Tag Archives: manoeuvres

How ‘evidence-based’ is your Algorithm?

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

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

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

How does the OptiBreech Algorithm align with national guidance?

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

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

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

How does the OptiBreech Algorithm differ from national guidance?

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

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

What evidence is the OptiBreech Algorithm based on?

First version

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

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

Refinements

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

How has the OptiBreech Algorithm been tested in practice?

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

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

The training evaluation

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

The implementation evaluation

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

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

The prospective observational cohort (In Press)

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

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

Total prospective VBBs

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

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

How does this compare to other vaginal breech birth research?

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

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

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

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

Does immediate assistance result in more complications?

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

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

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

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

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

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

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

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

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

What is the evidence for other algorithms currently in use?

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

We have identified one study (Hardy et al 2020), which evaluated training based on the ‘appropriate manoeuvres,’ Lovesets and M-S-V. The pre-training low Apgar rate was 0/56 and post-training it was 7/80 (8.8%, p=0.041). Special care nursery admissions also increased. In our view, these methods should not continue to be taught unless someone can produce any evidence at all that teaching them improves clinical outcomes.

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

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

— Shawn

Supporting the OptiBreech Teams

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This Monday, we held a training day at St. Mary’s Hospital in Paddington, London, to support the Imperial OptiBreech Team, led by Consultant Obstetrician Sabrina Das.

OptiBreech Just Giving Page

We will be donating 10% of any revenue obtained from this and all future study days to the OptiBreech Just Giving page, which is raising money to provide sites with extra support so that team members can continue to be on-call for women planning a vaginal breech birth.

We would be incredibly grateful if you would join us in this support by donating if you can and sharing the link with your social networks.

Below is some recent research to demonstrate how we are helping to make breech services better and safer for all families:

First OptiBreech results poster! Walker, S., Dasgupta, T., Hunter, S., Reid, S., Shennan, A., Sandall, J., Davies, S., 2022. Preparing for the OptiBreech Trial: a mixed methods implementation and feasibility study. BJOG An Int. J. Obstet. Gynaecol. 129, 70.  https://epostersonline.com/rcog2022/node/4909

Spillane E, Walker S, McCourt C, 2022. Optimal time intervals for vaginal breech births: a case-control study. NIHR Open Res. 2, 45.https://doi.org/10.3310/nihropenres.13297.1

Walker S, Dasgupta T, Halliday A, Reitter A, 2021. Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS): A systematic review on variations in outcome reporting. Eur. J. Obstet. Gynecol. Reprod. Biol. 263, 117–126. https://doi.org/10.1016/j.ejogrb.2021.06.021

Continuous cyclic pushing: a non-invasive approach to optimising descent in vaginal breech births — The OptiBreech Project

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Shawn Walker, RM PhD, King’s College London and Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex Hospital Sabrina Das, MB ChB, MRCOG, Imperial College Healthcare NHS Foundation Trust, Queen Charlottes & Chelsea Hospital Emma Spillane, RM MSc, Kingston Hospital NHS Foundation Trust Amy Meadowcroft, RM, Northern Care Alliance NHS Foundation Trust Background In the […]Continuous cyclic pushing: a non-invasive approach to optimising descent in vaginal breech births — The OptiBreech Project

What is the evidence for shoulder press / Frank’s Nudge?

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Learning shoulder press in Montreal with Isabelle Brabant

As physiological breech practice gains acceptance, guidelines are changing to reflect this change in practice. One of the questions those updating guidelines often ask is: What is the evidence? For example, what is the evidence for the shoulder press manoeuvre we teach in Physiological Breech Birth study days?

To answer this question, we have to consider what level of evidence underpins breech practice in general. To my knowledge, no breech manoeuvres have been tested in randomised controlled trials. A recent Cochrane Review looked at ‘Quick versus standard delivery’ for breech babies and found no reliable studies to inform practice.

Image from Louwen et al 2017, Does breech delivery in an upright position instead of on the back improve outcomes and avoid caesareans? Open Access, click on image for full report. Artwork by Chloe Aubert

Observational studies that contain clear descriptions of the methods of management used in that setting reported alongside perinatal outcomes contain one form of evidence. A problem with observational studies is that even when ‘classical methods’ are reported, the meaning of that expression varies between settings. So studies from Canada, for example, are not necessarily generalizable to settings in the UK because standard practice varies between the two continents. A notable exception is the study of outcomes associated with upright breech birth reported by the Frankfurt team (Louwen et al 2017), in which a very clear description of the ‘Frank’s Nudge’ manoeuvre is provided, alongside excellent perinatal outcomes associated with upright maternal positions.

Another type of evidence is the support of a ‘responsible body of similar professionals.’ This is related to the Bolam test for clinical negligence in English tort law (Bolam v. Friern Hospital Management Committee), which holds that, “there is no breach of standard of care if a responsible body of similar professionals support the practice that caused the injury, even if the practice was not the standard of care.” In our research with 13 obstetricians and 13 midwives who had attended a self-reported average of 135 breech births each (Walker et al 2016), 73% of those participating agreed or strongly agreed that health professionals attending upright breech births should be competent to assist by:

  • sub-clavicular pressure and bringing the shoulders forward to flex an extended head; and
  • pressure in the sub-clavicular space, triggering the head to flex.

Additionally, 86% agreed or strongly agreed that an essential skill was:

  • moving infant’s body to mum’s body, so that infant’s body follows the curve of the woman’s sacrum

This research avoided the use of names such as ‘shoulder press’ and ‘Frank’s Nudge’ in favour of descriptions because not everyone uses the same terms, or refers to the same actions even if they do.

Evidence for manoeuvres also comes from evaluations of training programmes, both breech-specific and obstetrics emergencies courses. In our review of the effectiveness of vaginal breech birth training strategies (Walker et al 2017a), we found no published studies demonstrating an association between any training strategy and improvement in perinatal outcomes. The evidence base for the PROMPT training programme, widely used in the UK, comes from a study that did demonstrate an association with training and a subsequent reduction in low 5-minute Apgar scores and HIE (Draycott et al 2006). But that study questionably excluded outcomes for breech births, and because of this the breech methods in PROMPT cannot be said to be evidence-based, although the programme’s overall approach of multi-disciplinary working and clear communication remains important.

Most obstetrics emergencies training programmes have been evaluated at the level of change in confidence and/or knowledge. Our Physiological Breech Birth training programme, which includes shoulder press, has also been evaluated at this level in published research and demonstrated good results (Walker et al 2017b).

Finally we have the most recent RCOG guideline (Impey et al 2017), which states: “The choice of manoeuvres used, if required to assist with delivery of the breech, should depend on the individual experience/preference of the attending doctor or midwife.”

— Shawn

Breech holiday, Frankfurt – from Olvindablog

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Justifying to a seven-year-old Anubis why I’m going to Germany for my week off – and missing mothers’ day, helped crystallise objectives and motivation for this busman’s holiday* (*a form of recreation that involves doing the same thing that one does at work). “I’m going to see some babies be born bottom-first.” “Don’t you see that […]

via Breech holiday, Frankfurt — Olvindablog

Running start

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frank breech

In Physiological Breech Birth training, we teach breech practice according to the consensus statements developed with experienced professionals in Principles of Physiological Breech Birth Practice (Walker, Scamell & Parker, 2016), including:

Care providers should not disturb women’s spontaneous movements in an otherwise normally progressing breech birth.

Mother-led positioning offers the greatest physiological advantages.

Sometimes maternal-led positioning is most conducive; sometimes judicious guidance is appropriate, especially to help resolve delay.

When facilitating a physiological breech birth, care providers proactively use maternal position (or change in position) to promote normal descent.

The pictures below demonstrate asymmetrical maternal movement in a normal breech birth, in which the mother assumes an upright, kneeling position, with freedom to move her torso up and down as she feels the need. Study of effective, spontaneous maternal movements during successful breech births teaches professionals about all normal birth. Instinctive maternal movement can be read as purposeful and meaningful, in light of radiological evidence of changes in pelvic diameters (Reitter et al, 2014) — rather than counter-productive and needing professional interruption or guidance.

In this picture series, the mother spontaneously lifts one of her legs into an asymmetrical, ‘running start’ position. Often a change in maternal position, or rhythmic maternal movement (“give it a wiggle”) will prompt spontaneous descent to resume.

If a professional detects a slight delay in descent, it may be appropriate to suggest a change of position by raising one leg or the other, as a first-line intervention, a ‘maternal manoeuvre,’ before hands-on intervention. If you are using a ‘Running Start’ position, assist the mother to lift the leg on the side the baby faces, e.g. the same side as the legs & umbilicus. This will open the pelvis on that side, creating space for the pubic arm to descend past the ischial spine, and encouraging rotation in a sacrum-anterior direction. If you intervene by lifting the leg on the side of the baby’s back, this will encourage rotation in a sacro-posterior direction.

Thank you to the staff at the Royal Jubilee Maternity Services in Belfast for giving us the language, “Lift the leg on the side the baby faces.”

This mother is raising and lowering her torso with the aid of her partner’s thighs.

Dropping her torso, arching her back and tucking her hips under.

Moving her hips back towards her heels.

Squatting back onto her heels. This creates maximum space in the pelvic outlet as the breech passes through the ischial spines. The mother will not ‘sit’ on her baby, preventing the birth, but will instead raise her hips again when she instinctively feels the urge to do so.

Rising up again, arching her back. Creating space in the pelvic inlet as the shoulders and head enter.

Squatting back down. Spontaneous movements constantly change pelvic diameters as the baby rotates through.

Torso and hips rise up as baby rumps. Thrusting hips forward has a protective effect on the perineum and opens the inlet to assist engagement of shoulders/head. ‘Fetal ejection reflex.’

Pressure as baby descends. The mother drops her torso down again.

Moving into Running Start. The baby has not completely rotated to sacrum-anterior. The mother spontaneously lifts the leg on the side of the fetal legs, creating further space to assist rotation of the torso and descent of the pubic arm.

Significant descent occurs with the next contraction.

Running start continues to make space for gravity to do it work.

Almost there.

Straight to his mother’s arms.

The physiological process of welcome continues without interruption.

Thank you to the mother, who gave permission for her birth photos to be used for educational purposes; and to her family and midwives. One of these images appeared in the article, Unexpected Breech: What can midwives do?  in The Practising Midwife. Click here to download – PDF.

The Birth of Leliana

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Jessica with Leliana

Image: Jacqueline Sequoia, used with permission

From Atlanta, back to Asheville …

Jessica’s baby remained persistently breech at term, and she was unable to find a provider in South Carolina to facilitate a vaginal breech birth. When she attempted to decline a CS and negotiate a vaginal birth, she was informed that if she came into the hospital in labour, she would be given general anaesthesia and her CS would be ‘a lot rougher.’ (Folks, the ACOG published something just for you: Committee Opinion No. 664: Refusal of Medically Recommended Treatment During Pregnancy.)

This was Jessica’s first baby, in a frank breech position (extended legs), with no additional complexities. Her sister, Family Practice Doctor Jacqueline Sequoia MD, heard about Dr David Hayes and Harvest Moon Women’s Health because they were hosting my physiological breech birth training. Jacqueline includes obstetrics as part of her practice and booked to attend the workshop with some colleagues. Jessica and her husband Brian met with Dr Hayes to consider their options, and once Jessica made her decision, found a rental apartment in Asheville on Craigslist.

Let’s contemplate that for a moment. In order to have support for a physiological birth, rather than the threat of a coerced CS, women are having to relocate to another state and rent temporary accommodation, because the baby is presenting breech.

When Dr Hayes and I arrived at Jessica and Brian’s apartment, Jessica’s labour appeared to be progressing well. As people entered her space, Jessica gradually moved into the tiny bathroom at the back of the apartment, reminding me of Tricia Anderson’s metaphor of cats in labour. I turned off the light. This labour had a journey, as all labours have. Throughout her journey, Jessica was surrounded by people who love her. At the end of it, Jessica beautifully and instinctively birthed her little girl, Leliana, who weighed 7lbs 8oz.

This video contains graphic images of a vaginal breech birth.

Being attuned to the general lack of training in physiological breech birth among health professionals, and the consequences for women and babies, Jessica and Brian were keen to share this video of Leliana’s birth to help others learn. If you would like to read more about the minimally invasive manoeuvres used at the end of this birth, you can read our blog on Shoulder Press and Gluteal Lift.

brian

Thank you, Jessica, Brian, Leliana, Dr Sequoia and Dr Hayes for sharing this video. The link to this blog post can be shared, but the video cannot be downloaded or reproduced without permission.

Shawn

https://twitter.com/jsequoia/status/736602696115879936

The midwives of Portsmouth and the aftercoming fetal head

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Claire Reading sharing her skills

Claire Reading sharing her skills

This Tuesday, 1 March 2016, Breech Birth Network travelled to Portsmouth again. The guest speaker was lovely doctor Ms Arti Matah, who spoke about an obstetrician’s view of vaginal breech birth, and led a lively discussion around whether the breech team / care pathway model might work for Portsmouth. Watch this space! I am incredibly impressed with the commitment Portsmouth midwives have shown to developing sound breech skills to support women who choose to birth their breech babies actively.

The skill which captured the group’s imagination most was how to resolve a situation where the head is extended and impacted at the inlet of the pelvis. My research suggests that identification of optimal mechanisms is a core skill for practitioners attending breech births. Therefore our approach to teaching this skill is:

  1. Identification of optimal mechanism — The aftercoming fetal head normally rotates to the oblique/transverse diameter as it enters the pelvic brim, just like the cephalic-presentation head does when engaging.
  2. Identification of deviation from optimal mechanism — In this complication, the fetal head is pinned in the anterior-posterior diameter, with occiput anterior, over the maternal symphysis publis, and chin or brow on the sacral promontory. The bottom of the fetal chin is felt like a ‘bird beak,’ pointing towards the sacrum. The maxilla bones are difficult/impossible to reach, so flexing the head using the usual techniques will be a challenge.
  3. Restore the mechanism — See below.

ShawnPortsmouthThe RCOG guideline suggests delayed engagement in the pelvis of the aftercoming head should be managed using one or both of the following techniques:

Suprapubic pressure by an assistant should be used to assist flexion of the head. Given our understanding of the head as impacted at the pelvic brim and our goal of restoring the mechanism by rotating the head to assist engagement, we suggest that the goal of suprapubic pressure should initially be to encourage this rotation. This mirrors the understanding we have of suprapubic pressure to resolve a shoulder dystocia by rotating the impacted shoulder off the symphysis pubis. Forcible pressure on an impacted fetal head is unlikely to be beneficial for the baby.

The Mauriceau-Smellie-Veit manoeuvre should be considered, if necessary, displacing the head upwards and rotating to the oblique to facilitate engagement. We use a doll and pelvis to explore why this elevation and rotation prior to re-attempting flexion is necessary. Watch the video below to see this demonstrated.

When a woman is birthing her breech baby actively, we facilitate the head to enter the pelvis using the same principles. Watch the video below, where Midwife Olivia Armshaw is teaching how  to intervene in the case of an extended head at the inlet, when the woman is birthing on hands/knees. In this video, the midwives are discussing how maternal movement – in this case, the woman shuffling her bottom back towards the midwife slightly – helps to elevate the head off the pelvic inlet to facilitate engagement, a technique we learned from the midwives of Sheffield. The principles – elevate, rotate & flex the head – are the same.

Thank you to the Practice Development Team at Portsmouth for organising the day. And thanks to the following midwives for assisting with the day:

  • Claire Reading, midwife in Somerset, who shared her breech experience gained working abroad, and facilitated one of the hands-on stations
  • Olivia Armshaw, midwife from Gloucester, who facilitated one of the learning station and presented on the process of developing a breech team in her local area
  • Tess McLeish, midwife from Lewisham who helped the day run smoothly

Our one sadness on this study day was that we were not joined by any of Portsmouth’s obstetric staff, aside from Ms Arti Matah, who needed to leave early because she was good enough to present at the study day following a night on-call. Across the UK, midwives are trying to engage their obstetric colleagues in a discussion about how to improve things for breech babies and their mothers, and we really need more doctors to come to the table for that discussion to result in a service which is as safe as possible.

Shawn Walker, Olivia Armshaw & Jenny Hall

Shawn Walker, Olivia Armshaw & Jenny Hall

BONUS was meeting and relaxing with Midwife Jenny Hall in Portsmouth after the study day!

— Shawn

Further Study Days can be found  here when they become available. View our Training page for more information.

Feedback from the Study Day:

“the group work was excellent Overall I thought the day was was a good balance of theory to practical”

“very interactive. realistic rather than textbook. real life experiences.”

“perfect study day. Interesting and kept my attention all day!!!”

“visual with the film clips and hands on with the doll and pelvis. Was very good to see normal and abnormal films and great discussion with colleagues to share experiences and what to do in that situation.”

“I also thought Shawn’s attitude to breech was very refreshing. I half expected it to be a bit like “you can have a vaginal breech no matter what”. this was not the case. She had a very safe and sensible approach.”

Assisting rotation of the fetal back to anterior in a breech birth

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This post builds on my primary research, Standards for maternity care professionals attending planned upright breech births: A Delphi study. The research reports an experienced panel’s consensus on the skills required for midwives and obstetricians supporting physiological breech births. The practical content of the article is my personal application of one of the findings to clinical teaching.

“Health professionals attending upright breech births should be competent [to assist] rotation of the fetal back to anterior (when the mechanism has deviated from normal)” (p 5). 77% of the panel agreed that this is an important skill. This standard of competence combines two skills: 1) recognising deviation from normal mechanisms; and 2) assisting by restoring the mechanism to normal.

  1. Recognising deviation from normal mechanisms

Within the past two weeks, two people have discussed with me concerns about an incorrect understanding of the correct position for the fetal back when a woman is in a hands/knees position. First, a Practice Development Midwife (PDM) says she advocates teaching breech in ‘only one way’ (eg. lithotomy) because people get confused. A midwife attending training advocated for hands/knees positioning, but when questioned about where the fetal back should be, replied, “The fetal back remains uppermost.” Similarly, a student I am mentoring in practice attended sessions on breech at university. Her lecturer suggested hands/knees may be a more advantageous positioning, but later she is told, even in hands/knees, “The fetal back remains uppermost.” The student had worked out that this couldn’t be correct and sought more information. Excellent critical thinking, Charlotte!

Geburtshilfliche Notfälle, Göbel & Hildebrandt, 2007

Geburtshilfliche Notfälle, Göbel & Hildebrandt, 2007

These are signs of a practice in transition, and the PDM and Charlotte are right to be concerned. Rotating the fetal back uppermost in a hand/knees position is a dangerous but not uncommon mistake. Even in textbooks, such as this German textbook for midwives (Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Göbel & Hildebrandt, 2007), the woman’s position is changed, but the professional is still following the rule of, “The fetal back remains uppermost.” (Just to reassure you, once the arms are born, they advocate rotating the fetal body 180° so that the head is born occiput-anterior.)

A physiology-based understanding of the normal mechanisms comes from closely observing spontaneous births which are not interrupted. In a spontaneous breech birth, the most common and most optimal (a.k.a. ‘normal’) rotation of the fetal back is to anterior after the sacrum is born, regardless of the position of the mother.

The simplest way for teaching this aspect of the mechanisms I learned from midwife Jenny Davidson. The baby should rotate “tum to bum.” In other words, the baby’s tummy (stomach/front torso) should be facing the mother’s bum (bottom/posterior), no matter what position the mother is in. If those teaching breech can adopt this language to describe mechanisms and positioning, fewer dangerous misunderstandings, and more flexible thinking mayoccur. Teaching breech as a set of rote manoeuvres leads to automatic behaviours, which are sometimes counter-productive. In my research, I am observing that the path to acquiring breech competence and expertise involves learning to problem-solve in complex, unique clinical situations, often un-learning ‘rules’ that one was taught in skills/drills — because the rules don’t always work (eg. ‘the fetal back remains uppermost’ does not apply in every situation). Experienced professionals replace inflexible rules with more flexible understandings and principles, over a period of time, and through much reflection with peers and mentors. Perhaps teaching should be about patterns and principles, rather than prescriptions?

2. Assisting rotation of the fetal back to anterior — restoring the mechanisms to normal

tum2bumYou should rarely have to do this, but if you do, this principle may be helpful: “Rotation, not traction.” You can assist rotation with your fingers on the bony prominences of the baby’s pelvic girdle, as for any breech manoeuvre. Consider as you do what is happening at the inlet of the pelvis – have the shoulders already engaged, or are they just beginning to enter the pelvic brim?

Safe facilitation of physiological breech births depends on the ability to determine when intervention will be beneficial, and when it is unnecessary and potentially harmful. A breech baby will normally rotate spontaneously, with the back to the anterior (“tum to bum”), as the shoulders engage in the transverse diameter of the pelvic inlet. Pulling or manipulating prior to this spontaneous rotation could cause problems. But if the rotation is to the posterior, it may be beneficial for attendants to intervene at this point rather than rotate an occiput-posterior head mid-pelvis. Or at least 77% of an experienced panel think so …

Shawn

References:

Gibes E & Hildebrandt S (2007) Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Thieme

Questions for reflection:

  • Watch the videos in this collection. Identify the normal mechanisms, beginning with descent of the sacrum transverse (to the mother’s side). As you are watching, identify which way you will expect the rotation to occur, anticipating the normal rotation. Did the baby rotate as you expected?
  • Imagine you are attending one of the births in the videos and quietly communicating with a colleague who has no previous breech experience, about what you are expecting to see, and what to document during the birth. What do you whisper to your colleague? Do this simultaneously with your colleague/fellow student as you both watch the video

Resources and a plug

2 Replies

Posterior arm born, anterior arm high, shoulders in A-P diameter - help is required!

Posterior arm born, anterior arm high, shoulders in A-P diameter – help is required!

In July, Gerhard Bogner of Salzburg presented data at a Breech Birth Network study day.  Although the series is small, the data indicate that when the mother is in all fours position to birth a breech baby, approximately 70% of those births will occur completely spontaneously, eg. without the need to perform assisting manoeuvres at all. Use of upright positioning also reduced the rate of maternal perineal damage from 58.5% to 14.6%, which is actually better than cephalic births!

The reduced need for manoeuvres potentially reduces iatrogenic damage to babies associated with interference at the time of birth, such as birth injuries and inhaled meconium. That’s great for that 70%, but what about the other 30%? The babies born with upright positioning in Bogner’s study had a slightly higher rate of low cord blood gases, indicating hypoxia, although no consequences for the infants or differences in 5 minute Apgar scores were observed.

If a woman is birthing her baby in an upright position, how do we assist the birth confidently and safely when delay is identified? How do upright manoeuvres differ from those performed when the woman is supine? To address a growing need for more practical training in upright breech birth, City University are offering Physiological Breech Birth Workshops in London and taster days around the country. The next one is on 2nd of December at the Whittington in Central London. Lots of hands-on training with a small group of doctors and midwives committed to extending breech skills. We also post conferences and workshops provided by others when we can.

Several people have been in touch to ask about the How and When to Help handout. I disabled the link because it is constantly being updated! Please feel free to download this one and use it in your practice area. But keep in mind understanding in this area is constantly expanding, and this is just one midwife’s current approach. I’m working on research to understand others’ approaches as well, but it will be some time until this is finished.

Look out for two articles appearing this month. In The Practising Midwife, I present a summary of current evidence related to ECV (external cephalic version), with some excellent photos provided by Dr Helen Simpson and Midwife Emma Williams of South Tees Foundation Hospital. In Essentially MIDIRS, Mariamni Plested and I talk about issues in providing innovative care for higher risk birth choices.

Finally, shameless plug: Today (30/9/14) is the last day to vote for my, um, remarkable cousin Jake in the NRS National Model Search. Read all about him here, and then click on the link at the bottom of the article to VOTE FOR JAKE!

Favourite quote from the article: “The funny thing is, some bulls are just like big dogs. They come up to you, put their butt in your face and say, ‘Scratch my butt.’ But as soon as they get that flank rope on them, it’s like, ‘Game on. I’ve got something to do now.'”

Awww. Gotta love a bit of passion, of finding your niche and loving it … We love you, Jake! (Just what every 18 year old boy always wanted, a plug on a breech birth information site. We clearly share a common love of butts.)

Update: He won! Go Jake!

Shawn

Bogner, G., Strobl, M., Schausberger, C., Fischer, T., et al. (2014) Breech delivery in the all fours position: a prospective observational comparative study with classic assistance. Journal of perinatal medicine. [Online] Available from: doi:10.1515/jpm-2014-0048