Tag Archives: Salzburg

Turning breech upside down

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February 2015

Yesterday, approximately 50 midwives and obstetricians shared some love for breech babies in Preston by hosting a Physiological Breech Study day!

prayer handsThe 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

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.

If you would like to read more about undiagnosed breech or antenatal detection of breech presentation, click on the links.

Emma Ashton, Gerhard Bogner, Olivia Armshaw, Tracey Cooper & Shawn Walker

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.)

Breech101These 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.

Shawn

Resources and a plug

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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

Emerging evidence for upright breech birth

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When I talk about ‘upright breech birth,’ I mean a birth where the woman is encouraged to be upright and active throughout her labour and able to assume the position of her choice for the birth. This is in contrast to the classic lithotomy position, in which the woman is flat on her back, usually with legs in stirrups. Upright includes all fours, kneeling, standing, sitting on a birth stool, lying on her side if her body (and not her attendant) tells her to, etc. Birth position is not a static concept. The defining feature of upright breech birth is the woman’s ability to follow her birthing instincts, to move spontaneously in order to assist the birth. However, many providers have developed preferences, having observed women birth successfully in a variety of positions.

Many advantages have been claimed for upright positioning. But if supporting this ideal is to become a reality, we need two things. Firstly, we need evidence regarding the outcomes for breech births managed in non-lithotomy positions. And we need skills in managing complications which occur when women are in non-lithotomy positions.

A step forward for the evidence occurred this week with the publication of research covering 11 years of experience at a large metropolitan teaching hospital in Australia (Foster et al 2014). This retrospective study, which used an intention-to-treat analysis, found much lower rates of complications than the Term Breech Trial, in line with those achieved by the PREMODA group, concluding that in experienced centres, vaginal breech birth is a reasonable option. For me, the take home message coming from the increasing number of studies which show the same comparatively better results is less about the inherent safety of breech birth, and more about how fundamental the local experience level and organised team approach is to achieving optimal safety levels.

Although the article does not discuss birthing position, the correspondence author, Dr Andrew Bisits, is well known for supporting upright breech births using a birthing stool, and in many of the births in this series, the women would have remained upright and active (see also Kathleen Fahy’s description of spontaneous breech birth). Some evidence indicates that use of a birthing stool may shorten duration of labour (Swedish birth seat trial), and this would certainly be an advantage for a breech birth.

Another advantage to using a birthing stool is that health professionals who are comfortable with lithotomy manoeuvres do not have to make any major adjustments to their practice, aside from a willingness to get closer to the floor. The baby emerges facing the same way, the same signs of descent are observed, very similar manoeuvres are used to resolve a delay in progress. An obstetric bed can also be adjusted to mimic a birthing stool, but women have more ability to stand up and move spontaneously when their feet are planted on the ground.

Active Birth Labour Support Stool

Active Birth Labour Support Stool

A number of birthing stools are available in the UK. Active Birth Pools supply a model which is very similar to the Birthrite seat. A birthing stool is a good investment for a Trust. As one of my former obstetric colleagues put it, “If they are good for breech, they are probably pretty good for cephalic babies as well!” Indeed.

Midwives have long supported women to birth in upright positions (for example, Maggie Banks, Jane Evans and Mary Cronk are well-known midwifery authors about breech), but as the RCOG guidelines (2006) recommend lithotomy, supporting this in hospital settings has been difficult. However, around the world, obstetric departments are increasingly discovering the benefits of enabling women to be upright, especially in all fours, kneeling and standing positions. These include teams in Frankfurt (some statistics, some background), Salzburg, Ecuador (Parto podalico), Brazil (parto natural hospitalar pélvico, Parto Pélvico Existe Sim!, and of course various parts of the UK.

Facilitating this type of breech birth requires a change in perspective and an understanding of new manoeuvres to assist in the event of complications or delay. The sooner these alternatives are incorporated into national skills/drills training, the more women with breech babies will be able to follow their instincts to assist with securing the safest possible delivery for their babies.

Shawn