Julia Bodle and Helen Dresner Barnes: The Sheffield breech service

Julia Bodle and Helen Dresner Barnes

The Sheffield Service: Setting Up a Breech Clinic

North of England Breech Conference, Sheffield

Day 2

This is the third of 3 hospitals presenting about starting a vaginal breech service. The other hospitals include Oxford University Hospital and Sachsenhausen Hospital, Frankfurt, Germany.

Julia Bodle is a Consultant OB and Helen Dresner Barnes is a midwife at The Jessop Wing in Sheffield. Together they run a breech pathway clinic, which began just a year ago, in addition to a 1-1 midwifery team that offers care to women who birth outside obstetric guidelines. They offer a "one-stop shop" for breech, counseling women with breech babies and offering ECV and vaginal breech birth.

Julia: We are overwhelmed at the people who have come to this conference.

Helen: It’s good to hear that there’s consistency between our practice and Oxford and Frankfurt. We base what we do on a philosophy of care that has the mother squarely at the top; her wishes take priority over both protocols and the birth attendant.

We try to be really evidence-based, and we are lucky that there’s more evidence emerging that we can share with parents. It’s important to be brutally honest and not let your own opinion come into that conversation; stick to the facts as best we have them in the research. We know we don’t have full sets of facts in the research, but there are some things we can be very clear about. The information we give to parents isn’t about just this baby, but also about the next baby, about her, and about her family.

It was very important to us to have Johanna Rhys-Davies come yesterday and present the philosophy of dignity and of a woman’s right to choose. We share the information, and then they we to know what the mother feels and is thinking. It’s no good listening if you don’t hear what the mother is saying to you. You have to absorb that into the plan you make. It isn’t your birth; it’s her birth.

We try to adhere to protocols that we have designed as a team; we recommend things based on these protocols. We are very heartened by the new RCOG Green-top Guideline on breech. The person looking after the mom needs experience, and we are upfront with the moms about how much experience we have. It takes hard work and dedication among the team members to provide 24/7 coverage for breech moms.

The midwives do most of the breech births themselves; they only call Julia when they know the need her.

How do we find our women? Often through community midwives who pick up the breech presentation via ultrasound around 35 weeks. Women usually go to our breech clinic around 36 weeks. It takes place on Mondays, so women might miss some of those Mondays because of holidays. During the breech clinic, we go through the various choices with the women. We offer ECV at 37 weeks and talk about the planned mode of birth.

Some of the articles we refer to during our evidence-based counseling:

• TBT 2000
• TBT 2004 (long-term followup)
• PREMODA 2006
• Glezerman 20005
• Reitter 2014
• Vlemmix 2014
• Berhan 2015
• Louwen 2017
• RCOG guideline 2017

During case selection, our aim  is to "identify a normal healthy pregnancy with a normal healthy breech baby in an optimal position." We look at the woman's pregnancy and previous births, do an ultrasound assessment, and go over protocols. When we counsel mothers about the birth, we talk about the baby's position, how we will monitor the baby, what happens in the event of poor progress, maneuvers that might be needed, and what happens if the baby needs resuscitation.

Julia: We started our breech clinic just one year ago, with another birth occurring last night! We have seen 155 women for a first appointment. Interestingly, most of their babies have been cephalic by time they came into the clinic. But that makes everyone happy. We have seen 63 women with breech babies. 22 chose ECV (4 of whom had spontaneous versions before the ECV). Of the last 18, 9 babies turned. 4 declined ECV in favor of VBB.

Sheffield breech clinic outcomes:

• 39 planned breech CS: one of these had a spontaneous version with a vaginal birth
• 13 planned VBB, of which 6 ended with a vaginal birth. Some were advised before labor to have a CS. 
• 11 planned cephalic births after ECV: 8 vaginal, 1 CS, 3 not delivered yet

In the same time period, Julia looked at all 221 breech births in the entire maternity unit at Sheffield (not just at their clinic). It was hard to find this data. Less than 1/3 of the women with breech babies visited the breech clinic. 131 women had “routine care” (not at breech clinic), 63 had the breech pathway care, and 25 additional women had undiagnosed breeches. (Julia would have expected more undiagnosed breeches.)

Routine care vs breech pathway care for ECV:
Routine care: 32% chose ECV (42/131), 19% success rate
Breech pathway: 42% chose ECV (22/52), 50% success rate

Routine care vs breech pathway care, Mode of birth:
Routine care: 0% chose VBB. 4 were sent to the breech clinic.
Breech pathway: 19% (13/63) chose VBB
Undiagnosed breeches had the highest VBB rate

Julia also looked at the overall rate of planned VBB in Sheffield, from 2011-2017, including before Breech pathway started and excluding undiagnosed breeches. 38 women total had planned VBB during that 6-year period, with 12 pre-labor CS and 10 in-labor CS. There were 16 completed VBBs (62% of those who labored).

Highlights and pitfalls:
We can increase the success of ECV; our numbers show that very clearly. We have one baby that has gone to ICU and is not well; it’s not clear what has happened.

Anke Reitter: Upright breech skills & recognizing and managing breech complications

Anke Reitter

Upright Breech Skills & Recognizing and Managing Breech Complications

North of England Breech Conference, Sheffield

Day 2

Dr. Anke Reitter is a Maternal-Fetal Medicine specialist and a Fellow of the Royal College of Obstetricians and Gynaecologists. She currently directs the maternity department at the Sachsenhausen Hospital in Frankfurt. She specializes in breech, multiple pregnancies, high-risk pregnancies, and ultrasound--and is also an IBCLC!

I would also recommend reading Anke's presentation about upright breech maneuvers from the 2016 Amsterdam Breech Conference. I omitted repeated material in this summary. Shawn Walker's posts about nuchal arms are also very helpful.

After seeing Gail Tully's presentation, Anke mentioned that she was very inspired--as usual! Her talk fit very well into Gail’s regarding how the levels of the pelvis require different actions.

Anke showed a video of a mother who had had a previous cesarean after an attempted vaginal breech birth; the cesarean happened at full dilation due to abnormal fetal heart tones. Her next baby was also breech, and the mother was very motivated to have a vaginal birth. The baby was born to its torso and the arms came out, but the body remained slightly oblique. Anke noted that the head was tipped back and sideways. The solution: helping bring the head back into the midline. After that, they were able to flex the head. This birth was a classic example of when to help in a vaginal breech birth.

She and Andrew Bisits have created a flowchart showing normal (green) and abnormal (red).

"Hands-off" if progress

"Hands-on" if delay

Rixa's note: This flowchart would go together well with Gail Tully's presentation and her Breech Birth Quick Guide. I have retyped the chart since it didn't show up well on the photos I took.

For Anke, rumping--meaning the bitrochanteric diameter is born--is the point of no return. A baby that has rumped has to be delivered vaginally. She asked the audience: do you all agree on this definition?

From Anke's time in Bergen, Norway, she learned everyone there does Løvset for breeches. They don’t know other maneuvers; they "really love Løvset." The key message is to grab something with a bony structure to protect the baby's internal organs, either the pelvic girdle (mother on back) or the shoulder girdle (mother on hands & knees).

Anke remarked that in Sydney, where Dr. Andrew Bisits works, most of the babies have no problems with the arms. She wonders whether we have maybe started to interfere too early? She turned to ask him, "Andrew, why do you have so few situations when the arms/shoulders are held up?"

Andrew: When we are using the birth stool with the possibility of going to H&K, the arms sometimes might be a bit extended, but they’re always low enough to release easily. I’ve never encountered anything as difficult as that.

In real life, if there is a nuchal arm, the body often is not entirely out and you have to go inside the mother to get to the shoulders.

Elevate and Rotate: When you turn a baby with the shoulder grip, don’t pull down. You might even want to push the baby up just a bit, and then turn it. Turn in the direction the baby’s arm is pointing. She often feels some resistance as the baby’s nuchal arm is just starting to slip past the head. Overcome that resistance, but remember: no traction. Turn a full 180, then 90 back. The baby should end facing the mother's anus.

From Louwen et al. 

Once the bitrochanteric diameter is out, you should have the whole baby out within 3-5 minutes.

Betty-Anne Daviss: There's been back and forth about whether you should be leaning forward on the bed. If you get a mother up on the birth stool, it often fills the hollow of the sacrum and the baby comes right down. When we watch these videos of mothers doing prayer positions, that’s the opposite of getting mothers upright on the stool. I’m trying to reconcile that.

Jane Evans: Regarding Andrew’s comment: maybe leaning too far forward encourages the anterior arm to be caught.

Gail Tully: Yes, you’re closing the brim if you lean over.

Time is an issue. After you release the arms, you still need to be aware of what’s happening. Don’t wait 1-2-3-4-5 minutes after the arms are born, even if the other signs are good. Be proactive, especially if you have less experience.

Gail: Yes, because you don’t know what you are going to run into next.

Shawn Walker: With women who have high BMIs, sometimes we need to lift the buttocks up. This releases the soft tissues to help the head release. It’s a soft tissue dystocia.

Anke noted that providers have learning curves as they are adapting to doing breeches on hands and knees. She showed a video of an American OB doing a H&K breech. This OB was hands-on several times when the signs did not warrant an intervention. The audience was visibly wincing and groaning at several points.

After we saw the video, Anke made an important point--this video shows us that learning is a good thing. If we do these trainings and if we start talking about upright breech, we need to really understand the things we learn in these conferences. If you offer a study day, it needs to make an impact in the right direction. This OB had the best intentions and it's great that she offers women the choice of a VBB. The birth would have been spontaneous if she hadn’t touched the baby. But there’s a learning curve at the beginning for providers. Anke herself  had a learning curve.

Shawn: In this video, we need to exercise compassionate understanding that there’s this learning curve. Don’t attack and be judgmental. We all change and adapt as providers. We need to understand providers’ learning curves so we can teach more effectively.

Jane: It’s really difficult for some people to turn things over when they are used to seeing women on their backs. Most people understand if I talk about following the curve of the sacrum. It’s easier to follow the sacral curve if you do the birth "upside-down" (having the woman upright or hands and knees).

Anke mentioned a few indirect maneuvers to help free the head:
1. Gluteal lift: It can release enough soft tissue to help a non-nuchal arm come out.
2. Maternal pelvic shift (push mother’s entire pelvis forward): This will help deliver the head according to the pelvic curve.
3. Controlled head delivery using the shoulder press (Frank's nudge) and modified MSV

Why still offer vaginal breech delivery?
Around 30% of breeches are still undiagnosed when labor begins. All maternity units must be able to provide skilled supervision for vaginal breech birth where a woman is admitted in advanced labor. Protocols for this eventuality should be developed.

A woman should be referred to a center if her own unit cannot provide the service. Centralization is the best strategy to ensure the most experienced team involved. You need a 24/7 "breech squad."

Vaginal breech birth prevents the first cesarean and thus a scarred uterus. Offering vaginal breech birth is an important factor in reducing the cesarean rate among primips. VBB can also help lower the repeat cesarean rate. This is important at both an individual and population level.

Finally, cesareans have a major impact on the life span of women in developing countries. (Rixa's note: as an example, see Dr. Thomas van den Akker's presentation Who pays the price? from the 2016 Amsterdam Breech Conference.)

Reviewed by Anke Reitter, May 29, 2017

Panel discussion on breech, part II

Panel Discussion on Breech, Part II

North of England Breech Conference, Sheffield

Day 2

This was the final session of the North of England breech conference. Panel members included

• Helen Dresner Barnes (midwife in Sheffield)
• Julia Bodle (consultant obstetrician in Sheffield)
• Anita Hedditch (midwife in Oxford)
• Jane Evans (independent midwife)
• Betty-Anne Daviss (midwife and researcher in Ottawa, Canada)

Adorable breechling legs. Photo from the conference website.

Fetal monitoring 
Audience member: At Oxford and Sheffield, what do you do about monitoring?

Helen: We talk to women, we present the evidence, we listen to what they want. We’re mindful of what our colleagues want, but we’re women-led. It’s fair to say we do both--some women choose intermittent, some use continuous. We have wireless monitors, so they aren’t strapped down at all. Those monitors can’t get too wet, but since we don’t have water births for breech that's not too much of an issue.

Julia: If they have an obstetric risk factor (gestational diabetes, VBAC, meconium, etc.), we monitor them. A lot of our breech births come from women who had wanted a home birth, so continuous monitoring is not on their agenda.

Anita: We use wireless CFM. Women do go into the pool in the first stage. We ask women if they want the monitors off a bit, but the women generally say it doesn’t bother them. Continuous monitoring hasn’t been challenged yet, but we wouldn’t force it on a woman. I'm very comfortable with both intermittent and CTG, but the recommendation is continuous. We look at baseline and variability; we worry less about dips. In some ways, 15-minute intervals of intermittent monitoring are better/safer than continuous, because you're really focusing on the heart rate, not just having it on on the background.

Betty-Anne: In Ottawa, there’s a large iatrogenic factor of being in hospital. I'm a community midwife: half of my births are at home, the other half are breeches in hospital. I try to use the best of both worlds. I am required to keep up a certain number of home and hospital births because of my license. I bring breech women in hospital around 7-8 cms. If they go in hospital too early, they get interventions. I do want to do the births in hospital because most Canadian women don’t want to have their breech babies at home. I am willing to offer home breech birth, though, for women who really want it. My insurers are totally supportive of me right now because I've gone to them many times when there's been an iatrogenic problem. I have documented 38 cases involving breeches where I had to intervene in the hospital because either the doctor didn’t know what he was doing or he was going against guidelines. I have the insurance on my side now, even if the hospital staff is not. That’s why I am very careful to do continuous monitoring in my situation so I can cover myself.

Gail: As a home birth midwife, I am encouraging my community of colleagues to do more frequent monitoring especially in 2nd stage. I see more early separation of the placenta with breeches. When the placenta is detached a few contractions before the baby is out but gravity makes the baby look pink, that baby actually has an issue. It’s worthwhile to keep a closer eye on those babies, especially 2nd twins.

Helen: If there is nothing to do, don’t do it. If we just let a woman be a mammal, she’ll do it. We do talk to our women about following their bodies and being instinctive. Even making a suggestion can interfere. Do nothing unless we have to.

Audience member: We tend to listen in just to cover our asses!

Waterbirth and aromatherapy
Audience member: What about water therapy or aromatherapy during labor? How much do things disrupt physiology versus help it?

Jane: I don’t think I ever said that aromatherapy would have been disruptive. Laboring in water with a breech is absolutely fine. Sometimes women refuse to move and they have their babies in the pool. That has happened a couple of times to me. When the women stay leaning forward, the buoyancy of water keeps the baby from doing the tummy tuck. If the woman is on her back, buoyancy brings the baby the “right” way around the sacral curve. So supine immersion might be better than H&K in the water, for a breech baby. Cornelia Enning has moms birth standing up in a water barrel for breeches. She has the dad put his hand down in the water so the baby can “stand up” on his hand.

ECV and hypnosis
Audience member: There has been lots of talk about ECV, but I haven’t heard any mention about using hypnosis for ECV. In our unit we refer to hypnobirth team for their breeches and have a high success rate. Maybe that’s something that could be explored?

Helen: We have lots of hypnobirthing teachers in town, but it is not offered through the Trust. We do hypnosis for all women, generally.

Audience member: Do you have a specific script for turning breech?

Helen: No.

Betty-Anne: There are 2 studies on hypnosis and ECV. One showed benefits and the other showed no effects.

Closing remarks by Dr. Andrea Galimberti
I see lots of enthusiasm here. I see people who are trying to go back and create something where there was nothing before. When we look at our roles as health care providers, our primary responsibility is to look after women. We are also accountable to our professional bodies and to our place of work as employees. If we are thinking about making changes or creating new services, it’s important that we evaluate our responsibilities in respect to all 3 roles within the triangle: mothers, profession, and employer.

Choice seems to be the main word that we’ve heard these past two days. I’ve heard quite disturbing accounts of colleagues who are unable to offer the choice that they should.

We need to relate to our employers. We need to be prepared to open a dialogue so that the system we put into place for breech birth is acceptable. When adverse events happen, we want our breech service to continue and not just be shut down.

Maybe we’ll meet again in a few years? This reminds me of talking to women after labor. They say “never again!” But...a few years later...they are back again!

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.

Anke Reitter: Setting up a breech service in Sachsenhausen Hospital, Frankfurt

Anke Reitter 

Setting up a Breech Service in Sachsenhausen Hospital, Frankfurt

North of England Breech Conference, Sheffield

Day 2

This is the second of 3 hospitals presenting about starting a vaginal breech service. The other hospitals include the Oxford Breech Clinic and The Jessop Wing in Sheffield.

Dr. Anke Reitter is a Maternal-Fetal Medicine specialist and a Fellow of the Royal College of Obstetricians and Gynaecologists. She currently directs the maternity department at the Sachsenhausen Hospital in Frankfurt. Anke did her obstetrics residency in the UK 20 years ago, which is why she is a FRCOG.

Anke agrees with Anita Hedditch’s recommendations for setting up a breech service. It sounds so logical and easy to set up a breech team, but in real life it is much harder. For the past two years Anke has been a consultant obstetrician and MFM specialist at her new hospital, and every day is a new challenge. She didn’t just start up a breech service; she was also building up her own obstetric unit.

When Anke came to Sachsenhausen in October 2014, it was a small teaching hospital doing only 800 births/year. Over the past two years, her unit has undergone many changes. Besides adding a breech service, Anke has opened a perinatal medicine department and offered high-risk pregnancy care. Her own team is comprised of two Senior Registrars and two Junior Doctors. There is no pediatric unit on site.

Her hospital's birth numbers have been going up. In 2016 they had 1,113 births, compared to 835 in 2014. The number of breech births also rose, from 30 in 2014 to 71 in 2016. Over that same time period, their cesarean rate has decreased from 36.6% to 23.6%, while the instrumental delivery rate has increased from 3.8% to 6.6%, since she uses forceps.

She urged providers and hospitals to record and share their own data. Even if you don’t have a large number of breech births, it’s important to share your outcomes with women.

Setting up a Breech Clinic
Setting up a breech clinic requires the involvement of all members of the birth team: midwives, physicians, and other medical professionals such as nurses and pediatric staff. You will need to collect and provide high-quality, consistent information. As you develop your unit's guidelines, consult other breech centers to see which guidelines they follow.

Your staff will need regular skills and drills training. Anke feels that it is wrong to put vaginal breech birth as part of an emergency obstetrics training day. It should be taught separately as a normal skill, not an emergency skill. Doing skills and drills is very important for breech--and also great fun. Anke has convinced some her team of this. They now enjoy playing around with the obstetric training models. They videotape simulated births and have become more relaxed with being filmed and with sharing and debriefing how the simulations went.

As the pregnant woman nears the end of her pregnancy, Anke's unit does an ultrasound to estimate the fetal weight, determine the type of breech presentation, and detect fetal anomalies. This last step is very important. Anke told a few stories of doing her own scans while counseling women with breech babies. She has discovered abnormalities that the women's own doctors hadn’t detected despite multiple scans.

The woman also needs informed consent. This process requires time--they schedule 30 minutes for the first consultation--and usually more than one visit. They provide written information to the woman, both their own guidelines and published guidelines. Their unit has a checklist to ensure comprehensive counseling for every woman and to document that all of the above steps were completed.

Anke's breech clinic offers the whole range of options: ECV, vaginal breech birth, and planned cesarean. External cephalic versions are done in the labor ward starting at 37 weeks. They use 250 ug s.c. of Terbutaline and do CTG before and after the ECV. The women go home the same day as the procedure. In the literature, ECVs have a 50% success rate with a 2% rate of complications and 2% of babies turning back breech. Their unit has a 60-70% success rate with ECV. She does the ECV together with a skilled Turkish colleague.

Primips, including multips who have not given birth vaginally, are given an MRI scan. The RCOG's Greentop Guidelines say that the evidence for MRI scans is unclear. Anke comes from the Frankfurt school, where primips have routine MRIs. They exclude around 20% of primips for vaginal breech birth based on their obstetric conjugates.

For planned cesarean sections, Anke's unit waits for labor to start on its own before doing the surgery. She noted that this will increase the rate of after-hours unplanned cesareans.

You will want to start by offering vaginal birth to the "easy" candidates: a baby with a flexed or neutral head, a baby that is not too big (under 3800g) and not too small (<= 10th percentile), no footling or kneeling presentations, and no prenatal fetal compromise. There are many unanswered questions about VBB: amniotic fluid levels, parity, provider experience level, frank vs. complete/incomplete presentation, and how to correctly choose the woman.

Advantages, disadvantages, and words of advice
Providing a breech service opens the door to physiological birth and to upright birth positions. Providers need to "respect the mechanism" of vaginal breech birth.

Offering a breech service can also make your obstetric service more attractive to women; Anke's unit has witnessed this first-hand as their numbers have nearly doubled since 2014. On the down side, a breech service means a higher work load and more staff needed to fulfill all the expectations (counseling, 24/7 provider availability, staffing for more unscheduled cesareans).

Setting up a breech service involves a learning curve and requires that everyone in the team is on-board. It takes time; be patient and allow things to grow. And most importantly, enjoy the opportunity to offer breech birth!

Research backing up your practice is important. Anke referred to the 2017 Frankfurt study on upright breech birth authored by Frank Louwen, Betty-Anne Daviss, Kenneth C. Johnson, and herself. It is the first study with a large cohort of vaginal breech births in the upright position, and it compares both upright and dorsal breech births. The Frankfurt study has introduced a new understanding of the cardinal movements of the breech and new maneuvers to resolve problems. Unlike large registry studies, this study had detailed information about each birth, making thorough assessment and comparison possible.

Anke worked at Dr. Louwen's Frankfurt clinic before coming to Sachsenhausen, so she knows that approach firsthand. Even in that hospital, where vaginal breech was considered safe and common, half of the planned cesareans for breech were at the mother's request. This indicates an ongoing perception among women that breech is unsafe. She lamented that most of the research on breech has compared cesarean with women delivering vaginally on their backs.

Anke stressed the importance of a "complex normality" paradigm, which recognizes the largely successful physiological process of a breech birth as "normal," but requiring unique skills and experiences. She references the following publications:

• Walker S, Scammel M, Parker P. Principles of physiological breech birth practice: A Delphi study. Midwifery. Dec 2016; 43: 1-6. 
• Evans J. Understanding physiological breech birth. Essentially MIDIRS. Feb 2012. (PDF)
• Walker S. Breech birth: An unusual normal. Pract Midwife Mar 2012; 15(3): 18,20-21.

In order to create a sustainable solution to breech, health professionals need to learn to "tolerate uncertainty" rather than trying to eliminate it. (See Simpkin AL and Schwartzstein RM. Tolerating uncertainty--the next medical revolution? NEJM 2016)

Vaginal breech birth can be a tremendous learning opportunity for providers. At the 11th Annual Normal Birth Conference in Sydney 2016, obstetrician Andrew Bisits commented, "Every breech birth was a goldmine of learning about normal birth."

Looking to the future
We have not finished learning. We need to continue to connect high quality care with physiological breech birth. We need to review our critical outcomes and create a national/international expert board. We should also collect more breech data internationally. We need to get the younger generations of midwives and OBs leading the charge because the older ones are burning out.

~~~~~

Dr. Andrea Galimberti commented that it's always interesting to see the differences in practice abroad. It is challenging to see things outside your own comfort zone.

Reviewed by Anke Reitter May 28, 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.

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. 

Andrew Bisits: Intrapartum CTG monitoring in breech presentation

Andrew Bisits

Intrapartum CTG monitoring in breech presentation

North of England Breech Conference, Sheffield

Day 2

Andrew Bisits is the Director of Obstetrics at the Royal Hospital for Women, Sydney, Australia. His hospital sees over 4,000 births per year. Andrew is working on several initiatives to promote normal birth by establishing primary midwifery care for women and by attending vaginal breech births. He has also created a vaginal breech training course, Becoming a Breech Expert (BABE).

Today’s presentation examined the evidence for CTG monitoring in breech presentation. To what extent is there evidence? To what extent are doing it because it’s part of our comfort zone and what we’ve always done?

Andrew does not have firm answers, but finds this topic necessary and helpful to discuss. At this conference, people can think clearly and are invested in the issue. At home where he works, people are so busy and so fearful that they just react, they don’t think. Here at this conference, we’re sitting back and thinking, discussing, and trying to look at evidence in the broader context. There are so many pressures back at the workplace that you can’t think about these things.

He will ask two main questions about CTG monitoring:

• Do normal women with normal babies need it?
• Can CTG help make VBB as safe as cephalic vaginal birth?

There are small—perhaps significant—differences between cephalic and breech vaginal birth.

The question of CTG monitoring has to be viewed within the context of the various pressures on providers to intervene: We have this normal process, yet we continually feel pressure to intervene. Some of the pressure might come from evidence, but social pressures and a huge medico-legal industry exert the most pressure. Despite being in an evidence-based era, the pressure to intervene based on factors other than evidence—medico-legal cases, social pressures, various opinions—is huge and cannot be ignored.

Learning from adverse events:
What prompted Andrew to talk about this? He was party to a number of adverse events in New South Wales related to breech. By adverse events, he means neonatal mortality (NNM), perinatal mortality (PNM), or very severe asphyxia. He’s familiar with 8 serious adverse events over the past 2 years: 3 births had mechanical difficulties. 2 births had clearly abnormal CTGs (blindingly obvious ones, no dispute). But the 3 other births had CTG patterns where the outcome was unexpected. Again, glaringly unexpected.

How breech relates to shoulder dystocia:
25 years ago, the whole approach to shoulder dystocia was terribly primitive. Well-meaning providers would yank, shout, and scream. The baby might have a bad outcome and the staff would be traumatized. If you read textbooks from that time, one instruction was to apply firm traction on the head. That’s been reversed because even though the evidence is not watertight, we’ve systematized the whole approach to shoulder dystocia, and it’s made a difference. He no longer hears about people shouting and screaming. Rather, today it’s very quick and focused: We got the woman into McRoberts, we did this, we did that, we did the next thing, and the baby came out. The providers followed a series of steps clearly.

A similar thing is possible with breech for mechanical problems; we can make those births safer. Knowing the normal and the abnormal in detail allows us to prevent the majority of nasty mechanical problems in a breech birth. We have to keep thinking about it in a creative way, but it’s manageable.

The tricky question, however, is the issue of intrapartum monitoring and how the baby behaves as a breech vis-à-vis oxygenation. When a CTG is glaringly abnormal, there’s no argument. You do something. You act right away in cases of persistent bradycardia or persistent tachycardia. But most cases are in between these two extremes.

Making breech birth safer
There are 2 achievable goals in making breech birth safer: getting better at resolving mechanical difficulties and acting promptly in the case of clear CTG abnormalities. But that leaves us with the remaining breech births with bad outcomes in which the CTG monitoring does not indicate a problem.

The evidence for CTG
The next part of Andrew's presentation delved deeply into the literature on CTG monitoring. The evidence we rely on for fetal monitoring primarily comes from cephalic births. He referred to the 2017 Cochrane review, with regard to neonatal seizures. If you looking at high-risk subgroups, the effect of CTG on NN seizures is not as strong as with low-risk groups. That has an implication for breech birth. The nastiest outcomes we have are HIE, including perinatal death. If the effects more obvious in the low-risk group, that might argue for doing monitoring for breech births, even for low-risk breech births.

Whatever evidence we do have, it’s indirect. The critical point is that CTG monitoring halved NN seizures with no effect on mortality, no effect on longer-term cerebral palsy, but with an increase in cesarean/forceps deliveries. Andrew noted, though, that this short-term difference in NN seizures didn’t translate into longer term CP.

(Rixa's note: Andrew referred to an Irish study but I didn't catch the citation; perhaps it was the 1985 Dublin RCT of IP fetal heartrate monitoring?)

INFANT study
Next, Bisits discussed a recent study by Brocklehurst et al, the INFANT study (Lancet March 2017). It was a RCT of 46,000 women in the UK. All women had indications for FHR monitoring (traditional risk factors). They were randomized into two groups: CTG with or without computerized decision support. Preliminary evidence suggested that computerized decision support might lead to better outcomes by eliminating interobserver variation and thus more accurately indicate when intervention was needed. This was a very well-designed RCT. The trial groups had very similar demographics and a similar frequency of induction, epidural, cesarean, forceps, and spontaneous birth.

3 years ago, Brocklehurst said that if this study doesn’t show a difference in outcomes, it would really raise questions about the overall value and future of CTG itself.

Andrew noted that big money was fueling this study. He didn’t say this maliciously—but 7% of the NHS budget goes towards settling claims in cases that involve CTG. 7% of the NHS budget! No wonder there’s an incentive to get the best out of CTG and find ways to minimize these huge payout cases.

The study itself found no difference in outcomes between the two methods of CTG interpretation--this despite big hopes for this new computerized technology. The researchers followed the babies for 2 years after birth: still no differences. Andrew noted that some of the authors dropped out of the study because of the findings.

We’re in an ongoing quagmire regarding CTG in general. And it’s a very messy quagmire. Andrew noted that CTG monitoring is “welded into the fabric of maternity care” because of medico-legal pressures, rather than because it’s effective. Yes, it does have a marginal effect, but it’s not as much as it’s made out to be.

When he talks to solicitors about CTG, they tell him, “What we believe is the CTG. What we hear from the doctors, that’s all subjective. But when we see something on paper, that’s something we can all agree on.” Despite all of its limitations, we are stuck with CTG.

The major conclusion of the INFANT study was that we have to look at other ways of monitoring fetal oxygenation during labor. CTG has significant limitations in being able to reduce major hypoxic damage to babies.

What are the implications of the INFANT study for breech babies? It depends on how you interpret the study! Some people would conclude that you should be doing CTG, others would conclude you don’t need to.

Andrew next referred to a 2016 Finnish study on CTG in breech versus vertex delivery by Toivonen et al. The authors found that late decels and decreased variability were more common in breech labors compared to vertex labors. For example, late decels were seen in 13.9% of breech vs 2.8% of vertex deliveries, and decreased variability in 26.9% of breech vs 8.3% of vertex deliveries. Overall, the authors found that CTGs are different in breech labors compared to vertex; whether or not those differences are clinically useful is still in question.

Shawn Walker: Yes, I also felt that this study was interesting but not strongly useful for clinical outcomes.

Jane Evans: Why? Do more breech babies have shorter cords so they are pulled more? We need to figure out why. These are all the things that would affect that. Can we measure the stress levels of women who aren’t on CTG vs who are (via a swab)?

Andrew Bisits: Yes, you could do that. There are a number of theories about the cording of breech presentations.

ST-waveform analysis
The next study of interest was a 2014 study by Kessler, Moster, and Albrechtsen titled Waveform analysis in breech presentation (BJOG). The authors took a series of 433 breeches and 5577 vertex babies who were monitored with ST-waveform analysis (a form of fetal ECG, different than traditional electronic monitoring). In theory ST-waveform analysis provides a better assessment of cardiac oxygenation.

Has it proven to be so? Overall there’s no glaring benefit to ST-waveform analysis. There are some enthusiasts, but if you look at the hard evidence, there are no huge standout figures. The vertex group was a higher risk group overall compared to the breech group. See the following slide for details:

There were 3 breech babies with significant problems. See the following slide for details.

In the one case of fetal death, the ST monitoring didn’t suggest an abnormality, nor was it a difficult birth. Maybe there was something wrong with baby? In this case, the CTG provided a falsely reassuring result.

There were also 2 cases of moderate HIE. One was quite severe with nasty seizures. But it wasn’t picked up in the monitoring, nor was it a difficult birth. In the other case of HIE, there was some suspicion due to the CTG tracings.

Overall, 2 of the 3 bad outcomes were not picked up by fetal monitoring. This means CTG/ST has a falsely reassuring rate of 2/500. This compares with the rate of severe outcomes with cephalic high-risk births (2/500). Would this have been higher in the breech group without monitoring? This is the question that is tough to answer.

Main conclusions (from a dearth of evidence): 
There are no clear answers about CTG monitoring for breech babies. It’s hard not to recommend monitoring; the social, institutional, and medico-legal pressures are too great. It’s too welded into the fabric of our care. Andrew doesn’t like saying that, but he thinks it’s the reality.

We need to be clear with women about the effectiveness of monitoring, and then a decision can be made whether or not it is done. We also need to look for other methods of monitoring the baby’s oxygenation during labor. Perhaps we should consider the use of buttock lactate/ph. In the 80s, these came up with a lower than normal pH for breech babies. RCOG guidelines said it’s not recommended.

~~~~

Q from Julia Bodle: I’m thinking back to what CTG does and doesn’t do—halving the rate of NN seizures. What are the long-term outcomes for the babies who have NN seizures?

Andrew Bisits: There are 2 differing views on this.
1) In the follow-up from Dublin CTG trial, they could not detect an excess of CP.
2) If you read the Cochrane review and the comments that they invite after it, a Swedish researcher quotes a Swedish study that looks at grade-2 HIE and its longer-term implications. From this particular Swedish study, there is a 48% incidence of CP. Further, 18% of babies had some significant cognitive issue (not sure at what age). Only 25% were actually normal at age 15. NN seizures are not benign in the long-term, according to that Swedish study. I always believed in that Dublin data, so I’d need to look up the original study the Swedish researcher citing.

Andrea Galimberti: In the UK we tend to prefer intermittent monitoring when possible because women can move around. What is the difference between high-risk women monitored and the low-risk women who have intermittent?

Andrew Bisits: From a biological point, nothing! From a psychological standpoint, lots.

Q from audience member: What about other outcomes besides CP, such as ADHD, autism, etc. Have you read anything about this?

Andrew Bisits: There is a weak link with ADHD. The slightly concerning one is cognitive impairments noted at age 15-17. They’re the ones that have been reported in Sweden.

Q from audience member: Might it have more to do with NN management and cooling?

Andrew Bisits: We haven’t changed the instance of CP despite all these advances; it’s still 1/1000.

Q from audience member: There’s no good evidence that any monitoring improves the outcomes because nobody’s done the studies. Certain CFM has known harmful effects. We may be doing a lot of harm while trying to reduce these small things.

Andrew Bisits: In the cold light of day, I would agree with you. The problem is we’ve got this whole mindset that is welded—not by a thread—into the whole fabric of maternity care at all levels.

Q from audience member: Don’t we have to make sure we do no harm, first?

Andrew Bisits: We would hope, yes.

Betty-Anne Daviss: As a practitioner, we have to be very careful in Canada and stay very close to the SOGC guidelines not to raise the ire of the OBs in our unit. I think we have to start understanding what the normal breech is with some of our other parameters. I’m concerned that we’re making the decision about what a normal Apgar is for a breech baby, because Apgars are different for breeches. We have to normalize a low pH for breech babies. We have to put those together with the monitoring. We should start to write down things like floppy/not floppy that seem to raise our concern. As researchers, we need to start putting those things together for what the norm is for breech.

Emilano Chavira: There’s such an obvious parallel between pros/cons of CFM and the breech birth itself. For example, the presentation by Lawrence Impey focusing on all the outcomes of NN survival vs death, and acknowledging that it’s just one outcome and there are so many others we can look at. Your presentation looked at NN seizures/death…but what about everything else—maternal procedures, cesarean sections—that comes with monitoring? I’m very sympathetic about both the audience’s questions and with your presentation. Is there any option at all? Can we engage in informed consent for these things? What approach does the mother want to take? Maybe informed consent is a first step towards dislodging this “welding” that we have.

Andrew Bisits: Yes.

Julia Bodle: This INFANT study affirms my belief that the world is a much more corrupt place than I had thought it was. I just saw a press release from the company that makes the K2 Guardian CTG technology, the one used in the study, claiming that it reduces stillbirth and brain damage! K2 medical systems is sending these press releases out, clearly misrepresenting the evidence from the INFANT study. In fact, the RCOG and BFMFS just sent a joint statement warning people about this press release. I just got the notice yesterday in my email. It’s outrageous! On the upside, you can use this study in court in your defense; the type of monitoring doesn’t make any difference.

(Rixa's note: I can not find the RCOG/BMFMS statement online, but I did find this news release mentioning it. K2 Medical systems is making those claims by comparing the outcomes of the INFANT study with the outcomes of the BirthPlace study.)

Andrew Bisits: Do any units do intermittent rather than routine CTG for breech?

Julia Bodle: The current policy is to talk to the women, give them evidence, and then they choose. Our unit has a policy that it’s recommended.

Andrea Galimberti: We are discussing modifying the policy. And of course women can choose.

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.

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.