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 responsiblebody of similarprofessionalssupportthepracticethatcausedtheinjury,even if thepracticewasnotthestandard 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: “Thechoiceofmanoeuvresused,ifrequiredtoassistwithdeliveryofthe breech,shoulddependontheindividualexperience/preferenceoftheattendingdoctoror midwife.”
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 […]
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.
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.
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.
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.
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.
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:
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.
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.
Restore the mechanism — See below.
The 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.
Further Study Days are listed under Events. 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.”
“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.
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!
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
You 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 …
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
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!
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
Helping the aftercoming head to flex in upright breech births
When women are in upright positions, many breech births will proceed completely spontaneously because the birth canal follows the flow of gravity. However, the attending clinician may need to assist, either because maternal effort no longer results in steady progress, or because the baby appears compromised and assistance will result in a quicker delivery. In this blog, I describe one manoeuvre to help in upright breech births.
The shoulder press is very effective in the following circumstances:
The aftercoming head has descended through the pelvic inlet and is either on the perineum (chin visible) or mid-pelvis (chin not visible, but easily reached in the sacral space); and the occiput is anterior
The mother is in an upright, forward-leaning position (e.g. all fours or kneeling)
The clinician facilitating the birth is behind the mother, and the baby is directly facing the clinician (‘tum to bum’ with mother), with head and body in alignment
In this scenario, the maternal pubic arch is directly behind the baby’s occiput. When pressure is applied to the baby’s torso along the clavicular ridge, guiding the baby’s body straight back through the mother’s legs, the pubic arch will push the occiput up and forward. This causes the aftercoming head to flex and descend, following the curve of the birth canal. The sternocleidomastoid muscles (SCM), responsible for head flexion, attach to the superior aspect of the clavicle and keep the head in alignment throughout this process.
Buttock/Gluteal Lift – If descents stops with the perineum tight on the baby’s forehead (bregma), and the shoulder press alone has no further effect, an assistant can augment the manoeuvre by lifting the woman’s buttocks up and out. This lifts the perineum over the bregma as the primary attendant performs the shoulder press, moving the baby in the opposite direction. This assisted manoeuvre is especially helpful when the woman is obese, or the perineum is especially tight and intact.
The feeling and effectiveness of this manoeuvre is very easy to replicate using an obstetric model, turned upside down, as in the video below.
Preserving an intact perineum. An intact perineum helps to maintain beneficial fetal flexion, and routine episiotomy should be avoided for this reason. However, when the aftercoming head has descended onto the perineum, reaching the maxillary or malar bones to perform a modified Mariceau-Smellie-Veit (MSV) can be difficult. Therefore, many clinicians will cut an episiotomy early in order to avoid cutting one while the baby’s face is on the perineum. However, this is not necessary. When the chin is visible, pressure on the maxillary bones through an intact perineum is possible, in combination with upward pressure on the occiput behind the pubic arch, enabling descent to continue. However, the shoulder press is more effective.
Clinicians who are inexperienced or untrained in manoeuvres specific to upright birth will be tempted to pull down on the baby’s torso to deliver the head. However, this does not follow the direction of the birth canal in the same way as the shoulder press as described. Pulling rather than pushing is potentially more likely to result in severe perineal damage, and may also cause cervical nerve damage in the baby due to increased resistance from the intact perineum.
Fractured clavicle. When applying pressure on the clavicle, fracture is an obvious potential risk, although neither I nor those I have learned from have reported fractured clavicles resulting from the use of this manoeuvre. This potential risk can be minimised by spreading the fingers to apply even pressure along the entire ridge, or by applying pressure with fingers or thumbs at the distal aspect, near the glenohumeral joint. The pressure exerted is firm but is not significantly different to that applied when delivering an anterior shoulder in a supine cephalic delivery, and therefore no more likely to result in trauma. The shoulder press minimises the amount of force needed to achieve delivery by promoting maximum head flexion and descent in the direction of the birth canal.
The shoulder press as described, on its own, may not resolve a dystocia caused by a deflexed or hyperextended aftercoming head. A very high chin, pointing upwards, identifies a hyperextended head; only the bottom jawbone (resembling a ‘bird beak’) is felt at the very top of the maternal sacrum. If the deflexed head has impacted at the pelvic inlet, the baby’s whole body may need to be lifted in order to flex and/or rotate the head to oblique so that it can enter the pelvis before the shoulder press is useful. Additionally, suprapubic pressure performed by an assistant may help flex the head enough to pass through the pelvic inlet.
The practice of supporting breech births with the mother in an upright position is somewhat controversial, as minimal research evidence regarding effectiveness exists. Although breech experience is generally at a very low level, most clinicians are only trained to perform lithotomy manoeuvres, and therefore the RCOG recommend lithotomy as the preferred maternal position (RCOG 2006). However, increasingly women are requesting freedom of movement and their own preference to be upright, which is potentially a more satisfying birthing position (Thies-Lagergren L et al 2013). In the absence of evidence that such an approach increases risks, introducing upright manoeuvres into mandatory training will enable this option.
In addition, through discussions with other midwives and participation in the risk management process for various Trusts, I have been informed of several cases of undiagnosed breech births where women were instructed to get onto their backs on their floor following the diagnosis of a breech in labour, due to lack of an obstetric bed in that setting. In some cases, this has been associated with severe delay in delivering the aftercoming head. In true lithotomy, head flexion is promoted by allowing the baby to hang off the end of the bed, where the maternal pubic arch again is responsible for lifting the occiput as gravity gently pulls the baby through the birth canal. This cannot occur on the floor, and the head becomes deflexed. In these cases, the midwives were only trained to perform lithotomy manoeuvres, and instructed that guidelines required them to manage breech births in this way, but the births occurred in settings with no obstetric bed. Providing mandatory training in upright breech to those working in midwifery-led settings will potentially improve outcomes in emergency cases in the short term, and increase maternal choice in the long term.
I first learned about this mechanism from Dr Anke Reitter, FRCOG, of Frankfurt, Germany, and Jane Evans, an experienced UK Independent Midwife. At the University Hospital Frankfurt a similar technique is called ‘Frank’s Nudge’ after the lead obstetrician, Prof Frank Louwen, who introduced the upright management of breech birth to their unit. I do not refer to the manoeuvre as ‘Frank’s Nudge’ because research indicates eponyms cause confusion and lead to inaccurate documentation. Some have described the mechanism as a reflex action, but my hands have experienced it as purely mechanical, and much more effective than Mariceau-Smellie-Veit when women are upright. Others have described a similar experience in my qualitative studies of how people learn vaginal breech birth skills.
RCOG (2006) The Management of Breech Presentation. RCOG Green-top Guidelines, No. 20b. London, Royal College of Obstetricians and Gynaecologists.
Thies-Lagergren L et al (2013) Who decides the position for birth? A follow-up study of a randomised controlled trial.” Women and Birth26(4): e99-e104.
Introducing more support for planned breech birth in your hospital setting? This post is for you.
The management of breech presentation is undergoing an important transition. In the past twenty years, we’ve gone from:
Management according to the preferences of individual consultants and/or units, tending increasingly toward caesarean section
Blanket caesarean section policy following the publication of the Term Breech Trial
A recognition in more recent guidelines that vaginal breech birth should remain an option for women
Increasing demand from women for more choice and involvement in decision-making around how they birth their breech babies
As a result, health care providers are needing to re-skill in the facilitation of breech birth, and in a way which matches women’s expectations. This requires introducing entirely new skills to manage breech births when the mother is upright and active, as women who choose to birth vaginally usually expect to be.
But transitions can be de-stabilising. Doing things ‘as they are always done’ provides some protection because team members are familiar with their roles. Each professional knows her/his place on the team. They are familiar with the range of events that might happen in this scenario, and they know by repetitive practice exactly how they will need to communicate and respond. The emergency caesarean section for the undiagnosed breech discovered at 9 cm – the team has been here before many times, and swings comfortably into action.
In contrast, a planned breech birth is novel territory. This is even more the case if the woman has planned to be upright and active, as many teams will have rehearsed emergency breech drills with the mannequin in a lithotomy position (legs in stirrups). Therefore, teams supporting this choice will need to employ different strategies to ensure effective teamwork around the time of birth.
Identify your breech birth dream team
(These suggestions apply to a planned breech birth which occurs in a hospital setting, particularly one where a planned breech service is being introduced.)
Ideally, the entire second stage and the birth of this breech baby will be primarily supported by three people. These three should be familiar with and aligned with the woman’s birth plan and each other, as any task or relational conflict will compromise decision-making ability (de Wit et al 2013, Puck & Pregernig 2014). They should each have a clear understanding of what their role in the team will be, and they should have rehearsed together the management of some common emergencies. They should have clear eye contact with each other throughout the birth, in order to confirm in an unobtrusive way the on-going evaluation that the birth is going well, or to prepare each other for the possibility that it might not be.
Each team member has a different primary responsibility:
1) Management – This person is primarily responsible for facilitating the birth, and may be an experienced midwife or an obstetrician. Ideally, this person will be known to the woman and have experience with breech birth in general (and the type of birth the woman has requested). The birth facilitator will be intimately familiar with the woman and her wishes, as well as the mechanics of breech birth, how to anticipate possible problems, and how to assist when required. They are responsible for co-ordinating care and preparing the rest of the team to assist when required.
2) Support – This person, usually a senior midwife, is responsible for taking over monitoring of the woman’s and baby’s well-being throughout the second stage, frequently relaying this information to the rest of the team and reassuring the woman. Positioned beside the woman, they are an important communication bridge, especially when the woman is in a kneeling position, facing away from the person managing the birth. In this position, the support professional is also placed to assist with applying suprapubic pressure and/or change of maternal position.
3) Perspective – This person is responsible for documenting the birth and providing a second evaluation of progress. This role requires breech experience because in order to document appropriately and accurately, the person needs to understand what they are seeing. Similarly, in order to assist with the evaluation of progress, this person needs to be familiar with normal progress in a breech birth. Because of their perspective, this person is also an important communication bridge with the rest of the team outside the door (eg calling for further help, alerting paediatricians to possible complications, etc.), and may alert the managing professional to potential problems. Therefore, this role is often taken by the most experienced person in the room, such as the obstetrician or the experienced midwife who is supporting another midwife to develop her skills.
The triangle: nature’s most powerful structure
Most normal births are attended by two midwives, and this is more than adequate. But a breech birth is not an everyday occurrence. Documentation will need to be of a gold star standard. Yet in most hospitals, each person in the room will still be developing their skills with breech and will therefore need to concentrate on the task at hand, making attendance to paperwork tricky. It is also easy to become enthralled with the beauty of an unfolding breech birth.
Therefore, supporting breech births with a primary team of three strengthens a situation made vulnerable by its novelty. A triangle is one of nature’s strongest structures; this mini-team is strengthened, given a base by the addition of perspective. Given the importance of documentation in any higher-risk birth, triangulation of data (eg strengthening the accuracy by using different sources) also makes practical sense. The triangulated team increases everyone’s safety in a novel situation.
Interestingly, many women instinctively form their own triangles, involving two supporters. The third person in this triangle also provides additional support, strength and perspective for both her and her partner.
Continuity: the way forward
Continuity of carer – ensuring a woman knows the professional who will be facilitating her birth, and ideally the entire team – has known, evidenced benefits. Fewer interventions, greater satisfaction. Knowing who else will be in the room, and what their role will be, will also help the woman to feel more relaxed and reassured about the upcoming birth.
Continuity has benefits for providers as well, especially when it comes to facilitating non-standard care. A number of sources have suggested on-call teams for breech births as the way forward (Kotaska 2009, Daviss et al 2010) and on-call midwives are a middle ground. Especially when experience is minimal, preparation is key. Where an on-call team is not available, the entire team who will be attending the birth should be identified when the woman is admitted to hospital, and again at handover if appropriate. This team should have a thorough discussion about roles and responsibilities, and a run-through of the ‘fire drill’ if things do not go as planned, well before second stage requires the additional team members to attend.
The team should meet afterwards to review the birth and identify if any group work issues have been identified that can be improved for future births. This review should involve the obstetric labour lead, a midwifery manager and/or risk management midwife if the breech service is new to the maternity team. A reflective approach in the early stages will pay off in increased safety and a more confident, united team in the long run.
Further information and inspiration for your dream team
Teamwork is crucial to the safety of breech births. Michael West has written extensively about the characteristics of ‘real teams,’ as opposed to ‘pseudo teams.’ Real teams have clear, shared team objectives; role interdependence and role clarity; and they meet regularly to review and improve performance (West, 2014). If we are to successfully change the culture of breech birth, and support women as safely as possible as we develop our skills and experience, we must function as real teams.
West, M.A., & Lyubovnikova, J. (2013). Illusions of Team Working in Health Care. Journal of Health Organization and Management, 27(1), 134-142. (more from West)
‘Into the Breech’ Workshops in Perth and Melbourne, December 2013
Anke Reitter, Danielle Freeth, Rhonda Tombros, Andrew Bisits
This month has seen a small series of Australian workshops, hoping to increase confidence among those already working to modernise breech birth in Australia. The ‘Into the Breech’ conferences were instigated by Dr Rhonda Tombros, an academic lawyer with an interest in human rights and the mother of a breech born baby, and organised by Barbara Glare. The conferences coincided with a six month research fellowship visit by Dr Anke Reitter (FRCOG) of the Frankfurt team, whose MRI research will soon be published, concerning changes in pelvic diameters with maternal position changes.
The Perth workshop, on 3 December, was held in the Perth Zoo and was opened by midwife Danielle Freeth, also the mother of two breech babies. As for obstetricians, it was quality rather than quantity on this occasion. One of the participants, Dr Liza Fower, Head of Obs and Gynea at the Armadale Hospital, gained significant experience facilitating breech birth in South Africa and has been able to continue to offer support. She also contributed to one of our practical workshops with some useful tips.
Anke Reitter frisking Andrew Bisits .. while demonstrating how to release stuck nuchal arms.
Dr Andrew Bisits (FRANZCOG) presented in Perth, on pathways for women and complications. Bisits is one of the Directors of the ALSO (Advanced Life Support in Obstetrics) course in Australia, which will be updated to include emergency manoeuvres when a woman is in an upright position. He and his team, including Midwifery Professor Caroline Homer, have launched an intensive course for professionals in Australia, the BABE (Become a Breech Expert) course. I am very much hoping to bring this course to the UK at some point in the future, and in the meantime will be ensuring that the information presented at the Breech Birth Network study days is in line with the systematic approach they are developing.
Melbourne attracted more consultant obstetricians, GP obstetricians and a lively group of midwives. Many conversations occurred during the break, suggesting a critical mass in this location, likely to move on with a more organised and collaborative approach to supporting women with breech presenting babies. This may require more working together across traditional boundaries if women are to have adequate support for viable choices, especially as breech services are reintroduced among teams with minimal recent experience.
Dr Rhonda Tombros
A highlight of both days was Dr Rhonda Tombros’ presentation on the legal aspects of informed consent and negligence focusing specifically on issues around breech birth. We all hope she writes this up for publication in the near future.
Although I present at these conferences (in this case, on the evidence base and ‘normal for breech’), I find them invaluable to developing my own practice. The two messages I found most interesting with this visit concerned timings and episiotomy.
Timings: Bisits and Reitter gave increased focus to achieving a prompt delivery, suggesting that 3 minutes from the birth of the umbilicus to the birth of the aftercoming head is ideal. “Three minutes is ideal, you are probably okay with five, but after that most babies will experience some sort of compromise.” This aspect has not been previously emphasised at the conferences I have attended, but the intense dialogue which has developed between midwives and obstetricians supporting breech has revealed differences. It seems that timings are almost taken for granted in obstetric training for breech, whereas midwives have a much higher tolerance for a ‘wait and see’ approach, emphasising the ‘hands off the breech’ philosophy. In reviewing the anecdotal experiences where breech is being reintroduced, the current consensus among our small collective of professionals is that, while a ‘wait and see’ approach will often result in a spontaneous resolution, it will also more often result in a severely compromised baby when that spontaneous resolution does not occur. Therefore, following the birth of the umbilicus, if the birth does not continue to progress promptly or you are not confident of the condition of the baby, intervening to facilitate the birth is recommended, using the systematic approach we are advocating:
Try to sweep down the arms in front of the face
If not possible, rotate in the direction of the nuchal arm (modified Lovesets)
Ensure the head is aligned with the body and the mother’s birth canal
Deliver the head using classic or modern techniques to achieve flexion
The skill of an experienced practitioner is in holding back from intervening when the birth is progressing normally, balanced with effective intervention when it is not, and developing this judgement is a key aspect of breech training days.
Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare
Episiotomy: In Melbourse, Consultant Midwive Michelle Underwood presented data from the Westmead Clinic which she runs with Dr Andrew Pesce in Sydney. While all of their statistics were fascinating – especially demonstrating a reduction in CS for breech from 90% to 63% in the first year of the clinic – I was intrigued by their stats on perineal damage. It seems that, compared to all births, the breech births have the highest rate of episiotomy AND the highest rate of intact perineum. This suggests to me that the majority of perineal damage from vaginal breech births may be iatrogenic, which is not surprising given that cutting a timely episiotomy is an over-emphasised part of some obstetric training for breech (Deering et al 2006), as is the use of forceps.
But is it necessary, or helpful (in most cases)? In his own practise, Bisits avoids episiotomy because he feels the perineum has an active role in encouraging breech babies to remain well flexed throughout the birth. Reitter also discussed her own personal stats – three (3) episiotomies cut in the last 10 years, a period which has included management of over 300 breech births and countless cephalic complications. The episiotomy rate in her unit in Frankfurt is exceptionally low overall. Change was accomplished when the Lead Obstetrician (Prof Frank Louwen) insisted that episiotomies would not be cut unless absolutely necessary, and that each episiotomy would need to be justified personally to him. That’s what leadership can do.