Heads Up! Breech Conference

International perspectives on breech (panel)

November 9, 2012

Panel members:

• Jane Evans (Independent Midwife, UK)
• Andrew Bisits (OB/GYN, Australia): has attended over 300 VBBs, planned and unplanned, since 1990s?
• Marek Glezerman (OB/GYN, Israel)
• Anke Reitter (OB/GYN, Germany)
• Michael Hall (OB/GYN, USA)
• Moderator: Betty-Anne Daviss (midwife, Canada)

Each panelist talked about the breech climate & protocols in their own country.

Jane Evans: UK
Once the Hanna Term Breech Trial (TBT) trial was released, it took away women's choice of a vaginal breech birth (VBB) in the UK with "horrendous speed." Gradually over the last 12 years, women have been saying no to cesareans and turning the tide. Still, women's choices are mostly to have a cesarean at a hospital or to have a VBB at home with a midwife. There are some small outposts within Scotland, Wales, and Northern Ireland where hospital providers still have vaginal breech skills. But breech is politically very delicate right now. In England, there are 1 or 2 isolated units where VBB was continued after the TBT, supported by brave obstetricians. We are left with a nearly 100% c/s rate for breech in most hospital units within the UK. In the last few years, a few forward-looking units have started to set up breech clinics. These were supported by midwives and gradually received more support from OBs. That has nudged other OBs into being more open to VBB.

Today there is a small groundswell for VBB because of the observational research coming out on VBB and on the research about the risks of a high cesarean (CS) rate. We may be able to start developing more choices for women with babies in the breech presentation. For example, there's a unit in Yorkshire with a skilled midwife; this unit receives breech referrals from the local OBs. There's a breech clinic set up in Norwich and another in Scotland. We will need a lot of time to develop the skills needed for breech birth. It's more hopeful in the UK than it was 3 or 6 years ago, when the first two breech conferences took place.

Jane works as an independent midwife. Because IMs have no malpractice insurance, hospitals have withdrawn privileges, which means the more skilled midwives have to transfer care to a less skilled provider if the woman wants to birth in a hospital. But largely the choice remains a CS at a hospital or a VBB at home.

Andrew Bisits: Australia
He was invited to participate in the TBT. He spearheaded a move to increase the numbers of VBB so they'd have sufficiently skilled providers for the trial. He was very skeptical when Mary Hannah read the protocol to them. He strongly felt that the TBT was not the best test for determining the feasibility of VBB. There were 6 participating centers in Australia. After the TBT, VBB was no longer an option in Australia. Everyone lost their skills "overnight." It came at a time when many legal pressure were mounting. There was a $12 million payout to a cerebral palsy baby, combined with other concurrent events, that led to a "hysteria" about the obstetric situation among OBs.

In this climate, the TBT emerged. The RANZCOG then advised the majority of women to have a CS, saying that some might choose a VBB-in reality, this meant that all women would have them. In 2006, RANZCOG revised their guidelines (PDF here) to be less restrictive. Dr. Bisits was called "mad" for doing VBBs. He commented that Marek Glezerman's 2006 article Five Years To the Term Breech Trial: The Rise and Fall of a Randomized Controlled Trial in the AJOG "saved my ass." (Full-text PDF available here.)

From 2000-2010, Newcastle John Hunter Hospital was the only in the country to offer VBB. Why? Some women strongly wanted it, midwives were keen to do it, and it provided an "important insight into normal birth. If we lose that, we lose an important source of insight in our training." Continuing to offer VBB also served as an important antidote to the medicolegal anxiety which dominated obstetric practice in Australia. It was just too important, at his hospital, to give up VBB. It was an important exercise in watching these women engage and deal with the risks.

Recent developments in breech research and training
The SOGC's 2009 revised statement had a "very significant" influence in Australia. Dr. Bisits finds it a useful counseling aid for himself and his hospital. In 2010, he moved to Sydney for family reasons. He started a breech birth service at the Royal Hospital for Women. There was resistance from the OBs, but marked enthusiasm from medical trainees and midwifery staff. In 2011, another teaching hospital has started a breech clinic under Dr. Andrew Pesce and midwife Michelle Underwood. Now RANZCOG is proposing breech training workshops to re-skill obstetricians. This was supported in part by a dangerously difficult CS in which the woman died; she had a breech baby, was fully dilated and ready to push, but not allowed to. This unfortunate event played a significant role in shifting attitudes towards vaginal breech birth.

Now in 2012, there are a number of "born again breech enthusiasts" who recently advocated for VBB in the RANZCOG journal. Women's Healthcare Australia has organized a breech conference on Nov 30 2012 at the University of New South Wales, with over 100 people already signed up to attend. On day 2, there's a breech skills workshop. They've also completed an audit of breech births in Newcastle from 1999-2010, which he'll discuss in more detail this afternoon. There are planned ongoing breech workshops through ALSO and more positive emphasis on VBB in medico-legal seminars. He also mentioned some ongoing qualitative studies examining the experience of women embarking on a VBB.

In sum, VBB is now offered in 3 major teaching hospitals in Sydney. He hopes that a similar service will be established in each of the other capital cities. There's an emphasis on detailed training using good birthing models (simulators). He noted that consumer and midwifery energy has driven most of these changes. It's also been fueled by more research highlighting the importance & value of normal birth. Obstetricians are remain apprehensive about VBB, while midwives and medical students are more enthusiastic. 

Marek Glezerman: Israel
Dr. Glezerman recently brought the Frankfurt team to his hospital in Tel Aviv, the Rabin Medical Center. It has 9,300 births/year.

You can't talk about general percentages of VBB in Israel, because it varies widely between cities and hospitals. In Israel, there are 25 medical centers that have maternity wards, and they all track their obstetric statistics. One hospital in Jerusalem had a 38% VBB rate, but it closed last year. His hospital has a 14% rate of VBB. On average, the VBB rate was 7.4% for 2010. It's about the same as at 2003. There was a decline through 2006, but then a rise after that.

When he was approached to join the TBT, he was enthusiastic about having a RCT. He was at Wolfson hospital at that time. He also got another hospital on board. When it slowly appeared that the TBT was on a wrong path, he felt somewhat responsible for the involvement of Israel's centers. He went out and gave talks about this; it helped to move the VBB rate up in the later 2000s. The rate of vaginal breech birth reached a peak in 2007 and 2009. Now it's been declining in the past few years. It's a question of politics, of being convinced about something, of geography, and of the people involved. He's had to reconsider the strategies he was using to get hospitals to come back on board.

He lamented that there's no discussion about the pitfalls of the TBT. There's no discussion of VBB in the right setting being a good option. It's like a power plant: everyone wants light and electricity, but no one wants the power plant in their backyard! Everyone might agree it's a good idea, but hospitals are reluctant to be the ones offering it.

What tools should we use in trying to convince hospitals that VBB is a good option?
Emphasize that we're always comparing risks with risks, not risk vs. no risk. You also need to think of the woman's future pregnancies, not just this one, when deciding between a cesarean and a VBB. We also need to focus on the risks involved with CS.

Looking at the numbers of cesareans done in Israel in 2011, 15% of CS were due to malpresentation (most of those for breech). 37% of CS were due to a previous uterine scar (most were a previous CS, with a few myomectomies). A lot of that 37% were due to an initial CS for breech presentation. Overall, about 40% of CS in Israel are done because of past or present breech presentations. We need to stress that point.
Dr. Glezerman next discussed ISOG's (Israel Society of Obstetrics & Gynecology) evolving position papers on vaginal breech birth. He and some colleagues helped rework and revise the recent position paper. It recommends:

• "VBB should be offered as an option to carefully selected women under defined circumstances." This also means that someone should be around who can offer it.
• "ECV should be considered."
• "Parturients should receive extensive information and give written informed consent. A senior obstetrician should be responsible for evaluation and delivery." (In Israel, midwives cannot deliver a breech at hospital or at home.)
• "A pediatrician and anesthesiologist should be available at delivery." (Not necessarily in the room, but on the premises)

This might seem a far cry from what should be the policy, but it's the best they could get. At least now they have this position paper. It's the major safety net for OBs performing a VBB if it comes to a medico-legal issue.

He wrote a recent commentary To rescue a vanishing obstetric skill--vaginal breech delivery in the journal Harefuah. 

Contraindications to VBB:

• EFW < 1500 g or > 3800 g
• Footling/incomplete breech
• Hyperextension of head (by ultrasound)

Considerations:

• Induction is optional
• Primiparity is not a contraindication (it used to be-there was a huge fight over this)
• Prematurity is not a contraindication

Dr. Glezerman acknowledged that some of these guidelines might seem overly restrictive, but they at least open the door for VBB. Once vaginal breech birth is well established, we may be able to loosen the guidelines somewhat. But we can't risk a bad case right now; we need to ensure that we have a very selected group of women likely to have good results.

Importance of simulation-based training
Simulation training is used to train physicians in many medical and surgical fields. We need to implement simulation training for VBB too. Anke Reitter and Betty-Anne Daviss did a course on VBB using simulation training; 22 of the 28 residents at his hospital attended.

Dr. Glezerman ended his presentation by showing a pictures of the first H&K delivery at his hospital. Anke Reitter and Betty-Anne Daviss were present for the birth.

Before the next speaker, Betty-Anne Daviss added that Marek Glezerman and Frank Louwen took a huge amount of heat from skeptical obstetricians in Israel. We owe Marek a big congratulations for his efforts. She then introduced the next panelist, Anke Reitter, commenting that she had searched all over Europe for a unit doing vaginal breeches in an innovative fashion and became "glued" to Frankfurt once she found it.

Anke Reitter: Germany
Anke Reitter started her training well before the TBT and did a lot of VBB in Britain in a big unit in Liverpool. She often had undiagnosed breeches coming in. At the time, it wasn't a big deal; she was trained from the senior OBs with no fear. When she came back to Germany, the TBT came out and everything had changed. VBB was rarely, if ever, done. However, she noted that demand for breech and vaginal twins are coming back; as obstetricians we must be well-trained and train our juniors.

Contraindications to vaginal breech birth in Germany:

• IUGR
• EFW weight > 3800 g (*she doesn't at all agree with the 3800 g cutoff. She has found that the bigger the baby is, the easier it is to birth)
• disproportion (unclear whether this meant pelvic disproportion or head/body disproportion in the fetus)
• footling breech
• pelvic anomaly
• inexperienced OB

German guidelines dating August 2010 recommend:

• ECV should be offered and must be part of special obstetric training
• Clinical assessment of pelvis; MRI or x-ray not essential
• do an EFW ("highest chance for a successful VBB will be in a normal size baby)
• Unit should have an experienced OB on site, plus neonatologist and anesthesiologist (She asked *how many does this mean? How often? What does experienced mean?)
• Prenatal counseling and information about the unit
• Informed consent for VBB

In Germany, ECV is done starting at 36 weeks. They use no tocolytic drugs or anesthesia for the procedure.

Pelvic MRI
In Frankfurt, every primip receives a pelvic MRI. An obstetric conjugate of <12 cm leads to a planned cesarean. Primips with an obstetric conjugate of >12 cm can have a trial of labor. They don't look at any other parameters other than the obstetric conjugate.

The Frankfurt clinic does a lot of primip breech births: 70% of their vaginal breech births were with primips. Their numbers of vaginal breech births have doubled since 2004. A lot of women travel to their clinic to have a breech birth. They are an island in how they approach breech birth. In many other hospitals in Germany VBB isn't really an option. Because of that, they're very exposed and have to adhere to relatively conservative guidelines. Dr. Reitter showed this flow chart for her unit's exclusion and inclusion criteria: Women who fall into the following categories require a prenatal work up. 

She compared her unit's outcomes to the PREMODA and Dublin data. You'll notice that the Frankfurt clinic has a higher rate of planned VBB and a lower rate of successful VBB than the PREMODA study. Overall, however, a greater percentage of all women with breech presentations in Frankfurt have vaginal births.If a woman plans a cesarean section for a breech presentation, they prefer to wait for labor to begin spontaneously or until around 40 weeks.

Women who live far away continue their prenatal care with their normal midwife or OB, then come back to the Frankfurt clinic during labor. They prefer for labor to begin on its own, but they may induce at 10-12 days postdates.

To conclude, Anke Reitter expressed her commitment to physiological breech birth. Like Eric Bracht, she and Dr. Louwen "do not want to disturb the physiological process of a vaginal breech birth, we in fact want to support it." From the hundreds of upright breech births they have done int he past decade, they conclude the following:

Take home messages:

• Upright position does expand the pelvic [dimensions] and therefore will facilitate labor and delivery
• This advantage should be used in all deliveries
• In pregnant women with normal pelvic measurements, a vaginal breech birth does not lead to any increased risk for mother and child

Michael Hall: USA/Colorado
There were only three minutes left in the session when Dr. Hall began speaking, so he had to abbreviate his comments.

Michael Hall, an obstetrician in the Denver area, expressed his frustrations that he couldn't get ACOG representatives to attend this conference, despite extensive efforts by him and other physicians. He is a fellow of ACOG but not spokesman for the organization. He's in the trenches, not an academic OB/GYN. He has recently received privileges at a teaching hospital in Denver so he can start teaching the residents vaginal breech skills. It took a year to get privileges.

He has met a lot of resistance from his peers about attending vaginal breech births. Pediatricians are particularly resistant to VBB, since breech babies come out needing assistance more often than vertex babies. However, he keeps on doing it and doing it. Now his local hospital is comfortable with it. His nurses now are very comfortable with VBB and very respectful of him. But it's a long process to get there. It's not whether or not we can do VBB. We can do it. Most of obstetricians know how to do it. But many don't want to. If they see some of their peers doing it again, then we can make some inroads.

Our hypothesis is that the maternal position during labour impacts on the natural descent of the fetus, on the necessity of using manoeuvres or interventions, and on maternal and fetal outcomes.

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