This weekend, I have been lucky enough to visit Stockholm, Sweden, at the invitation of the Södersjukhuset (BB SÖS), with Dr Andrew Kotaska, author of the 2019 Canadian breech guideline. We delivered training in breech research and practice to obstetricians and midwives from across Stockholm, a contribution to their recent effort to establish city-wide guidelines.
Breech Team Leader Tove Wallström and Breech Midwife Monica Berggren
The day was organised by senior obstetrician Julia Savchenko (pictured with Andrew above). Julia and fellow senior consultant Tove Wallström lead the Labour Ward and the SÖS breech team. These inspirational women presented their local audit results, showing how their vaginal breech births have increased from 9 in 2014 to 50 so far in 2019. Almost all women give birth in an upright position, and all births are attended by a breech-experienced obstetrician and a breech-experienced midwife from the breech team.
Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre
“We believe that we do well what we do often.” – Caroline Daelemans
Drs Caroline Daelemas and Sara Derisbourg
Contact Hōpital Erasme Clinique du Siège on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be.
This month I visited Hōpital Erasme, in Brussels, Belgium. Led by Lead Obstetrician Caroline Daelemans, Erasme began to offer a dedicated Breech Clinic in December 2015. Much of the organisation and development of the clinic has been done by Dr Sara Derisbourg, who continues to research the impact of instituting a dedicated breech service.
I came to Brussels to provide our usual physiological breech study day. The breech team has transitioned to using physiological methods, including upright maternal positions (Louwen et al 2016), after attending training in Norwich in 2017. They now needed the rest of the team to understand the philosophy behind this approach. But the day began with Caroline describing the impact of instituting a dedicated Breech Clinic, and this was particularly exciting for me.
Josephine and Thiago talk about their experience of Ulysse’s breech birth at Erasme
My own research concerning the development of breech competence and expertise, and the recovery of these skills within a service, indicates that developing a core team with significant experience is the most effective method of safely offering a vaginal breech birth service (Walker et al 2016). This skilled and experienced core is more important than the ‘selection criteria’ that are used to predict the likelihood of a good outcome (but in fact are not very predictive). Skill and experience facilitate good outcomes and enable other colleagues to develop competence (Walker et al 2018). The Erasme team even encourage other health care professionals to come with their clients and attend them in labour with their support, to encourage the growth of breech skills.
The need for new ways of organising care has been emphasised in an on-line survey of Dutch gynaecologists just published by Post et al (2018, Does vaginal breech delivery have a future despite low volumes for training?): “Potential suggested alterations in organization are designated gynecologists within one centre, designated teams within one region or centralizing breech birth to hospitals with a regional referral status. Training should then be offered to residents within these settings to make the experience as wide spread as possible.”
Daphne Lagrou of Médecins Sans Frontières demonstrates shoulder press
Daelemans and Derisbourg began with a small team of 5 people. This has gradually expanded and now includes eight members who together provide 24/7 cover for all breech births within the hospital. Women with a breech presentation are referred by colleagues and increasingly by other women. The environment at Erasme is ideal because the hospital has a very positive approach to physiological birth in general, and a 15% overall caesarean section rate in 2017. This compares to 20.2% in Brussels and much higher in many places globally.
Practising collaborative manoeuvres for resolving head extension at the inlet of the pelvis (elevate & rotate)
What has the Breech Clinic changed? Before the introduction of the clinic, the planned vaginal breech birth rate was 7.19%, and in just a few years this has climbed to 42.7% of all breech presentations. Neonatal outcomes have remained stable. Actual vaginal breech births have climbed from 4.2% to 35.96% of all breech presentations within the hospital. The success rate for planned vaginal breech birth is 76.3%, which suggests that within experienced teams, the emergency caesarean section rate is also reduced. (The RCOG guideline suggests about 40% of planned breech births end in CS.)
All of this is very impressive. The message is clear: a physiological approach and an organised care pathway, including a breech clinic and experienced on-call team, can reduce the caesarean section rate significantly without negatively impacting neonatal outcomes. We should all look out for Derisbourg’s papers when they are published.
If you are a woman seeking support for a physiological breech birth, or a health care professional looking to refer a woman to the breech clinic, they can be contacted on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be. Caroline Daelemans will be teaching with me in Lewisham, London, on 12 November.
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!
Understanding the physiological process of a breech birth
The following pictures show the way a breech baby wiggles her way through a mother’s pelvis when mum is upright (e.g. kneeling or hands/knees), and the signs a breech birth attendant looks for to tell if this process needs help or not.
A breech baby may engage before labour, or may not engage until after her mother’s cervix is fully dilated.
Some midwives feel engagement with the back on one side or another may be ideal. (See Jane Evans‘s ideas on this, on Rixa Freeze’s blog.)
I am happy for the back to be on either side, and these pictures depict the birth of a baby whose legs are extended (frank breech), with her back on her mother’s left.
Descending LST, anterior buttock leading
The breech typically descends with the sacrum transverse, anterior buttock leading. On vaginal examination, this will feel asynclitic – the anal cleft is closest to the maternal sacrum. This is normal for breech.
Maternal movement assists this process in the same way it assists cephalic descent.
The buttocks will be born by lateral spinal flexion (wiggling the bum from side to side).
Anterior buttock rumping
The anterior (maternal front) buttock is born first, followed by the baby’s anus (usually squirting a thick glob of meconium) and the posterior buttock.
The sacrum will soon rotate to sacro-anterior (‘tum to bum’ – the baby’s rear should be in line with the mother’s front). If rotation is tending toward sacro-posterior, this may be an indication for intervention (to gently encourage sacro-anterior rotation).
Birth of the extended fetal legs
Baby’s legs seem to stretch forever, but will be born spontaneously as long as there is descent with each contraction. If one leg slips down before the other, this may indicate that full internal rotation has not occurred, and help with the arms may be needed.
“If it progresses, wait and see.” – Mary Cronk
Birth of the umbilicus
After baby’s legs flop down, you will have a clear view of the umbilicus and may even be able to see the baby’s heart rate from her chest. Do not touch the umbilicus, but observe: colour, tone, flexion/movement.
Reassuring sign: If you observe cleavage (the sternal crease) on the baby’s chest, you know the arms are in front and should be born with the next contraction or active maternal effort between contractions. If not, you need to help.
Indication for intervention: If full rotation has not occurred by the time the nipple line is visible, or progress stops for >90 seconds at any point, you will need to assist with the birth of the arms.
Rotation to drop the anterior arm below the pubic arch
In most breech births, the arms will be born spontaneously with the baby’s torso in a sacrum-anterior position (‘tum to bum’).
Occasionally, as the head engages, baby rotates slightly to release one arm below the pubic arch, then rotates the other direction to release the other arm.
Birth of the fetal arms
Baby should be ‘tum to bum’ following the birth of the arms, and the head should be aligned in the pelvis in an occipit-anterior position.
Unflexed head obstructed in pelvis
A well-flexed head will pass easily through the pelvis.
Commonly, women experience an urge to lower their bottoms to the surface on which they are kneeling (e.g. bed, floor mat, etc.) This maintains and promotes flexion in the baby’s body and should not be interrupted.
Flexed head passing through pelvis
Babies have often been observed doing a ‘tummy crunch,’ or full body flexion recoil, spontaneously pulling their knees up into a fetal position. This also promotes flexion and helps the head to be born.
Note: A compromised baby will not do this, and you will need to assist more, and sooner.
If progress arrests – no descent with maternal effort – help to flex the head is indicated, especially if baby’s tone and colour are not ideal.