Shawn talks about some of the challenges of improving the way we deliver care for mothers and their breech babies.
Yesterday was International Day of the Midwife. I saw but didn’t participate in the social media celebrations. Not because I wasn’t feeling it, but because my clinical academic midwife life was full to the brim. 931 more words
Continuous cyclic pushing is a non-invasive tool for expediating breech births with minimal hands-on intervention, or for confirming in a timely manner that further intervention is required to achieve a safe outcome.
Shawn Walker, RM PhD, King’s College London and Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex Hospital
Sabrina Das, MB ChB, MRCOG, Imperial College Healthcare NHS Foundation Trust, Queen Charlottes & Chelsea Hospital
Emma Spillane, RM MSc, Kingston Hospital NHS Foundation Trust
Amy Meadowcroft, RM, Northern Care Alliance NHS Foundation Trust
In the United Kingdom (UK) National Health Service (NHS), we have been working towards a collaborative, multi-disciplinary trial for breech presentation at term. Our complex intervention*, based on physiological breech birth practice tailored for a hospital-based care pathway, is called OptiBreech Care. In the OptiBreech Care Trial (IRAS 303028, ISRCTN 14521381) feasibility study, vaginal breech births are facilitated using physiological breech birth approach. This approach has been developed through prior research and testing of strategies described by others, 1–4 including midwives practising in out-of-hospital settings. As a result, it differs from assisted delivery techniques most hospital-based clinicians are familiar with. This creates a need to clearly articulate each component for effective implementation in practice. The purpose of this article is to articulate the theory and practice of one element of our complex intervention that we consider essential to the method: continuous cyclic pushing. Although different from most clinicians’ habit of ‘waiting for the next contraction,’ continuous cyclic pushing can easily be incorporated into assisted breech delivery practice.
* In clinical trials, an ‘intervention’ is the thing you do differently to try to change the outcome. Complex interventions contain more than one component, and the effect is thought to be the sum of the parts. OptiBreech Care is a care pathway intervention – a new care pathway for women and others whose babies are breech at the end of pregnancy.
Physiological Breech Birth
In a 2012 article, UK midwife Jane Evans described an approach to supporting spontaneous vaginal breech births as ‘physiological breech birth.’5 This approach centres on the normal mechanisms and movements of both mother and baby, in contrast to assisted breech delivery, where the birth attendant routinely manoeuvres the baby. Upright maternal birthing positions, such as kneeling, are frequently used, in contrast to routinely directing women to assume a supine position. Evans described how a normal breech birth exhibits ‘steady progress with each contraction.’5(p20) She also described how mothers move in response to the movements a healthy baby makes, especially the ‘tummy crunch’6(p48) or full body recoil flexion.3 Evans, who practiced for decades as an independent midwife, also observed that such a normal breech birth was ‘now hard to replicate within the UK’s National Health Service (NHS).’
In the OptiBreech Trial, we are trying to do just this: introduce a physiological breech birth approach into NHS practice settings, particularly obstetric units, and evaluate the outcomes. This has several potential advantages, including greater equity of access for more women, immediate access to the multi-disciplinary team (MDT) during birth, and shared learning throughout the MDT, with the potential to influence cultural changes.
But approaches to care (known as ‘complex interventions’ in the context of a trial) do not always work the same way in different settings. For example, physiological birth processes seem to work more efficiently the further one gets from an obstetric unit.7–10 Women who use NHS services have a much wider range of needs, complexities, birth philosophies and preparation levels than women who employ independent midwives. And greater involvement of the MDT means the physiological breech birth approach intersects with, and may conflict with, other cultural norms and practices. This may make it harder to implement some of its components, and potential conflucts may introduce additional risks.
Therefore, when testing a complex intervention in a trial, there is a need to clearly articulate each of the main components.11,12 This helps ensure those implementing the package of care know exactly what they are implementing. It also enables us to evaluate whether each aspect has been implemented as planned. We have observed that, although relatively simple itself, the concept of continuous cyclic pushing conflicts with current embedded cultural norms and assumptions about vaginal breech birth in many settings. An improvement in outcomes is likely to require a change in approach, but change can create uncomfortable feelings as teams deal with uncertainty in attempting a new approach.13,14 We hope to make the process of implementing continuous cyclic pushing, as a tool to support physiological breech birth, easier and safer by articulating the rationale and making visible some of the conflicting assumptions.
Description of the Technique
Continuous cyclic pushing: what it is and when it is used
Consistent with the Royal College of Obstetricians and Gynecologists’ guideline,21 we do not encourage active pushing until the breech is visible on the perineum, although we do not interfere with spontaneous maternal effort. This permits maximum recovery and fetal oxygenation between contractions. Continuous cyclic pushing begins when the birth attendant encourages the woman to push following the birth of the fetal pelvis. ‘Continuous’ refers to its use both during and between contractions until the birth is complete. ‘Cyclic’ refers to alternation between pushing effort and brief pauses for rest and breathing, resuming effort again when the woman is ready, regardless of whether a contraction is present. Following the birth of the pelvis, due to the high likelihood of cord compression, a significant pause between contractions is counter-productive for preserving fetal well-being.
We are aiming to complete the birth within the intervals recommended in the Physiological Breech Birth Algorithm: within 7 minutes of rumping (+3 station), within 3 minutes of the birth of the umbilicus.3,15 Attendants support women through continuous cyclic pushing with language such as: “Well done. Now take a few deep breaths. Your baby is almost here. [brief pause for the deep breaths] And when you are ready, just collect your strength and push again.” In this way, it more closely resembles spontaneous pushing, in which women generally push three to five times per contraction, rather than directed pushing, in which women are instructed to take a deep breath at the beginning of the contraction and then hold it and bear down throughout the contraction.16
Once the fetal pelvis has passed completely through the perineum, there is often a short pause, much like there is with a head. The woman feels a release of pressure and sense of relief. She may stop pushing and take a few deep breaths, over a period of about 20 seconds. In an ideal physiological breech birth, the woman will have received no direction about pushing5 and will be completely tuned into her body, usually in a forward-leaning kneeling position. Following this natural pause, some women will continue to feel pressure and an urge to push, and they will simply collect their breath and do that when they are ready. If this doesn’t happen, the next contraction will occur within about a minute from the end of the previous contraction. Consistent with the available evidence,3,15 this process will be complete in an average (median) of about a minute and a half, and in most cases under three minutes, with no assistance required. The combination of maternal effort, movement and gravity is sufficient.
There are many examples of situations that deviate from the ‘ideal’ physiological breech birth described above. Being in tune with one’s body in labour and being supported to give birth without any directed pushing is very difficult to achieve in the hospital environment. It is routine practice in many hospitals to put women into lithotomy (supine, legs in stirrups) for a vaginal breech birth. Or she may have chosen an epidural, which will affect the Ferguson’s or fetal ejection reflex, even if it is a mobile epidural. Sometimes, there are concerns about the baby arising late in labour, such as the presence of late decelerations or a rising baseline on fetal heart auscultation, where one would not want the birth to take any longer than absolutely necessary. Intervals between contractions can also be longer than optimal, for example if the woman is exhausted in second stage or from the stress of undertaking an unplanned breech vaginal birth. Even well-meaning directions from the birth team can detract from the physiological birth process: “Now relax. Just breathe. And wait for the next contraction.” The woman’s attention is now focused on the attendant’s directions, away from the pressures and promptings of her own body, as she gains mastery over any spontaneous urge she may have, believing this is essential for her baby’s safety.
Many of us supporting physiological breech births within NHS settings have used continuous cyclic pushing in practice when we have observed the situation to be less than ideal for a completely physiological breech birth, for any of these reasons. And we have observed that, where there is no entrapment of arms or head, continuous cyclic pushing effects continuous progress. With the next episode of maternal effort, rotation begins and the legs are born, with the next effort the arms are born, etc. The head usually requires more than one episode of maternal effort, but with less time between. This similar to the ‘little pushes’ a midwife may coach a woman through as the head is being born in a cephalic birth, or the birth of the shoulders between contractions, guidance intended to optimise the perineal outcome. In either type of birth, when there is no entrapment, the process is not strenuous; it is simply effective. Furthermore, it is effective regardless of the woman’s birthing posture, but when upright, prompted maternal movement also assists descent and rotation, eg. ‘give it a wiggle’.
How does continuous cyclic pushing help us to identify complications early?
In contrast, strenuous effort and minimal or no progress is indicative of need for manual assistance. Consider the following scenario: the pelvis is born sacrum transverse as we would expect. Between contractions, the woman has no spontaneous urge to push. With the next contraction, a few centimetres of descent are observed, so that the baby’s knees are now born. No rotation has occurred. This repeats with the next contraction, two minutes later. With quite a bit of encouragement and effort during the contraction, the feet are finally born, about four minutes after the pelvis. The baby has still not rotated. The team await the next contraction, two minutes later. No descent occurs, and it is now very clear that the birth is complicated by a nuchal arm entrapment. Resolution of the entrapment is difficult because the baby has descended deeply into the pelvis with the arm extended, with less room and more resistance when rotational manoeuvres are attempted. The process takes three minutes. And then assistance is needed for the head. It is easy to see how the minutes add up, even when contractions continue to come regularly. And sometimes they do not.
Our observation is that, by encouraging continuous cyclic pushing, we can observe the signs of obstruction earlier, enabling us to intervene more quickly and effectively. In the above scenario, following the brief pause that occurs after the birth of the pelvis, if the woman does not resume movement and effort spontaneously within about 30 seconds, the attendant would gently encourage it (‘wiggle and push’). If pushing were strenuous and progress minimal, especially with no rotation, we would assume this was due to obstruction and deliver the fetal legs. We would again encourage the woman to collect her breath, and to ‘wiggle and push.’ If the next episode of strenuous effort did not result in the birth of the arms, we would assist this with rotational and other manoeuvres. And so on.
Potential conflicts with current practices
Applying cephalic birth ‘habits’ to breech births?
Each of us has seen in practice and in clinical reviews of adverse outcomes a tendency to instruct the woman to breathe and wait for the next contraction after delivery of the pelvis or arms. We consider that professionals may be doing what they would do in a cephalic birth. Following delivery of the head, there is (sometimes) a pause until the next contraction that delivers the body. During this time, reassurance is often given to the woman that she has done well and that with the next contraction she will have her baby.
A similar confusion may present itself when we observe ‘rumping’ to occur. Clinicians may think it normal to observe the presenting part for some time prior to the birth as this is what we may observe in a cephalic birth with no detriment to the fetus. But in a cephalic birth, only the head is in the pelvis. Due to the different mechanisms of a breech birth, once both buttocks remain on the perineum between contractions, the umbilicus is in the pelvis along with both the body and the legs. This increases the likelihood of cord occlusion and progressive acidosis if delay is not recognised and action taken. It is also very difficult to accurately assess the fetal heart rate with external monitoring when the pelvis and body are this deeply engaged.
Historical use of ‘wait for the next contraction’ as a breech-specific strategy
Very few trials have been done comparing different approaches to managing vaginal breech births. But in 1989, Arulkumaran et al published a trial in which they compared two techniques. In Group A (expediated breech delivery), “During one contraction and bearing down efforts, spontaneous expulsion of the buttocks were allowed up to the hip of the fetus so as not to deliver the umbilicus. Then the patient was requested to relax till the onset of the next contraction with the aim of delivering the whole fetus with the subsequent contraction.”17(p48) Group B was similar, but women were allowed to deliver the baby up to the shoulders, and a loop of cord was pulled down. The design of the trial was based on the assumption that fetal oxygenation is considered to be potentially impaired once the umbilicus is delivered, due to umbilical cord compression.18 Women gave birth in supine positions. The trial results were inconclusive. But ‘wait for the next contraction’ was part of a routinely interventive approach to managing a breech birth, contrasting with Evans’ repeated calls for “no directive pushing”5(p18) in physiological breech births.
Power from above is safer than pulling from below
The fundamental purpose of skill and technique with vaginal breech birth is to prevent progressive acidosis as much as possible, while avoiding the potential trauma of a quick or overly-manipulated delivery. To this end, the theme that power from above is safer than pulling from below repeats frequently in literature related to upright breech birth,19 the physiological breech birth approach,2 as well as many guidelines. The current Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on Management of Breech Presentation at Term explains, “Techniques to maximize power from above include effective maternal effort, hands and knees posture, the Bracht manoeuvre, and oxytocin augmentation.”20(p1201) Again, we need to consider the effects of context with regards to which sources of power from above we can effectively employ.
The Royal College of Obstetricians and Gynaecologists guideline does propose the use of the Bracht manoeuvre as an alternative,21 but this requires the woman to give birth on her back, which, when assisted by physiological breech birth-trained professionals, over three quarters of women do not do.22 To perform the manoeuvre, the attendant raises the legs and trunk of the baby over the mother’s pubic symphysis and abdomen, using an upwards movement without traction to achieve delivery of arms and fetal head. Of the Bracht manoeuvre, Professor Peter Dunn described, “[I]n this method, the obstetrician does little more than gravity would have achieved, had the woman been allowed to deliver in the natural upright position.”23(pF77) As UK midwives and obstetricians are not routinely trained in the safe use of the Bracht manoeuvre, we prefer to simply allow women to deliver in the upright position when they want to. And we supplement this with continuous cyclic pushing if appropriate.
In 2017, Louwen et al19 described 229 successful upright breech births in Frankfurt, where women gave birth in upright maternal birthing positions, usually hands and knees. The team provided a detailed description of their approach. To achieve power from above rather than below, they explained, “We rely on the mother’s contractions, but sometimes proceed to the use of oxytocin, and fundal pressure (the Kristeller manoeuvre)”19(psupp) (indications not given). While Louwen’s team’s work provides a precedent and example for upright breech hospital-based practice, this cannot directly translate to UK-based practice, in which the Kristeller manoeuvre is not routinely used, nor to the context of the OptiBreech Trial, in which most physiological breech births are led by midwives unless recourse to instrumental or surgical delivery is required. While the OptiBreech team members work closely with the MDT, oxytocin is not routinely prescribed for the purposes of increasing frequency and power of contractions around the time of birth. We cannot assume that without the total package of tools, or a replacement, we can achieve the same results.
Continuous cyclic pushing is a core skill taught in the Breech Birth Network’s Physiological Breech Birth training course. This is the only training programme focused on vaginal breech birth that has been evaluated including outcome data for actual breech births.22 Among 21 vaginal breech births attended by professionals who completed the training in 6 NHS hospitals, there were no severe adverse neonatal or maternal outcomes (using the composite definition used in the Term Breech Trial24), compared to a background rate of 7% among other breech births in the same hospitals, attended by professionals who did not complete the training. Additionally, among those 21 births, 11/21 (52%) of women had intact perinea.
We might compare this to available evidence concerning more invasive means of preventing delayed descent in a vaginal breech birth: oxytocin infusion and fundal pressure. Although both of these interventions are considered acceptable in different contexts,19,20 there is evidence that injudicious just could cause harm. Secondary analysis of the Term Breech Trial data indicated that the use of oxytocin augmentation increases risks in vaginal breech births.26 Concerns have also been raised about the risks associated with fundal pressure, especially when excessive force is used, including increased cervical and perineal tears, neonatal injuries and maternal dissatisfaction with care.27,28 While there may still be a place for the use of these interventions by experts, there is a need for high-quality evidence of their benefit before recommending them to the general population of practitioners in guidelines. When upskilling professionals who have had minimal exposure to and experience with vaginal breech birth, we prefer to start with less invasive interventions that are unlikely to cause harm and likely to be more acceptable to women who wish to have active births, in which they feel like a primary agent.
As clinicians regularly attending vaginal breech births in NHS hospitals, we are satisfied that continuous cyclic pushing produces clear effects with none of the risks associated with preventable delay, if the next contraction is slow in arrival, or hands-on interventions applied before we have confirmed they are necessary.
In our approach, we rely heavily on maternal movement (enabled by upright postural positions), maternal effort, fetal effort (full body recoil flexion)2,3 and gravity to optimise the likelihood of an unassisted vaginal breech birth. Where the team considers it beneficial to minimise the time required for the baby to emerge, for any reason, the first intervention is always to encourage maternal movement and effort (‘wiggle and push’). This is recorded and evaluated as a fidelity measure in the OptiBreech Trial. With this approach, we recognise the locus of greatest efficacy lies within the mother-baby unit,2 and this is the first source of power we draw upon when a safe outcome appears to be at risk for any reason.
We therefore consider continuous cyclic pushing is an important tool for expediating the birth with minimal hands-on intervention, or for confirming in a timely manner that further intervention is required to achieve a safe outcome. We cannot yet make any claims that use of continuous cyclic pushing does or will increase the safety of vaginal breech births. But we hope by clearly described the practice itself, its rationale, and its relationship to alternative courses of action used in other settings, others may consider and evaluate its usefulness in their own practice.
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27. Hofmeyr GJ, Vogel JP, Cuthbert A, Singata M. Fundal pressure during the second stage of labour. The Cochrane Database of Systematic Reviews. 2017;2017(3). doi:10.1002/14651858.CD006067.PUB3
28. Farrington E, Connolly M, Phung L, et al. The prevalence of uterine fundal pressure during the second stage of labour for women giving birth in health facilities: a systematic review and meta-analysis. Reproductive Health. 2021;18(1):1-17. doi:10.1186/S12978-021-01148-1/TABLES/6