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Chair, afternoon session: Susan Oakey, Consultant Midwife, Chelsea & Westminster Healthcare NHS Trust

The management of breech presentation in a DGH with a low caesarean section rate

Dr Mich Mohajer, (MM) Lead Obstetrician in Fetal-Maternal Medicine, Royal Shrewsbury Hospital

The Royal Shrewsbury Hospital is a large DGH serving a population of over 430,000 people. The maternity unit is responsible for over 5,000 deliveries annually. Due to the topography of the county, at least 25% of all deliveries take place outside the consultant unit (either at home or in the outlying seven midwife-led units). This along with other driving forces has led to Shropshire having the lowest CS rate in the UK. The contribution of breech presentation to the CS rate is small (2-3% at term), but this still accounts for 100-150 births per year in Shropshire.

The population, who have large families, are averse to multiples CSs. But breech birth has always been associated with a higher than average CS rate, and it was unfortunate that women who had a breech presentation were automatically booked into our consultant unit while they may in every other way have been perfectly healthy, thus denying midwife delivery to those of low risk.
For this reason we set up a weekly breech clinic in 1997 where we could perform external cephalic versions (ECV) and if successful send the mothers back to their midwife-led units for the births of their babies. ECV is performed there from 37 to 42 weeks, although the procedure does become progressively harder. With an ultrasound scan we assess the type of breech, and check briefly for anomalies; head and abdominal circumferences are measured, the liquor volume is assessed and the position of the cord checked. Doppler scan is carried out if indicated. If suitable for ECV the mother is counselled accordingly and the procedure explained. If unsuitable for ECV, or ECV is unsuccessful, the pros and cons of vaginal birth versus CS are discussed. In general, the majority of women opt for vaginal birth.

For the procedure the mother lies flat unless the breech is engaged in the brim of the pelvis, when the couch can be tilted head down. We use plenty of ultrasound gel, but the most important component of the procedure is the ability of the mother to relax her abdominal muscles. The breech is disengaged with the palm of the hand and moved laterally with constant pressure, aiming to get it to the level of the umbilicus, which starts a forward roll of the baby; the head is then pushed gently forwards. We may attempt a backward roll, particularly with an extended breech. With a multipara lifting the breech in this way may lead to the head descending of its own accord, but more usually it needs some help. We need to be sure that the head is sitting well in the brim of the pelvis at the end of the version.

If the baby's feet are in the pelvis it is necessary to lift the breech even higher to clear the brim of the pelvis, otherwise the presentation is likely to revert to breech. Reversion to breech is most likely where the lie is unstable, not a true breech presentation. Following the procedure the fetal heart is checked and their is a repeat scan and CTG; all being well the mother is allowed to go home to continue with her GP or midwife care.

Failure is more likely where there is a low liquor volume relative to the baby's weight, with a big baby, and where the mother is overweight or unable to relax. If ECV is unsuccessful we discuss the mode of delivery, taking into account the type of breech, the baby's estimated weight, and the previous obstetric history. The procedure is impossible and accordingly contraindicated with spontaneous rupture of the membranes, multiple pregnancy, or where there is oligohydramnios. Other contraindications include planned CS for any other reason, rhesus disease, significant fetal growth restriction, and fibroids as large as eight to ten centimetres.

Our annual audit has shown an increase to 98 referrals, with an ECV success rate of about 50%. . We have conducted the procedure without complication during labour and in the presence of CS scars, when babies are small for gestational age but without evidence of growth restriction, and, which is very useful, for the second twin in labour after the birth of the first.

Mothers who have opted for breech births are booked into the consultant unit; the breech should be of the extended or flexed type, but footling breeches are delivered vaginally for some multiparae. Induction and augmentation are now avoided; if not in labour 7 to 10 days after their due dates mothers are offered CS. In other words and importantly labour should be spontaneous and unassisted, as most of our women wish. Very few of them request CS, and we get quite a number of women coming from other units where they have not been permitted to opt for vaginal breech birth.

We were embarrassed by the conclusion of the Term Breech Trial (Hannah et al. 2000), that "planned caesarean section is better than planned vaginal birth for the term fetus". Also
the RCOG recommended that all singleton term breech pregnancies should be offered CS as the preferred mode of delivery, and our management of these cases became potentially more complex, since the majority of our clients wished to avoid CS. So a 10-year study of our results was undertaken, using data derived from delivery registers, neonatal discharge summaries, and the child health database. Statistical analysis was by chi-square with Fisher's exact modification. This addressed in the short term perinatal mortality and morbidity, five-minute Apgar score, admission to neonatal unit, neonatal convulsions, and birth trauma. Long term observations included infant and childhood deaths and morbidity, special needs assessment, and the need for special education. There were 1433 term breech births, of which one third were emergencies, one third were planned vaginal births, and one third were delivered by CS. There were four infant deaths. A higher incidence of long term neurodevelopmental problems was noted in babies where the pregnancy went beyond 41 weeks. That this was true also for babies of birthweight below 2.5 kilograms indicates that the breech presentation was not causative, but the finding has modified our practice. We have also changed our practice in relation to induction of labour, which proved to be followed by a higher incidence of morbidity. However, when the long-term outcome was assessed there was no difference whether the infants were delivered vaginally or by CS. In addition, the babies that exhibited short-term morbidity (increased in incidence as suggested by the Term Breech Trial) showed no increase in long-term handicap as compared to those born in good condition. This data has added valuable evidence to the breech debate and has allowed our clients to make informed choices on modes of delivery according to local information and research.

Discussion.

(Q) Did you use drugs, hypnosis, or any other relaxation technique to aid ECV?
(MM) There is a difference between uterine relaxation and maternal abdominal relaxation; we have used subcutaneous terbutaline for short term tocolysis, and it seems to make little difference. It is often possible to carry out the procedure between contractions in labour, but some women are unable to achieve sufficient abdominal relaxation. Some women cannot tolerate the necessary pressure, others have probably come unwillingly and don't actually want ECV. The only method of relaxation I used is to talk to the women for 10 to 15 minutes beforehand.
A 30% vaginal breech delivery figure over the 10 years of the trial is probably explained by the early appointment of a consultant who insisted that women presenting with a breech should deliver by the breech; the other consultants soon came round to ECV when they saw what was happening.


A midwife's approach to vaginal breech delivery
Mary Cronk, Independent Midwife

Breeches will either progress or they won't; when there is failure to progress delivery must be by CS.

I regard breech presentation to be normal, if unusual; most midwives, and nowadays most obstetricians have little experience in assisting vaginal birth at term in this situation.

Maternal reasons for breech presentation include placenta praevia, which does not always cause bleeding before labour. Ultrasound scan can be very helpful in excluding this condition or other masses such as fibroids or ovarian cysts in the pelvis, and I always try to persuade those who are reluctant to have this examination. It can also exclude fetal causes of breech presentation such as hydrocephalus or anencephaly; poor muscle tone as in Down's syndrome may be the cause of the presentation. Vaginal birth may not be impossible where there is a bicornuate uterus, but this depends on the degree of the condition.

The higher mortality and morbidity of breech presenting babies is not fully understood, although they may be due to compromising events during the pregnancy.

I believe that a normally progressing labour can lead to the normal birth of a breech presenting baby. However there is no place in my opinion for induction or augmentation of labour or actively managed breech extractions where there is a breech presentation. It is often quite safe for many breeches to be born vaginally, and I and others believe that it is a mistake to perform CS simply for breech presentation. In this situation it is important to discuss the birth process with the woman and to tell her that she may be asked to adopt certain positions to assist in a normal birth. She should understand the circumstances when her baby may need help, and that this is somewhat more likely with breech presentation.

What is progress in labour? It starts spontaneously at or near term - 38 to 41 weeks. The labour should evolve normally in strength and frequency of contractions, and the presenting part should descend easily through the birth canal, the cervix effacing and dilating. The rate of progress need not be an issue, but in my experience with breech presentation this is often quite rapid. A second midwife or other competent practitioner should be present. I use episiotomy more readily with breech birth, particularly first births. Even where the legs are extended a hands-off policy should be observed and the legs will flop out easily without help. Assisting the birth of the head with two fingers over the shoulders and one in the baby's mouth (Mauriceau-Smellie-Veidt manoeuvre) is now regarded as inadvisable, possibly causing damage to the jaw; when necessary I now get the head to flex by applying fingers to the cheeks on either side of the nose. This flexion to ease the birth may also be aided by "conversion to Islam" from the Christian prayer position. A footling birth, even with a prolapsing cord, need not be the cause for great anxiety, as the cord will not be compressed until the head engages in the brim of the pelvis. This confidence is justified where the labour has progressed well; the temptation to apply traction must be avoided. We are always prepared to resuscitate if necessary.

A mother making very slow progress proved at full dilatation to have the baby in the sacro-posterior position; satisfactory progress to birth was unlikely; she was transferred to hospital and delivered successfully by CS. The registrar wanted to augment the labour and proceed to a vaginal delivery; I invited him to reconsider. On another occasion the knee of the anterior leg presented, while the posterior leg was fully extended. Nonetheless progress was very good, and the mother proceeded to have her baby with little difficulty to her and some slight assistance. Another baby delivered its posterior leg first and then its posterior arm first, but the anterior arm was stuck behind the symphysis, holding up progress despite a good contraction, indicating that assistance was required; I needed to rotate the shoulder into the hollow of the sacrum, when the birth proceeded normally.

Breeches will either progress or they won't; when there is failure to progress delivery must be by CS.

(The descriptions above were accompanied by a series of slides, and the author recommends anyone who is interested and able to do so to hear Mary Cronk in person on this topic.)

Twins, mothers and midwives - working with mothers of twins in labour

Jenny Smith, Head Midwife, Delivery Suite, Queen Charlotte's & Chelsea Hospital

This presentation discusses a woman-focused approach to care, and the realistic labour options for mothers of low risk dichorionic twins who have enjoyed a normal pregnancy.

A mother expecting twins arrives on the labour ward near the end of her baby's journey through pregnancy.

Her mind flashes back to the discovery of her pregnancy, the shock of finding she is carrying twins and the realization that normal is not quite normal in the eyes of the professionals. She remembers her ever-expanding abdomen, the changing relationship with her partner (the challenges of sex!), the movements of her babies, the angst and joy of the double helpings of pregnancy she has carried. She also remembers the continuous advice and comments from her mother-in-law, the women in the playground and the postman. <
She remembers her pregnancy quickly being labelled high risk at her antenatal appointments, with the plan of management decided for her rather than by her. She is fearful and wonders what the choices are in the light of so many perceived risks. She soon learns that she is no longer "the woman" but has become "the twins".

Midwives can provide good support in labour, offering choices to empower women to birth their babies normally, and the reassurance that a medical safety net is in place to catch them should they fall. The safety net need not inhabit the mother's labouring space, and the knowledge of it must be implicit rather than explicit: consider the violation that women feel if vaginal assessments are performed in a room full of people. Do we have to consent women for having a lot of professional people in the room at the time of birth? Only too often fragmented, impersonal care puts the twins at the centre of all interactions and treats the woman as merely a vehicle for the gestation; and the care is informed by the lamentable dictum "Expect the worst - pregnancy is only normal in retrospect".


Does it have to be like this for all women? How can it be different?

Dr. Jonathan Miller has said "They don't call it the operating theatre for nothing". Similarly childbirth is not without the passion and drama of opera. Carers know well the dangers that lurk, if rarely, for a seemingly normal mother and her babies during pregnancy and in labour with twins, and so our key objective should be to nurture the confidence of the mother and reinforce her belief that her labour outcome can be normal and safe. The foundations for this certainty can be laid in the antenatal period by a specialised multidisciplinary team of carers (RCOG 1995) who are dedicated to delivering the highest standard of clinical care, in a sensitive and empathetic manner, recognising that it is the mother's wellbeing that will ultimately deliver the safe outcome. The midwife has the opportunity to complete this triangle in that model of woman-centred care.



Despite the increase in twin rates due to IVF and the increasing age of women conceiving, as midwives we are losing the art and skill to care for these women in labour. We need to retrain and pass on our skills to avoid arriving at the situation where all twins are delivered by CS. Good preparation and support contribute to the desired good labour experience, in which the mother must remain the focus of care, the star of the opera, while all necessary skills and equipment stand by. In our practice we have been able to let labours proceed as mothers want them, with the willing cooperation of doctors staying in the background unless needed. And if a problem can only be solved by CS, all is not lost: under epidural analgesia a mother can experience the birth of her babies and be granted close and early contact, skin to skin, with them.



Now we need lead midwives to support twin pregnancies and births, parallel with the work of the Multiple Births Foundation, brainchild in 1988 of Dr. Elizabeth Bryan. More than this these women, carrying the burden of two babies, could benefit from the nurturing afforded by complementary therapies - massage, reflexology, and so on; they also need the information and support for good mothering which the Foundation can provide before and after the birth.



- my imagined triangles completed.


I'll do it my way - a mother's view of giving birth to twins
Emma Mahony, Author of 'Double Trouble: Twins and How To Survive Them' and feature writer for The Times

I am a journalist and mother of three; I have just finished my second book for the publisher Harper Collins, called "Stand and Deliver! And Other Brilliant Ways to Give Birth".

I am going to tell you the story of how I came to birth my twins with the NHS using independent midwives. I was scared and sensitive of the wrong information while pregnant. All my books on birth seemed so full of fetal abnormalities and all the complications caused by smoking and alcohol. I thought that NCT stood for Natural Childbirth Trust, not National Childbirth Trust, and that we would be urged to get down on all fours and moo like cows during the antenatal meetings.

I would never have dreamed of opting for a home birth because I thought they were for people who wore sandals, and at the time I thought of myself as more of a sad career girl.

Twins were diagnosed at 13 weeks. Although I am a twin myself, I believed the old wives' tale that twins skip a generation, and never suspected that I might carry them myself. I was shocked on hearing the news, despite the best efforts of the sonographer to break the details carefully. My response to her sympathetic "You might be feeling more tired because you have got two in there" was mild blasphemy.

On learning that there was no room for me at the hospital, I decided to keep going for the scans, because surely they couldn't refuse me right of entry on the day. Perhaps for this reason, I didn't have a first appointment with my doctor until I was 30 weeks gone. Apart from one home visit from a young community midwife for my blood tests, and the two scans, my pregnancy was barely interfered with.

My 30-week appointment with the mild-mannered obstetrician was a complete shock when he told me how he saw the birth going. He said: "We call 'term' for twins 36 weeks. Because the second baby is lying transverse, and the first baby head down, you will have to deliver the twins in theatre, in case of the need to move to a CS for twin two. It may be better that you consider delivering the first one naturally and the second by CS, because recent studies in the British Medical Journal have shown that second twins tend to have lower Apgar scores."

"How many people will there be in this theatre?" I asked. "Probably around 12," replied the doctor, "we won't exactly be selling tickets at the door… but they'll all be there".

I called the private birth centre run by Caroline Flint in South London, but balked at the price. I even called the NCT but gave up when I became lost in the worst telephone system in the world. Finally I found the number for the Association of Improvement in Maternity Services (AIMS) and spoke to the indomitable Beverley Beech.

Beverley faxed me my birth rights as prescribed by the Changing Childbirth document that was approved in 1993. By the 32 week appointment I was so armed with birth plans that the doctor could not fail to give me more than five minutes. First I asked the medical student to leave the room; I didn't ask permission, I knew it was one of my rights.

Secondly, I wanted to change doctors, preferably to a female doctor, but apparently every doctor subscribed to the same set of hospital protocols so there was little point.

The protocol read "There is no need for urgent delivery of the second twin if all is normal and the CTG is satisfactory." Then the next sentence said "It is customary to ensure the delivery of Twin II within 20 minutes of delivery of Twin I". And "There is no place for a physiological third stage in twin delivery". I had read birth stories from AIMS of mothers delivering their second twin in water, or over an hour apart. "Why ever not?" I scrawled on the paper. "Why would I want to have 'Oxytocin infusion 40 units in 500ml of normal saline via IVAC ready to commence immediately post delivery with an ergometrine injection ready in case of PPH'? instead of just standing up or coughing to get the placenta out?"

I gave up with doctors and met the heads of the community and hospital midwives in the hospital to discuss my birth plan with them. They agreed to see me, because I said that my reason was for research purposes for a birth piece in the Times. They were clear that I could only labour in water until I was two centimetres dilated, when I would need fetal monitors. I asked whether I could have one midwife on call who had seen a natural twin birth, or preferably had conducted one. I learned that only 7 out of the 70 midwives on rota had any experience of this, and there was no guarantee that one of them would be on call on the day.

I had spoken to the Independent Midwives Association, and to Mary Cronk. I asked her whether she would agree to assist me if they agreed to allow her to practise as a bank midwife in the hospital. But no, the NHS trust could not be seen to be paying to book Mary Cronk over and above any other bank midwife for my circumstance. And what if I pay for her services? I offered. Again no, only if they were paying was it possible, for insurance reasons.

There seemed no flexibility for women to take responsibility for how they wanted their birth to go, and that the hospital protocol was setting me up for failure. Everyone seemed fearful about the outcome of the second breech twin, except me, who was born a breech twin herself, and never felt I suffered a day because of it.

Finally, thanks to independent midwives, I had the appearance of a friendly face offering the Sonicaid to my three-year-old to listen for the baby's heartbeat and no mention of Twins Being the Biggest Birth Disaster that Could Happen to a Woman. With Mary Cronk, Andrea Dombrouve and Annie Francis, I knew I was in safe hands, and there was time to talk about the really important aspects of a new babies coming, such as who would look after them while I had a bath. Mary went through the routine with me about the best way to give birth - on hands and knees - and we made a list together of other important items, such as curvy drinking straws. Suddenly, having made the decision to pay for independent midwives I was looking forward to the birth and enjoying my pregnancy again.

Term for me was not the predicted 36 weeks but 40 plus weeks, my labour starting with twinges and niggles that went on for four days. I knew that if I was in hospital for four days I would have been speeded up with an induction. At home, it mattered to no-one how long these gentle contractions went on - as long as the babies and I were deemed to be doing fine.

On day four, when I hit 6-8cms dilated, "What might be stopping labour?" asked midwife Andrea. Nothing in particular, except perhaps that I still secretly wanted to give birth in hospital, where the mess could be contained and my new mattress would be spared. Mary had kept in touch with the hospital midwives during the beginning, middle, middle and middle of labour, so a quick call told them that we were on our way.

As we settled into the Twin Birth Suite, the hospital midwife came in and announced that she was in charge now. Mary disagreed. "I think you will find that my client is in charge", said Mary, very firmly. And I felt terribly empowered in that moment.

There was less than half an hour between hopping on the bed and having the babies. I was on my hands and knees as we had practised, and took the gas and oxygen. Within minutes of rupturing the membranes, the contractions were coming like a train through a station, and within fifteen minutes I was fully dilated, my body ready to push a baby out. Michael arrived exactly five minutes later, with only one expletive as he came through the ring of fire, and was held by Andrea for me to look and admire; his Apgar scores were 10,10,10. It took less than five minutes for the contractions to return to birth his sister Millie, who came down the birth canal with an arm and a leg. If I had been at home I would have had a third midwife holding my stomach to give me something to push against.

Still on my hands and knees, Mary suggested I panted rather than pushed, while Millie was pushed back up the birth canal and delivered breech. Perhaps someone less experienced might have panicked at the sight of an arm and leg and wasted time calling for a doctor; Millie needed the skill of an experienced midwife to oversee her birth. And when she was shown to me immediately she did something that no newborn is supposed to do - she smiled!

The next day I didn't feel battered and bruised as I had after the epidural and episiotomy of my first birth, I just felt like my old self. Except for the smile on my face.

When you get to birth the way you want, doing it your way with the kind of emotional support that every new mother deserves but doesn't always get, it is the very best present you can give yourself. I wish all the twin mothers yet to give birth equally happy birth days.

What are the morals to be drawn from my experience and from the experiences of other women who had good births?

1) Too little flexibility exists in the system if you want to do anything aside from the hospital protocol, and particularly if you are labelled as High Risk. Hospitals and most doctors behave as if they, not the mother, are in charge of a woman's baby and her body.

2) Most doctors have forgotten in the rush to offer medical assistance the huge natural feeling of elation that accompanies birth if the hormones are allowed to do the job on their own. Women who are given drugs and epidurals instead of good old-fashioned encouragement are missing this tremendous life-affirming experience.

3) Because the hospital doctors never see the women that come through their maternity wards again, they never witness first hand the later effects of medical intervention during labour. A woman coping with major abdominal surgery and looking after a newborn is not their concern. Research published in May 2001 by Dr Charles Woolf of the Department of Public Health Medicine at Guy's, King's College and St Thomas' Hospitals showed that around 65% of the 40,000 women from South East England surveyed had not fully recovered from their CS after three months, citing problems with tiredness, backache and depression.

4) The aim of the medical profession should be to provide women with a Good Birth, not just a Safe Birth. All too often the medical profession uses the excuse "It is for the safety of the baby" to wave away a mother's wishes. A good birth aims to care properly for the mother as well as the baby.



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