North of England Breech Conference II
March 31-April 1, 2017
Julia Bodle and Helen Dresner Barnes: The Sheffield breech service
April 1, 2017
This is the third of 3 hospitals presenting about starting a vaginal breech service. The other hospitals include Oxford University Hospital and Sachsenhausen Hospital, Frankfurt, Germany.
Julia Bodle is a Consultant OB and Helen Dresner Barnes is a midwife at The Jessop Wing in Sheffield. Together they run a breech pathway clinic, which began just a year ago, in addition to a 1-1 midwifery team that offers care to women who birth outside obstetric guidelines. They offer a "one-stop shop" for breech, counseling women with breech babies and offering ECV and vaginal breech birth.
Julia: We are overwhelmed at the people who have come to this conference.
Helen: It's good to hear that there's consistency between our practice and Oxford and Frankfurt. We base what we do on a philosophy of care that has the mother squarely at the top; her wishes take priority over both protocols and the birth attendant.We try to be really evidence-based, and we are lucky that there's more evidence emerging that we can share with parents. It's important to be brutally honest and not let your own opinion come into that conversation; stick to the facts as best we have them in the research. We know we don't have full sets of facts in the research, but there are some things we can be very clear about. The information we give to parents isn't about just this baby, but also about the next baby, about her, and about her family.
It was very important to us to have Johanna Rhys-Davies come yesterday and present the philosophy of dignity and of a woman's right to choose. We share the information, and then they we to know what the mother feels and is thinking. It's no good listening if you don't hear what the mother is saying to you. You have to absorb that into the plan you make. It isn't your birth; it's her birth.
We try to adhere to protocols that we have designed as a team; we recommend things based on these protocols. We are very heartened by the new RCOG Green-top Guideline on breech. The person looking after the mom needs experience, and we are upfront with the moms about how much experience we have. It takes hard work and dedication among the team members to provide 24/7 coverage for breech moms.
The midwives do most of the breech births themselves; they only call Julia when they know the need her.
How do we find our women? Often through community midwives who pick up the breech presentation via ultrasound around 35 weeks. Women usually go to our breech clinic around 36 weeks. It takes place on Mondays, so women might miss some of those Mondays because of holidays. During the breech clinic, we go through the various choices with the women. We offer ECV at 37 weeks and talk about the planned mode of birth.
Some of the articles we refer to during our evidence-based counseling:
- TBT 2000
- TBT 2004 (long-term followup)
- PREMODA 2006
- Glezerman 2005
- Reitter 2014
- Vlemmix 2014
- Berhan 2015
- Louwen 2017
- RCOG guideline 2017
During case selection, our aim is to "identify a normal healthy pregnancy with a normal healthy breech baby in an optimal position." We look at the woman's pregnancy and previous births, do an ultrasound assessment, and go over protocols. When we counsel mothers about the birth, we talk about the baby's position, how we will monitor the baby, what happens in the event of poor progress, maneuvers that might be needed, and what happens if the baby needs resuscitation.
Julia: We started our breech clinic just one year ago, with another birth occurring last night! We have seen 155 women for a first appointment. Interestingly, most of their babies have been cephalic by time they came into the clinic. But that makes everyone happy. We have seen 63 women with breech babies. 22 chose ECV (4 of whom had spontaneous versions before the ECV). Of the last 18, 9 babies turned. 4 declined ECV in favor of VBB.
Sheffield breech clinic outcomes:
- 39 planned breech CS: one of these had a spontaneous version with a vaginal birth
- 13 planned VBB, of which 6 ended with a vaginal birth. Some were advised before labor to have a CS.
- 11 planned cephalic births after ECV: 8 vaginal, 1 CS, 3 not delivered yet
In the same time period, Julia looked at all 221 breech births in the entire maternity unit at Sheffield (not just at their clinic). It was hard to find this data. Less than 1/3 of the women with breech babies visited the breech clinic. 131 women had "routine care" (not at breech clinic), 63 had the breech pathway care, and 25 additional women had undiagnosed breeches. (Julia would have expected more undiagnosed breeches.)
Routine care vs breech pathway care for ECV:
Routine care: 32% chose ECV (42/131), 19% success rate
Breech pathway: 42% chose ECV (22/52), 50% success rate
Routine care vs breech pathway care, Mode of birth:
Routine care: 0% chose VBB. 4 were sent to the breech clinic.
Breech pathway: 19% (13/63) chose VBB
Undiagnosed breeches had the highest VBB rate
Julia also looked at the overall rate of planned VBB in Sheffield, from 2011-2017, including before Breech pathway started and excluding undiagnosed breeches. 38 women total had planned VBB during that 6-year period, with 12 pre-labor CS and 10 in-labor CS. There were 16 completed VBBs (62% of those who labored).
Highlights and pitfalls:
We can increase the success of ECV; our numbers show that very clearly. We have one baby that has gone to ICU and is not well; it's not clear what has happened.