Saturday, May 27, 2017

When the birth doesn't go as planned--a manager's perspective

Andrea Galimberti, Clinical Director of Obstetrics
Paula Schofield, Nurse Director and Head of Midwifery
Sheffield Teaching Hospitals
North of England Breech Conference, Sheffield
Day 2


Rixa's note: This presentation addressed many processes and structures unique to UK. where there is a nationwide, uniform procedure for reporting and investigating adverse events. 






With regards to adverse events, what is “special” about breech?
  • There are a wide range of clinical opinions about vaginal breech birth.
  • Breech is an emotionally charged topic. If you expect something to wrong, your experience will confirm what you expect. It creates a very unique set of circumstances within the obstetric service. Normally clinical incidents are accepted in the obstetric service, but breech evokes a different set of reactions.
  • There are varying levels of practical experience between staff at different levels of seniority. This is again peculiar to breech and unlike most things in obstetric services. You might have a young consultant with more experience in breech than an older consultant, or perhaps a very trained midwife and a consultant with no experience. This changes up the normal hierarchy/framework of calling for help.
As managers, we have 5 tasks when something goes wrong (not unique to breech)
  1. Determining how serious the event is
  2. Interacting with the Trust at a corporate level and with the Commissioners
  3. Dealing with and supporting the family involved
  4. Dealing with and supporting staff who were involved with the clinical incident. They are still our colleagues.
  5. Reassuring HM Coroner that the care provided was to appropriate standards
The most important thing for clinical managers is to AVOID KNEE JERK REACTIONS! We have to be calm and supportive because another breech might come the next day and we still have to deal with that woman and that labor. We can’t create a system that makes people unable to look after the next case.

1. How do we decide how serious an event is? 
A Serious Untoward Incident (SUI) is defined as having such magnitude that the consequences have a serious impact on individuals or the organization. Based upon the "measure of consequence," birth-related significant incidents in the UK may classify as Major (leading to long-term disability) or Catastrophic (leading to death).

The risk of litigation and/or loss of reputation are also extremely high. Newspaper always love to get hold of dead baby stories.

The grading of an incident is based mainly on its consequences. Incidents graded as Serious Untoward (SU) or Moderate (M) always require a formal investigation to include root cause analysis. They would also involve a “duty of candour.” All SU or M incidents must be shared with the family involved. We can’t withhold that information; we must volunteer and share with the family all of our findings and our action plans.

2. How do we interact with the Trust and the Commissioners?
The point of contact is the Trust Clinical Governance Group. These people come from all walks of life and professions, and they are the voice of patients within the Trust at a high level. We also have a SUI group that has the final word on the grading of an incident.

If the incident is classified as SU or M, the SUI group will oversee the investigation and its reporting to the Commissioners. They have timescales for reports and actions. If the incident involves doctors in training, it is shared with the Director of Postgraduate Education.

3. How do we deal with and support the family involved?
We ensure that patients are made aware of the incident and receive an apology as appropriate. Sometimes there aren’t things to apologize for, but we should apologize when there is something warranted. Where continuing care is required, this will normally remain the responsibility of the patient’s Consultant who was involved, but sometimes it’s appropriate to change care to someone else. Postnatal support can include counseling or psychologist input. PTSD is a well-recognized consequence of difficult births.

4. How do we deal with and support staff members?
If something serious or catastrophic happens, we offer immediate practical support, day or night. We come in immediately to help at critical moments to make sure that people complete their work and records and to maintain the functionality of the obstetric service. It can be very difficult for staff to continue on with their shift after a difficult event. If it’s near the end of the shift, we might support the staff to go home once they have completed essential tasks.

Before the staff come back to work, it’s really important to meet with them, not just send them back to work the next day. In the meantime, we take a look at the case and review if the staff members can continue to work or if they might need to change areas for a time. Once the staff comes back, some people seem very able to deal with it and others don’t.

The staff will often need to be interviewed about the event, and that can be very difficult. The sooner you do the interviews and investigation, the better. We (Paula and Andrea) either do the investigations ourselves, or we engage a senior midwife or obstetrician to do it. We also prepare the Coroner’s Inquest.

5. What do we do during the investigation process?
During the investigation, staff can bring in a colleague if they wish. The staff need to understand the value of being interviewed. When things don’t go well, the medical records tend to be very scrappy. We can’t assume decision-making rationales; we need to be able to interview the staff to get their thought processes.

We try to encourage our colleagues to get support from avenues other than ourselves: maybe their GP, workplace well-being counselor, occupational health doctor, or Trust psychologist. People who see a psychologist give very positive feedback about their experiences. We are working towards having a full-time psychologist for our OBs, midwives, and neonatologists. We are optimistic that we are going to secure this full-time support. We are mindful that families are in the same position and that the full-time psychologist would also be there to support the families.

Staff feedback on the investigation process
The SUI processes can take months to decide, and the staff can get angry or frustrated at the delay. SUI reports tend to have lots of back-and-forth to clarify what happened; it takes patience.

The staff need to prepared if the investigation goes to a Coroner’s case. If that happens, they will have a Trust barrister who will support them at the Coroner’s court. When they go to the Coroner’s, we have to absolutely clear of the facts and statements. That’s why we need to support the staff right away.

We also develop action plans. It can help at the Coroner’s court to show you have developed one. The SUI reports are kept transparent, and the parents remain informed of what is happening. It is a transparent process. If the family feels they are kept informed, they are generally very grateful. The best people to champion changes and action plans are the people involved in an incident; it’s often hard because these people can feel publicly shamed among their colleagues.

~~~~~

Betty-Anne Daviss: I wrote to Helen and Julia that I love the model they are creating and that it’s a model we should be following. I am a midwife doing vaginal breech births in a hospital where most of the physicians are not supportive. The pediatricians and nurses tend to want to make the Apgars lower than they really are. They make a big deal out of every single birth that occurs because the people in the room haven’t seen it often, so they think what they see is a bad outcome. But to me, it’s a great outcome and normal for breech. Things get created into a bad incident when there was nothing bad at all.

Andrea: This talk was about serious or catastrophic incidents: death or permanent disability, not low Apgar scores. Yes, there is a tendency to make things worse than they are. For minor incidents, staff are encouraged to report worrisome things (inadequate staffing levels, etc). Everything like that is investigated, but at a much lower key. Internal investigations don’t take any legal process; that’s a separate process. Our investigation is simply to learn what happened and communicate it to staff and family.

Paula: Yes, people can be very supportive. We have to be very cautious and very careful. We want to keep our colleagues well-supported, but we also can’t protect them from investigations and self-analysis. As OBs and midwives, we are terrible at deciding something is bad when it’s not really.

Andrew Bisits: I am a manager, too. When an adverse event happens, the most important thing is that people have to be stopped from any discussion about it immediately. That’s the most destructive phase--the knee-jerk reactions. You spoke about the very formal process. The other area of interest is how people get together and talk about it at a clinical meeting. It’s an important opportunity to support staff and to enhance teamwork. It’s also been, unfortunately, an opportunity to destroy teams as well because of the way people talk.

Andrea: Yes, we do tend to have debriefing meetings with a leader/mentor who wasn’t involved. The purpose is to gather information and allow them to download in a supportive environment. We also have clinical review meetings for various outcomes. Yes, you’re right, sometimes they’re scientific and sometimes they’re very emotional and destructive. That’s why we have the controlled mentor meetings to be sure they’re constructive.

Paula: We need to be very cautious with the duty of candour and with what we share in certain multidisciplanry meetings. We have to be sure things are factually based.

Q from a Trust midwife: Instead of doing individual interviews, we bring groups of peers together and give everybody an opportunity to discuss their personal statements in relation to the incidents. People were worried about what other people were saying, so the group interviews helped relieve that worry.

Paula: When we do our interviews, the senior person interviews the staff member involved. At the end, if there is contention, we bring everyone together for a group meeting. When I look at SUI reports and other internal governance documents from various Trusts, some are doing incredibly well and some are doing terribly.
Read more ...

Wednesday, May 24, 2017

Gail Tully: Breech Complications Illustrated

Gail Tully
Breech Complications Illustrated (particularly rotation and descent)
North of England Breech Conference, Sheffield
Day 2


Gail Tully is a midwife in Minnesota and founder of Spinning Babies. She expressed her gratitude for being here today and says she feels like the "little sister" among all of the breech experts--"a less developed observer who, therefore, is likely to come up with some surprise perspectives."

Gail thanked the influential people who have taught her about breech: Ina May Gaskin in the 80s and 90s, presenters at the 2009 International Breech Conference in Ottawa, UK midwives such as Mary Cronk and Jane Evans, Anke Reitter, Frank Louwen, and Betty-Anne Daviss.


Gail asked the question: Who is the new face of the US breech expert? Her answer was both funny and sobering: It is the fireman, the policeman, and the paramedic. These are the people who are allowed to attend vaginal breech births in the US. Doctors and midwives are not.

Improving the safety and success of ECV
If we help prepare and loosen the soft tissues, we theoretically can make the ECV more successful. Self-care, body-balancing, fascia therapy, and pelvis alignment may all improve safety and success in ECV. There’s a midwife/doctor team in Rio who are sending parents home for a week with these techniques with great results. (Rixa's note: I'd love more information on this team if anyone is familiar with their work.)

3 pillars of safe breech
1. Hands and knees
2. Hands off the breech--Unless baby needs help!
3. Don't clamp the cord

Her session will address pillar #2: when to help.

Frank Louwen has taught us that what you see on the outside tells you what’s going on inside. In the US, providers often don’t know when to step in or not. Gail critiqued American home birth midwives for waiting too long to intervene in a breech when there are clear signs that the baby needs help. If the baby's tone and color seem good, but descent has stopped, help the baby without delay.

Review of the cardinal movements of the breech baby
Gail showed us how the pelvic floor muscles guide the rotation of the baby, explaining why the breech baby generally rotates to sacrum lateral. For more details, consult Anne Frye's Healing Passage p. 89. Next, the baby descends and the chest rotates to sacrum anterior.

When to be hands-on
1) When descent stops
2) When the baby appears deflated, hollow, or limp. If the baby's head is well-flexed, use Kristeller (fundal pressure).

Can we reduce complications with breech births? Gail thinks we can when we consider the anatomy.

Match the baby to the pelvis
When progress stops, ask, “what has happened inside?” First, figure out where the stuck part is within the pelvis (inlet, mid-pelvis, outlet). Then use solutions that match the pelvic diameter.

From Gail's presentation, I learned that breech babies can be incredibly resourceful in how they get themselves stuck inside the pelvis. You have to outsmart these babies--kind of like figuring out a 3-D brain-teaser.
For detailed illustrations of all these solutions, I highly recommend purchasing Gail's Breech Birth Quick Guide, available as a spiral-bound booklet ($24 USD) or digital download ($19.95 USD). Gail's presentation went over many of these, but quite quickly. My summary won't be able to supply all of the necessary details. (I have no financial arrangements with Gail--just a deep appreciation of her knowledge of the maternal pelvis.)


Inlet dystocias (stations -2, -3, -4)
When the arms are stuck, this occurs in the pelvic inlet. You'll see the lower ribs visible. The baby will usually be turned facing sideways, rather than facing the mother's anus. Different ways the baby can be stuck in the inlet:
  • The baby might have one or both shoulders stuck in the inlet with its arm(s) behind its head. 
  • The baby's upper arm might be trapped inside a separating symphysis (which Gail has encountered).
  • The baby might have its arms crossed over its face--sometimes the baby will be rotated to direct anterior or posterior, but then descent halts. The baby might do the tummy crunch to get the next body part into the pelvis. If the baby does this and no descent happens, you must take action! 
  • The baby's head might be caught up high on the inlet or brim (stargazer). In this case, the shoulders will be born but the perineum will be empty. 
  • The baby is anterior and its head is caught on the sacral promontory (rare). 
  • The baby is posterior and its chin is stuck on the symphysis (rare). 

Use solutions that turn the shoulders to oblique and transverse diameters to permit descent. You might need to:
  • Rotate the baby by grasping the shoulder girdle and rotating 180, then 90 the opposite direction. Baby's hand points the way of the first rotation. Baby faces mother's anus when you are done. 
  • Open the pelvic inlet via maternal positioning (H&K: posterior pelvic tilt. On back: Walcher's)
  • Turn the baby's head/chin to the oblique. 
  • Lift & rotate the stuck part off the symphysis/sacral promontory. 

Mid-pelvis dystocias (stations -1, 0, +1)
The baby's head can be stuck in the mid-pelvis when the head is still turned to the oblique and not fully flexed. You will see the baby's body full born. The chest might be facing you or turned to the oblique.

Solutions:
  • Have the mother do a diagonal lunge, also called the "running start"
  • Reach in to turn the baby to OA, then flex the head

Outlet dystocias (stations +2 and lower)
At this point, the baby is born to the neck. When a baby's head is well-flexed and in the pelvic outlet, the mother's anus and perineum appear full or bulging. You might even see a bit of the chin. These are all good signs.

If the anus or perineum appear empty or hollow, this is a sign that the head is extended. You must flex the head.

Solutions:
  • Use maternal positions that open the pelvic outlet (anterior pelvic tilt, running start, Walcher's).
  • Flex the baby's head by pushing up on the occiput and dragging down on cheek bones.
  • Flex the baby's head using finger flexion: put your fingers on the temporal bones and flex the head.
  • Gently press the baby's subclavicular space to encourage the baby to flex its head. This is called SAFE: Subclavicularly Activated Flexion and Explusion. This is a variation on Frank's nudge that uses a physiologic response instead of mechanical pressure. SAFE was developed by Adrienne Caldwell, Therapeutic Massage Therapist and anatomical adviser to Spinning Babies.

Gail showed us slides and videos of many breech births she has attended with various kinds of dystocias. One birth in particular stuck out to me--the baby had multiple dystocias that Gail resolved over a total time of 2.5 minutes. This included a baby with shoulders stuck in the inlet, an arm stuck inside the partially separated symphysis, a head stuck in the midpelvis due to a tipped coccyx, and then a head that needed manual flexing. This required a deep knowledge of the pelvis and of how a baby should descend through the various diameters. Thanks to Gail's skilled hands, this baby made it safely with Apgars of 10/10. (And extra kudos to the mama--this was not just a breech baby, but also a VBAC!)

Again, I highly encourage you to purchase a copy of Gail's Breech Birth: Quick Guide. All of these problems and solutions are illustrated with both photos and drawings. Study this booklet until you know it by heart, backwards and forwards.

Reviewed by Gail Tully, May 24, 2017. 
Read more ...

Thursday, May 18, 2017

Anita Hedditch: The Oxford breech service

Anita Hedditch
The Oxford Breech Service
North of England Breech Conference, Sheffield
Day 2

This is the first of 3 hospitals presenting about starting a vaginal breech service. The other hospitals include The Jessop Wing in Sheffield and Sachsenhausen Hospital, Frankfurt, Germany.

Anita Hedditch is a midwife at Oxford University Hospital and has been in practice since 1992, allowing her to witness the changes brought about by the Term Breech Trial. She leads a group of midwives who provide 24/7 access to upright breech birth. She has also been involved with Oxford's ECV clinic since 2010. Established in 1999, the ECV clinic has a database of 2,500 ECV attempts. The Oxford Breech & ECV Clinics are also the home of the Greentop Guideline for Breech Presentation (headed by Lawrence Impey).

In the beginning, establishing a breech service at Oxford wasn't a purposeful decision, but rather a gradual evolution. Since 2014 they have offered a complete vaginal breech service. They have had 51 successful of 77 planned breech births.

They do 36 week growth scans at Oxford, which has allowed them to drastically reduce the number of undiagnosed breeches.

Where do you start in setting up a breech service?
  • You’ve really got to know your stuff
  • Give staff/colleagues exposure to breech training; seek out experts in the field
  • Involve senior key obstetric and midwifery “influence-ors”
  • Talk about it--generate interest
  • Prepare guidelines, patient leaflets, care plans, and data collection forms
  • Be prepared to learn
  • Keep mom and baby at the center of decisions
  • Be prepared to work as a multidisciplinary team
  • Ensure 24/7 coverage to provide consistency in care
  • Involve the pediatric team in preparation. Pediatricians have learned over the past several decades that breech birth is bad. We have to teach them again that breech is okay and that it can be done safely.
  • Expect resistance & knockbacks
  • Remain within labor guidelines. (Anita noted that these guidelines have been challenged recently. There are different opinions on which guidelines are absolutes and which may be open to revision.)
  • Learn from your outcomes to improve the future (for example, a different pattern of labor can be okay). 
You will need to develop the paperwork for running a breech service. Information leaflets will be used to counsel the families as they make informed decisions. You will also need to write guidelines, care plans, and data collection forms.

Remember, it’s up to the women what to do.

Make sure the information given to women is consistent between providers so they aren’t getting mixed messages

Evidence on how to provide a safe service
They looked at the PREMODA study intensively, noting significant differences between the TBT and PREMODA protocols. Some of the main areas of difference were fetal monitoring, presence of an experienced attendant, prenatal ultrasound to look at head flexion and estimated fetal weight, pelvimetry, and length of labors. They strive to follow the same protocols as the PREMODA study.


How to do a breech the "right" way
The "right" mother has an engagement with active birth and goes into spontaneous labor at term.

The "right" baby is not too big and not too small, with a flexed or neutral head, and in extended or flexed breech presentation (i.e., not footling or kneeling).

The "right" way starts with the birth team who all follow these practices:
  • no stretch & sweeps
  • no augmentation
  • minimal vaginal exams (ideally very few, sometimes none at all)
  • careful auscultation
  • awareness of critical birth signs (knowing the normal rotation & descent of the breech baby)
  • observing for color, tone and perfusion of the baby as it is born – and intervening promptly if either any of these are cause for concern
  • leaving the cord intact if at all possible. Anita explained that an intact cord helps a baby resuscitate itself. If you cut the cord on an asphyxiated baby, you interfere with the blood/brain circulation
Next, Anita showed slides of EFM tracing from various breech labors and and talked through different scenarios.

Oxford's outcomes
Anita ended by presenting Oxford's breech outcomes and comparing them against the PREMODA study.


57% of primips and 82% of multips planning a VBB had vaginal births. At Oxford the women tend to have quick 1st stages, with some passive 2nd stages.

The babies weighed between 2220g - 3860g. 94% had 5-minute Apgars >= 7. There were two cesarean-related complications (both postpartum hemorrhage) and 3 manual removals of the placenta. There were 2 episiotomies, 18 intact perineums, and no 3rd degree tears.

Their ECV clinic has a 50% success rate of turning breech babies head-down. Of the women with successful ECVs who went into labor with head-down babies, 70% of primips and 94% of multips had vaginal births.

~~~~~

Dr. Andrea Galimberti commented that these are very impressive figures. He's thinking back to the time before 2001 when vaginal breech delivery was the norm. He’s been talking with several people interested in setting up a breech service in their hospitals.
Read more ...

Tuesday, May 16, 2017

My letter to DeKalb Medical regarding their reaction to a breech twin birth

Last week, DeKalb Medical revoked See Baby Midwifery's privileges after Dr. Bootstaylor attended the birth of breech-breech twins. The parents of the twins--both born with excellent Apgar scores-- wrote a letter this week attesting to the quality of their care. They lived 4 hours away in Savannah and relocated for the last month of her pregnancy in order to have the chance of a vaginal birth.

Dr. Bootstaylor is meeting with DeKalb today to discuss the situation. I wrote the following letter in support of See Baby Midwifery and Dr. Bootstaylor. (Click on the image for a PDF version.)


Monday, May 15, 2017

Dear DeKalb Medical,

I am writing to express my extreme consternation about your revoking See Baby’s privileges. As I understand the situation, Dr. Bootstaylor supported a family who wanted a vaginal birth for their breech-breech twins. The twins were both born with excellent Apgar scores; the second twin sustained a long bone fracture that is healing without complication.

I am a maternity care researcher and academic, and one of my main research interests is vaginal breech birth. I am also a mother of four children, so restricting women’s choices in childbirth is a personal issue as well as a professional concern.

I am currently collaborating with a British midwife and breech expert, Shawn Walker, to help hospitals safely implement vaginal breech services. As the evidence mounts that vaginal breech birth can be a safe option, especially when supported by experienced providers (1), it is unethical to ban women and their providers from the option of a vaginal breech birth. Studies on breech-first twins are rare, but the best evidence indicates that cesarean section is no safer than vaginal birth (2). The most recent ACOG practice bulletin upholds vaginal breech birth with experienced providers (3).

I want to remind you that banning vaginal breech birth or vaginal twin births by removing experienced providers such as Dr. Bootstaylor forces women to have surgery without their consent and forces providers to coerce their patients into surgery. This directly violates the principle of informed consent, which includes the right to informed refusal (4). AGOG’s May 2016 practice bulletin strongly upholds pregnant women’s right to refuse medical treatment. It reads:
[A] decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected. The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge. As such, it is never acceptable for obstetrician–gynecologists to attempt to influence patients toward a clinical decision using coercion. (5)
Forcing women to have cesareans for cases such as breech, twins, or VBAC also violates U.S. legal rulings that uphold the right of competent adults to refuse surgery (6). In particular, the Georgia Medical Consent Law has a section on the “Right of persons who are at least 18 years of age to refuse to consent to treatment”:
Nothing contained in this chapter shall be construed to abridge any right of a person 18 years of age or over to refuse to consent to medical and surgical treatment as to his own person. (31-9-7) (7)
I have read Jessica and Kevin Hake’s statement about why they chose to have their twins with Dr. Bootstaylor. Nothing in that letter shows evidence of illegal, unethical, or unsafe practices. In fact. Dr. Bootstaylor’s commitment to patient advocacy by respecting Jessica’s right to informed consent and self-determination should be commended.

Short-term morbidity, such as a long bone fracture, can happen after cesarean sections, including cesareans for breech babies (8). Forcing all women to have cesareans for breech or twins because of a long bone fracture is as illogical as forcing all women to have cesareans to avoid shoulder dystocia, or requiring all women to have vaginal births to avoid placenta accreta.

Women who have cesarean surgeries face a higher risk of death (9). Their subsequent pregnancies have worse outcomes than those of women who had vaginal births (10).  Removing the option of a vaginal birth for women with breech, twins, or uterine scars births forces these women to undertake these risks, often with no added benefit.

The See Baby team is one of the few practices in the area—even in the state, as the Hake’s story can attest to—that offers women a full range of choices. I urge you to reinstate See Baby’s privileges. I also urge you to encourage all maternity care providers at your hospital to provide full informed consent and a full range of choices to their patients, including the right to refuse a cesarean in favor of a vaginal birth.

All women deserve to give birth in the manner of their choosing, free of coercion. The law requires it. Medical ethics demands it. And most importantly, women want it.

Sincerely,

Rixa Freeze, PhD

References

1.
  • Alarab M, Regan C, O’Connell MP, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004;103:407–12.
  • Albrechtsen S. Breech delivery in Norway—clinical and epidemiological aspects [dissertation]. Bergen: University of Bergen; 2000:1–68.
  • Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194:1002–11.
  • Haheim LL, Albrechtsen S, Berge LN, Bordahl PE, Egeland T, Henriksen T, et al. Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team. Acta Obstet Gynecol Scand 2004;83:126–30.
  • Hellsten C, Lindqvist PG, Olofsson P. Vaginal breech delivery: is it still an option? Eur J Obstet Gynecol Reprod Biol 2003;111:122–8.
  • Kumari AS, Grundsell H. Mode of delivery for breech presentation in grandmultiparous women. Int J Gynaecol Obstet 2004;85:234–9.
  • Rietberg CC, Elferink-Stinkens PM, Brand R, Loon A, Hemel O, Visser GH. Term breech presentation in the Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33824 infants. BJOG 2003;110:604–9.
  • Rietberg CC, Elferink-Stinkens PM, Visser GH. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcomes in the Netherlands: an analysis of 35453 term breech infants. BJOG 2005;112,205–9.
  • Uotila J, Tuimala R, Kirkinen P. Good perinatal outcome in selective vaginal breech delivery at term. Acta Obstet Gynecol Scand 2005;84:578–83.
2. Blickstein I, Goldman RD, Kupferminc M. Delivery of breech first twins: a multicenter retrospective study. Obstet Gynecol. 2000 Jan;95(1):37-42.

3. American College of Obstetricians and Gynecologists. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol 2016;127(2):e54–61.

4.
  • Chavkin W, Diaz-Tello F. When Courts Fail: Physicians’ Legal and Ethical Duty to Uphold Informed Consent. Columbia Medical Review. 6 Mar 2017; 1(2): 6-9.
  • Goldberg H. Informed Decision Making in Maternity Care. Journal of Perinatal Education. 2009; 18(1): 32-40.
  • Hammami MM et al. Patients' Perceived Purpose of Clinical Informed Consent: Mill's Individual Autonomy Model is Preferred. BMC Med Ethics. 10 Jan 2014; 15: 2.
  • Kotaska A. Informed Consent and Refusal in Obstetrics: A Practical Ethical Guide. Birth. 2017; 00: 1-5.
  • Moulton B, King JS. Aligning Ethics With Medical Decision-Making: The Quest for Informed Patient Choice. J Law Med Ethics. Spring 2010; 38(1): 85-97.
5. American College of Obstetricians and Gynecologists. Refusal of medically recommended treatment during pregnancy. Committee Opinion No. 664. Obs Gynecol 2016;127:e175–82

6. See, for example:
Union Pacific Railway Co. v. Botsford, 141 U.S. 250, 251 (1891)
Schloendorff v. Society of New York Hospital, 105 NE. 92, 93 (N.Y. 1914)
Cruzan V. Director, Missouri Dept. of Health, 497 U.S. 261, 270 (1990)
In re Brown, 478 So.2d 1033 (Miss. 1985)
Cruzan V. Harmon, 160 S.W.2d 408, 417 (Mo. 1988)
Matter of Guardianship of L.W., 482 N.W.2d 60, 65 (Wis. 1992)
In re Fiori, 673 A.2d 905, 910 (Pa. 1996)
Stouffer v. Reid, 993 A.2d 104, 109 (Maryl. 2010)
7. Code 1933, § 88-2907, enacted by Ga. L. 1971

8.
  • Canpolat FE, Köse A, Yurdakök M. Bilateral humerus fracture in a neonate after cesarean delivery. Arch Gynecol Obstet. 2010 May;281(5):967-9.
  • Capobianco G et al. Cesarean section and right femur fracture: a rare but possible complication for breech presentation. Case Rep Obstet Gynecol. 2013;2013:613709
  • Cebesoy FB, Cebesoy O, Incebiyik A. Bilateral femur fracture in a newborn: an extreme complication of cesarean delivery. Arch Gynecol Obstet. 2009 Jan;279(1):73-4.
  • Farikou I, Bernadette NN, Daniel HE, Aurélien SM. Fracture of the Femur of A Newborn after Cesarean Section for Breech Presentation and Fibroid Uterus : A Case Report and Literature Review. J Orthop Case Rep. 2014 Jan-Mar;4(1):18-20.
  • Kancherla R et al. Birth-related femoral fracture in newborns: risk factors and management. J Child Orthop. 2012 Jul;6(3):177-80.
  • Matsubara S et al. Femur fracture during abdominal breech delivery. Arch Gynecol Obstet. 2008 Aug;278(2):195-7.
  • Morris S et al. Birth-associated femoral fractures: incidence and outcome. J Pediatr Orthop. 2002 Jan-Feb;22(1):27-30.
  • Rasenack R et al. [Fractures in neonates as a result of birth trauma caused by caesarean section]. [Article in German] Z Geburtshilfe Neonatol. 2010 Oct;214(5):210-3.
9.
  • van Dillen, J., Zwart, J. J., Schutte, J., Bloemenkamp, K. W.M. and van Roosmalen, J. (2010), Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstetricia et Gynecologica Scandinavica, 89: 1460–1465.
  • Schutte JM, Steegers EA, Santema JG, Schuitemaker NW, Van RJ. Maternal deaths after elective caesarean section for breech presentation in the Netherlands. Acta Obstet Gynecol Scand 2007;86:240–3.
10. Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179–93.
Read more ...

Monday, May 15, 2017

Andrea Galimberti: Day 2 opening address

Andrea Galimberti
Chair opening address
North of England Breech Conference, Sheffield
Day 2


Dr. Andrea Galimberti is the Clinical Director & Consultant OB at the Jessop Wing in Sheffield. Sally Freeman, a Senior Lecturer at Sheffield Hallam University, introduced him and noted that his most important unofficial role is that of midwife. 

Andrea began by noting that yesterday was a great day; it was very informative, and he learned a lot of new things. It got him thinking. Lawrence Impey showed us the facts about breech presentation: “the facts are facts and shouldn’t be disputed,” Lawrence said. With breech, people form very strong opinions, and they use those opinions to dispute the facts. Women listen to different opinions and believe facts only if they’re presented in the right way. Often their wishes aren’t represented by the obstetric community because of this wealth of opinion rather than a wealth of facts. We need to bring back a knowledge of the facts to the obstetric community.


If we don’t respect women’s wishes, we both fail the obstetric profession and go against human rights. All this shows how important this work is and leads us to today’s next session: experiences setting up breech services in hospitals in the UK and Europe. This will help us to bring on a system that allows women's wishes to be respected. 
Read more ...

Jane Evans: A day at the breech

Jane Evans
A day at the breech
North of England Breech Conference, Sheffield
Day 1


Jane Evans has presented at several breech conferences around the world. I highly recommend reviewing at her presentations at those conferences: Mechanisms of Breech Birth (Amsterdam 2016), Physiological Breech Birth (D.C. 2012), and Cardinal Movements of the Breech Baby (D.C. 2012).

She began today's lecture by mentioning the book Normalizing Complex or Challenging Childbirth. She wrote chapter 8 on breech birth.

Jane saw just one vaginal breech during her midwifery training and then went 10 years without seeing any breeches. Later she became an independent midwife (IM). She, Mary Cronk, and another midwife started meeting to discuss upright/kneeling breech births. They held their first Breech Study Day in the Grafton hotel showing slides of a VBB with a woman in a kneeling position. They kept studying breech with their group of IMs and began offering more Study Days around the country.

After TBT shut everything down for vaginal breech birth, she and other independent midwives still felt very strongly that they must keep their skills alive because 1/3 of breech babies are undiagnosed until labor. Until you’ve had a surprise breech, you’re not a midwife! It’s easy to not really be able to feel a breech on internal examination. Jane Evans also has a personal connection to vaginal breech birth; her granddaughter was born breech and she was the midwife.

Goals for Study Day participants:
  1. Feel confident that many women are able to give birth to their babies, even though that baby is in an unusual position
  2. Have a clear understanding of the mechanisms and the path through the pelvis that the breech presenting baby takes. What is normal, what are the mechanisms.
  3. Feel confident about recognizing when/where to help
  4. Enjoy learning how amazing nature is. Feel able to confidently offer women a truly informed choice when a breech is discovered.
Jane then reviewed the causes of breech presentation, which include
  • Gestational causes: (the shorter the length of gestation, the more often babies are breech)
  • Fetal causes: 10% of breech babies have something wrong with them
  • Maternal causes: ovarian cysts, uterine anomalies, pelvic fractures, etc
Definition of a breech birth (midwives' version):
  • A breech birth follows the spontaneous onset of labor at or around term, i.e. 37th to 42nd week of gestation. No induction & no augmentation.
  • Labor progresses well, gets stronger, and contractions come "much too often and far too long to the woman." (ie, a well progressing labor)
  • The presenting part descends, and there is effacement & dilation of the cervix. As long as this is happening, at whatever speed, the outlook for a vaginal birth looks good. Some women might take a lot longer. A stop & start labor is a red flag that the birth might need help at some point. Slow, steady progress is ok.
  • 2nd stage: the baby descends and is born on mother’s efforts, without traction. The baby makes movements and is not a passive passenger.
Jane then explained why so many women adopt a kneeling or all-fours position for both breech or cephalic babies. If squatting is part of their normal everyday life, women will often squat during the birth. But if they are more used to chair sitting--which is common for many women today--squatting isn’t as comfortable for their bodies. So upright kneeling tends to be a position of choice. When the women feels most comfortable, physiology will then work for her. We can’t ignore physiology or neglect applying our knowledge of anatomy!

Jane then showed a series of slides and films of vaginal breech births as she summarized the cardinal movements of a breech baby. Some words of advice:
  • Don’t push a woman back up if she moves her bum towards the ground/bed—it’s helping to open her pelvis.
  • When the baby flexes laterally, their shoulders flex down—this puts the posterior shoulder to the posterior wall of the pelvic floor. The baby is spiraling out. While you’re seeing the baby's bottom emerging, the shoulders are going into the brim of the pelvis. 
  • Don’t flip out the legs. If you do, you’re going to interfere with the baby's normal movements at this point (tilting its head back around the sacral prominence). The baby will arch its back really, really far back, and its legs seem to go on forever. Again, at this point, women will often drop down. Don’t push them back up! When women drop down at this point, the uterus contracts and helps flex the baby and the baby’s head more. A flexed baby is good!
  • You don’t really need to worry about cord compression until both arms are out; at that point, the head comes into the pelvis.
  • When the baby does a "tummy scrunch" or "tummy tuck" after the torso and arms are born, that movement rotates the back of the baby's head on the internal symphysis pubis. When the baby does the tummy scrunch, the moms often need to move, and the baby usually drops out. (Rixa's note: several presenters emphasized that a tummy tuck is a normal, physiological part of an upright breech birth. Sometimes it happens really quickly; other times you can easily see the baby lifting its arms and legs and scrunching in its belly, as if it's doing a sit-up in the air. An inexperienced provider might see a baby doing a tummy tuck and think that the baby is seizing or otherwise in danger.)
Throughout this whole presentation, Jane kept referring to head-down babies being "reverse breech." This was an ongoing joke at the conference.

Here is an alphabet soup of the breech baby's cardinal movements:
  • Baby starts RSA: RSA, RST, RSA, DSA, LSA, DSA, Tummy Tuck and out it comes
  • Baby starts LSA: LSA, LSL, LSA, DSA, back to LSA (which means they haven’t done their own Lovset twirl)
Disclaimer: As with all of the conference summaries that I write, I do my best to provide a detailed summary of each speaker. If something I have written is not accurate, please contact me so I can make the appropriate changes.
Read more ...

Thursday, May 04, 2017

Obstetric blinders: Overlooking the obvious solution to breech because "modern" women do not birth upright

With my nose deep in old articles about breech, I came across this gem: In 1970, two English obstetricians described the Bracht maneuver for an article in the ANZJOG. Note this section immediately following the mechanisms of assisted breech delivery and preceding the Bracht maneuver:
Spontaneous Breech Delivery:

If one closely observes a spontaneous breech delivery an entirely different course of events is seen.

This phenomenon may best be observed in quadruped mammals which deliver standing up, or in the apes which deliver squatting. This latter situation was employed by the midwife of the middle ages using her delivery-stool, and up till the present, parturient woman of the Bantu tribes squat on their haunches, the trunk bent slightly forwards (Botha, 1968). The Polynesians revert completely back to our evolutionary forebears and are delivered lying over a cross beam with the pregnant abdomen downwards thus dispensing with the need for any manipulative interference in the delivery of a breech presentation.
Despite these observations, the authors next describe the "modern" approach that usse the Bracht maneuver as a substitute for gravity.
With the modem mother in the dorsal position the breech presents with the sacrum directed laterally and the buttocks are born with the bitrochanteric diameter in the anteroposterior diameter of the pelvic outlet....Ignoring the pull of gravity, the spiral motion of this compact form continues upward and forward until the baby’s back lies directly against the mother’s symphysis pubis. (153-154)

The solution lies right before their eyes, yet the authors cannot see it due to their obstetric and cultural blinders. The authors note that upright, leaning-forward positions eliminate the need for obstetric maneuvers to deliver a breech baby. The weight of tradition, cultural superiority, and "modern" obstetric practice hinders these obstetricians from seeing spontaneous breech birth as anything but a quaint, historical footnote. Not a lesson to be learned nor a reason to change obstetric practice.

How much else have we failed to learn due to the blinders that we wear?

Email me if you'd like to read the full text.




Read more ...

Wednesday, May 03, 2017

Italy day 5: Lucca

I had never heard of Lucca before my mom helped us plan our trip to Italy. She has friends who live nearby, so they met us there for the day.

Lucca was amazing! It's a large medieval city completely surrounded by the original walls. My experiences with walled cities were Avignon and Carcassonne. Lucca was entirely different; the walls were so thick that there was a road (only for bikes/pedestrians) and playgrounds on top of the walls!

Poor Dio got Ivy's fever, so he was having a hard time that day. He barely made it around the walls--and then we dragged him all around the city, too.

We made the 4-hour drive home with no puking. I gave Inga the job of counting tunnels: 169.

Read more ...

Tuesday, May 02, 2017

Italy day 4: Pisa

After 3 full days of hiking in Cinque Terre, it was nice--and strange--to have a lazy day walking around town. The leaning tower of Pisa was magnificent. It's hard to imagine how big and tipsy it is until you see it in person.

There were thousands of tourists at the tower, so I didn't mind doing the cheesy photographs of us holding up the tower.

Ivy and Inga were too little to visit the tower. They are still sad about that.

The rest of Pisa is also lovely to visit. It has a huge old town with bicycles everywhere.

Read more ...

Monday, May 01, 2017

Cinque Terre day 3: Manarola to Riomaggiore

Ivy woke up with a high fever. But fevers do not keep the Freezes from hiking! I put her in the Ergo and she snuggled in, singing to me the entire hike.

Getting to Manarola was an adventure. The first road we took ended with a sign saying "Road closed--risk of death." So we turned around and found another route. We had to drive back down to Vernazza, up another mountain, then down to Manarola.

The lower hike between the two villages is still closed, so we took trail #531. It goes straight up the mountain that separates the two cities. It's the steepest hike I have ever done. It was spectacular. And, thankfully, short.

Ivy rode the train back to Manarola with my mom, so the return hike was much easier.

Read more ...

Saturday, April 29, 2017

Cinque Terre day 2: Vernazza to Corniglia

We drove from our house in Puin down to the outskirts of Vernazza. Not for the faint of heart--the last 6 km were steep, winding roads on the side of a mountain. The road was only wide enough for a single car and several parts were washed out (at least those parts had cement barriers around them). And no guardrails. We had to honk every time we went around a curve in case someone else was coming the other direction.

We parked about a mile outside of Vernazza, which was as far as you can go unless you're a resident.

The hike was gorgeous. We took Sentiero #2, the seaside trail that connects all 5 villages. There was enough elevation gain to make it feel like a proper hike. Coming into Corniglia was magnificent--you see the colorful city on the top of a peninsula jutting into the sea, the houses built right to the edges of the steep cliffs.

We spent a long time at the ocean, so we decided to take the train back to Vernazza. I was also feeling feverish so I didn't mind skipping the return hike.

Dio managed to lose his shirt while we were down at the water. We looked everywhere but no luck....Zari lent him her shirt and wore her swimsuit + shorts on the way home. Someone in Cinque Terre now has a light blue shirt that says "Freeze" on it.

Read more ...

Friday, April 28, 2017

Cinque Terre day 1: Soviore to Monterosso

I'm taking a break from posting about breech birth to share what our family has been up to. During our last school vacation, we took a trip to Italy with my mom. We visited Cinque Terre, Pisa, and Lucca.

Here's our first day in Cinque Terre, a collection of 5 seaside villages accessible mainly by foot, boat, or train. (You can also technically get to them by car, but it requires a high tolerance for extremely narrow roads on the side of a mountain.) We hiked on trail 509 from the Sanctuary of Soviore down to Monterosso al Mare and back.

I love that we can drive for only 3 hours and be in these magnificent places! If I drove for 3 hours back home, I'd still see cornfields in every direction.

Read more ...

Thursday, April 27, 2017

Panel discussion on breech

Panel Discussion
North of England Breech Conference, Sheffield
Day 1

Panel members:



Cathy opened the session with a commentary on Montgomery (see Johanna's presentation for specifics): use this law proactively. Don’t ask "What does the law say?" Instead, employ this legal framework actively and you will be fine.

~~~~~
Informed Consent 

Q from a UK midwife: I run a breech/ECV/VBAC service. I have a burning question about whether I or the consultant OBs should be doing the informed consent. I recently posed this question to one of my consultant OBs. My clinic does informed consent as a lengthy process. For example, my VBAC women go to a VBAC class, a VBAC workshop, and see me or another midwife at 30 weeks. Then we go through the women's previous birth and discuss what they want to do this time around. After that point, the women then make their choices. It struck me, though, that maybe I shouldn’t book women for a cesarean once they’ve chosen that route. And who should be the one doing the consent: me, or the consultant OBs?

Johanna: What you’re doing is great. Your practice sounds exemplary in terms of going through all that information, giving them the time, and letting things evolve over the pregnancy.

Betty-Anne: In my area, the doctors aren’t willing to offer those choices after I tell women about their options. That’s why I ended up doing breeches—because the head of Obstetrics said they aren’t willing to do breeches. Be prepared for everybody in the medical staff to hate you, because you’re offering something that isn’t there.

Cathy: This is a genuine dilemma for lots of midwives. Another classic example is home birth. Johanna, what advice would you give to a midwife if you know that their particular NHS service is really poor at actually enabling home birth?

Johanna: I suggest a 2-fold approach. 1) Make it clear to the woman that it’s her decision to make. 2) Go into your places of work and have that dialogue with your colleagues.

Q about Montgomery: If a woman has a request and you’re happy to agree to it, how duty bound are you now to explore the counterpart of those requests?

Johanna: You are still duty-bound to set out all of the different risks/benefits of all of the choices. At first, I wanted an elective cesarean, but when I met with my provider, they set out all of my options, and I ultimately chose a very different kind of birth. [I believe she had a home birth.]

Q: But in the real world, doing that [presenting the counterpart once a woman has expressed her preferences] can be taken in an antagonistic way, as if you don’t want the woman to have a choice.

Johanna: Montgomery shows us how important it is for us to have those difficult conversations.

~~~~~
What if breech isn't an option in your area? Lack of provider experience, difficulties in receiving referrals, etc.

Cathy: What do you do in terms of having a UK unit where vaginal breech birth really isn’t an option? What would you say to midwives in terms of offering the choice of a VBB?

Betty-Anne: I suggest to them that they move. [laughter from audience] Find a better practitioner if they can’t find one in their community. 23-30 years ago I sent people to The Farm, to Guatemala, to Nova Scotia. At one time I was going to send people to Frankfurt.

Cathy: Isn’t that slightly different? The woman who comes into your clinic absolutely wanting a VBB…sure, we can open up proper informed choice to all women, but they may not have the capacity to travel to other places.

Comment from a provider from Oxford about receiving referrals from other units/hospitals: We have a massive issue with funding because the maternity pay has already gone to the woman's booking hospital. We can’t offer ECV or other services to women from other booking areas.

Julia: My clinical director is very happy for people to come to Sheffield to have their babies.

Jane: Being told that you cannot have a vaginal breech birth because they haven’t got any experienced professionals in the local hospitals is surely a human rights issue. Why are we letting this happen?

Frank: Is there any way to get more information in England about who is experienced? To satisfy quality management in Germany, every clinic has to fulfill a certain criteria. There’s a score that indicates if breech is offered and how many they do every year. (He referred to a person from England who created this score; I didn't catch the name).

Consultant OB from Preston: We have recently expanded our vaginal breech deliveries. We get referrals from neighboring hospitals with small delivery rates because of lack of breech experience. The new 2017 RCOG breech guidelines say that institutions should refer women to experienced centers. Instead of having a blanket ban, there should be more sharing between institutions to help providers train and learn.

Johanna: It’s multifaceted. The first option is to move the woman, but Birthrights doesn’t generally advise that. The other option is to move the professional; start writing the hospital and putting pressure on them, ask them to bring in an outside professional to attend the breech birth.

Q: At Sheffield, can you have visitors come to observe breech births?

Julia: Not right now, but that’s why we organized the conference!

Betty-Anne: It’s not an either-or. When you go to a place where they’re not experienced in breech, they will bait-and-switch. Maybe they’ll say they’ll do it, but then they’ll find every possible reason to move to cesarean because they’re scared.

~~~~~
Inappropriate use of scare tactics

Consultant midwife from Birmingham: A woman in my unit asked for a home breech birth. I was happy to go along with it, but some other providers were very fearful. Some midwives were confident but non-competent. Midwives need to attend training sessions to become more competent. Telling a woman her baby is going to die, over and over again, is a horrific thing to say to a woman. This was told to this particular woman 6 times. We used the Birthrights leaflet to show that this scare tactic was unnecessary exposure of risk.

Jane: I will cover a bit about the National Midwifery Council. It’s the midwife’s responsibility to become skilled, otherwise they shouldn’t be on the register. We shouldn’t get women changing locations to have their breech babies, because it goes totally against physiology.

~~~~~
Undiagnosed breeches

Q: I hate seeing a woman with an undiagnosed breech in labor coming in and a run to the operating theater for an "emergency cesarean." How do you get informed choice in that situation? Where does consent come in in this time-sensitive situation?

Frank: Undiagnosed breech isn’t common in Germany. We do a workup in the woman late in pregnancy, so in most cases we know beforehand. In my study, the women were all counseled at 36 weeks. ECV is offered at 38 weeks. Many women in this study have MRIs if they are functional primips. Undiagnosed breeches are extremely uncommon in Germany, but in the Netherlands they are common. It’s more important to each people how to deal with it vaginally, especially since cesarean is more dangerous late in labor.

Julia: We have undiagnosed breches in our unit. Over the 5 years Helen and I have been working together, we harp on about breech all the time. We talk about it all the time. I'm always getting the pelvis out on the labor ward and showing how the baby just falls out of the pelvis if you turn the pelvis upright. Every single doll and pelvis does the same thing. I do this over and over on the labor ward, and the junior doctors and the midwives now realize how breech works. They get it. So now, the philosophy in our unit has changed. When there’s an undiagnosed breche, we don’t panic and rush to theater. We sit back, assess the situation properly, and discuss the options. But yes, it’s hard to discuss right as the woman is pushing. If a woman comes in 3-4 cms, you’ll have more time. But when a leg is coming out, you can’t do much discussion. I have seen a sea change in my own unit.

Jane: There is no evidence that says you should take an undiagnosed breech into theater. It’s very dangerous. We must rebuild our skills, slowly, slowly, because we let it all go in the late 90s and early 2000s. The TBT, which opened the gates to all cesareans for breech, was about planned CS at 38 weeks. We’ve misread it and totally forgotten what it says. It has nothing to do with emergency cesarean for unplanned breech.

Johanna: Here are scenarios for how to do informed consent right, even with an undiagnosed breech:
1. Over the entire pregnancy, you talk with the woman about her options, and build up a relationship, so the absolutely trusts you.
2. The woman shows up in labor with a surprise breech, but you have a little bit of time to have a discussion. Do your best. But it’s never the OB’s decision. It’s the woman’s decision. Can we do our best, without emotion, to get some sort of informed decision?

Jane: I often see women stopping their labors so they are able to make their decision—physiology can kick in at times.

Betty-Anne: Here is my perspective on MRIs and surprise breeches. At my unit, doctors will use the lack of an MRI as an excuse not to do a surprise breech vaginally. They will say, “Well, the woman hasn't had an MRI or an ultrasound to make sure the baby isn’t too big.” I have helped my unit to stop saying things like: “You need to know that if you’re having this baby vaginally, your baby might have cerebral palsy, might die, or we might have to decapitate the baby.” Now my unit has to list the 33 dangers of cesarean and the 1-2 dangers from vaginal breech birth.

Shawn Walker: When I went into the labor ward in a new Trust, I initially kept my interest in vaginal breech birth quiet. I was working in postnatal ward when I was asked to take care of an undiagnosed breech. The woman was receiving abominable counseling from a junior registrar. The consultant walked in, whom I knew well. I had a word with the consultant. Meanwhile they gave the woman terbutaline and within 10-15 minutes they were in theater doing a cesarean. This woman lost over 2 liters of blood on the operating table. I realized that I needed to get out of the breech closet so this wouldn’t happen again. It’s really tricky to avoid creating dangerous conflict in these situations.

Johanna: I know a woman with an undiagnosed breech. She said she felt overwhelemed with the amount of choice in her situation…but later she was grateful to have the information even if it was scary.

~~~~~
Hospital breech bans & lack of breech competence 

Rixa: I commented about situation with breech bans in American hospitals, often as a knee-jerk reaction to a bad outcome (but sometimes for no apparent reason and no bad outcomes).

Julia: I hope the ACOG will look at the RCOG guidelines and man up.

Andrew Bisits (Australian OB/GYN): It boils down to the fact that after the TBT, there was an abrogation of responsibility--that we obstetricians no longer have to do VBBs, therefore we won’t worry about them. All these cases show that professional bodies need to mandate breech competence. We can’t tolerate this primitive medical-legal attitude of “I don’t have to do this, therefore I won’t, so I’ll send you to someone else or rush you to theater.” Even a skeptic in Australia has said that every OB and every midwife has to be breech competent. It’s a human rights issue.

Johanna: That’s why that the global Human Rights In Childbirth movement is so significant. Now this is the 2nd conference in the series. Once the rest of the world has got on board, you can’t ignore it.

Disclaimer: I am working from typed notes, not from recordings. If something I have written is not accurate, please contact me so I can make the appropriate changes.
Read more ...

Friday, April 14, 2017

Johanna Rhys-Davies: Human rights in childbirth

Johanna Rhys-Davies
Human Rights in Childbirth
North of England Breech Conference, Sheffield
Day 1

Reviewed by Johanna Rhys-Davies, April 8, 2017

Johanna Rhys-Davies is a barrister, mother, and La Leche League leader in the UK. She began by describing how she came to work in human rights and childbirth. She has worked as a barrister for 10 years in domestic violence, family law, and human rights cases. She had her first child in 2009, and the birth had a profound effect on her. She realized there were some really big problems with maternity care in her community of Yorkshire. She co-founded Airedale Mums and helped support a local birth center. She recently changed career paths to work with Birthrights.

How did Birthrights begin? In 2013, Barrister Elizabeth Prochaska decided that childbirth was missing from the discourse in law and human rights in the UK, so she established the nonprofit organization Birthrights to bring childbirth into the conversation. Johanna gave an overview of Birthrights’ mission and current projects. She is very excited about the RCM e-learning module about human rights in childbirth that she is writing .

Today’s presentation reviewed how a human rights framework operates in a maternity care setting. Joanna’s main argument was that human rights and human rights law provide a framework for quality maternity services that respect women’s autonomy. Providers can use a human rights framework in their own practice.

Why care about human rights in the UK if giving birth is statistically quite safe?
There’s been an awakening in the last 6-7 years that human rights in childbirth isn’t just about access to care, but also about the type and quality of care. Johanna quoted Mande Limbu of the White Ribbon Alliance: “Disrespectful and abusive care happens even when women have free access to healthcare.” Human rights in childbirth comes into play particularly around questions of morbidity and trauma--those wider decisions beyond stillbirth and NN/PNMR.

Johanna argued that human rights are already part of maternity care and law. Human rights are a foundation for respectful, woman-centered care and protect women's rights to make decisions for themselves.

Adherence to or breach of fundamental human rights has lasting effects on individuals’ well-being. Women’s experiences of childbirth persist vividly throughout their lives and affect their relationships and sense of self. Joanna and her colleagues at Birthrights think that human rights offers a framework for care that benefits both care providers and childbearing women.

Next, Johanna noted 4 parts of the legal framework for maternity care in the UK:
1. The Nursing & Midwifery Council Code
2. Criminal law
3. Clinical negligence
4. Human Rights Act (1998) & Equality Act (2010)

Providers are most afraid of #3—clinical negligence--but is that fear proportionate? There are approximately 1,900 births/day in the UK. In 2012, a 10-year review of maternity claims found that less than 0.1% of all UK births were subject to claims. Of that 0.1%, 39% of claims were discontinued. We have a system of big payouts for a small number of cases, and that skews our perception about negligence claims.

Human rights law provides a powerful corrective to the dominance of negligence law in the UK. The really exciting thing about HR law is that it’s not just a counterweight to fears of clinical negligence, but it also has preemptive value. A maternity system where human rights are respected provides for mutual trust, mutual understanding, and mutual respect. A human rights framework can guard against harm and guard against claims.

Human Rights Act of 1998
Next, Johanna introduced the Human Rights Act of 1998 (HRA). This act implemented the rights in the European Convention on Human Rights (ECHR) into UK law and is NOT affected by Brexit. The HRA guarantees these minimum standards in 2 key ways:
1. All public bodies and their staff, including hospitals and health professionals, are legally obligated to respect human rights as set out in the Convention and the Act (Section 6 HRA)
2. All legislation, including health and social care law, should be compatible with human rights or “human rights compliant” (section 3 HRA).

Individuals can’t sue other individuals for human rights violations; they can only sue public bodies and their employees.

Some rights are absolute or non-derogable. Others are derogable; they can be interfered with or restricted, but the interference must be lawful, necessary, and proportionate. Joanna guided us through each of the 5 relevant articles from the ECHR: 2, 3, 8, 9, and 14.

Article 2: The right to life (non-derogable)
Article 2 reads: “Everyone’s life shall be protected by law. No one shall be deprived of his life intentionally (save in the execution of a sentence of a court…)” Good maternity care should take reasonable steps to protect a woman’s right to life. Of course, this does not mean providing treatment if someone does not consent, even if that treatment is potentially life-saving. But sometimes access to maternity care is also affected. Perhaps someone was denied access to maternity services because they were an overseas visitor who didn’t have money to pay for their care. Article 2 also has to do with facilitating informed choices. Some women might go elsewhere because their birth choices aren’t well supported in their care system, and they are fearful of the care they might receive.

Article 3: The right not be subjected to torture or inhuman or degrading treatment (non-derogable)
This human right covers serious harm, abuse, or neglect. Johanna gave a few theoretical situations that might apply to maternity care under Article 3: failing to obtain consent for medical procedures or not assessing and responding to the need for pain relief during and after childbirth. So far there are no legal cases in the UK specific to maternity care and Article 3. Following the Francis report into Mid Staffordshire Trust, 100 cases brought under article 3 were successful.

Article 8: The right to a private life (derogable if necessary and appropriate)
Article 8 reads “Everyone has the right to respect for his or her private and family life, home and correspondence.” This includes the right to physical and moral integrity and bodily autonomy.

The most significant legal case involving Article 8 is the 2010 Ternovszky v Hungary. In 2010, the European Court of Human Rights (ECrtHR) ruled that the choice of where to give birth is part of one’s private life under Article 8 ECHR. The court ruled in favor of Mrs. Ternovszky that she had the right to choose the circumstances of her birth. The court was very clear that women’s decisions about childbirth were expressions of their physical autonomy:
The court considers that, where choices related to the exercise of a right to respect for private life occur in a legally regulated area, the State should provide adequate legal protection to the right in the regulatory scheme….In the context of home birth, regarded as a matter of personal choice of the mother, this implies that the mother is entitled to a legal and institutional environment that enables her choice, except where other rights render necessary the restriction thereof.
Johanna presented four other relevant Article 8 cases:

Konovalova v Russia, October 2014, ECtHR
This reaffirmed Article 8 rights and reject the concept of blanket consent. In Russia, women were routinely presented with blanket consent forms and weren’t able to consent or refuse individual items. The court reaffirmed that blanket consent was unlawful and that individual procedures need to be properly consented to at the time that they happen.

Dubská and Krejzová v Czech Republic, Dec 2016, ECrtHR
Johanna noted that this case was a concerning change of direction in human rights law. Dubská wanted regulation for midwives in the Czech Republic. Dubská lost and the Czech Republic wasn’t obligated to regulate midwives. 5 judges dissented in this decision. Johanna noted that this case does not affect the right to give birth at home.

Re DM, 2014, EWHC (Fam)
This case ruled that mothers facing removal of their children at birth must be consulted and involved in the process to protect her Article 8 rights, except in exceptional circumstances.

Montgomery v Lanarkshire, March 2015, Supreme Court UK
This is a groundbreaking case that Johanna referenced several times in her presentation. Montgomery brings Article 8 rights home to the UK. The case actually began as a negligence case, not about human rights per se, involving a diabetic mother whose baby was severely injured after a shoulder dystocia. (A useful summary of the case & judgment can be found here. If you wish to read the full judgment, click here.)

The judges were very clear that there have been developments in human rights law; they looked at negligence within the framework of human rights and they used the language of Art 8 in their decision. Johanna quoted from Lady Hale’s judgement: “It is now well recognised that the interest which the law of negligence protects is a person’s interest in their own physical and psychiatric integrity, an important feature of which is their autonomy, their freedom to decide what shall and shall not be done with their body.” (para 108) Montgomery v Lanarkshire means the language of Article 8 rights is now being used within negligence law.

Are there restrictions on Art 8?
Yes, sometimes, but restrictions have to be necessary, lawful and proportionate. Johanna gave an example: a particular NHS Trust installs CCTV in every room, hallway, bathroom, etc. to keep patients safe. This might be considered disproportionate and the Trust would have to scale back on the number of CCTV cameras to a more reasonable number.

Article 9: Right to freedom of belief
No case law in maternity care exists at the moment. Johanna provided some hypothetical examples of how this might arise in maternity care: a woman declining a blood transfusion for religious reasons, a woman requesting only female care providers for religious reasons, treating women respectfully who choose abortion, particularly those who choose abortion after 26 weeks.

Art 14: The right not to be discriminated against in the application of the other articles
This is a piggyback right; it has to connect to another right in the HRA. Johanna provided an example of how this might play out: if a midwife violated Article 2 by not providing life-saving care, and the midwife did so because she had a discriminatory attitude about the woman’s age or disability, that would engage Article 14 along with Article 2.

So how does do the Human Rights Act and the various legal cases cited previously help us on the ground? Birthrights has identified 3 key legal principles underpinning human rights law: dignity, autonomy, and informed consent. Principles matter on the ground. Once you can adopt these principles into your practice, that human rights approach can transform the way you care for women.

1) Dignity
Johann is here today because of something Julia Bodle said in 2015: “Well, in other words, the mother is not just a suitcase.” Childbearing women are not just a vessel, not just a means to an end. Women’s interests are often diminished and neglected in favor of what are seen as her baby’s interests. The principle of dignity gives women the ultimate respect and should compel the provision of healthcare. As Cathy Warwick, CEO of the RCM has said, "We are human beings first; then professionals; then employees." Dignity is a legal principle that underpins Articles 2 and 3. Dignity reinstates women as the center of childbirth.

The principle of dignity acts as an antidote for, and a protection, against human rights abuses. This sentence in one of Johanna’s slides stood out: “Focusing on dignity is not simply an approach to improving experience of care, but could be an antidote to unsafe practice.”

She referenced a closing remark by Lord Kerr from the Montgomery case:
[A]n approach which results in patients being aware that the outcome of treatment is uncertain and potentially dangerous, and in their taking responsibility for the ultimate choice to undergo that treatment, may be less likely to encourage recriminations and litigation, in the event of an adverse outcome, than an approach which requires patients to rely on their doctors to determine whether a risk inherent in a particular form of treatment should be incurred….[R]espect for the dignity of patients requires no less. (para 93)
Johanna referenced an OB, Florence Wilcox of Kingston Hospital, who put herself into a lithotomy position in a delivery room and then documented her experiences. For the first time, Florence realized how undignified and vulnerable this position made women feel.

2) Autonomy
Johanna highlighted two court cases that reaffirmed the principle of autonomy:

Re MB (1997), Court of Appeal
A competent woman, who has the capacity to decide, may, for religious reasons, other reasons, for rational or irrational reasons or for no reason at all, choose not to have medical intervention, even though the consequence may be the death or serious handicap of the child she bears, or her own death.

St George’s Healthcare Trust v S (1998)
In our judgment, while pregnancy increases the personal responsibilities of a woman, it does not diminish her entitlement to decide whether or not to undergo medical treatment. Although human…an unborn child is not a separate person from its mother. Its need for medical assistance does not prevail over her rights. She is entitled not to be forced to submit to an invasion of her body against her will, whether her own life or that of her unborn child depends on it. Her right is not reduced or diminished merely because her decision to exercise it may appear morally repugnant.
Autonomous decision-making is always going to be very individualized, as Lady Hale affirmed in Montgomery v Lanarkshire:
A patient is entitled to take into account her own values, her own assessment of the comparative merits of giving birth in the “natural” and traditional way and of giving birth by caesarean section, whatever medical opinion may say, alongside the medical evaluation of the risks to herself and her baby. She may place great value on giving birth in the natural way and be prepared to take the risks to herself and her baby which this entails. The medical profession must respect her choice, unless she lacks the legal capacity to decide. (para 115)
Johanna also mentioned other cases dealing with autonomy and court-ordered cesareans: Re AA (2013) and The Mental Health Trust v DD (2014). The courts have authorized cesareans for mentally incapacitated women when there was evidence to suggest that a vaginal birth might harm the baby. However, Elizabeth Prochaska and S. Lomri raised this warning in their article Court-ordered caesareans in The Practising Midwife (Nov 2014):
A court-ordered CS is likely to be a profoundly distressing experience for a woman who is already vulnerable. While lack of capacity may justify intervention in extreme circumstances, all those involved in such cases need to explore every option for ensuring that incapacitated women’s choices about their births are respected. The rush to surgery in these cases should be intensely scrutinized by lawyers and health professionals alike.
What risks and benefits people attach weight to will vary. In Montgomery v Lanarkshire, Lord Kerr noted:
The relative importance attached by patients to quality as against length of life, or to physical appearance or bodily integrity as against the relief of pain, will vary from one patient to another….The doctor cannot form an objective, “medical” view of these matters, and is therefore not in a position to take the “right” decision as a matter of clinical judgment. (para 46)
[T]he assessment of whether a risk is material cannot be reduced to percentages….The assessment is therefore fact-sensitive, and sensitive also to the characteristics of the patient. (para 89)
Johanna shared a line from Rachel Joyce’s novel The Unlikely Pilgrimage of Harold Fry: “everyone was the same, and also unique; and that this was the dilemma of being human.” Maternity care providers face this dilemma with every woman they care for. Johanna mentioned that Hannah Dahlen of the University of Western Sydney and others have emphasized the need for individualized risk assessments.

More commentary from Lord Kerr in Montgomery v Lanarkshire:
The social and legal developments which we have mentioned point away from a model of the relationship between the doctor and the patient based upon medical paternalism. They also point away from a model based upon a view of the patient as being entirely dependent on information provided by the doctor. What they point towards is an approach to the law which, instead of treating patients as placing themselves in the hands of their doctors (and then being prone to sue their doctors in the event of a disappointing outcome), treats them so far as possible as adults who are capable of understanding that medical treatment is uncertain of success and may involve risks, accepting responsibility for the taking of risks affecting their own lives, and living with the consequences of their choices. (para 81)
Joanna also mentioned a 2016 case in Ireland, HSE v B. It ruled against forcing a cesarean on a woman against her will. (Overview of HSE v B here.) Ms. B wanted a VBA3C and the Irish Health Service Executive sought to compel her to have a cesarean. The Irish High Court ruled against the HSE and affirmed the right of the mother to refuse medical treatment:
If Ms. B was not pregnant, the performance of invasive surgery upon her, against her will, would be a gross violation of her right to bodily integrity, her right to self-determination, her right to privacy and her right to dignity. (para 17)

This Court does not understand why she does not follow medical advice, just as it may have been puzzling why the parents in the HW and CW case did not follow medical advice. However, this Court does not believe that the increased risk which she is undertaking for her unborn child is such as to justify this Court in effectively authorizing her to have her uterus opened against her will, something which would constitute a grievous assault if it were done on a woman who was not pregnant. (para 19)

[T]his Court concludes that it is a step too far to order the forced caesarean section of a woman against her will, even though not making that order increases the risk of injury and death to both Ms. B and her unborn child. (para 21)

What about fetal rights?
In the UK the fetus has no separate rights until it is born; this was upheld in Re MB (1997) and St George’s Healthcare Trust v S (1998). However, we have an unfortunate cultural conception of fetal separateness and antagonism with its mother. She gave two examples of this belief from obstetrical literature:
“[T]he physician and other obstetric providers have an independent obligation, as a matter of professional integrity, to protect fetal and neonatal patients.” Chevernak et al, Planned home birth: The professional responsibility response. AJOG 2012

“Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.” Lancet editorial, Home birth—proceed with caution. July 31, 2010
Johanna noted that both statements are mistaken—women absolutely do have the right to make decisions about their bodies and their obstetric care, no matter the perceived risks to themselves or their fetuses. The waters are more murky in the USA and Australia than they are in Ireland and the UK.

Johanna referred to another case, CP v Criminal Injuries Compensation Authority, Sep 2014. It ruled that the plaintiff could not sue her mother for damages due to fetal alcohol syndrome.

Lady Hale commented in Montgomery v Lanarkshire: “Gone are the days when it was thought that, on becoming pregnant, a woman lost, not only her capacity, but also her right to act as a genuinely autonomous human being.” (para 116)

Johanna also cited an article by Kruske et al 2013 titled Maternity care providers' perceptions of women's autonomy and the law. Many maternity care providers did not understand the legal rights of the mother and believed the needs of the fetus could override the rights of the mother.

3) Informed Consent
Montgomery brings a paradigm shift in patient decision-making. It should be informed consent, not informed compliance. No one can give informed consent without the counter-option of informed declining. So why is Montgomery a paradigm shift? Prior to that decision, courts had the “reasonable body of medical opinion” test. If you could find a body of people saying they were doing the same thing in their practice, then the courts would uphold it, as long as it wasn’t grossly negligent. But after Montgomery, this has changed. Lord Kerr explains: “The doctor is under a duty to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments.”

We need to be crystal clear that Montgomery has only changed the legal test surrounding medical discussions, dialogues, and procedures of obtaining informed consent with a service user or patient. It has not changed the test for actually carrying out a surgical procedure, carrying out a medical action, prescribing a medication, etc. All of those "action" based parts of medical care are still subject to the "reasonable body of medical opinion" test, also known as the Bolam Test.

Johanna briefly told the story of Mrs. Montgomery (summarized here and written in detail in the judgment.) Initially, a Scottish judge ruled against Mrs. M, saying that “too much in the way of information may only serve to confuse or alarm the patient” and that it’s up to the practitioner to decide where the line should be drawn. But when the case when to the UK Supreme Court, that perspective was shot down. Lord Kerr spoke of a paradigm shift in health care and patient decision-making; it must be individualized and thorough. “It would be a mistake to view patients as uninformed, incapable of understanding medical matters of wholly dependent upon a flow of information from doctors,” he wrote.

Informed consent must occur as a dialogue between the doctor and patient, including a complete set of risks, benefits, and alternatives to any proposed treatment. Printed information leaflets are not sufficient for obtaining informed consent. Informed consent also cannot assume that all people balance risks the same way (material risks). Montgomery specifically addressed consent forms: information must be presented in a way that the patient can understand: “The doctor’s duty is not therefore fulfilled by bombarding the patient with technical information which she cannot reasonably be expected to grasp, let alone by routinely demanding her signature on a consent form.” (para 90)

A new case, Thefaut v Johnston (March 2017), just came out and reaffirms Montgomery. It’s not about childbirth, but it addresses the issue of informed consent. More details on the ruling here.

We are moving away from paternalism. A main theme of Montgomery was making providers take responsibility for how they treat and counsel patients and giving patients responsibility for their own informed decisions.

How do human rights improve maternity care?
Johanna argued that a human rights approach improves care for both women and midwives. Research by Hodnett 2002, Waldenstrom 2004, and Stadlmayr 2006 found that positive experiences in childbirth came from two key factors:
1. supportive relationships with health professionals
2. women’s sense of control over decisions made during birth

A human rights approach can improve maternity care by:
  • Clarifying responsibility for the woman and professional
  • Giving responsibility back to the woman for decisions and subsequent harm
  • Shielding professionals from criticism if they have supported an informed choice, even if that choice falls outside guidelines
Joanna also provided a list of healthcare practices that violate human rights:
  • Physical abuse: non-consented force, restraint, unnecessary procedures including episiotomy, failure to provide pain relief
  • Disrespect: verbal abuse, bullying, blaming, humiliation, reprimands, “shroud-waving”
  • Non-confidential care: unauthorized revelation of personal details, physical exposure
  • Non-consented care: procedures performed without adequate information or dialogue to enable autonomous decision-making, undue pressure to make specific clinical choices
  • Misinformed care: biased, non-transparent clinical information, disabling women from giving true informed consent
  • Depersonalized care: inflexible application of institutional policy, failure to take into account women’s individual circumstances, including around companionship of choice
  • Discriminatory care: unequal treatment based on person attributes such as age, race and disability
  • Abandonment of care: refusal to provide care due to inability to pay or birth choices outside guidelines

Joanna’s experience of birth was transformative thanks to her maternity care team. That is why she came to this conference—and why she changed what she does for a living. Her two take-home messages regarding human rights in childbirth are that 1) the legal framework is there and 2) the global community is there. Never underestimate the impact you will have when you are truly supporting a woman’s human rights in childbirth and how your care affects her, her relationships, and her involvement in the community and with the world.

Other References & Resources


Read more ...
Related Posts Plugin for WordPress, Blogger...