Andrew Bisits: Establishing a training course in breech vaginal birth in Australia

First Amsterdam Breech Conference, Day 2

Andrew Bisits

Establishing a training course in breech vaginal birth in Australia

Ruth Evers introduced Australian obstetrician Andrew Bisits. His hospital in Sydney sees over 4,000 births per year. Andrew is working on several initiatives to promote normal birth by establishing primary midwifery care for women. Women are traveling long distances to birth with him, because he’s the only one they can find to attend their births.

Today Andrew Bisits talked about an approach to teaching breech skills. In our current situation, we have several important obstetrical skills (breech, twins, forceps, deeply impacted head at cesarean, etc.) in a climate of decreasing skills and increasing litigation. What do we do? Right now, the pressure is towards cesareans for breech, for primips, for labor in general. That is one approach: a cesarean section for everyone. He remarked that it might sound flippant, but there is an "insidious" trend towards universal cesarean.

What we have to develop more imaginative ways of learning from:

• Simulation
• Experience
• Obstetric mannequins (such as the one at the hands-on training in Amsterdam—the mannequin was so lifelike that people were getting nervous during the simulated births!)
• Computer technology
• Reflection and discussion

We also need to focus more on being sensibly confident. The business of handling anxiety is such an important part of teaching. In our current, slightly neurotic social situation, people lose confidence despite (or perhaps because of) the numeration of all the risks.

Becoming A Breech Expert (BABE)
Andrew has developed a course for teaching breech skills called Becoming A Breech Expert (BABE) in 2012 with colleagues Caroline Homer, Anne Sneddon, and Helen Cooke. After helping organize a breech conference in Sydney in 2012, they wanted to create something useful that would further promote vaginal breech skills. It’s a multidisciplinary course between faculty and participants. It’s conducted via the AMaRE (Advanced Maternal and Reproductive Education) company of Australia. Instructors are volunteers, and course is copyrighted.

Andrew noted that this project (and, I would argue, this entire conference) is not just about breech birth; it affects the rest of maternity care and the way we care for laboring women.

How the BABE course works
The course focuses on an individual woman, “Wanda,” rather than starting with statistics and numbers. They wanted to put the focus on the reality of an individual with a breech baby.

Evidence--objectives
• Understand the evidence about breech birth
• Discuss how this informs our communication with women with a breech presentation late in pregnancy. Communicating numbers is tricky. Most people don’t add them up like a balance.
• Make use of the evidence in communicating with women.

Next they discuss ECV, since it’s part of the breech package. They show videos and make a strong plea that ECV should be enthusiastically encouraged.

They discuss the mechanics of breech birth. In Andrew's experience, once women see the mechanics, they say “aha! Now I get it. I feel much better.” It gives women an anchor from which to make a decision. They emphasize that this knowledge of the mechanics has to be hard-wired into everyone attending the birth. They talk about the practicalities of the birth (post dates, monitoring, what will happen in labor, is a breech harder or longer, do women have to have an epidural, induction/augmentation, etc.). He emphasizes that continuous monitoring is for litigation. If women don’t want it, they don’t have it.

They then watch a breech birth as a group, including things to learn from it, things he might have done differently today. He reemphasized the value of videos in learning breech skills (echoing Frank Louwen's admonitions to use videos as a primary learning tool).

They also present women’s perspectives on VBB. They have many stories of women who found it very difficult to negotiate for a VBB within the Australian healthcare system.

Dealing with the unexpected breech
They show a video of an unplanned breech home birth; the midwife was not planning on attending a breech and couldn’t transfer the mother. (The midwife showed the video at the 2012 breech conference in DC and asked for input on what she did wrong. At that conference, they gently suggested what could have been done differently.)

Creating a safe space for physiological breech birth
In this part of the course, women describe how they set up the birth space in the hospital so they felt safe. They also use the story of a midwife who traveled a long distance to have a breech baby vaginally in a hospital.

Hands-on stations
Using the Sophie obstetrical mannequin by MODEL-med, they do normal breech in different positions. They also practice abnormal breeches, including how to resolve difficulties with arms and heads. They practice breech births in many positions: semi-recumbent, H&K, and birth stool

Andrew noted that once the breech is birthing and the bitrochanteric diameter is out, the baby will birth. From the birth of the BT to the birth of the head, he’s most comfortable when the baby is out in 3 minutes. So once you see the umbilicus, give yourself 3 minutes. Once the shoulders are out, 1 minute. These guidelines aren’t dogma, but they give an anchor for people to make decisions from.

Counseling the woman with a breech
They partner up and practice counseling, with the audience interacting. They have to communicate more than numbers. It shouldn’t be all about risks, and it's important to keep positive.

The course finishes by reviewing essentials for a safe service and giving practical suggestions for providers.

They’ve done about 8 courses since 2012. The main issue is: will this make a difference, increase VBB, and make things better? He doesn’t know yet, but he’s waiting the results of one survey. He still wonders what the best way is to train providers in VBB.

Andrew's main conclusion was that breech skills can be taught. He made the analogy with shoulder dystocia. SD skills have taught very effectively with various approaches. Things have greatly improved over the past 2 decades with the systematization of training for SD. The same is doable for breech. His course is more than just mechanics. They encourage ongoing learning from each case. Even during cesareans for breech babies, he demonstrates the mechanics of VBB to show residents how it works.

~~~~~

Q: I have a question about communicating the numbers about vaginal breech birth. Yesterday, we saw different approaches of how can can do it. What is your suggestion?

A: I literally put the numbers on a simple table. The numbers I communicate are:

• PNMR for VB is probably around 1/500 to 1/700. 
• For cephalic babies, it’s probably 1/1200 to 1/1500. 
• For ECS for breech, it’s 1/2000 or less. 

I do similar things for trauma. Then I talk to that. If you want to have a good idea of the risks of breech compared to other modes of births, you have to look at a lot of numbers. I want to emphasize that these bad outcomes don't occur very often. Everyone has a different take on risk, and they will have to process it for themselves.