Monday, 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
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.


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