{"id":39918,"date":"2023-02-10T10:39:36","date_gmt":"2023-02-10T10:39:36","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjgh\/?p=39918"},"modified":"2023-02-10T10:40:24","modified_gmt":"2023-02-10T10:40:24","slug":"resurrecting-a-lost-obstetric-skill-to-reduce-global-maternal-death","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjgh\/2023\/02\/10\/resurrecting-a-lost-obstetric-skill-to-reduce-global-maternal-death\/","title":{"rendered":"Resurrecting a lost obstetric skill to reduce global maternal death"},"content":{"rendered":"

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The incidence of having a baby in the bottom-down (\u201cbreech\u201d) position at the end of pregnancy is about 1 in 25.\u00a0 The \u201cTerm Breech Trial\u201d<\/a> (TBT) is a landmark randomised controlled trial that changed the management of breech birth since its publication in 2000.\u00a0 It concluded that a planned Caesarean birth is safer for the baby, with no increase in morbidity for the mother, compared to a planned vaginal breech birth.\u00a0 Despite the follow-up study<\/a> not showing any difference in longer-term (two year) outcomes, we have observed a steady decline in vaginal breech birth in high-income countries, and subsequent loss of obstetric skill.\u00a0 In the UK, about 96% of breech presenting babies are born by Caesarean.\u00a0 Vaginal breech birth has become increasingly stigmatised<\/a> as \u201cout of date\u201d and \u201cdangerous\u201d for babies and mothers.<\/p>\n

I became involved in the Optibreech Collaborative<\/a> after working in Yemen as an obstetrician in a humanitarian response in 2021.\u00a0 In Yemen and many other low-income countries, the risk of Caesarean birth<\/a> for the mother is too high to justify the small potential benefit to the baby.\u00a0 In contexts where women have a high fertility rate, and where oxytocin boluses are sometimes used in the village setting when labour is slow (or even obstructed), uterine rupture is much more common and is a major cause of maternal death. Other complications from Caesarean birth in a subsequent pregnancy include scar ectopic pregnancy, abnormal placentation and surgical risks of multiple Caesareans \u2013 all life threatening complications when high quality obstetric care is limited.<\/p>\n

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Enhanced training in physiological breech birth include manoeuvres in an upright birth position (photo copyright: Sabrina Das, consent obtained)<\/small><\/figcaption><\/figure>\n

Optibreech Care<\/a> is an innovation care package based on research:<\/p>\n

    \n
  1. Women are encouraged to adopt an upright \u201call-fours\u201d position as opposed to traditional lithotomy (the evidence shows that upright positions are associated with shorter labours and fewer interventions);<\/li>\n
  2. Birth attendants receive enhanced training in physiological breech birth;<\/li>\n
  3. Manual manoeuvres and time-based indications for interventions are used.<\/li>\n<\/ol>\n

    This is a significant departure from traditional obstetric teaching on breech births.\u00a0 Doctors are rarely taught how to assist a birth (breech or otherwise) with women in any other position apart from supine or lithotomy.\u00a0 Whilst midwives and traditional birth attendants may be more skilled in upright birth techniques, their status is lower in the hierarchy of medical practice.\u00a0 The World Health Organisation\u2019s Guideline<\/a> lists lack of a skilled birth attendant, previous Caesarean, and \u201cclinically inadequate pelvis\u201d as indications for a Caesarean birth in the context of breech presentation, which reflects a lack of skill and confidence in vaginal breech birth even in low-income settings.<\/p>\n

    It should also be noted that antenatal screening and ultrasound scanning is not universally available.\u00a0 A larger proportion of breech babies in low-income settings will have an underlying fetal anomaly.\u00a0 I performed a Caesarean section for a woman with a breech baby in South Africa and the baby actually had a lethal skeletal dysplasia, dying within a few hours of birth.\u00a0 Caesareans of this nature violate the \u201cfirst do no harm\u201d principle of non-maleficence as they have no benefit to the baby and only increase the risk of future pregnancy for the mother (in addition to any potential surgical complications in the index pregnancy).<\/p>\n

    Undoubtedly, a large motivator for the Optibreech Care Trial<\/a> is its mission to provide choice<\/a> to women with breech presentation at term.\u00a0 In ethnic-diverse London, I have treated women from Somali, Ethiopian, Pakistan, and other cultural origins where it is considered \u201cbetter\u201d to have a vaginal birth.\u00a0 \u201cI just think my body can do it\u201d, one Somali woman with breech-breech twins told me.\u00a0 She already had two babies vaginally and was concerned with the recovery from a Caesarean, potential complications, and managing with 4 children under 5.\u00a0 She beamed with joy after the spontaneous, uncomplicated birth of both babies and told me, \u201cYou were the only doctor who believed in me.\u201d<\/p>\n

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    Birthing beds with lithotomy poles in a maternity hospital in Yemen (photo copyright: Sabrina Das)<\/small><\/figcaption><\/figure>\n

    The Optibreech algorithm<\/a> and enhanced training has given my unit in London the confidence to offer safe vaginal breech birth.\u00a0 More women having vaginal breech births in turn challenges myths and resurrects this lost obstetric skill, which has the potential to save mothers\u2019 and babies\u2019 lives globally.\u00a0 Introducing upright vaginal breech methods will take an enormous cultural shift in how we think about maternity care in low-income and humanitarian settings:<\/p>\n