Episode 31 Bottom Down

What happens when a baby is bottom down or breech at the end of pregnancy? Can we encourage it to turn and what are the options for birth if it won't?

Want to try and turn your baby?
https://www.spinningbabies.com/pregnancy-birth/baby-position/breech/

Cochrane ECV

https://pregnancy.cochrane.org/sites/pregnancy.cochrane.org/files/public/uploads/cochrane-review-of-ecv-at-term.pdf

Interested in understanding more about breech birth?
Hannah Term Breech trial https://www.thelancet.com/journals/lancet/article/PIIS0140673600028403/fulltext

RCOG guidance & Pt info https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14466

https://www.rcog.org.uk/en/patients/patient-leaflets/breech-baby-at-the-end-of-pregnancy/

Frankfurt series

https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.12033

Physiological breech birth https://breechbirth.org.uk/category/videos/ videos and algorithm

You can find out more about me on Twitter @FWmaternity & @TheObsPod please check out #MatExp matexp.org.uk for ideas about how to improve maternity experience.
 
 My beautiful artwork is thank to Anna Geyer www.newpossibilities.co.uk

Thank you all for listening,  My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Its easy to explore my back catalogue of episodes, I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Instagram @TheObsPod and email me on TheObsPod@gmail.com Please also check out #MatExp matexp.org.uk for ideas about how to improve maternity experience.
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Florence 0:00

Hello, my name's Florence. Welcome to the Obspod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife, maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case, and for that matter anyone else that's interested, the Obspod is for you. Episode 31. What do I mean by bottom down? Well the medical word for this is breach presentation. And at the end of pregnancy, 37 weeks and beyond, 3-4% of babies are breach, bottom down. That is they haven't turned into what we consider the correct position, which is head down or cathallic. It matters because being bottom down is more common earlier in pregnancy. Babies are much more mobile, so it's more common to have a breach or bottom-down baby if you go into labour at an earlier number of weeks. But if the baby hasn't turned by 36 or 37 weeks, we need to start thinking what to do. The thinking is that this is problematic. When a baby is head down, the head is a lovely round shape and that sits on the cervix, and as contractions happen, it presses evenly on the cervix so that with each contraction the head is applying pressure to the cervix, opening it up, dilating it, and progressing the labour. If the baby is bottom down, that doesn't necessarily work quite as effectively. It can do, but it can make birth more complicated. Today's topic is a really big topic because I would argue that actually birth may not be that much more complicated, but we tend to make it so. So I'm going to explore quite a lot of issues. The first thing we're going to talk about is turning the baby. The National Guidance recommends ECV or external cathallic version that's turning the baby to head down outside of the womb, with our hands outside of the womb, that is, in the first instance, to try and correct the fact that the baby's bottom down and make it head down. ECV has gone in and out of fashion over the years, but it is currently recommended and currently is very safe. There are situations in which ECV is not sensible, contraindications, and that is if the womb is a different shape. So it might be a different shape because of large fibroids, perhaps, or it might be a different shape because the way the womb has developed in the mother is unusual. So you can have a womb that is horn-shaped or even has two horns, and that can make bottom-down or breech presentation more common and less likely to turn. We also wouldn't want to turn a baby that is very big or a baby that's very small, as turning the baby could be stressful for them. We also want to make sure that the baby's head is flexed so the chin is tucked into the chest, and ideally, what we're trying to do is encourage the baby to do a forward roll. Some doctors feel that having a cesarean scar on the womb is a contraindication. I would say it's a relative contraindication. I do undertake an ECV in women that have had a cesarean before if they want to. Then we have flex breach, that's where the baby's bottom is there, but the knees are up and the feet, it's almost like it's sitting cross-legged. So the baby's feet are by its bottom with the knees flexed. The final type of breach is a footling breach, and that's what everyone gets worried about. A baby whose feet are down and the bottom isn't there with them, so-called footling breach. So if a woman is coming for me to try and turn her baby, she's admitted to a room on our labour ward, we do a heartbeat tracing, and we give her some medication that helps relax the muscles of the womb, makes it soft, makes it less likely for her to have contractions or tightenings, so that I can help turn her baby. A forward roll is easiest, and you have to work with the baby. So the first thing is to lie the woman very flat so that you can push the baby up out of the pelvis and then bring its bottom round part way round, and as the baby starts to wriggle, be patient, wait for it, hold it with firm pressure, and then try and push it round. The key is holding on to the bottom and moving the bottom. Otherwise, you're just swinging the baby's head from side to side. Some babies turn quite easily, and I've had women say, Is that it? I was expecting something much worse. Some babies are hard to turn and they won't turn at all. So it's only 50-50 whether we're going to be able to successfully turn a baby. I love turning babies, it's incredibly satisfying, and it feels like an old-fashioned laying on of hands with your hands doing something really, really practical that can instantly correct the baby's position. So that in five or ten minutes you can go from a woman who's stressed and worried about the fact her baby is bottom down to a woman whose baby is now head down, whose pregnancy has effectively gone back to normal. Some women do find the procedure really uncomfortable. They describe it as feeling like a Chinese burn, pain on their skin because I'm pressing quite firmly. Some women seem to find it absolutely fine. I have to apply quite firm pressure, sustained for five or ten minutes, and the woman has to lie completely flat or even with her head down, which feels odd when the whole pregnancy we've told her not to do that. I think having an ECV is a high degree of trust in the person that's trying to turn the baby. If a woman is nervous or anxious and she's tensing up, you're not going to be able to turn her baby. She's got to have confidence in you that this is the right thing to do and be motivated that she wants to turn her baby and that she can relax enough to let you move her bump and press on her tummy much more firmly than she will have had done during the rest of the pregnancy. I usually have two or three women a week come and see me to try and turn their babies, and our stats are pretty good. There's a very small risk that a woman might need a cesarean then and there, either if the baby gets distressed or if there's bleeding. I've only had that happen twice in the many many years I've been trying to turn babies. So it is very safe. Before women come and have their baby turned or attempted to be turned, we often tell them to use the Spinning Babies website. There are some fantastic exercises on that that can help a woman turn her own baby. I've put a link in the programme notes and you can go and have a look. There are some exercises that look quite tricky lying upside down on an irony board, but they do seem to work. I've had women who haven't been able to have an ECV because, for various reasons, they can't have someone push on their tummy, and they have succeeded in turning their babies just by using this postural management. I always recommend it to people before they have their ECV because it actually stops the breach, the bottom, from going down and engaging in the pelvis and making it harder. I think our success rates are definitely getting better since women are more prepared and more active in doing something to try and help turn their baby themselves. So when we diagnose a baby that is bottom down, we organise a growth scan to check it's not too big or too small, and in the first instance, we advise ECV turning. But what if that doesn't work? What do we do then? My experience of breach birth is one of the most profound changing areas of practice over the course of my career. When I trained, when I started in my training, vaginal breech births were not unusual. Breach births could be very quick and straightforward. In fact, one consultant taught me to always put forceps on a breech baby's head to control the delivery of the head, the birth of the head, to make sure that the head didn't come out too rapidly, popping out like the cork of a champagne bottle. That wasn't good. We were taught to control it by putting the forceps on and helping the birth slowly. So I had quite a lot of experience of vaginal breach birth. Then in 2000, there was a fundamental change. The Hannah term breach trial was published. Overnight it fundamentally changed how we advised women with a breach bottom-down baby. The HANA breach trial was a multi-center randomized controlled trial. It was across 121 centres in 26 countries, and it concluded that planned cesarean birth was safer for breach babies, with a reduced risk of perinatal morbidity, so injury, and mortality compared with planned vaginal breach births. This led to a complete change in practice. Studies showed in the Netherlands that the overall cesarean rate for breach babies went from 50% to 80% within two months of publication. And another follow-up trial showed that 92 of the participating centers had changed clinical practice to planned cesarean for all term breach presentations. You might say that's good. Evidence-based. It's safer. We should be encouraging women to have a cesarean. Let's think back to last week's episode about statistics. Evidence is not always what it seems. The term breach trial has been much criticized. It was, yes, a randomized controlled trial. Sounds really good, gold standard. But it was across so many different centres in so many countries with so many variations in practice and so many different types of resources and different skills and experience from birth attendance, that it's very difficult to make the conclusions that they did. Over time, the term breach trial has been much criticized. It also became obvious at a later point that although the initial neonatal outcome, so the outcome of the baby in the first few days of life, might be slightly different between vaginal breach and cesarean birth, that actually at age two years there was no difference between the cesarean group of women and the vaginal breach birth group of women. So we swung from vaginal breach birth as a routine, not uncommon with skilled doctors and midwives to do it, to the other extreme cesareans for everybody. And this has had a massive impact, not just only on the women having these caesareans for a bottom down baby, but on the staff, because the resulting swing to cesarean section meant that junior doctors' training and junior midwife's training no longer understood or saw breach vaginal births. I'm very lucky that I trained in the time pre-publication of the HANA trial, but if you think now it's 20 years since publication, and in 20 years we've been doing a lot of cesareans, that is a massive loss of skill. So what if you don't detect the fact that the baby is bottomed down and you come in in labour? Or what if you do want to have a vaginal breach birth? What then? Well, over time, we've continued to do vaginal breach birth. Either because a woman has been admitted in the late stages of labour and we didn't know the baby was bottomed down, or because the birth was actually quick. Hang on a minute, you might say birth was quick. We've said that birth for a breech baby, bottom-down baby, is more complicated, isn't it? Well, actually, that's not the case. And that's why I said at the beginning of this episode that perhaps we are overcomplicating things. Yes, it's true. If you compare bottom-down babies and head-down babies, the bottom-town babies are more likely to have complications. But many bottom-down births are very straightforward. I remember when I was a registrar, I'd come from a hospital where a lot of women were having vaginal breach birth, partly because of their ethnicity, they had large families, they were actively choosing not to have a cesarean. Culturally, that wasn't particularly acceptable to them, they would have a vaginal breach. So I was fairly practiced in vaginal breach, and as I already said, I'd been trained to do it and trained to put forceps on to control the birth of the head. Then I rotated to another hospital, and when a woman came in with a baby bottom down in labour, I rang the consultant and was told, even though it was her second baby and she'd given birth vaginally easily before, I was told I should take her to theatre for a cesarean. Well, it's difficult when you're a junior doctor, even though you feel you have the skills and you think you know what's best, there's a hierarchy. There's someone more senior who's in charge, who's responsible, who's telling you what to do. So I went to the woman and I said, I've spoken to the consultant and they're recommending that I take you to theatre for a cesarean. And she agreed somewhat reluctantly, and we went to theatre. Well, you may or may not know that to have a spinal anesthetic ready for a cesarean, you're either lying down on your side or you're sitting up. This woman was lying down on her side, having her spinal put in. Part of the way through the spinal insertion, before it was completely effective, she said, I think I can feel something between my legs. So we opened her legs and looked down, and lo and behold, she was birthing her baby. The baby had come out so quickly that there was no time to do a cesarean. And I felt relieved. I felt really relieved that I hadn't done a cesarean. I felt really relieved that this baby had taken it into its own hands and her body had done what her body needed to do, and that she'd had a straightforward birth. The woman took it in very good humour, actually. She actually thought it was really quite amusing that she'd beaten us to it. It was annoying because she had had a spinal anesthetic, and we needed to wait for that to wear off, but she had avoided major surgery. At other points in my career, because of my experience with breech birth, colleagues have called me. I would get a phone call. Are you around? I've got a lady with a breach in labour. I remember being called to theatre once, coming in to help a colleague, going into the theatre and seeing a foot, a foot protruding from the vagina. Now, a foot in the vagina does not mean a footling breach. People worry about a footling breach coming feet first because it's more common to have a cord prolapse if the baby's feet are coming first, because there isn't a nice bottom or head blocking the cervix and preventing the cord from coming down and distressing the baby. So people worry a bit when it's a foot, but actually, a foot is part of the way that a flexed breech baby may birth. You may get what's called a dropped foot. So one foot and leg are coming down the vagina first. So I went into theatre and saw a foot, examined the woman, the bottom was coming nicely behind the foot, so it wasn't a footling breach, it was a flexed breach, and I took over the birth. A lot of breach birth is about gaining confidence and trust with that woman. So the first person that sees that woman when she comes in and it's discovered that her baby's bottom down can massively influence how that woman feels about that birth and what she decides to do. So I said to her, the baby's bottom is really low in your pelvis. Um, I can already see the foot, and let's go with what your body's doing because actually, to do a cesarean could be more complicated and more difficult in this situation. And I remember as the foot came. Down that this baby had the chubbiest leg, and as the leg started to appear, I remember feeling a little bit glug. What have I done here? This looks like quite a sizable leg. Bear in mind if a woman hasn't been picked up as having her baby bottom down antenatally, we won't have had a scan that tells us a bit about the baby's size. So I can feel her tummy and think roughly what I think size-wise, but the sight of this really quite chubby leg descending made me think, ooh, this baby is of considerable size. But actually, she was progressing well. The baby was descending, she was pushing brilliantly, and we did a very straightforward breach birth, and the baby turned out to be four kilograms, and I still think that is the biggest baby I have ever helped birth vaginally in the breach position, and the woman was completely thrilled, absolutely thrilled. So breach bottom down birth can be very straightforward. One of our midwifery assistants at Kingston is famous for having helped a woman give birth to a breach baby on the bench outside the maternity unit. It was so fast. So we do make a big issue out of something that could potentially be straightforward. If we're thinking about vaginal breach birth, what are the important things? There was a time when obstetricians used to suggest epidural just in case. Epidural for good pain relief, in case we needed to manipulate and help the baby out. Well, actually, epidural is not great because you really need the woman to feel what she's doing. And spinal that is the last possible thing you want. So a spinal anesthetic, if you've given a spinal to do a cesarean and the baby actually is delivering vaginally, spinal is a bit of a nightmare because you definitely need her to push effectively, and you just can't with a spinal, it's such a dense regional anesthetic block. What about birth position? When I was training, we always did breach birth in lithotomy position, and four years ago I went to the Royal College of Obstetricians and Gynecologists World Congress, and I heard Frank Lewin from Frankfurt speak about what's now called physiological breach birth. Physiological breach birth is about birthing a bottom-down baby in an upright position, so with the mother usually on her knees or in a kind of all fours position, so leaning over the back of the bed. And he gave the most amazing talk and showed the most incredible videos. And he turned my thinking about bottom-down breach vaginal births literally on its head. Because I'd never seen anyone do it that way before. And what he described and the videos he showed made complete sense. And it became very exciting to me the idea of helping a woman birth like that. But how to start? It's very difficult if you've always done something one way, so you've spent twenty odd years helping women give birth on their backs to change. Because to change, you need experience, and I knew I could help a woman birth a breech baby if I had her on her back with her legs in stirrups, and I knew the manoeuvres that I could do, and I knew I could put forceps on the baby's head if necessary, and I knew I could do that safely because I've done it many times before. So although I saw this incredibly exciting presentation and I was really interested, one cannot just suddenly change what we're doing. Change to a completely different way of doing things. Some midwives in the UK are working with the team in Frankfurt and other places across Europe to look at physiological breach birth. And there's a little revolution going on in Breach Birth at the moment as a result. I've put a link in the programme notes to both the publication from Frankfurt into their outcomes with Breachbirth in this new novel upright position, and also to breechbirth.org.uk run by fantastic Sean Walker. And I would really suggest that you have a look at breechbirth.org.uk and watch some videos. Luckily for me, there was support at work to have a physiological breachbirth study day. And I also attended some training that Sean gave at a conference, and where I work, there are a couple of midwives who are very experienced in physiological breach birth. So to improve my skills, I started just taking the opportunity when there was a breach birth in progress, being supervised and supported by one of these midwives, I would stay behind. I would make myself available, I would just sit quietly in the room with the midwife, with the woman, with her permission, and just watch and observe. And I did that for several births, and they were awesome. I think that's the best word I can use. The magic of a really good vaginal breach birth with the mother working with her body in a beautifully calm environment with an experienced practitioner who really understands the mechanisms of what is happening, when to intervene and when not was amazing. And I was in awe of the women giving birth in this way, but also as much in awe of the incredible skill and support of the midwife. Having seen a few, witnessed some births like this, and having attended the training and having watched videos, I had a woman come in in preterm labour with a bottom-down baby, and I felt sufficiently confident that I could help her birth in this way. It was like something had shifted in my brain, so that now the way I saw breach birth was with the woman in that position, with the baby's abdomen facing towards me, and I didn't any longer instinctively feel the need for her to be in lithotomy position with the baby's back towards me. And I undertook to support the woman and help her birth with a couple of midwifery colleagues, and there was a brief moment in the middle of the birth when I knew I needed to make a small intervention just to help release the baby's head. And as I stepped forward to do it, I heard a voice over my shoulder, and it was that midwife, the skilled breech midwife, who'd snuck into the room unknown to me, and was there by my side, supporting me as much as supporting that woman, and prompting me to do the thing that yes, I was just about to do. So, although I've always been comfortable with breech birth, unlike some of my colleagues who really feel no cesarean is the way they would prefer, I've I've had a shift in the way I would approach it, which is fantastic. And I think how we feel about breach birth as individuals, colour how we talk to women. So when I run my ECV clinic, my turning clinic, I'm able to talk to women about the option of vaginal breach birth and the option of cesarean section so that they have a balanced view and they can make a well-informed choice about what is right for them. And I wouldn't advocate that vaginal breach birth is for everybody. Equally, I wouldn't advocate that cesarean section is right for everybody. Caesarean of a baby that is bottom down and the woman's in labour can be tricky, can be complicated for both mother and baby. And it can be that working with a woman's body and the way the baby is going is actually better all round. So there's a spectrum of practice with breech babies, bottom-down babies. There's a lot to think about. The thing that makes me sad is when I think a woman hasn't been correctly informed or correctly given a choice or correctly counselled. Perhaps correct isn't quite the right word. So it makes me sad when a woman is frightened into a cesarean section. If I see documented in a woman's notes that they've talked about vaginal breach and then the next thing they've written is head entrapment. That makes me furious. So much so that I wondered where it's coming from. Head entrapment is extremely rare. It's more common in a preterm breach birth, where the body and limbs can descend through an undilated cervix and the head is trapped behind the cervix. So if you imagine a preterm baby, the body can be quite skinny and the head proportionately bigger. So the body can descend through a partially dilated cervix and the head is held back up in the womb. That is head entrapment, not the head coming out more slowly at birth from the vagina. Head entrapment is the head stuck behind an undilated cervix. And the treatment for that is to cut the cervix to release the baby's head. Because I was thinking about where this information is coming from, I recently undertook the Royal College of Obstetricians and Gynecologists e-learning package on vaginal breach. And in there it does talk about incising the cervix and also symphysiotomy, that's where you divide the pelvic bone at the front of the pelvis. Both of these procedures are designed to release the baby if it's stuck. But both procedures are procedures I have never had to do in 26 years of obstetric practice. Not only that, they're both procedures that I don't think I've heard anyone else do in 26 years of obstetric practice. The e-learning package also talks about undiagnosed hydrocephalus, which is something not found in developed countries these days. Undiagnosed, that means we haven't picked it up on ultrasound scan. As everybody now has routine ultrasound scans, that just doesn't happen. So are we too hung up on the past issues where breach presentation bottom down may have been an indication something was wrong with the baby? That was true in the past, but it isn't true now. So why are we still frightening women talking to them about head entrapment and instrumental birth and poor outcomes for vaginal breach birth when actually we know that the evidence is not as clear cut and that the complications we're talking about are extremely rare. Let's now think a little bit about the zesty bit. If you're a midwife or obstetrician, do not fear a breach baby because of your lack of confidence or competence. We've put ourselves in a situation where young doctors and midwives have lost confidence in their ability to help women birth their babies. I'm lucky I trained pre Hannah, and I have a responsibility to train others. Pass on those skills. Learn new ones. Yes, of course it's right to have a healthy respect for breach vaginal birth, but that's true for any birth. Any birth can have complications and needs a skilled practitioner. Vaginal breach birth is no different. It's our responsibility to equip ourselves and understand the mechanisms and get those experienced staff to support us so that we can get more experienced staff. Increase the pool of staff who feel competent and confident. Don't let your own fear sway the way you talk to women about breach birth. Be open and honest about your limitations. If you don't feel able to talk to a woman, then get her to talk to someone who does have the right knowledge and skills and experience. Suggest ECV in the first instance, it's very safe and effective. But if that's not an option or is unsuccessful, make sure you give the right information about vaginal breach birth and caesarean section. If you're pregnant and listening to this and your baby is bottom down, understand your options. We do recommend trying to turn your baby. But also have a look at the Spinning Babies website in the programme notes and see what you can do to try and help your baby to turn. Watch some videos on the breach birth website. Understand your body. Know the facts and understand what your options are. Vaginal breach birth is not something to be scared of, but something we can support you with. And if you choose a cesarean, that's okay too. And know that women that have a cesarean because their baby is bottom down have a very good chance of vaginal birth in the future. All these options are open to you. Don't be afraid, don't be upset, don't feel negative about the fact your baby is bottom down. We are here to support you and look after you just the same as if it was the other way up. So I do hope you've enjoyed listening to the Obspod. If you have, do like, subscribe or leave a review and join me again to explore more about the life of an NHS obstetrician. I'm finding it really exciting to have people listening and give me feedback about what they've found interesting. So please do recommend the Obspod to other friends, colleagues, or people who you think might find it interesting. I'd love it if you'd share with me what you've enjoyed about listening and if you've done anything differently as a result. I can be found on Twitter at FWMaternity and at the Obspod. And please do check the Matexp hashtag, hashtag M A T E X P and the website matexp.org.uk for more information and ideas on how to improve women's experience of maternity care. Finally, I'd like to reassure you that I take confidentiality very seriously, and although I'm talking about experiences from my working life, I'm taking great pains to make sure that I anonymise the stories and talk in more general terms so that I keep confidentiality of my women I currently care for and have cared for in the past very safe. Many thanks for listening.