Tuesday, August 08, 2017

Please participate in the "Birth On My Terms" project

From the Birth On My Terms Project at Texas A&M University:
Were you coerced, forced or pressured to have a procedure(s) during labor and birth? Such procedures may include: epidural, episiotomy, induction of labor, augmentation of contractions, IV medication or fluids, cesarean section, Pitocin, antibiotics or other medications, electronic monitoring, movement or lack of movement, or pushing position.

If so, we would be interested in learning about your experience.

We are conducting a study that examines the experiences of women who have been forced or coerced to have a procedure, including cesarean sections, during labor or birth. If you have had such an experience and are willing to share your experience, please click on the link at the bottom of this post. You will be directed to our secure and confidential survey site. The survey will include questions about you, your reproductive history and questions about the pregnancy, labor, and birth that involved a forced or coerced procedure(s). Participants will also be asked about any consequences of having the forced or coerced procedure. Completion of the survey is expected to take about 30 minutes. Participants names will not be used in any publication of results. To access the Spanish version of this survey, follow the link bellow and select the language option in the top right corner.
For more information, contact:
Theresa Morris, Associate Professor of Sociology
(979) 862-3193
BirthOnMyTerms@gmail.com
www.facebook.com/BirthOnMyTerms
http://sociology.tamu.edu/morris-theresa/

IRB NUMBER: IRB2016-0084D
IRB EXPIRATION DATE: 12/01/2017.

Survey Link: https://tamu.qualtrics.com/jfe/form/SV_0HeWuF8x3FLKX41

**Feel free to share with those you feel would like to participate**


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Saturday, July 22, 2017

Cabin fun & misadventures with tires

We came home from France last Thursday night and left the next morning for a 9-hour drive up to my parent's cabin.

We blew one tire on the way up to our parent's cabin (turning the drive into a 12-hour trip), and another tire on the way home today. We are now experts in putting on the spare tire and hobbling to the nearest auto center.

Despite these misadventures our week in northern Wisconsin was fantastic.

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Sunday, July 09, 2017

How do medical information and patient preferences affect how a breech baby is born?

I just finished translating an excerpt from a French article that examines the interplay of medical information and patient choice in breech presentation. The authors include eloquent observations on how giving one-sided information to patients about the risks of vaginal breech birth, but not the risks of cesarean section, is "disinformation." They note that vaginal breech birth might face extinction in France, not for medical reasons, but because social pressures have heavily influenced obstetricians' fears and patients' preferences.

Original article: J Delotte, C Schumacker-Blay, A Bafghi, P Lehmann, A Bongain. Medical information and patients’ choices: Influences on term singleton breech deliveries. Gynécologie Obstétrique & Fertilité 35 (2007) 747–750. 

Excerpt from pp. 748-750 translated by Rixa Freeze, PhD, 2017. PDF version of the translation here.
Email me
if you'd like to read the original article and see their illustrations.


Discussion
Studies debating the preferred mode of birth for breech presentation highlight the value of studying and learning obstetric maneuvers [6]. Medical information and patient preferences are both important criteria in influencing how women give birth to their breech babies. The type of medical information given to patients is crucial because it reflects obstetricians’ current fears. Moreover, the nature and bias of the information provided during consultations influences patients’ choices. Patients' preferences are also derived from their own knowledge, their interpretation of information provided by their provider, and the influence of their close associates and therefore of society as a whole.

We first analyzed written information that specifically mentions risks related to vaginal breech birth. Indeed, the very act of including information about a potential complication in a patient’s file shows that the provider has overtly presented and emphasized certain risks. Written information included in patients’ files indirectly represents providers’ attitudes towards vaginal breech birth and how they likely discuss it in person with their patients. If, during a medical discussion, providers emphasize certain complications, they can influence patients’ choices. Although our study does not reflect the totality of information given to patients about breech presentation, it nevertheless provides a good approximation of providers’ overall attitudes during consultations. There has been an almost constant increase in giving patients this type of information (Figure 1). In 1996, no additional specific information relating to the risks of vaginal breech birth was noted in patient files. In 2005, this information was found in almost 70% of files.

The value of this additional written information is debatable. Doctors have an ethical obligation to give their patients clear, unbiased, and honest information, and their care must be evidence-based. Thus, exclusively presenting the complications of vaginal breech birth without presenting the complications of cesarean section clearly shows how current controversies over mode of birth for breech presentation are influencing the type of information given to the patients. This one-way information is likely not fair or unbiased. This type of information is, in effect, disinformation, since patients only learn about the risks of vaginal breech birth but not about the risks of cesarean. Patients’ choices can therefore be influenced by providers who give their patients written materials to protect themselves from medico-legal risks linked to the duty of informed consent. A possible solution may lie in standardizing the information provided to the patient and in presenting the risks of both planned vaginal breech birth and cesarean in a fair and honest manner [7,8]. Creating such a document is difficult and must take into account different varieties of obstetric practice. While documents on the modalities and complications of cesarean section have been produced by obstetrical societies, there is no such document concerning breech presentation. Until the French College Gynecologists and Obstetricians (CNGOF) produces a patient information sheet, patient information is currently based solely on what each individual provider or institution provides.

The second criterion that we analyzed, maternal choice, is probably influenced by providers but also by the beliefs of the patient or those around her. The rate of maternal demand for cesarean section for a term breech presentation was less than 10% until 2000, the year the Term Breech Trial was published. Since then, planned cesarean section solely for maternal choice has steadily increased to 25% today. In contrast, demand for cesarean section upon hospital admission, in patients who had previously consented to a vaginal breech birth during a consultation, increased at a slower rate. Nevertheless, this still occurs in nearly 15% of cases. This rate is particularly alarming since a cesarean performed during labor leads to increased maternofetal morbidity compared to planned caesarean section. Thus, if we consider the total population of women admitted to hospitals with a term breech presentation, about 30% of cases end in cesarean section due to maternal choice. This figure has tripled in the space of six years.

So does the debate on breech affect medical information, or does the exposure of this debate in the media influence patient choice? It is probably a combination of these two phenomena, since comparing the curve concerning maternal choice with written information about vaginal breech birth shows similarities—in particular, a very significant increase in their respective rates beginning in the 2000s to a stagnation at the present time.

Maternal choice, which is increasing in importance, has a strong influence on the debate over mode of delivery for breech. Indeed, to maximize reduction of maternofetal risks during vaginal breech birth, providers need to adequate experience and training during residency [9]. Current maternal choices are leading to a decreased rate of vaginal breech birth. This trend also leads to a decrease in the practice and teaching of maneuvers for vaginal breech birth. If maternal choices continue to evolve over the next few years, the practice of vaginal breech birth may no longer be taught in hospitals. In the absence of a rapid change favoring vaginal breech birth, the choice of delivery route for a term breech presentation may disappear, not for medical reasons but because of a societal debate that has influenced obstetric practice.

Conclusion
Breech delivery involves 3% of term pregnancies. Medical information and patients’ perceptions strongly influence providers’ abilities to learn and practice maneuvers for vaginal breech birth. This trend threatens the future of vaginal breech birth in France.


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Friday, July 07, 2017

Last day of school

Last day of school in France...lots of tears this afternoon.

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Tuesday, July 04, 2017

A life event of enormous magnitude

Here's a little gem I just unearthed from a 2004 article about vaginal breech birth in a tertiary hospital in Trinidad. In the conclusion, the authors write:


That last sentence...yes.
The individual woman's wishes must be taken into consideration as for some, labour is an integral and treasured experience and a vaginal delivery is a life event of enormous magnitude.


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Tuesday, June 27, 2017

Puget-Théniers

Two Sundays ago we visited a friend in Puget-Théniers, a little mountain village an hour away. Dio puked on the way up and Ivy almost did, but a piece of chewing gum saved the day.

We went on a post-lunch stroll and ended up taking an impromptu swim in a mountain stream. Clothing optional. My artist friend took the pictures.












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Friday, June 23, 2017

Articles on informed consent, autonomy, and forced/coerced interventions

I have discovered several recent articles about autonomy, informed consent, and forced/coerced interventions during childbirth that I highly recommend:

Also some older articles that are still relevant and useful:
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Thursday, June 22, 2017

The Vermelin method of vaginal breech birth

While translating this French article about nonfrank breech birth, I came across a reference to the "Vermelin method" of breech delivery. The author referred to Vermelin as if it were common knowledge--and it is, apparently, in the French obstetrical tradition. I found three theses from French-speaking midwifery or medical students that explained the Vermelin method.

In 2010, Jennifer Thomé wrote a thesis (PDF) as part of her midwifery degree from the Ecole des Sage-Femmes de Bourg en Bresse. She wrote:
Vermelin's non-interventionist method
Expulsion then takes place through uterine contractions and maternal expulsive efforts.

The operator attends the physiological delivery as described above and plays the role of "attentive observer," ensuring that dystocia does not occur. See appendices I and II.

A hard surface is placed under the perineum to receive the fetus.

The practitioner can pull down a loop of cord as soon as the abdomen has emerged and perform a Bracht maneuver to assist the expulsion of the fetal head, preceded or not by a Lovset maneuver (Lansac 2006). (p. 13-14)

France takes part in the approach of not using any systematic prophylactic maneuvers but instead resorts to them in cases of dystocia (DuBois 1990). For Bracht in 1938, "the number and the precocity of interventions" during the birth of the breech was the cause of the high fetal mortality rate; he therefore advocated abstention from maneuvers and promoted spontaneous emergence of the fetus for as long as possible. In 1948, continuing Bracht's advocacy, professors Vermelin and Ribon of Nancy also advocated spontaneous breech birth, showing that childbirth can take place entirely spontaneously; the hands-off "Vermelin method" was fairly widely adopted. (p. 17)

Appendix I: Spontaneous birth of the frank breech. 

Appendix II: Spontaneous birth of the nonfrank breech
Both illustrations are from Lansac J, Body G, Perrotin F, Marret H. 
Pratique de l'accouchement, 3ème éd éditions Masson, mai 2001.

In 2011, Marie Moncollin of the University Henri Poincaré in Nancy wrote a thesis (PDF) for her MD degree. She largely echoed the same points in Thomé's thesis.
At the beginning of the 20th century, most authors considered the breech presentation to necessitate obstetric intervention: prophylactic lowering of the foot, full extraction or release of the arms as promoted by Lovset in 1937. In 1938, Bracht reacted to this attitude and advocated abstention until expulsion. He then presented his maneuver for freeing the head, which we shall discuss later.

In 1948, the authors Vermelin and Ribon of Nancy defended an even more absolute abstention from obstetrical maneuvers. For Professor Vermelin it was important not to see pathology where it did not exist. While breech delivery was considered abnormal, even obstructed, at the time, Professor Vermelin wanted to show that a breech delivery could unfold in its entirety without intervening at all. He demonstrated that Mauriceau's maneuver, apparently innocuous, could be the starting point of cerebro-meningeal lesions, neonatal death factors, or psychomotor sequelae, and that it was better to do without the maneuvers. Thus Vermelin's technique of spontaneous delivery of the breech remains a classic for obstetricians of the Ecole de Nancy (see Vermelin 1956). (p. 28)

We have seen that the School of Nancy was marked by the Vermelin technique for the birth of the breech (he was a professor at the Maternité de Nancy from 1943 to 1961), but what about 50 years later? (p. 67)
Moncollin notes that French obstetricians today are not as hands-off as Vermelin advocated for; they generally assist with the birth of the arms and the head:
The birth of the breech according to Vermelin (1948) consisted of complete abstention from maneuvers. Thus, no maneuvers were practiced. However, to prevent asphyxia in the fetus, it is now advisable to finish the delivery, when the point of the shoulder blades appears in the vulva, by releasing the arms that are in the vagina and then the head. The Lovset (1937) maneuver will facilitate the expulsion of the shoulders, then the Bracht (1938) or Mauriceau (1668) maneuvers will free the fetal head. (p. 53)
She also makes this comment about breech birth at home:
Home birth:
Do not touch the breech presentation if obstetric maneuvers are not perfectly known. In this case, it is advisable to adopt the Vermelin maneuver. (p. 66)

Finally, a 2015 MD thesis by Daouda Aliou Kone (PDF) repeats the same information about Vermelin found in the other two theses.


References:
  • Dubois J, Grall J-Y. Histoire contemporaine de l’accouchement par le siège. Rev. Fr. Gynecol. Obstet, 1990; 85(5): 336-341.
  • Kone DA. Etude épidémio-clinique et pronostique des accouchements par le siège dans le centre de santé de référence de la communie II du district de Bamako. Thèse pour le Docteur en Médicine. Université des sciences, des techniques et des technologies de Bamako. Faculté de médecine et d’odonto-stomatologie. 6 Jan 2015.
  • Lansac J, Marret H, Oury J-F. Pratique de l'accouchement, 4ème édition, Paris, Masson 2006 553p: pp 125.
  • Moncollin MM. Choix de la voie d’accouchement en cas de présentation du siège: évaluation des pratiques cliniques à la Maternité Régionale de Nancy en 2008. Thèse pour le Docteur en Médecine. Université Henri Poincaré, Faculté de Médecine de Nancy. 11 Oct 2011.
  • Thomé J. La présentation du siège unique à terme: enquête sur les politiques de prise en charge des maternités du réseau AURORE. Université Claude Bernard Lyon 1, Faculté de Médecine Rockefeller, École de Sages-femmes de Bourg en Bresse. 2010.
  • Vermelin H, Ribon M, Facq J. Présentation du siège complet avec déflexion primitive de la tête; dégagement spontané en occipito-postérieure. Gynecol. Obstet. 1948; 47: 1250-1253.
  • Vermelin H. [The teaching and practice of the gynecology and obstetrics specialty] [Article in Spanish]. Tokoginecol Pract. 1956 Oct 15 (145): 569-81.

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Monday, June 12, 2017

A car birth, a bus birth, a yurt birth, an en caul birth, and a mother-supported birth

This reminds me of a Dr. Seuss book...
I can give birth in a car
I can give birth in a bus
in a yurt
with the caul
with my mom
A car birth
An Australian family pulls over onto the side of the road and has their baby in front of an apple shop.


A bus birth


A yurt birth
Through June 18, you can have your baby in this fully-equipped yurt in the middle of the Amsterdamse Bos. No charge to use the yurt. Sponsored by Birth Project: Look Again, which is hosting a number of activities in June. More information here.


An en caul water birth
The father lifts the caul off his daughter's face after she is born. Watch the video and read the birth story.


A mother-supported birth
A mother supports her daughter having her second home birth




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Sunday, June 11, 2017

Urgent--I need a Hamilton-style pregnant silhouette

Dear pregnant readers--I need your help! I need a photo of you, with your gorgeous pregnant belly, posing like Alexander Hamilton. Posed just like this, or as close as you can get and still clearly show off your belly.


Tight-fitting clothing is best. Bonus points if you are wearing tall leather boots!

I need a head-to-toe shot. Doesn't matter what's in the background as long as it's easy to distinguish between you and everything else (I will be turning it into a black-and-white silhouette).

To be used for an awesome project TBA.
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Wednesday, June 07, 2017

Breech and the art of obstetrics

Sometimes doing research is really, really boring. Other times I come across gems like this 1961 Lancet article titled "Management of Breech Presentation" by Leonard Lang. His humor and colorful language bring his words alive, contrasting with the dusty pages they now live on.

Also worth reading is his commentary on the last page about the trend towards increased cesarean for breeches.

The old masters in obstetrics of one or two generations ago—the mean who taught many of us—had a great deal of respect for the breech. Each of them had special technics and pet maneuvers that worked well in his particular hands. Each warned against certain dangers and pitfalls that should be anticipated, carefully searched for, and then properly handled, sometimes in rigid mechanical sequence. Many of these dedicated teachers had slogans and bits of advice that clearly expressed their concern. Dr. Williams often said that he could tell a really good obstetrician by the manner in which he conducted a breech delivery. Our old teacher, Dr. J. C. Litzenberg, liked to say that “any physician who said that he wasn’t afraid of a breech or never had trouble with a breech was either someone who didn’t do any work in obstetrics or was an ‘outright’ liar, and he could choose his own category!” Another exhorted the medical student to always be friendly with his competitor across the street, “because you may need him to help you with a breech some time!” They were acutely aware of the dangers inherent in breech delivery. They had to be. They had to depend upon their hands and keen mechanical sense which experience developed into a type of intuitive perception and manipulation that DeLee liked to call the “art of obstetrics.” They couldn’t readily resort to cesarean section once delivery from below was chosen. They didn’t have blood banks, antibiotics, and highly trained anesthesiologists.

No doubt our old teachers are turning in their graves as they contemplate upon the number of cesarean sections we are doing for breech today. We can only hope that St. Peter has tried to explain why things have changed. That might help a little but I’m sure that it wouldn’t completely satisfy that fine group of “Old-Timers.”
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Monday, June 05, 2017

A breech conference, 60 years ago

On November 22, 1957, the Obstetrics & Gynaecology section of the Royal Society of Medicine held a conference on breech. Conference notes were published in the March 1958 edition of the Proceedings of the Royal Society of Medicine (PDF).


It is a fascinating read. As I have been finishing conference summaries from the 2017 Sheffield breech conference, I reflected on how similar these two conferences were in spirit, although miles apart in content. I found the same collegiality, curiosity, and desire to improve outcomes. However, many of the practices seem quite out-of-date now. (Which makes me wonder: 60 years from now, what innovations discussed in Sheffield will have stood the test of time?)

I also noticed a marked gender shift in conference presenters, from exclusively male in 1958 to majority female in 2017 (with the 2017 audience predominantly female).

Here's a breakdown of speakers & topics and a "summary of the summaries," if you will. I would definitely read the originals, so I hope my brief teasers are enough to get you interested.

Dr. G. F. Abercrombie (London): The Timing of External Version. He advocates early external version beginning around the 30-32 weeks. Reports on his personal series of ECVs.

Mr. John Hamilton (Liverpool): Discusses the Burns-Marshall technique developed in and used by the Liverpool Maternity Hospital. General advice on selection criteria and labor management. A pithy statement about breech birth at home: "I will say at the outset that there is only one place for breech delivery, whether multigravida or primigravida, and that it in hospital." (Remember, at this time in England and Wales, around 33% of births still took place at home. See the UK Office of National Statstics report on home births.)

Mr. J. H. Peel (London): Makes an argument for ECV to lower the rate of breech deliveries and thus the overall mortality rate due to breech. Advocates for ECV around 34 weeks. Reports on both a personal series and a hospital series.

Mr. David Methuen (Oxford): Presents a series of 448 breech deliveries from his department in Oxford between 1952-1956. Advocates for using pudendal block or epidural anesthesia rather than general anesthesia for breech deliveries.

Mr. C. K. Vartan: Advocates for inducing all breeches at 38 weeks to produce "smaller babies which would not need to be extracted." A brief discussion of FHR after the baby is born to the shoulders.

Mr. Gilbert Dalley: Prefers ECV to breech delivery. Presented a 10-year series of births at West Hill Hospital in Dartford, both vaginal breech births and ECVs. Advocates performing ECV before the 35th week.

Mr. J. S. Hesketh: Concerned about the amount of traction described by Mr. Hamilton in the Burns-Marshall technique.

Mr. Wilfrid G. Mills: We should distinguish between extended (frank) and flexed (complete/incomplete/footling?) breech. Strong advocate of ECV, although he thinks it should be performed whenever the breech presentation is diagnosed, rather than at a set time. Gives an alternate explanation for why intracranial hemorrhage occurs in some breech deliveries.

Dr. J. Vincent O'Sullivan: Supports Mr. Peel's plea to do ECVs and suggests between 30-34 weeks. Discusses a different technique for delivering the aftercoming head by "rolling" the head over the perineum and pressing the nape of the neck close against the symphysis.

Mr. John Hamilton then replied to some of the earlier comments.



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Thursday, June 01, 2017

Obstetric Blinders: Cord Clamping

In my last post on obstetric blinders, I quoted a 1970 article that discussed upright birth among the Bantu and Polynesian people. That article quoted M.C Botha's 1968 article on the management of the umbilical cord in labor from the South African Medical Journal. (Full text here.)

I managed to track it down and was blown away by what I found--both by the evidence against cord clamping and by the obstetric blinders that Botha wore.

Botha's article begins with some quaint observations about childbirth in the Bible and other ancient literature. Botha then examines "primitive" birthing practices:
The most primitive of the Bantu people believe that it is completely wrong to touch the cord until the whole placenta is expelled. Once bearing-down pains commence, the parturient woman sits on her haunches, as if in defaecation. The trunk is bent forward, thus increasing the intra-abdominal pressure. Her bearing-down efforts are not new to her, since she has repeated the same act in defaecation daily since she was born.

Once the baby is born, the woman (Fig. 1) will remain in a squatting position watching her new baby. The placenta delivers itself from the vagina without any maternal effort (Figs. 2 and 3). Once the placenta is delivered, by gravity, the membranes usually remain in the vagina. The patient then lifts herself on her haunches and the membranes fall out. Only now does she pay attention to the cord (Fig. 4).

Hooten [1 sic] reported the same observations. Vardi [2], on account of this observation by Hooten, investigated the extra amount of blood that can be transfused into the baby by gravity; the residual blood in the placenta was approximately 11.2 ml. By bleeding the cord the total average blood volume was 100 ml. They thus concluded that by gravity, and not clamping the cord, the baby gets an extra 89 ml. of blood. This is exactly what happens in the Bantu baby.

Working among the Bantu for 10 years, attending 26,000 Bantu and seeing only abnormal cases, I found many other complications, but a retained placenta was seldom seen. If called to a case, I usually found that the terminal part only of the membranes was still in the vagina, and had merely to be lifted out. Blood transfusion for a postpartum haemorrhage was never necessary.

It gets more interesting. In the next paragraph, Bantu writes:
In accordance with this observation, the third stage of labour in White patients was managed with the use of Syntometrine [Pitocin], letting the cord bleed, and the Brandt-Andrews manoeuvre, and in 800 cases over the past 10 years no retained placenta or postpartum haemorrhage needing blood transfusion has been found. 
Note the difference in care between Bantu women (cord left intact) and White women (oxytocics, managed 3rd stage, cord clamped on the baby's side and left to bleed on the maternal side). Bantu babies also received an "extra" 90 ml of blood compared to White babies.

Let's see what else this article has to offer. I'm going to skip the next section on the history of cord clamping from the 16th century to the present. It's worth reading on your own, however.

Next, Botha discusses a study he conducted on a consecutive series of 60 unselected women, 30 with clamped cords and 30 intact cords. In both groups, "the uterus was not handled after the birth of the baby. The placenta was not handled until the mother felt the urge to bear down herself and was only received when it appeared outside the vagina. No oxytocic drugs were used." Women with intact cords birthed their placentas much more quickly and with much lower blood loss, compared to women whose cords were clamped.

Botha did another study in which he injected dye into the placenta immediately postpartum via the umbilical vein and took a series of X-rays to visualize the descent and birth of the placenta. He found that placentas with unclamped cords delivered more quickly than placentas with clamped cords.

Let's go to the end of the article, now, in which Botha discusses his findings. He begins with an unsurprising observation: "In the cases where the cord was not clamped in the third stage there was a statistically significant difference in duration and blood loss compared with those where the cord remained clamped."

Further down, he notes that an upright maternal position helps the placenta birth rapidly and with little resistance:
As there is fundal dominance in uterine activity, the placenta is forced in the direction of least resistance towards the lower segment and vagina. If the cord is bled, this process is so rapid that retraction has not yet taken place in the cervix, and the placenta, reduced in size, is expelled without resistance into the vagina. If the patient is sitting on her haunches, it will fall out by gravity.
Skipping ahead a bit more:
If the cord is clamped, counter-resistance from the placenta may be so great that retraction may come to an end. The placenta will then be separated by retroplacental blood, which, in my opinion, is not normal but abnormal. this takes place slowly and by the time the placenta is separated the cervical muscle has also retracted. The placenta is bulky, due to the blood it contains, and expulsion is difficult. If expulsion is not possible, the inevitable result is that in a certain percentage of cases the placenta will be retained, with associated postpartum hemorrhage.
Botha notes several times that the baby receives an "extra" 90 ml of blood if the cord is left intact. (I suggest phrasing it in the inverse: when the cord is clamped, the baby loses 90 ml of blood.) His next paragraph again mentions the difference in blood received by the baby:
If the cord is not clamped until the placenta is expelled, the baby will receive an extra amount of blood, which is approximately 90 ml., as reported by Vardi. 
He also notes that Rh- sensitization is rare when the cord is left intact and the placenta is birthed spontaneously.

The conclusion is fascinating--and disturbing--in how firmly Botha's obstetric blinders were in place. I had expected his conclusion would recommend leaving the umbilical cord intact until the placenta is birthed. This would both reduce both retained placenta and postpartum hemorrhage and give the baby its full blood volume. But instead, Botha recommends a surprisingly complicated method of third stage management:


Ironically, midwives would be giving superior care by simply leaving the cord intact and waiting for the birth of the placenta, because the baby would also retain 90 ml of blood in the process.

This is a classic example of how "modern" obstetrics pursues an invasive and complex solution (oxytocic drugs, bleeding the placenta, removing the placenta with controlled traction and pressure on the uterus) while discarding the simpler, better solution (leaving the cord intact and waiting for the placenta to birth on it own)--even though the "primitive" solution is easier for the attendant and better for the baby. 

References
  1. Hooton, Earnest A. Man's Poor Relations. 1st ed. New York: Doubleday, 1942. p. 412. (Corrected from the original)
  2. Várdi, P.: Placental transfusion: an attempt at physiological delivery. Lancet 2:12–13, 1965.
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Julia & Harry: Having our breech babies in Sheffield

Julia & Harry
A parent's view: Having our breech babies in Sheffield
North of England Breech Conference, Sheffield
Day 2

We had a lovely family talk about their two breech births: Julia & Harry. Julia first talked about the birth of Frank, her oldest, who is now 2 1/2. They had been trying to get pregnant for around 4 years and finally succeeded with AIUI. The whole process was very involved medically, with lots of scans and visits, and emotionally stressful.

They found out Frank was breech around 28 weeks, but initially Julia's providers told her not to worry, he might turn. Julia tried all sorts of natural techniques to encourage him to turn: moxabustion, acupuncture, inversions, swimming upside down, etc. Her providers booked her in for a cesarean, and at that point Julia's whole world crumbled. She hadn't realized how much emotional stress she was carrying. That last straw—to say we’re going to just come in and take your baby out—made her feel powerless, like there wasn’t anything she could do. Her whole life she had looked forward to giving birth. It was a very primal thing. And being told that she was going to have a cesarean really upset her.

Harry: If someone tells you you can’t do something, you generally want to do it.

Julia: Julia told her midwife  that she wasn’t happy about the cesarean. She had wanted a home birth. Her midwife said, you know, there’s a team who can do breeches! She got referred to Helen Dresner Barnes and felt so relieved that she’d have a chance to try. She did lots of reading and research and read other birth stories. Julia had a cesarean booked in, so she had a bit of deadline, but at least she had a deadline and some options. Julia went into labor naturally and was in a good head space: if I needed a cesarean, it would be fine. In the end, she had her baby vaginally in the hospital. Although the whole process of pregnancy was quite hands-on, the actual delivery day was very hands-off, with no intervention by the midwives. All three of them just let her do her thing to get him out.

Two years later, they weren’t actively trying to get pregnant, and Julia wasn’t having any periods. The doctor said she’d need to go through AIUI again to get pregnant. Julia went in a week later for a bloated belly and discovered that she was 4 moths pregnant! With the second pregnancy, the midwives were more hands-off. Julia had just one scan at 16-17 weeks.

Harry: Such an opposite experience form the first pregnancy.

Julia: Julia went into labor planning a home birth and thinking her baby was head-down. Florence came within 2 hours of labors tarting. Julia had the same team of midwives, who liked to care for “repeat offenders.” She had Florence on her own. Sally, one of the midwives, arrived 10 minutes later.

Her two pregnancies were very very different experiences, from high intervention the first time and pretty much nothing the second time. Julia doesn't think the second time would have gone the way it did—the trust in herself, in her own instincts—without the first experience and having had the team there the first time.

The main thing Julia learned from her two breech experiences: "I wanted the power myself to be able to make an informed decision on what I was to do, whether it was to have a cesarean or not. You can only trust yourself if you have the support in order to feel you can trust yourself."

Harry: In hindsight with Frank, we were engaged with medical science and technology at every point. I was amazed at how instinct kicked in when labor started. And the breech team gave that space, that light touch, to let it kick in. That was the most surprising and, in hindsight, the most obvious thing I realized after Frank.

Julia: If we had known Florence was breech before she was born, there might have been more intervention.

Helen Dresner Barnes: I learned that Julia had a breech birth when I came into her home. Julia told me, “It was okay; I recognized what was happening. I don’t know what I would have done if the baby was head first!”
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Monday, May 29, 2017

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
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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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Sunday, May 28, 2017

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:
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. 
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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.
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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. 
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