Tuesday, December 20, 2016

Leonie van Rheenen: Free choice in birth position, change of practice…An obstetrician's point of view

First Amsterdam Breech Conference, Day 2
Leonie van Rheenen
Free choice in birth position, change of practice…
An obstetrician's point of view

One of the "mothers" of the Amsterdam Breech Conference, Leonie van Rheenen is an OB/GYN and is used to working in close collaboration with midwives. The session's announcer noted that for the first time in his life, he's seeing midwives and physicians working and learning together in close cooperation--thanks to this conference. 

Leonie convinced her physician group to shift from supine to all-fours positions in just 6 months. For change management, that’s spectacular--and all due to Leonie's leadership. Leonie and others wanted to learn more, so they initiated this breech conference.

Leonie opened her presentation by saying that her dream has come true: it’s happening and we’re all coming together at this conference. She's already thinking about the next breech conference—possible topics include the 1st stage of labor, monitoring, dilation, trapped heads, and more!

Leonie's presentation was about how an obstetrician came to learn about, accept, and start attending upright breech births. So how did it all begin? Leonie came to work at OLVG. She began as a young OB/GYN, having attended just 7 vaginal breech births during her residency (plus some breech twins and preemies). This hospital had a tradition of breech births and she needed to be able to do them on her own. It gave her some doubts.

They collected numbers on their breech patients. Women have a 60-80% chance of a successful vaginal breech in her hospital. However, most women choose a planned cesarean. Are these numbers (on average, 41 attempted and 28 successful vaginal breech births per year) enough to keep up physicians' experience? She doesn't know.

Leonie needed a mentor to help her with vaginal breech birth. She saw that people were posting clips and videos online and on social media. She saw breech births on all-fours and at home, and it was really new to her. She found out about a course in Sheffield to learn breech skills.

Leonie told a story about being on call when a primip came in labor with a breech baby. At this point she had read about upright breech births and watched YouTube videos, but had never seen one in person. All was going well with a relaxed atmosphere. The mother was standing next to the bed, moving and wiggling her pelvis. She became fully dilated and started pushing. Somewhere during the labor, Leonie asked the mom to go on the bed, and the mom said she didn’t want to. So there Leonie was with this excellent birth, everything going well. The midwife asked Leonie if she was going to ask the woman to lie down on the bed again.

She thought about it. She went through several stages as she considered whether she was okay with attending a breech birth on all fours--something she had never done before:
1. No, never, it's impossible!
2. I don’t see any advantages. Why is it better?
3. How can I learn? How can I get enough experience?
4. What if…
She started to think, There isn’t really evidence for being on your back; it’s more tradition than anything else. But how am I ever going to learn to do breeches on all fours? And on top of that, she was thinking, How can I tell this mom that I’ve never done it before and only have seen it on YouTube?!

She came up with a solution: she placed the mom upright between the stirrups so the mom could stand up and lean over. If Leonie needed to, she could sit her back down. The mom birthed the baby perfectly. She saw the baby do the tummy tuck and, thanks to YouTube videos, she knew the baby wasn’t gasping or in any danger.

Afterward outside the birth room, the birth team gave each other a big High-Five!

Her experience from attending upright breech births:
  • Don’t focus on all fours, and don’t start that position too early (especially for primips). Find out what’s best for the woman at that moment.
  • Try to find the easiest way and change labor positions.
  • Keep the same rules as in lithotomy.
  • Train your team. The first time they might be a bit disoriented, but if they’re well trained they’re not nervous and know what to expect.
  • Work on exposure/experience: by attending together, use video. Try to get permission to film and share if women are willing. If you have experience, attend with another who doesn’t have that experience. Also get residents there so they can learn.
One of the skills for breech birth is patience. For birth itself is patience!

Leonie also emphasized the importance of teamwork. In her hospital they do obstetric training every week with different teams. She suggested turning your mannequins over and training on all fours.

She showed some videos of upright breech births from her own hospital.

Leonie ended with some advice: the next time you have the opportunity to see an upright breech birth, keep these two things in mind:
  • The laboring woman knows best
  • You can do it! It’s not so difficult. Worst case, if you feel a bit lost, you can always turn her around and put her in stirrups if that’s how you’ve been trained. You have to start somewhere.

Q: I’m a midwife in the Netherlands. To gain experience with birth on all fours, are you enabling this more for women with head-down babies too at your hospital?
A: Yes, I think so we do. However, I don’t personally attend a lot of spontaneous cephalic births; once I get in there, something’s wrong. We’ve invested in wireless monitoring, which makes it much easier for women to move around. We have birthing balls and a birth pool. We have a lot of midwives working in our ward, so that helps get women out of bed. We're trying to teach our residents as well.

Q: This is not a criticism, more of a comment. We do use wireless CFM but never use a scalp clip because it hurts a baby. What is the prevalence of a Morrow reflex with the clips? My experience with breech birth is that you do pick up the fetal heart very well abdominally even on all fours. They’re a no-no in our trust.
A: I don’t think clips hurt that much. A lot of women don’t want the clip on the baby for the same reason: that it hurts. In the pushing phase, the baby is so deep in the pelvis, we lose the fetal heart rate. That’s when the team starts worrying and wants to intervene. However, if we know that all is going well with the baby, it’s easier for us to keep our hands behind our back.

Interested in Leonie's work? You can follow her on Twitter.


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