Missed our Facebook Live event with Fernandez Hospitals? Watch the recording here:
PMET student Arunarao Pusala receives her training certificate in Karimnagar
This month I am in Hyderabad, India, visiting Dr Evita Fernandez and UK Consultant Midwives Indie Kaur and Kate Stringer. Today at 5pm IST (that’s 11.30 GMT), we will be having a Facebook Live discussion on Breech Birth in India. This will be followed by hands-on workshops on the 12th and 19th in Hyderabad.
with Senior Midwives Theresa and Jyoti
The Fernandez Hospitals are at the forefront of compassionate maternity care on a large scale in India. The Stork Home facility has been beautifully designed and rivals some of the best midwifery units in the UK. But Dr Evita and her team of doctors and midwives are very ambitious. They want to revive vaginal breech skills so that women can confidently choose this option. How will this work in Hyderabad? Join us for a discussion.
Midwives and doulas support women together in the beautiful Stork Home facility in Hyderabad
From Arunarao: “My special thanks to dr Evita ,lndie mam Kate mam and Shawn mam for the opportunity to participate in BREECH BIRTH WORKSHOP at karimnagar.i am so panic about breech presentation and breech birth before I come to professional midwifery training, know iam very excited to assist the spontaneous and assisted breech birth,because now I came to know breech also has its own mechanism and always always we have to respect those mechanism and iam aware of the manoeuvres to apply whenever it’s needed.thank you all of you mam iam so blessed to have a teaching faculty like you.” Thank you Arunarao — you really got it!
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 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.”
Yesterday, approximately 50 midwives and obstetricians shared some love for breech babies in Preston by hosting a Physiological Breech Study day!
The day was organised by inspirational Consultant Midwife Tracey Cooper, with the help of midwives Emma Ashton and Emma Gornall, and we felt so welcome! Collaborating with their obstetric colleagues, these midwives have led changes in Preston, where guidelines now advise midwives to use hands and knees maternal positioning for all undiagnosed breech births occurring outside the obstetric unit, including the MLBU and home births. In these settings, obstetric beds are not usually available. Adverse outcomes have occurred across the UK because midwives who have only been trained in lithotomy manoeuvres, following guidelines mandating the lithotomy position, have instructed women to lie on the floor, either to perform a hasty and unnecessary vaginal examination, or to ‘manage’ the birth in the way that feels most familiar. As a result, women have then abandoned the most physiologically advantageous forward kneeling position in order to accommodate health professionals. When a woman is supine on a flat surface, the baby’s body cannot hang the way it does in true lithotomy position, and this may cause difficulties with the birth and/or delivery of the head.
Learning to negotiate nuchal arms when women are upright
I have been encouraging midwifery leaders to address this problem for some time, after becoming aware of such troubling events occurring not infrequently. In addition, I performed an audit covering a 20-month period in my previous practice setting, and the results indicated that 80% of the breech presentations diagnosed for the first time in labour occurred among otherwise low-risk women under midwifery-led care. This population does not routinely receive a third trimester scan in the UK, and the research does not necessarily indicate that doing routine scans would improve outcomes. However, it does suggest that each midwifery-led setting should have a plan in place to ensure all midwives have setting-appropriate training for managing unanticipated breech births, and that women have access to skilled and supportive counselling and care when this occurs. As more births are occurring in midwifery-led settings following the recommendations of the 2014 NICE Intrapartum Care guidelines, this forward planning will be more and more important, to promote safe physical and psychological outcomes for women and babies.
Emma Ashton, Gerhard Bogner, Olivia Armshaw, Tracey Cooper & Shawn Walker
We were privileged to be joined by Dr Gerhard Bogner of Paracelsus Medical University in Salzburg, Austria. Bogner shared his experience of trailblazing for breech in Austria by introducing the practice of all fours (im Vierfüßer) breech births, which he has been studying in singletons and twins, with good outcomes. We look forward to the publication of Bogner’s twin data, later in the year. (Read more about Bogner’s work on ResearchGate or Pubmed.)
These international gatherings always prompt discussions about differences in practices. Some audience members were surprised to find that midwives in Austria perform a vaginal examination every hour! Therefore, the evaluation of ‘second stage’ is determined by dilatation. In contrast, visitors from Sheffield – Midwife Helen Dresner-Barnes and Consultant Obstetrician Julia Bodle – explained how in Sheffield, vaginal examinations are not routinely performed during breech labours. Progress is evaluated by observing the woman’s spontaneous expulsive effort, and if she is bearing down for some time without any noticeable descent, this would be considered an arrest in the second stage of labour necessitating a caesarean section. Such differences raise interesting discussions around why we do what we do – for safety? for measurement? for documentation? for protection in case of litigation? And what effects such seemingly neutral interventions may have – interfering with physiology? lowering the threshold for CS with or without benefit? reassuring or undermining the woman and her health professionals? We may not have all the answers, but at least we are beginning to ask the questions.
Thanks also to Lisa Walton of Blackpool and Oli Armshaw of the University of Western England for helping make the day a success.
Professionals: Concerned about women waving giant sticks of burning wacky weed around their wee toes in a desperate attempt to turn their breech babies?! Take action NOW! Ensure that these women can access support for a vaginal breech birth with an experienced, trusted professional, and you will no longer have to busy yourself trying to root out such madness!
Last week the results of a trial (Coulon et al 2014) were released which appeared to show moxibustion with acupuncture ineffective in causing more babies to turn head-down. The trial had its good points. A reasonable number of women randomised (328) at the appropriate point in pregnancy (33+4 – 35+4) to use moxibustion for maximum effectiveness. This in itself was impressive, as most centres do not bother about breech presentation until 36 weeks, making recruitment for studies during this time period difficult. The team looked at the percentage of babies who remained breech at 37+2, the point when ECV (a procedure to manually try to turn the baby in the uterus to a head-down position) would be offered, and found that 72% who had the treatment were still breech, compared with 63.4% who had the placebo. They reported this was not statistically different, but superficially it looks like the treatment had the opposite of the desired effect.
On the other hand, they appear to have used actual needles, heated with moxibustion, rather than the method most commonly used in UK-based moxibustion practices, which involves using the heated sticks only. Also, the intervention and placebo were applied for only six sessions. Generally, women using moxibustion in the UK are usually taught to home-administer (usually with the help of her partner) and then instructed to follow a ten-day course, applying moxibustion twice a day, and continuing whether the baby turns or not. The ten-day, moxibustion-only practice follows a less treat-to-cure, and more treat-to-nourish philosophy, the idea being that the moxibustion nourishes the energy of the womb and promotes optimal positioning. (No swearing until I’ve finished the article, please!)
I’m a fan of observing responses to research on Twitter. (See this previous discussion on hypnosis for childbirth.) And Twitter did not disappoint. The Green Journal announced the Coulon study, and obstetricians celebrated their vindication for having dismissed the practice years ago. There’s nothing like the joy of scientific confirmation of one’s deeply held beliefs. It was as if somebody walked into a room full of midwives and said, “Hey, guess what? Continuity of carer improves outcomes for everybody!” (By the way, it does.)
But then a woman who had actually experienced a breech pregnancy pointed out the obvious: What are the alternatives? Generally, women are highly motivated to give birth vaginally (Raynes-Greenow et al 2004, Guittier et al 2011). They instinctively feel what the research tells us – that a normal birth, wherever possible, is beneficial for both babies and women. There are many hospitals throughout the Western world, including some in the UK, where women cannot even access an ECV, let alone a vaginal breech birth. I’ve had phone conversations where I’ve asked to speak with the person who performs ECVs and been told, “We don’t do that here for liability reasons.” Folks, it’s 2014.
With evidence-based counselling based on the outcomes of the Term Breech Trial, Kok et al 2008 found at least 35% of women preferred to plan a vaginal breech birth. Evidence-based counselling includes the lack of evidence of any difference between two-year outcomes whether an elective caesarean section or a vaginal breech birth is planned (Whyte et al 2004). We can reasonably conclude that if approximately 1/3 of women are not planning a vaginal breech birth in a given setting, then they are probably being directively counselled towards a caesarean section. This would include feeling forced to choose a caesarean section because no plan will be put in place to ensure attendance at a vaginal breech birth by an experienced and supportive professional.
Women resort to practices such as moxibustion and handstands in the swimming pool because they are constantly given the message that breech presentation is ‘wrong’ and should be corrected, with very few alternatives. Whereas the evidence indicates that turning babies, even with ECV, does not improve outcomes for those babies, though it certainly improves the chances of a vaginal birth in settings with minimal support for vaginal breech birth (Hofmeyr and Kulier, 2012 – Cochrane Review). I am increasingly uncomfortable with the current situation, where women do things they do not actually want to do because they cannot access a vaginal breech birth at all, or will not be supported to choose that option until they have done everything else (especially ECV).
Personally, I have no strong opinion on the use of moxibustion itself, as I generally prefer to leave the use of complementary therapies up to what works for individual women, as long as they do not pose a threat to her or her baby. I have taken training to be able to offer women advice, and I have supported women through the use of moxibustion. (We usually spend the ‘treatment’ time talking through the issues around breech birth.) When I speak publicly about breech management, someone usually asks me why I have not included moxibustion. And I tend to dodge the question, not so much because I am convinced of its efficacy or not, but because I believe it is professionals’ attitudes towards breech presentation and not the breech itself that needs to be ‘corrected.’
Let me propose this radical solution: Why don’t we channel some of that indignation over moxibustion practices into ensuring that breech services improve to a point where women will not need to look elsewhere? Let’s ensure every woman has access to a well-supported vaginal breech birth, an ECV attempted by a highly experienced practitioner, and/or a woman-centred caesarean section as late in her pregnancy as she wishes to plan it, including in early labour. Let’s ensure that women have sympathetic, experienced counselling and continuity from a midwife while they navigate these choices, and the attendance of a highly experienced consultant, ready to step up and be that expert in complications of childbirth, backing up the team at birth.
No Re-tweet, sadly 😉
While we must always make room for those who choose a different path, I suspect that if we got a bit more comfortable with breech in general, the debate over whether moxibustion has a place in the mainstream or not would fade into the distance. Stop blaming pregnant women for their misled attempts to avoid a caesarean section, and the sympathetic midwives who are desperate to help them, and sort out primary breech services.
[Note: I can only access the abstract to Coulon et al at the moment, as it has been posted ahead-of-print. I’ll update the post when it’s published, if there’s anything more to say.]