Thursday, April 27, 2017

Panel discussion on breech

Panel Discussion
North of England Breech Conference, Sheffield
Day 1

Panel members:



Cathy opened the session with a commentary on Montgomery (see Johanna's presentation for specifics): use this law proactively. Don’t ask "What does the law say?" Instead, employ this legal framework actively and you will be fine.

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Informed Consent 

Q from a UK midwife: I run a breech/ECV/VBAC service. I have a burning question about whether I or the consultant OBs should be doing the informed consent. I recently posed this question to one of my consultant OBs. My clinic does informed consent as a lengthy process. For example, my VBAC women go to a VBAC class, a VBAC workshop, and see me or another midwife at 30 weeks. Then we go through the women's previous birth and discuss what they want to do this time around. After that point, the women then make their choices. It struck me, though, that maybe I shouldn’t book women for a cesarean once they’ve chosen that route. And who should be the one doing the consent: me, or the consultant OBs?

Johanna: What you’re doing is great. Your practice sounds exemplary in terms of going through all that information, giving them the time, and letting things evolve over the pregnancy.

Betty-Anne: In my area, the doctors aren’t willing to offer those choices after I tell women about their options. That’s why I ended up doing breeches—because the head of Obstetrics said they aren’t willing to do breeches. Be prepared for everybody in the medical staff to hate you, because you’re offering something that isn’t there.

Cathy: This is a genuine dilemma for lots of midwives. Another classic example is home birth. Johanna, what advice would you give to a midwife if you know that their particular NHS service is really poor at actually enabling home birth?

Johanna: I suggest a 2-fold approach. 1) Make it clear to the woman that it’s her decision to make. 2) Go into your places of work and have that dialogue with your colleagues.

Q about Montgomery: If a woman has a request and you’re happy to agree to it, how duty bound are you now to explore the counterpart of those requests?

Johanna: You are still duty-bound to set out all of the different risks/benefits of all of the choices. At first, I wanted an elective cesarean, but when I met with my provider, they set out all of my options, and I ultimately chose a very different kind of birth. [I believe she had a home birth.]

Q: But in the real world, doing that [presenting the counterpart once a woman has expressed her preferences] can be taken in an antagonistic way, as if you don’t want the woman to have a choice.

Johanna: Montgomery shows us how important it is for us to have those difficult conversations.

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What if breech isn't an option in your area? Lack of provider experience, difficulties in receiving referrals, etc.

Cathy: What do you do in terms of having a UK unit where vaginal breech birth really isn’t an option? What would you say to midwives in terms of offering the choice of a VBB?

Betty-Anne: I suggest to them that they move. [laughter from audience] Find a better practitioner if they can’t find one in their community. 23-30 years ago I sent people to The Farm, to Guatemala, to Nova Scotia. At one time I was going to send people to Frankfurt.

Cathy: Isn’t that slightly different? The woman who comes into your clinic absolutely wanting a VBB…sure, we can open up proper informed choice to all women, but they may not have the capacity to travel to other places.

Comment from a provider from Oxford about receiving referrals from other units/hospitals: We have a massive issue with funding because the maternity pay has already gone to the woman's booking hospital. We can’t offer ECV or other services to women from other booking areas.

Julia: My clinical director is very happy for people to come to Sheffield to have their babies.

Jane: Being told that you cannot have a vaginal breech birth because they haven’t got any experienced professionals in the local hospitals is surely a human rights issue. Why are we letting this happen?

Frank: Is there any way to get more information in England about who is experienced? To satisfy quality management in Germany, every clinic has to fulfill a certain criteria. There’s a score that indicates if breech is offered and how many they do every year. (He referred to a person from England who created this score; I didn't catch the name).

Consultant OB from Preston: We have recently expanded our vaginal breech deliveries. We get referrals from neighboring hospitals with small delivery rates because of lack of breech experience. The new 2017 RCOG breech guidelines say that institutions should refer women to experienced centers. Instead of having a blanket ban, there should be more sharing between institutions to help providers train and learn.

Johanna: It’s multifaceted. The first option is to move the woman, but Birthrights doesn’t generally advise that. The other option is to move the professional; start writing the hospital and putting pressure on them, ask them to bring in an outside professional to attend the breech birth.

Q: At Sheffield, can you have visitors come to observe breech births?

Julia: Not right now, but that’s why we organized the conference!

Betty-Anne: It’s not an either-or. When you go to a place where they’re not experienced in breech, they will bait-and-switch. Maybe they’ll say they’ll do it, but then they’ll find every possible reason to move to cesarean because they’re scared.

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Inappropriate use of scare tactics

Consultant midwife from Birmingham: A woman in my unit asked for a home breech birth. I was happy to go along with it, but some other providers were very fearful. Some midwives were confident but non-competent. Midwives need to attend training sessions to become more competent. Telling a woman her baby is going to die, over and over again, is a horrific thing to say to a woman. This was told to this particular woman 6 times. We used the Birthrights leaflet to show that this scare tactic was unnecessary exposure of risk.

Jane: I will cover a bit about the National Midwifery Council. It’s the midwife’s responsibility to become skilled, otherwise they shouldn’t be on the register. We shouldn’t get women changing locations to have their breech babies, because it goes totally against physiology.

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Undiagnosed breeches

Q: I hate seeing a woman with an undiagnosed breech in labor coming in and a run to the operating theater for an "emergency cesarean." How do you get informed choice in that situation? Where does consent come in in this time-sensitive situation?

Frank: Undiagnosed breech isn’t common in Germany. We do a workup in the woman late in pregnancy, so in most cases we know beforehand. In my study, the women were all counseled at 36 weeks. ECV is offered at 38 weeks. Many women in this study have MRIs if they are functional primips. Undiagnosed breeches are extremely uncommon in Germany, but in the Netherlands they are common. It’s more important to each people how to deal with it vaginally, especially since cesarean is more dangerous late in labor.

Julia: We have undiagnosed breches in our unit. Over the 5 years Helen and I have been working together, we harp on about breech all the time. We talk about it all the time. I'm always getting the pelvis out on the labor ward and showing how the baby just falls out of the pelvis if you turn the pelvis upright. Every single doll and pelvis does the same thing. I do this over and over on the labor ward, and the junior doctors and the midwives now realize how breech works. They get it. So now, the philosophy in our unit has changed. When there’s an undiagnosed breche, we don’t panic and rush to theater. We sit back, assess the situation properly, and discuss the options. But yes, it’s hard to discuss right as the woman is pushing. If a woman comes in 3-4 cms, you’ll have more time. But when a leg is coming out, you can’t do much discussion. I have seen a sea change in my own unit.

Jane: There is no evidence that says you should take an undiagnosed breech into theater. It’s very dangerous. We must rebuild our skills, slowly, slowly, because we let it all go in the late 90s and early 2000s. The TBT, which opened the gates to all cesareans for breech, was about planned CS at 38 weeks. We’ve misread it and totally forgotten what it says. It has nothing to do with emergency cesarean for unplanned breech.

Johanna: Here are scenarios for how to do informed consent right, even with an undiagnosed breech:
1. Over the entire pregnancy, you talk with the woman about her options, and build up a relationship, so the absolutely trusts you.
2. The woman shows up in labor with a surprise breech, but you have a little bit of time to have a discussion. Do your best. But it’s never the OB’s decision. It’s the woman’s decision. Can we do our best, without emotion, to get some sort of informed decision?

Jane: I often see women stopping their labors so they are able to make their decision—physiology can kick in at times.

Betty-Anne: Here is my perspective on MRIs and surprise breeches. At my unit, doctors will use the lack of an MRI as an excuse not to do a surprise breech vaginally. They will say, “Well, the woman hasn't had an MRI or an ultrasound to make sure the baby isn’t too big.” I have helped my unit to stop saying things like: “You need to know that if you’re having this baby vaginally, your baby might have cerebral palsy, might die, or we might have to decapitate the baby.” Now my unit has to list the 33 dangers of cesarean and the 1-2 dangers from vaginal breech birth.

Shawn Walker: When I went into the labor ward in a new Trust, I initially kept my interest in vaginal breech birth quiet. I was working in postnatal ward when I was asked to take care of an undiagnosed breech. The woman was receiving abominable counseling from a junior registrar. The consultant walked in, whom I knew well. I had a word with the consultant. Meanwhile they gave the woman terbutaline and within 10-15 minutes they were in theater doing a cesarean. This woman lost over 2 liters of blood on the operating table. I realized that I needed to get out of the breech closet so this wouldn’t happen again. It’s really tricky to avoid creating dangerous conflict in these situations.

Johanna: I know a woman with an undiagnosed breech. She said she felt overwhelemed with the amount of choice in her situation…but later she was grateful to have the information even if it was scary.

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Hospital breech bans & lack of breech competence 

Rixa: I commented about situation with breech bans in American hospitals, often as a knee-jerk reaction to a bad outcome (but sometimes for no apparent reason and no bad outcomes).

Julia: I hope the ACOG will look at the RCOG guidelines and man up.

Andrew Bisits (Australian OB/GYN): It boils down to the fact that after the TBT, there was an abrogation of responsibility--that we obstetricians no longer have to do VBBs, therefore we won’t worry about them. All these cases show that professional bodies need to mandate breech competence. We can’t tolerate this primitive medical-legal attitude of “I don’t have to do this, therefore I won’t, so I’ll send you to someone else or rush you to theater.” Even a skeptic in Australia has said that every OB and every midwife has to be breech competent. It’s a human rights issue.

Johanna: That’s why that the global Human Rights In Childbirth movement is so significant. Now this is the 2nd conference in the series. Once the rest of the world has got on board, you can’t ignore it.

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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