Physiological Breech Birth

IMPROVING SAFETY THROUGH RESEARCH

SHAWN WALKER, RM PHD

MIDWIFERY LECTURER , K ING’S COLLEGE LONDON

ELAINE CARTY VIS IT ING SCHOLAR 2020, UNIVERS ITY OF BR IT ISH COLUMB IA

How can we

improve the

safety of

vaginal breech

birth?

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Physiological management, including the use of upright maternal positioning

Teach when and how to put ‘Hands ONthe breech’

Repetition and reflection – Talk about it

Specialists: Higher degree of skill and experience, enabled to support the wider team

NHS Resolution Report 2017

Five years of cerebral palsy claims, 2012-2016

Breech presentation = 12% of all claims

2016 NHS Hospital statistics: Breech = 0.4% of

all births

5 / 6 claims were diagnosed late in labour

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Magro, M. (2017) Five years of cerebral palsy claims. NHS Resolution.

Breech training for the Regroupment Les

Sages-femmes du Québec,

Montreal 2017

Physiological Breech Birth

from the woman’s point of view …

“a breech birth in which the woman is encouraged to remain upright and active throughout her labour and supported to birth in the position of her choice.”

e.g. not required to lie on her back

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Squatting back to open the pelvic outlet

Video 005:

‘Birth of

Leliana’

Do not disturb!

... unless intervention is

required.

Marc Chagall, The Pregnant Woman / Maternity, 1913

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Physiological Breech Birth

from the professional’s point of view …

“a breech birth in which the management

is focused on anticipation of the need to

intervene (or not) based on careful

observation of the birth and progress.”

Spontaneous upright births:

Time between umbilicus & birth?

39 seconds

BREECHBIRTH.ORG.UK

Reitter, Halliday & Walker (2020). Practical insight

into upright breech births from birth videos: a

structured analysis. Birth: Issues in Perinatal Care

Findings

Median times (min:sec)

Pelvis → Head (n=36)

◦ Md=1:52 (IQR 1:05–2:46)

◦ Spontaneous Md=1:02 (IQR 0:23–1:31)

Umbilicus → Head (n=42)

◦ Md=1.26 (IQR 0:45–2:17)

◦ Spontaneous Md=0.39 (IQR 0:13–1:31)

Emergence

sacrum transverse

27/42 (64%)

Emergence

sacrum oblique

15/42 (36%)

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Sp

ont

ane

ous

Sa

cro-A

nteri

or

Rota

tion

Complete rotation

27/42 (64%)

4/27 (15%)

manoeuvres

Partial rotation

12/42 (29%)

7/12 (48%)

manoeuvres

No rotation

3/42 (7%)

100%

rotational manoeuvres

Second stages

A passive second stage is common, even in

unmedicated women.

Do not encourage active pushing until the

buttocks are visible on the perineum.

(PREMODA, 2006)

Conclusions

Most upright breech births occur within 3 minutes

of the birth of the pelvis.

A pause at any point >90 indicates completely

spontaneous birth is unlikely.

Use maternal movement and effort to diagnose

obstruction before intervention.

“Just breathe …

Wait for the next

contraction …”

Why specialists? Why breech teams?

Because …

The Term Breech Trial.

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Why

specialists?

Why breech

teams?

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Who is on a Breech Team?

• Has attended enhanced training *

• At least 10 vaginal breech births, including

complications

• Regular breech births or simulations

• (3-6 per year)

• Teaches others

* Breech Birth Network training is fully evaluated at the same standard as other obstetric emergencies trainings

The Belfast Royal Victoria breech team:

Obstetricians Niamh McCabe and Janitha

Costa, and Breech Specialist Midwife

Jacqui Simpson

What does a Breech Specialist Midwife do?

Presentation diagnosis by USS

Counselling

ECV/moxibustion

Support other maternity staff at breech births, planned

or unplanned

Teach updates at mandatory events and for students

Reflective review after breech births / study group

Risk management related to breech / Audit

Research and conferences

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Questions & Discussion

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