Tag Archives: Portsmouth

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.”

A craftsman’s job

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Two weeks, two inspirational obstetric colleagues, two very welcoming UK cities. So much commitment to improve the system for breech babies and their mothers.

eclipse tweetOn the 20th of March, Dr Elie Azria of the Hôpital Paris Saint Joseph and Descartes University, joined me in Dundee, Scotland, to teach through the eclipse! The French and Belgians have continued to support breech births in the last 15 years, responding to the Term Breech Trial (TBT) with a prospective observational study (PREMODA, 2006) which involved over twice the number of planned breech births (VBB) than the TBT, and demonstrated no statistically significant difference in outcomes between those who planned a VBB and those who planned a caesarean section (CS). Azria was the lead author on a follow-up analysis of the data examining factors associated with adverse perinatal outcomes in the PREMODA data.

AzriaIn our Breech Birth Network study day, Azria presented new research concerning whether breech presentation is an independent risk factor in preterm breech birth, with interesting results which we hope to see published soon. He also gave an inspiring presentation on the “Traps of Evidence Based Medicine,” using the example of term breech delivery, building on his work to reconcile the need for maternal autonomy and medical responsibility in shared decision-making about mode of childbirth.

I always enjoy teaching with experienced practitioners who come from a different practice culture. Practice constantly improves and evolves from sharing these different ways, if we are open to learning from each other. Azria pointed out that, sadly, even within a culture where support for VBB has remained standard, the use of CS is on the rise. As he described, “Breech delivery is a craftsman’s job,” an art as well as a science. Learning breech skills requires commitment, dedication and practice, which not everyone is willing to offer. Nor are many people keen to take the risk of learning in the current risk-averse climate of maternity care.

Read more about How singleton breech babies are born in France, from the AUDIPOG network (Lansac et al 2015).

Julie Woodman (Queen Alexandra) & Miss Nicola Lack (UCLH)

Julie Woodman (Queen Alexandra) & Miss Nicola Lack (UCLH)

On the 27th March, I was joined by Miss Nicola Lack, Consultant Obstetrician from University College London Hospital NHS Trust. Lack gave a fantastic presentation on the research base for counselling about mode of childbirth with a breech presenting baby. One of the problems with a decimated skills base is that, while we may have a strict set of inclusion criteria for what constitutes ‘normal’ for a VBB, it may be quite difficult to find someone who can actually assess those criteria at a moment’s notice on labour ward, eg. a hyperextended neck on ultrasound. Breech skills are not just the manoeuvres which may be used around the time of birth. Skilled practice also involves the ability to provide detailed individualised counselling and make relevant antenatal assessments, as well as on-going interpretation throughout pregnancy and labour.

Portsmouth

photo by Michelle Ball

Lack’s presentation drew extensively from her own experience of working in the UK and Africa, as well as her understanding of medico-legal issues and constraints caused by a litigious practice culture. She explained how, when counselling, we really need to talk about the potential benefits of VBB as well as the risks. For example, she reflected on how, when she first qualified as an obstetrician in 1999, placenta percreta was relatively rare. Now, she and her colleagues encounter it approximately once a week or fortnight, due to the increase in CS rate. That’s very concerning. Lack also facilitates a postnatal birth reflections clinic, where she has had the opportunity to learn how women feel about breech childbirth experiences, both CS and VBB, after the event.

Midwives Michelle Ball and Shawn Walker

with my Twitter friend @Shelly_RM

My one sadness on both days was that, despite the best efforts of the organisers and the high calibre of the obstetric speakers at the events, so few obstetric colleagues attended the study days. This is a real problem. Midwives are increasingly advocating for women to have the realistic option of a well-supported VBB if that is their informed choice, but this needs to be a collaborative effort. I urge our obstetric colleagues to come to the table to learn and work with us, so that the women and babies we care for, and we as professionals, can benefit from the best possible support of the wider multi-disciplinary team.

Thank you to Consultant Midwife Phyllis Winters of the Montrose Maternity Unit and Julie Woodman of the Queen Alexandra Hospital in Portsmouth for organising the study days.

Shawn