North of England Breech Conference II

March 31-April 1, 2017

Anke Reitter: Setting up a Breech Service in Sachsenhausen Hospital, Frankfurt

April 1, 2017

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:

  • Walker S, Scammel M, Parker P. Principles of physiological breech birth practice: A Delphi study. Midwifery. Dec 2016; 43: 1-6.
  • Evans J. Understanding physiological breech birth. Essentially MIDIRS. Feb 2012. (PDF)
  • Walker S. Breech birth: An unusual normal. Pract Midwife Mar 2012; 15(3): 18,20-21.

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.

Original conference report published here (with pictures).