop new skills not just clinically but operationally and strategically. It will give you a stepping stone into research, audit and teaching, build your confidence as a practitioner and most of all, empower you to provide the best evidence-based care for those families who need that knowledge and support at a crucial time in their pregnancy to help them to make the right decision on mode of birth for them and their breech baby.

Following the implementation of all that has been discussed in this post, the results within the large teaching hospital I work are as follows:

Planned caesarean section increased from 55.8% (n=43) to 62.9% (n=66);
Unplanned caesarean section decreased from 42.9% (n=33) to 24.8% (n=26);
Vaginal breech birth increased from 1.3% (n=1) to 12.3% (n=13)

All results are for those over thirty-six weeks gestation, there were no differences in neonatal mortality or morbidity prior to or following the implementation of the service. This is a positive change and shows how supporting vaginal breech birth in a safe environment can increase the normal birth rate. The results are after a year of implementing the service and will hopefully continue to improve as time goes on and more midwives and doctors become more confident to facilitate breech births.

Emma

Building confidence and changing practice through participation on training days

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Emma Spillane

Emma Spillane, Training Co-ordinator at the Breech Birth Network, has attended six breech births in the last six months in an NHS hospital. Rebuilding breech skill is possible, guided by evidence about how breech competence develops. Emma writes about how she gained confidence in teaching and attending physiological breech births by assisting at Physiological Breech Birth study days.

In January 2017 I attended a Physiological Breech Birth study day in Norwich by Dr Shawn Walker and Dr Anke Reitter. Breech birth had always interested me from my first breech birth as a newly qualified midwife. I didn’t understand the physiology of breech birth at this time, it had always been taught as something abnormal, an obstetric emergency. I could never understand though, how breech birth could be so abnormal if babies were on occasion born like this. My interest had been piqued, and so a few years later, and a few more breech births later, I found myself on the study day to develop my knowledge and skills in vaginal breech birth.

The study day taught me the tools required for supporting women to have a physiological breech birth and to resolve possible complications whilst supporting physiology. Following the training I went and introduced myself to Shawn and told her of my interest in breech birth, I felt so inspired to start a breech birth service within the trust I work. On my return to work I started putting plans in place to develop a service within the trust. Shawn contacted me a few days later and invited me to help teach the hands on clinical skills on her next Physiological Breech Birth training day in South Wales. I jumped at the chance to attend and found it so useful to listen to the day again and then help with the hands on teaching. It helped to embed what I had already learnt previously and give me the confidence to teach the skills within my own trust.

I started talking about breech, a lot! Shawn continued to invite me to help on training days and with each one my confidence grew. I started viewing the videos differently. Instead of looking for what was ‘normal’ and ‘abnormal’ I started analysing them with a deeper understanding of the physiology. Shawn also encouraged me to start teaching parts of the presentation. Admittedly I was more than a little ropey to begin with but with Shawn’s nurturing and encouragement and the more I learnt from each training day, each time I attended my confidence grew. Eventually I was able to transfer this new knowledge, understanding and confidence into practice. I was asked to attend a breech birth!

I supported a woman with a physiological breech birth, along with a consultant obstetrician colleague and one other midwife. An arm complication occurred with the birth, and I was able to resolve using the manoeuvres I had learnt and taught on the course. The baby was born in good condition, and I felt relieved and elated! I immediately contacted Shawn to tell her about the birth but it had also sparked an interest in the consultant obstetrician who had attended. We debriefed from the birth and I spoke about the Breech Birth Network and the training it offers. I took the opportunity to ask if my obstetric colleague would like to be the lead consultant in my quest to set up a breech birth service, to which they agreed. It had taken me nine months – the length of a full term pregnancy – from when I first attended the training until this physiological breech birth. It was the birth of an exciting change in knowledge and culture.

Claire Reading, Emma Spillane and Shawn Walker

Attending training days has not only helped to embed my own learning but it has given me the skills and confidence to set up a service within the trust I work, support women who choose to have a vaginal breech birth and support colleagues to facilitate breech births themselves. I have found repeating the information and skills has been the key to my learning and enabling change within practice. It has given me the confidence to attend births and increased the number of breech births within the trust by instilling confidence in others. If you would like to build your confidence in vaginal breech birth, develop a service within your trust and teach others I highly recommend coming along and helping at future training days. You can view a list of upcoming opportunities to help deliver training here. Please let us know by getting in contact via email or the contact form.

Emma

Research indicates that providing teaching is an important part of the development of breech expertise. Read more: Expertise in physiological breech birth: A mixed-methods study

Fantastic talk from @spillane_emma on upright breech birth #BICS18 @BicSoc At @RLHMaternity @RoyalLondonHosp we are counselling all our women who choose vaginal breech delivery about giving birth in all fours – and training our staff to support them @MatthewHogg9 @alihbirth

— Susie Crowe (@susannacrowe) June 18, 2018

New RCOG guideline published today!

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The new RCOG Management of Breech Presentation guideline has been published today. This guideline substantially revises recommendations in the previous version, published in 2006. If followed, it will undoubtedly improve women’s access to and experience of breech care. Below I will highlight two of the new guideline’s game-changing recommendations, and then raise two key questions concerning areas of on-going exploration.

Reference: Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. BJOG 2017; DOI: 10.1111/1471-0528.14465.

Victoria and Kirin Owal celebrate the healthy birth of their twins (#2 breech) with their NHS Team.

Counselling (Section 4.1)

The guideline offers specific recommendations around counselling, following the summary presented by lead author Mr Lawrence Impey at the RCOG Breech Conference in 2014. When discussing perinatal mortality, rather than focusing on the dichotomy between elective caesarean section at 39 weeks (0.5/1000) and planned breech birth (2.0/1000), the guidelines also recommend women consider these figures in light of those for planned cephalic birth (1.0/1000).

@SisterShawnRM “Women near or in active 2nd stage of labour should not be routinely offered caesarean section [New 2017]” #breech @RCObsGyn

— Oli Silverwood-Cope (@olvindaRM) March 17, 2017

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This is important. If we follow the logic that has dominated breech care for the last 17 years – elective CS for all because it reduces perinatal mortality – we would need to apply this to planned cephalic births as well. The truth is always somewhere in between. All childbirth options carry benefits as well as risks, and women should be supported to apply their own values to decision-making, rather than feel obligated to adopt uniform recommendations arising from contemporary risk-focused discourse. This new guideline is much clearer about the obligation of health care professionals to present women with genuine breech childbirth options.

Maternal birth position (Section 6.7)

The guideline has changed from recommending lithotomy birth position to the following: “Either a semi-recumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant.” This will be joyously welcomed by midwives and obstetricians who have been gradually incorporating upright breech methods into clinical skills training for some time, and the women who have been insisting on the freedom to choose their own birthing position.

Shame Louwen and Reitter’s paper on #breech in upright position wasn’t reviewed for @RCObsGyn #breechGreentop https://t.co/W1nMdodrET

— Oli Silverwood-Cope (@olvindaRM) March 18, 2017

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But as the explanatory notes indicate, “The principle difficulty with an all-fours position is when manoeuvres are required. Most obstetricians are more familiar with performing these in a difficult breech birth with the woman in the dorsal position.” This begs the question of how we will overcome the difficulty resulting from lack of obstetric familiarity with performing manoeuvres when women are in upright, particularly kneeling positions. Our recently published evaluation of the Breech Birth Network Physiological Breech Birth training days reported that one of the greatest concerns expressed by participants in the workshops was lack of involvement and collaboration from obstetric colleagues, whom they had difficulty convincing to attend the training in order to learn effective manoeuvres. Hopefully changes in our national guideline will prompt more interest.

Question #1: What does it mean to be ‘skilled’ in breech birth birth?

The word ‘skilled’ recurs 15 times in the new RCOG breech guideline. Variations include: ‘skilled intrapartum care,’ ‘skilled birth attendant(s),’ ‘skilled supervision,’ ‘skilled attendant(s),’ ‘operator skilled in vaginal breech delivery,’ ‘skilled support,’ ‘skilled personnel.’ Each reference suggests skill is a key ingredient of safe vaginal birth.

What does it mean to be ‘skilled’ in vaginal breech birth? Is it a quality possessed by individuals, or institutions, or both? How is skill assessed? How is it maintained?

The danger with lack of definition regarding breech skill is that by default it will be judged in retrospect. A good outcome occurs = the attendants were skilled. A bad outcome occurs = the attendants lacked skill and were overconfident in assessment of their own competence. A health professional attends four spontaneous breech births which do not require intervention = they are now perceived as ‘skilled.’

The guideline points to evidence from the PREMODA study, in which good outcomes were achieved in a study with senior obstetrician presence in 92.3% of cases. Association is not causation, but we need to take seriously the value the PREMODA researchers placed on this as a key to their success. In a UK context, or elsewhere, does that mean we can (or should?) reasonably expect all senior obstetricians to be ‘skilled’ at vaginal breech birth? What if the senior obstetrician does not feel ‘skilled’ her/himself? What if a midwife is the most experience person available to attend a breech birth?

The new RCOG guideline further recommends: “Units with limited access to skilled personnel should inform women that vaginal breech birth is likely to be associated with greater risk and offer antenatal referral to a unit where skill levels and experience are greater.” And: “All maternity units must be able to provide skilled supervision for vaginal breech births where a woman is admitted in advanced labour and protocols for this eventuality should be developed.” How will all maternity units be able to provide skilled supervision for undiagnosed breech births, if some of them will also need to be up front about their lack of skill to support planned breech births?

The new guideline recommends that “simulation equipment should be used to rehearse the skills that are needed during vaginal breech birth by all doctors and midwives.” The extent to which such simulation training will result in skill development in settings where skills have become depleted over the last 20-30 years is unclear. Our recent systematic review highlights the lack of evidence regarding the ability of standard training programmes to improve outcomes, and suggests that teaching vaginal breech birth as part of an obstetric emergencies course may actually reduce the chances that providers will actually attend breech births (Walker, Breslin, Scamell and Parker, 2017).

Value of midwifery #breech knowledge and skills, and continuous support acknowledged in @RCObsGyn #BreechGreentop pic.twitter.com/lChFVNxMVN

— Oli Silverwood-Cope (@olvindaRM) March 18, 2017

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The development of professional competence to facilitate breech births is a complex matter to which institutions may like to pay closer attention as they develop the ‘routine vaginal breech delivery service’ envisioned by the new guideline. Some of this complexity is explored in these two papers involving research with experienced practitioners: Standards for maternity care professionals attending planned upright breech births and Principles of physiological breech birth practice.

Question #2: What is a footling presentation?

Despite the acknowledged paucity of evidence regarding factors that increase the risks of vaginal breech birth, ‘footling presentation’ remains a clinical indication for advising women that the risks associated with vaginal breech birth are likely to be independently increased. Unfortunately, neither the guideline nor generally available breech literature provides a clear definition of what this means, nor is it likely that a similar definition has been used among disparate studies looking at outcomes associated with variations of breech presentation.

The danger with this lack of definition is that in many complete and incomplete breech presentations, where one or both legs are flexed, one or more feet will be palpable on vaginal examination. This is especially the case at advanced dilatation, when legs will often slip further down due to the increased space in the sacral cavity, into which the breech has also descended. And of course in advanced labour, the dangers of performing a caesarean section for a dubious indication are increased. It has never made sense to me to perform a caesarean section at advanced dilatation because one might need to perform a caesarean section! Where skill levels are minimal and practitioners are not taught to locate the sacrum as the denominator, many complete and/or incomplete breech presentations will be labelled ‘footling.’

Dr Susanne Albrechtsen teaching breech skills

In my practice, I follow the nomenclature suggested by Susanne Albrechtsen (unfortunately only available in Norwegian): a footling breech is one in which both feet present first, and the fetal pelvis is disengaged, above the pelvic brim. A fetus whose pelvis is engaged with one or more feet palpable alongside is a flexed breech (complete/incomplete).

We will await more professional debate and actual evidence concerning the definition of ‘footling breech’ and its association with fetal outcomes. Perhaps now that the new RCOG is more supportive of vaginal breech birth, more professionals will feel experienced enough to engage in discussions which will move our knowledge base forward and further increase the safety of breech birth.

Shawn

Jean-Christophe Lafaille and the HBA3C

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Image: http://kylekeeton.com/

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:

the woman’s decision to birth her baby at home attended by midwives, after having had three previous caesarean sections; and
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.

Image: http://www.unet.me

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.

Image: http://www.free-picture.net/

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)

The longer-term effects of CS for breech in Denmark

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Something is rotten …

Well, I suppose a backlash was inevitable. Due to the campaigning of women and the willingness of a significant number of health care providers to provide women with a real choice when it comes to breech childbirth, the argument for re-skilling to better support breech births has been gaining momentum. But this week saw the publication of two studies arguing this is not such a good idea.

First it was a Dutch group (Vlemmix et al 2014) who made the argument that at 1.3/1000 compared to nil, vaginal breech birth (VBB) results in ten times the mortality of planned CS. They overlooked the need to match the word ‘planned’ with an intention-to-treat analysis, and their own research (Vlemmix et al 2013) suggesting that neonatal mortality was doubled in pregnancies following an elective CS compared to those where a VBB was planned in the first pregnancy (2.5/1000 vs 1.3/1000). (Read my response here.)

When baby’s head has descended into the pelvis, the pubic bones are directly behind the occiput

Now a Danish study asks, “Can Caesarean section improve child and maternal health? The case of breech babies” (Jensen and Wust, 2014). Wait, did I read that right? Are we asking whether CS can improve maternal health? Really?

Unlike their Dutch counterparts, Jensen and Wust have decided: “In our estimation sample, we observe only few infant deaths for breech babies. Thus we do not consider this very rare outcome in the proceeding analysis.” One country decides this outcome is a deal breaker, another feels it is so rare that it is not necessary to consider it.

Jensen and Wust present a lot of beautiful graphs and calculations showing that there was a noticeable improvement in Apgar scores and a reduction in visits to the GP, but no significant change in serious morbidity (ill-health) or hospitalisations in the first three years of life, following the sudden increase in elective CS for breech associated with the publication of the Term Breech Trial in 2000.

Although I am in favour of attempting to calculate the longer-term effects of such sweeping changes, I am concerned about what they did and did not choose to speculate upon.

Their most statistically significant finding was an increase in prolonged maternal hospitalisation following an elective CS. This has noticeable financial implications, which they calculated, but they do not address the increase in costs and risks in future births. The financial blind eye is concerning, but their conclusion that CS does not affect the health of the mother, without considering future births, is even more disconcerting.

On the other hand, they speculate that the additional expenditure for elective CS is balanced by costs savings as a result of significant reductions in cerebral palsy and subsequent care needed. They did not have information on actual rates of CP in this population. Instead, they reference a 2001 study by Krebs, which did NOT note a relationship between CP and mode of delivery, and found in 20,000 breech births a total of 4 serious long-term disabilities and 18 minor disabilities possibly related to low Apgar scores. They ignored Krebs previous research (1999) indicating that an increase in CP for breech-presenting babies was NOT associated with mode of delivery. They also ignored a recent systematic review and meta-analysis (O’Callaghan and MacLennan 2013) demonstrating that CS does NOT reduce the risk of CP for breech-presenting babies.

It’s important to get this right. Low Apgars are definitely associated with increased CP and other problems in head-down babies, possibly because the birth itself less often causes minor asphyxia, and therefore the cause is often an underlying fragility. In Krebs’ work, he found the association was mostly with small for gestational age infants; this corresponds with other breech research which consistently associates smaller babies with poorer outcomes. But because many breech babies have lower Apgars as a consequence of the way they are born, Apgars are not such a clear indicator of future risk in this population. They were not in the Term Breech Trial (Whyte et al 2004), and that is the best evidence we have to go on at the moment.

The main outcomes shown in this research are an increase in overall Apgar scores and a decrease in visits to the GP in the first year, less significantly in the second year, and not significantly different in the third year of life. They found no increase in significant neonatal morbidity or hospitalisations in the first 3 years of life. Although it was not originally one of their primary outcomes, the GP visits could be significant. It could also be that in the wake of a major change in practice suggesting that breech-born babies are at increased risk, everyone’s a bit nervous in the first couple of years? We need more information regarding these babies’ actual health problems to understand and use this data, because it conflicts with a Finnish study which found the opposite was the case at 7 years (Ulander et al 2004).

So Jensen and Wust have given us more research indicating an increase in short-term morbidity (with mortality being rare and insignificant?) but no difference in significant neonatal morbidity and the need for increased medical care after 2 years. This matches the information from the Term Breech Trial. Despite the authors insistence they have uncovered evidence that CS is best for all breech babies, and that it is ultimately cheaper (based on their non-evidence-based speculation on future costs of CP only), it actually adds to the literature confirming no concrete evidence of a difference in long-term outcomes for breech babies. Just goes to show you how you can take a group of statistics and put just about any spin on it you like, especially if your mathematical ability makes your analysis fairly impenetrable to most people. (Good thing I live with an actuary.)

Turning now to the elephant in the room

Being born vaginally may be more risky for some babies than being born by CS. Most of the evidence seems to indicate that, in the short-term at least, using standard lithotomy delivery practices, this is the case. On the other hand, most of the long-term evidence does not indicate lasting effects.

What concerns me about literature like this, which makes predictions about what would be saved or not, financially or physically, with this approach or that – is that women, as long as they are human, will continue to have their own unique approach, and they should. That is what being human is about. Many will want to deliver their breech babies by CS, and they should have access to that care, even if it means a greater financial burden. And many will want to give birth vaginally, even in awareness that the rare outcome of neonatal mortality is more likely to happen to them, even in the awareness that if something goes wrong, they will need to live with it for the rest of their lives. We will always have death, and handicapped children that require our grief, our love and our devotion. This cannot be eradicated. Women deserve to be able to make this very personal decision without being made to feel criminal.

Instead of continuing to do research which tells us what we already know, we should invest in research exploring modern management strategies which are showing promise in reducing risk to babies born vaginally, so that women who live in countries where there ought to be a choice actually have one, and women who live in countries where CS is either inaccessible or a real danger to their health have the best chance of going home with a healthy baby. We should stop trying to have the last word on how breech babies should be born, let women decide how to balance the complex array of risks and benefits in their own lives and families, and develop our skills at being ‘with woman’ and her breech.

Shawn

Can we eliminate all risk for breech babies?

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Closer to my heart, by Leah Sandretsky, www.etsy.com/shop/heartbeatstudio

Closer to my heart, by Leah Sandretsky, http://www.etsy.com/shop/heartbeatstudio

This week (August 2014), a Dutch research team published the results of a large retrospective cohort study concerning the results of all breech births in the Netherlands. They concluded that an increase in the caesarean section rate following publication of the Term Breech Trial (TBT) has resulted in a significant reduction in perinatal mortality related to breech presentation, and therefore a policy of universal caesarean section for breech would improve outcomes for breech babies even further.

In the year prior to October 2000 (the team does not present data from earlier than 1999; why not?), the perinatal death rate was 1.3/1000 for all breech deliveries (VBB and CS inclusive). Elective sections increased from 24% prior to publication of the TBT to 60% afterwards, and from December 2000-2007, the perinatal mortality rate was 0.7/1000 for all breech deliveries, with an overall VBB rate of 22%. Moreover, the team showed that all of the perinatal deaths occurred during what they called planned breech deliveries (although their understanding of ‘planned breech delivery’ is very different from mine, as I discuss below), so the actual perinatal mortality rate for breech babies born vaginally remained steady at 1.6/1000 during both periods.

A rate of 1.6/1000 is actually quite low compared to the mortality rate of approximately 1/100 reported in the Term Breech Trial. However, the authors propose that the results of this study should replace the information currently given to women in Dutch national guidelines, because according to their calculations, “A policy of elective caesarean section for all term breech deliveries could lower the overall term neonatal mortality in term deliveries by 6.8%, from 172 to 162 per year.”

Unfortunately, it’s not so simple.

Dreaming the impossible dream.

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

The first problem with this prediction is that it’s not possible to pursue a policy of elective caesarean section for all term breech deliveries, even if you ‘convinced’ the 40% of women who choose to plan a VBB in the Netherlands to plan a CS. The researchers themselves noted that approximately 1:5 of the perinatal deaths observed occurred when breech presentation was not diagnosed until birth. Without instituting expensive changes to breech screening on a national basis, these outcomes will not necessarily be improved, certainly not without performing many more risky caesarean sections in advanced labour. (When these births were excluded from the analysis, the perinatal mortality rate for VBB’s which were actually planned was 1.3/1000 overall. The Netherlands has a high rate of home birth, so some of these unplanned VBB probably occurred at home with surprised, rather than prepared, midwives.)

Also, the researchers note that they have not performed an intention-to-treat analysis of their data. Multiple studies have noted that approximately 10% of women who plan caesarean sections go into labour unexpectedly before their scheduled operation, and 9.7% of the woman randomised to CS in the TBT gave birth vaginally. The researchers say that those for whom this was the case ‘could not be included in the caesarean section group’ for their study. Why? Were they included in the ‘planned’ vaginal breech birth group? The authors note this category was a ‘composite of vaginal delivery and emergency cesarean.’ Regardless of whether these women actually planned a VBB?

In an intention-to-treat analysis, the outcomes for babies who turn head-down spontaneously would also be included, as the decision to plan a VBB influences whether or not they will. In the Term Breech Trial, twice as many turned when a VBB was planned than when a CS was planned, so that 3.8% of all babies who planned a VBB were born in a cephalic position. Failing to do an intention-to-treat analysis disregards the complexity of breech decision-making and the full range of consequences.

Putting the figures into perspective.

The researchers note that 40% of women in the Netherlands choose to plan a vaginal breech birth, in collaboration with their doctors and midwives, and approximately 55% of them achieve this. This results in an overall perinatal mortality rate for breech presenting babies in the Netherlands of 0.7/1000, which happens to be the same perinatal mortality rate for low-risk women giving birth in hospital settings in the Netherlands (de Jong et al 2009; the mortality rate was slightly lower for women who planned a home birth at 0.6/1000). From where I am sitting, this looks like a good example of collaborative decision-making reducing risk while preserving choice.

Earlier this year, another team also led by Vlemmix (2013) published an abstract in the AJOG using further data from the Dutch nationwide perinatal registry from 2000-2007. This demonstrated that in addition to greatly increased maternal morbidity, neonatal mortality in pregnancies which followed an elective CS for breech presentation was 2.5/1000, compared to 1.3/1000 following pregnancies where a VBB was planned (which will be an average of the 2.5/1000 risk following a CS, and substantially lower risk following successful planned VBB’s). How then does this affect the prediction that elective caesarean section for all breech presentations would further significantly reduce the overall national perinatal mortality rate? Only if these women do not have any more children. Seems worth a mention to me, when you are recommending that all breech babies with a neonatal mortality risk of 1.3/1000 be delivered by CS.

Consider statistics given in the RCOG guideline on Birth After Previous Caesarean Birth. They summarise the data relating to term VBACS: “Planned VBAC is associated with a 10/10,000 risk of antepartum stillbirth beyond 39 weeks of gestation and a 4/10,000 risk of delivery related perinatal death (if conducted in a large centre).”

So a woman choosing to await spontaneous labour past 39 weeks and attempt a VBAC has a 1.4/1000 risk of losing her baby, but this is not only perceived as a reasonable decision, it is positively encouraged in most hospitals in the UK. Entire midwifery-led care pathways are set up to support women making this choice, and primiparous women to whom elective section for breech is recommended are proactively counselled that they can feel positively about attempting a VBAC the next time around.

But a woman choosing to birth her breech baby vaginally, knowing that she has a 1.3/1000 chance of losing her baby, is suspect. Does anyone else get the feeling we are robbing Peter to pay Paul?

The researchers identified no sub-classification of women for whom breech birth was more risky, or less risky compared to CS. They did observe that babies with a birth weight of over 3500 g (often excluded from VBB) actually only had a perinatal mortality rate of 0.8/1000. Contrary to what they have concluded, encouraging any woman who plans to have more children and wishes to attempt a VBB (at a relative PMR of 1.3/1000) as opposed to advocating universal elective CS for breech (and exposing subsequent children to double the mortality rate, at 2.5/1000), seems a measured approach.

The team’s representation of morbidity statistics also distorts the picture, as long bone fractures (included in their composite statistic) are common in cephalic births as well. They heal well, and are not generally considered ‘serious morbidity.’ Nonetheless, the morbidity rate of 22/1000 reported in this research was also significantly less than the rate of approximately 1/20 reported in the Term Breech Trial.

Designing research which meets the needs of women and their partners

Descending LST, anterior buttock leading

The researchers have called for the results of their study to replace the information in their national patient information leaflets, which are based on the data from the Term Breech Trial, including the information that outcomes at 2 years of age did not differ between planned VBB and planned CS. One of the authors named in this Vlemmix study has also conducted research into what information matters most to women and their partners (Kok et al 2008).

Kok’s study (2008) demonstrated that women were mostly concerned with the safety of their baby and fear for a handicapped child, and that the 2-year outcome was what mattered most to them. Why then has this team conducted yet another study telling us what we already know – that short-term morbidity and mortality is significantly greater when VBB is planned in most cases – rather than robust research addressing what matters most to the families making these decisions? Whyte’s team (2004) emphasised that the 2-year results surprised them, as the group of children who went on to have handicaps at 2 years of age did not overlap at all with the group of children who experienced severe morbidity in the neonatal period. They were all born apparently healthy, and in the Vlemmix study would have been included in the ‘proof’ that universal CS is a safer policy. Given the numerous studies demonstrating a higher risk of cerebral palsy and other adverse outcomes for breech-presenting babies regardless of mode of delivery (O’Collaghan and MacLennan 2013), the question of whether the babies we save from death in the first 7 days go on to lead full and healthy lives is a fundamental question. And it is the concern which matters most to women.

On the other hand, according to Kok et al (2008) the concern which matters most to women’s partners is the outcomes for women. This study reported only 2 maternal deaths in the 1999-2007 period, despite acknowledging another study already published by the Dutch Maternal Mortality Committee reporting 4 deaths following elective section for term singleton breech in the Netherlands in 2000-2002 alone.

Why are the women disappearing?

If this study does not address the central concerns of women and their partners, why should it take precedence in the information given to aid informed decision-making? If the authors have not performed an intention-to-treat analysis, how can they possibly claim to know that their treatment will have the predicted result? If the study has demonstrated a risk similar to that of planning a VBAC, why are both choices not considered equally reasonable?

These authors are all very much involved with research concerning external cephalic version (ECV) and also feel the results of this research demonstrate the need to use ECV more liberally in order to reduce the incidence of breech presentation at term. While I am a fan of their ECV research and a proponent of ECV as a readily available option for women with breech presenting babies, again we cannot ignore the fact that ECV has not yet been demonstrated to improve neonatal outcomes, possibly for the same reasons the 2 year outcomes for children are not affected. However, ECV does significantly reduce the CS rate for women, particularly in centres where the option of VBB is not well supported. Again, I would like to see this highly experienced and highly influential team turn their attention to answering questions we do not already know the answer to, including whether or not manually turning a breech baby from a breech to a head-down position improves the short- and long-term outcomes for these babies, beyond increasing their chance of being born vaginally.

Shawn

De Jonge, A., van der Goes, B.Y., Ravelli, A.C.J., Amelink-Verburg, M.P., et al. (2009) Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG : an international journal of obstetrics and gynaecology. [Online] 116 (9), 1177–1184. Available from: doi:10.1111/j.1471-0528.2009.02175.x [Accessed: 12 August 2014].

Vlemmix, F., Kazemier, B., Rosman, A., Schaaf, J., et al. (2013) 764: Effect of increased caesarean section rate due to term breech presentation on maternal and fetal outcome in subsequent pregnancies. American Journal of Obstetrics and Gynecology. [Online] 208 (1, Supplement), S321. Available from: doi:http://dx.doi.org/10.1016/j.ajog.2012.10.102.

Vlemmix, F., Bergenhenegouwen, L., Schaaf, J.M., Ensing, S., et al. (2014) Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study. Acta Obstetricia et Gynecologica Scandinavica. [Online] 93 (9), 888–896. Available from: doi:10.1111/aogs.12449 [Accessed: 12 August 2014].

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

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

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

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