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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Thursday, May 18, 2017

Anita Hedditch: The Oxford breech service

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

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

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

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

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

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

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

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

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


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

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

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

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


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

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

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

~~~~~

Dr. Andrea Galimberti commented that these are very impressive figures. He's thinking back to the time before 2001 when vaginal breech delivery was the norm. He’s been talking with several people interested in setting up a breech service in their hospitals.
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Tuesday, May 16, 2017

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

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

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


Monday, May 15, 2017

Dear DeKalb Medical,

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

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

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

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

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

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

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

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

Sincerely,

Rixa Freeze, PhD

References

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

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

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

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

8.
  • Canpolat FE, Köse A, Yurdakök M. Bilateral humerus fracture in a neonate after cesarean delivery. Arch Gynecol Obstet. 2010 May;281(5):967-9.
  • Capobianco G et al. Cesarean section and right femur fracture: a rare but possible complication for breech presentation. Case Rep Obstet Gynecol. 2013;2013:613709
  • Cebesoy FB, Cebesoy O, Incebiyik A. Bilateral femur fracture in a newborn: an extreme complication of cesarean delivery. Arch Gynecol Obstet. 2009 Jan;279(1):73-4.
  • Farikou I, Bernadette NN, Daniel HE, Aurélien SM. Fracture of the Femur of A Newborn after Cesarean Section for Breech Presentation and Fibroid Uterus : A Case Report and Literature Review. J Orthop Case Rep. 2014 Jan-Mar;4(1):18-20.
  • Kancherla R et al. Birth-related femoral fracture in newborns: risk factors and management. J Child Orthop. 2012 Jul;6(3):177-80.
  • Matsubara S et al. Femur fracture during abdominal breech delivery. Arch Gynecol Obstet. 2008 Aug;278(2):195-7.
  • Morris S et al. Birth-associated femoral fractures: incidence and outcome. J Pediatr Orthop. 2002 Jan-Feb;22(1):27-30.
  • Rasenack R et al. [Fractures in neonates as a result of birth trauma caused by caesarean section]. [Article in German] Z Geburtshilfe Neonatol. 2010 Oct;214(5):210-3.
9.
  • van Dillen, J., Zwart, J. J., Schutte, J., Bloemenkamp, K. W.M. and van Roosmalen, J. (2010), Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstetricia et Gynecologica Scandinavica, 89: 1460–1465.
  • Schutte JM, Steegers EA, Santema JG, Schuitemaker NW, Van RJ. Maternal deaths after elective caesarean section for breech presentation in the Netherlands. Acta Obstet Gynecol Scand 2007;86:240–3.
10. Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179–93.
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Monday, May 15, 2017

Andrea Galimberti: Day 2 opening address

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


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

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


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

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


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

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

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

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

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

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

Here is an alphabet soup of the breech baby's cardinal movements:
  • Baby starts RSA: RSA, RST, RSA, DSA, LSA, DSA, Tummy Tuck and out it comes
  • Baby starts LSA: LSA, LSL, LSA, DSA, back to LSA (which means they haven’t done their own Lovset twirl)
Disclaimer: As with all of the conference summaries that I write, I do my best to provide a detailed summary of each speaker. If something I have written is not accurate, please contact me so I can make the appropriate changes.
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Thursday, May 04, 2017

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

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

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

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

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

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

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




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Wednesday, May 03, 2017

Italy day 5: Lucca

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

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

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

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

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Tuesday, May 02, 2017

Italy day 4: Pisa

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

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

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

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

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Monday, May 01, 2017

Cinque Terre day 3: Manarola to Riomaggiore

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

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

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

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

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