Breech holiday, Frankfurt

Justifying to a seven-year-old Anubis why I’m going to Germany for my week off – and missing mothers’ day, helped crystallise objectives and motivation for this busman’s holiday* (*a form of recreation that involves doing the same thing that one does at work).

“I’m going to see some babies be born bottom-first.”

“Don’t you see that at work anyway?”

“No. Not really”

“How come?”

“Because everyone with bottom-first babies has an operation to get the baby out, so we don’t get to see them born normally.”

“Oh yeah, I know, and you want to help people so they don’t have to have an operation.”

This post journals my experiences and reflections on a week at Johann Goethe-University Klinikum, Frankfurt, the centre that recently published its data on all women who presented for singleton breech delivery between January 2004 and June 2011. The study compared outcomes for women who gave birth in upright positions with those who gave birth in dorsal positions, and found that:

“Upright vaginal breech delivery was associated with reductions in duration of the second stage of labor, maneuvers required, maternal/neonatal injuries, and cesarean rate when compared with vaginal delivery in the dorsal position”. (Louwen, Reitter, Daviss and Johnson, 2017)

On call, a seven-minute cycle ride away from the Kreißsaal (delivery suite), where I hope to witness some planned physiological breech births. I’ll be present in a non-clinical capacity, just watching, waiting, making drawings, listening, asking questions and reflecting afterwards upon:

• the distinction between vaginal/physiological deliveries/births
• why we should be able to support planned breech birth
• what learning a new skill looks like and how it feels. (What am I even learning?)
• how effective new practices can be developed
• why relying on emergency skills to support vaginal breech isn’t enough.
• how a breech service becomes sustainable

I also want to consider the new RCOG breech guidelines‘ implications for service; what do they mean for us as practitioners in the current un-breech-friendly environment? Though that may be another post, after next week’s North of England Breech Confernce.

“Caesarean section cannot be the response to suboptimal care for vaginal breech birth” ~ Benna Waites, mother of a breech baby, 2003

As a clinician I feel a duty of care to investigate and increase vaginal breech competence – which is not simply about performing PROMPT or other learned manoeuvres, but developing skills of observation, assessment, communication, problem-solving, physiology optimisation and qualities of trust, patience and calmness (Walker, Scamell and Parker, 2016). Vaginal birth may become more widely chosen and experienced by women with breech babies, so the standard of care must flex to meet their needs – especially in view of the demise of independent midwifery, which has hitherto provided care for women making a variety of birth choices. The breech babies will keep appearing – mainly unexpectedly (Hemelaar, Lim and Impey, 2015) – and as there is no evidence for emergency CS if the breech is at the perineum and progressing well, we should be ready. This means learning how and when to help – and how not to turn a physiological birth into an emergency delivery: creating dystocias and delay by introducing pathological maternal position and/or risky manoeuvres that necessitate more.

The RCOG Management of Breech presentation Greetop Guideline 20b recommends we provide skilled supervision (support even better), and develop protocols for vaginal breech. So, let’s.

“Although every health professional should maintain basic competence to assist unanticipated breech births, establishing enhanced training and standards for those who support planned breech births may help protect users and providers of maternity services, while introducing greater choice and flexibility for women seeking the option of vaginal breech birth” (Walker, Scamell and Parker, 2016)

Skilled birth attendants as the key determinant of safe and successful breech birth, is unanimously agreed upon. And as such, breech competence is a hot topic – not only what constitutes it, but how to achieve and maintain it (Walker, Breslin, Scamell and Parker, 2017).  There are some good breech training programmes available, (one of which is evaluated here) including hands on simulation of how and when to help, videos, reflection, discussion, mechanics of physiology – but it’s not enough. No matter how many Jane Evans’ ‘Days at the Breech’, Breech Birth Network study days, Jenny Davidson breech skills workshops, Maggie Banks’ online interactive courses, Breech Conferences in Amsterdam, Sheffield; RCOG lectures attended, videos watched, research papers and books read or dissertations written, the fact remained: I had never attended a breech birth – planned or unplanned (just the one preterm breech as a student). After obsessive attendance at every study day for 3 years, even helping out on learning stations and presenting on sustainable breech models at some of them, @SisterShawn finally had a word: “Look, you really need to be at some breech births now, Oli.” Right there’s the rub of the breech catch 22 in which we find ourselves, individually and organisationally. In a maternity care culture that is systematically unsupportive of vaginal breech birth, we have to seek information and training outside our usual workplaces and spheres of reference. Our mandatory training on breech as an emergency doesn’t prepare us to advocate and support planned physiological breech birth. Hence, midwife researcher @mariamni, calls for ‘proactive skill acquisition and knowledge expansion’ (e.g. emergency manoeuvres for women in upright positions) required for planning intrapartum care for ‘higher-risk’ women (Plested, 2015).

With Benna Waites’ words  – “Your ignorance, your fear cannot be the reason for my lack of choice” – ringing in my ears, I’ve arranged this foray to Frankfurt, hoping for some planned physiological breech births.

Five vaginal breech deliveries later..

Description and reflection:

Freitag (Friday)

After 10 hours waiting and chatting at the delivery suite, I leave my temporary German phone number there and head to bed early in case I get called in the night. A woman with beckenendlage (breech) is on the ward, waters broken, some mild tightenings. The doctor asks me if I wanted to be called at 5cm or 8cm – 5, I say, already conflicted about turning up to observe without knowing the woman. I wonder if she’s aware someone has flown in to be present at her birth. Last week there were a couple of midwives here from the Netherlands who didn’t see a breech birth all week. Will I be luckier?

One of the registrars tells me they always call their consultant in when a breech baby is being born, even though she feels confident about manoeuvres and when to use them: ‘safety depends on the skill of the practitioner.’ She highlights CTG interpretation – without the possibility of FBS, and recognition of the moment when recourse to caesarean is necessary – as more complex and nuanced than in a cephalic birth. To her though, as with the midwives in the unit, vaginal breech birth has become normal practice. Most women are in upright positions, supported squats, kneeling or hands and knees ‘because it’s just way easier’, she says with the brisk assurance of experience. She is proud of their unit and how women with breech babies have come from all over Germany, and even America to give birth there.

Nonetheless, there’s a mild sense of bafflement amongst the midwives about us breech pilgrims willing to hang out for days on end, not in any clinical capacity, just to witness what has come to be part of their everyday work. It reminds me of Mary Cronk’s matter of fact approach to breech:

“I don’t see what all the fuss is about. It’s simple really: the breech is either coming or it’s not. If it’s coming, get ready and if it’s not, help is needed.” ~ Mary Cronk, 2015

The big boss Frank Louwen is away, back Monday. I wonder how much input he has ongoing in steering the service, how much his physiology-friendly philosophy governs and underlies others’ practice to keep the service sustainable.

Samstag (Saturday)

Last night I got called to attend a VBAC breech birth. It wasn’t the woman on the ward with SRM who I was expecting it to be, but another with a breech baby, from a town 30km away: A 28 yr old G3P1, (previous CS, for breech in 2014), in spontaneous labour at term. She herself is one of four children, two of whom were born breech.

On admission, she was found to be 4cm dilated, vaginal examination revealed a foot presenting, and the bottom at +3, posterior position confirmed on USS. She had an epidural at 4cm and shortly afterwards, contracting well, SRM with copious meconium. She lay on her side with her partner spooned behind her, breathing through the contractions. The epidural seemed to be light as she was feeling them strongly, and was agile and mobile. When I arrived the midwife examined her and confirmed she was fully dilated, toes visible now at the entroitus, CTG reassuring. When she felt like pushing the midwife went to call the doctor who sauntered in and suggested she get into all fours position leaning over the back of the bed. As she pushed, the baby’s left foot emerged posteriorly, toes pointing to the maternal left (i.e. towards the right – she was kneeling), followed by his right foot below. You could see from the way the toes were pointing that the baby was rotating, currently sacro-posterior as it descended (but still only feet visible with lots of spiralling down yet to do, shoulders would be at pelvic inlet now). I was quite surprised at what happened next: the doctor asked the woman to turn over into a dorsal position – which she did like a gazelle – and he began to draw out the first leg, then the second. Then he corkscrewed the baby into a sacro-anterior position by his pelvis, did Løvset’s to release the arms, followed by Mauriceau Smellie Veit to get the head out, before casually passing the baby up to his mother. It all happened in a flash, and the cool doctor sauntered out again. Surely his relaxed approach, and lack of adrenaline, benefited the hormonal physiology of childbearing (Buckley, 2015).

Afterwards he talked me through what happened and explained his rationale: it was specifically his concerns about posterior presentation that prompted the expedited delivery.

1) Baby RSA, legs extracted               2) to avoid sacro-posterior position.

I was curious about the possibility of waiting until the legs were born to assess presentation, then restoring the normal mechanism if necessary (rotation to sacro-anterior, or tum-to-bum) by gentle counter pressure on the hip, then waiting to see how the birth progressed, given there were no other concerns regarding size, health of baby, CTG reassuring and continuing descent. It felt counter intuitive to disturb her spontaneous movements as the birth appeared to be evolving normally at this point. Pulling out the legs inevitably entailed some traction, which potentially caused nuchal arms, necessitating further manoeuvres. I feel that the intervention of change in maternal position and extraction of legs happened too soon and think of Mary (Cronk)’s advice:

“If it progresses, wait and see.” ~ Mary Cronk

In this case I think Mary would have waited to see how the breech revealed itself, with mother continuing in a physiologically advantageous position. I hope it’s possible to have an opinion that queries how the birth was managed, without criticizing the doctor’s practice. I recognize my privilege as an observer without any clinical responsibility for this birth, decision-making or the reputation of the unit. I do not know how it felt to be in his shoes, I don’t know what he knows, I don’t know how much patience or trust he is willing to embody, or what are his held beliefs and experience of women’s physiology and breech birth. I’m a midwife, and not a doctor.

But for me it brings into question the underlying philosophy and ethos about maternal position and how much it is trusted and used to promote normal descent. Are we facilitating a physiological breech birth, or doing a breech extraction? Right here’s a potential divergence of midwifery and obstetric perspectives.

Every birthing room has one of these warming cabinets, full of fleecey sheets for the baby – such a nice, practical idea!

Back to the birth: all was well; manoevres executed with ease; cord swiftly cut (as it stopped pulsing almost immediately); and baby put skin-to-skin – covered in warm flannelette from the special cupboard – while the doctor suctioned his nose and mouth. There wasn’t a paediatrician present, but the midwife called him after about 10 minutes as the baby continued to grunt, no nasal flaring or chest recession, was well-perfused. He checked the baby over, wasn’t concerned, but said if we were, to call him back – otherwise he’d return in an hour. She had a 1^st degree tear, which was sutured by another doctor (midwives don’t suture), following a physiological third stage, then the baby had a good breastfeed, stopped doing grunty breathing and they all went home 4 hours later.

Baby suckling, mother glowing, she told me how triumphant and happy she felt to have done it. She wishes she’d known she could do it like this with her daughter, and that she hadn’t been scared into caesarean by the doctors’ horror stories. She had found the surgical procedure, lack of skin-to-skin and recovery difficult and upsetting, plus they want to have more children so ‘one caesarean is more than enough’, she said.

As I cycled back at dawn, I reflected on how low key and relaxed the birth was, despite being way more managed than I’d expected. No stress, no sense of urgency or emergency, just low lights, lighthearted and calm atmosphere – it seemed so normal, like a birth centre birth. I felt extremely privileged to have been there, quietly supporting and watching.

NB: Oxytocin is never used in breech births, and interestingly, very rarely used for induction or augmentation for any births here – only prostaglandins.]

Continuing on call, getting my head down early in case the woman on the ward with SRM at 38 weeks labours tonight.

Listening to people’s birth stories is part of being a midwife and my Frankfurt AirBnB host is no exception. Here is a woman welling up with sadness as she recounts the birth of her first son by caesarean 46 years ago; how he was taken from her immediately, how she ached to feel him on her skin but couldn’t, for what felt like hours. Then, when he was finally brought to her: the sensation that he wasn’t hers, struggling to connect with him, to feed, and unable to exercise because of abdominal pain for many months. If ever there were any doubt about the value of learning skills to facilitate real choice for women (with breech babies): the stories of women who remember forever how they felt having children.

Sontag (Sunday)

Oh happy night! No breech babies for 5 years, then two in one night!

00.14 diddy breech phone rings, by 00.35 I’m at the delivery suite again. Not one, but two women are in labour with breech babies, both primps, both at 5cm dilation, One is the woman who’s been on the ward with SRM and another, Lara (not her real name) has appeared in spontaneous labour from a town outside Frankfurt. When I join her, she’s on her knees in full on labour, no analgesia just breathing well through contractions, supported by her partner. The midwife breezes in and out – she’s looking after another woman too. When the doctor examines, Lara is 8cm and he recommends Buscopan for pain relief and to soften the cervix. Lara has this, but it doesn’t seem to touch the contraction pain and so when examined an hour later and found to be 9cm, the doctor recommends a spinal shot of anaesthesia. She’s not keen but exhausted from the pain, accepts. At 9cm the baby’s feet are palpable in the vagina – he’s sitting cross-legged (complete breech) left sacro anterior (LSA). A period of FH deceleration resolves when Lara goes onto her left side. She’s fully dilated now and the doctor thinks the baby is turning sacro-posterior as his toes are pointing upwards as he descends, balls now visible.

So Lara stays semi-recumbent, as the doctor prefers this position for doing manoevres. He rotates the baby’s bum upwards (she’s semi recumbent), by pressing on the baby’s hips with his fingers as they are still inside the vagina, then pulls out the baby’s legs, the baby pees.

Løvset’s, MSV with finger in the baby’s mouth, (which appears forceful to me), then the baby is out, cries. No paeds present or called to check.

The second woman with breech presentation was lying on her back in lithotomy, fully dilated, with deep decelerations on the CTG. On examination the doctor found the baby’s back to be to the maternal right (RSA), he encouraged her to pull up on her left leg and push hard. Decelerations continue on the CTG, doc calls for second doctor to do Kristeller manoevre (fundal pressure), so there she is kneeling on the bed pushing onto the top of the mother’s belly with all her force, continuing like that while the doctor pulls the breech down, fingers hooked into the hip creases. “Weiter, weiter, weiter!” (Keepitcomingkeepitcoming!). Then the legs are released, Løvset’s and MSV. Baby born flat, white, cord left intact, skin-to-skin, lots of stimulation, baby cries and pinks up. I didn’t feel very connected to the progress and rhythm of that birth as hadn’t been there long enough to meet the woman and be with her.

Montag (sunday)

Calmly writing up these births when the diddy breech phone goes again.

“Come, Olivia! You’ll have to be quick, she’s fully dilated”.

Hurtle through the streets, slip in at the back of the room to a now familiar scene: woman on her back, baby’s legs have already been brought out. She’s pushing hard.

Katarina (not her real name) is a primip, 38 weeks, estimated fetal weight: 2600g – just inside the selection criteria for a planned vaginal birth. She had been on the ward at 1cm not contracting, when all of sudden she was found to be 10cm dilated and contracting regularly. So terbutaline was given and she was brought to delivery suite. CTG normal. Same cascade of manoevres ensues: Løvsets, then MSV finger in baby’s mouth, which was not successful at bringing out the head. Doctor calls for forceps (‘schnell, schnell’), but doesn’t use them, instead an episiotomy and Bracht then MSV -it’s a difficult delivery.

Afterwards, on discussion with the midwife and both doctors present, a divergence of perspective is clear. Separately, both explain what happened:

The midwife examined her and found this: RSA, feet in the vagina. Given the CTG was perfect and pushing well, she would have waited a bit longer to allow for descent to see which way the baby appeared to be turning, instead of extracting the legs.

The doctor, when asked about indication to extract the legs, and what would have happened if the legs hadn’t been extracted then, confirms the same examination and presentation, but had concerns about the woman’s power to push, as well as the size of the baby. More complications occur with small babies than with large babies, as the Frankfurt study authors argue:

“..the bigger the fetus, the more robust, and that the abdominal circumference and legs create the required wider opening for the arms and head that follow.” (Louwen, Reitter, Daviss and Johnson, 2017)

Although the estimated fetal weight of 2600g put Katarina inside the criteria for planned vaginal birth, the baby weighed in at 2210g. Cord gases were 7.21 and 7.36. I didn’t like this birth for many reasons – not least that I had flown it at the very last minute without even meeting the mother.

I see a theme starting to appear in these breech deliveries.

In three of four of them, the same exact moment can be identified where a divergence of perspectives occurs:  The moment when a few more contractions in a physiologically conducive maternal position, of ‘wait and see what happens’, of ‘trust the physiology’ may have enabled birth to progress without incident.

Mittwoch (Wednesday)

Having not been called out the last two nights my busman’s holiday has turned into an actual holiday, cycling in the spring sunshine, swimming at Textorbad, going to yoga and having delicious dinners with Anke (co-author of the Frankfurt study, who has set up another breech service in nearby Sachenheusen) – we don’t talk about breech birth all night. On my way home I popped into the delivery suite to collect my shoes and say goodbye. Lo and behold there is a woman labouring with breech, her fifth child. They were just about to call me as she was 4-5cm. Unbelievable! I feel so lucky. Ultrasound scanner is used to confirm fetal position: LSA. The woman is in a right lateral position, and feeling lots of pressure so is examined and found to be fully dilated, from 5cm an hour ago. Baby’s buttocks palpable, no feet or cord presenting, the genital cleft is felt horizontally. Now she is kneeling up. I’m getting a good feeling about this one, if only the CTG wasn’t showing decelerations with the majority of contractions. Decision to start pushing in view of CTG. On pushing, thick toothpaste meconium and buttocks appear both together, with the midwife very hands on, pushing back the perineum over the advancing baby’s rump. With the next push, more of the baby is visible – it’s definitely a girl, in frank breech and her legs pop down without being released. Hurray! It looks just like all the videos and photo sequences. Then the baby is born as far as umbilicus and doesn’t descend at all with next the contraction. The upper torso isn’t reperfusing, looks pale and there is no notable cleavage in the baby’s chest to reassure that the arms were not nuchal and won’t need bringing down.  I can’t see the condition of the cord. The CTG is rubbish so the doctor asks the woman to go onto her back as it’s ‘easier to do the manoeuvres to get the baby out if she’s in that position’. It’s quite a cumbersome transition with baby half in-half out, but the woman does it amazingly efficiently. Løvsets to release the arms, easy! And MSV to bring our the head, also performed without difficulty. Cord twice around neck, which was credited with preventing descent. Cord gases are decent: another good outcome. This birth was the furthest I’ve seen a breech birth progress without intervention. The legs birthed normally. It was only once the torso stopped coming that manoeuvres were done. I would have loved to see the manoeuvres done in upright position (se fig below) as for the 17.5% of women in upright position whose babies needed manoeuvres to release the body in the Frankfurt study (compared with 92.5% of those lying down). (Louwen, Reitter, Daviss and Johnson, 2016)

Manoeuvres created by Dr Frank Louwen to assist during vaginal breech delivery with mother in an upright position (on knees, all fours, or standing). The top left image shows what should be seen during a normal vaginal breech delivery, whereas the top right image shows a sign of shoulder dystocia. The middle three images show the “180 degree torque” maneuver. When shoulder dystocia occurs, the practitioner grasps the shoulders and turns the fixed shoulder away from the maternal symphysis (the opposite direction to the Loveset), and back 90°. The bottom two diagrams show “the Frank Nudge” manoeuvre, in which the practitioner pushes the neonate’s shoulders up against the pubic bone to flex the head to enable it to emerge.

Fifth breech in one week, a midwife must count her blessings. And to think I only popped in to pick up my shoes!

While I’m extremely grateful for the opportunity to see these vaginal breech deliveries, they don’t reflect what I expected based on the Frankfurt data and hearing Dr Louwen’s talks. I’d imagined a more proactive use of upright maternal position to facilitate physiological breech birth, and less intervention when birth was progressing normally. But what’s really important here is that these breech babies are being given a chance, and the women are avoiding major surgery – a huge step in the right direction.

Enlightening to see a maternity culture in which breech is commonplace, but the question of my undergraduate dissertation remains unanswered: ‘Is physiological birth an option for a woman with a term breech baby?’ Heading to the North of England Breech Conference in Sheffield from here, where I’m particularly looking forward to hearing Birthrights‘ Johanna Rhys-Davis’ talk on Human Rights in Childbirth, related to breech. And midwives talk on clinicians’ competency and experience of vaginal breech birth in South Yorkshire. ‘Setting up a Breech service’ sessions on Day two will be interesting too. In July I begin a Birth Unit secondment, excited about going back to Labourland, deeper into normal birth physiology.

Thank you Frankfurt for this time to reflect about breech, and consider why it matters so intensely, and magnetises such passion, interest and contention from such a diverse array of people.

Breech birth is a fascinating crucible* containing diverse elements and violent reactions: human rights; informed choice; evidence based practice; woman centred care; duty of care; humanisation; salutogenesis; power dynamics; locus of control; physiology/ pathology; long term effects of birth; decision-making; nil nocere; midwifery; obstetrics; collaborative practice; intellectual, social, economic and political forces, philosophy – all the dichotomies, tensions, opportunities, challenges and ethics that exist in childbirth in general, are intensified in the microcosm that is breech.

(*a container that can withstand very high temperatures, violent reactions between compounds, used for smelting and melting).