Breech birth team work

Introducing more support for planned breech birth in your hospital setting? This post is for you.

The management of breech presentation is undergoing an important transition. In the past twenty years, we’ve gone from:

  1. Management according to the preferences of individual consultants and/or units, tending increasingly toward caesarean section
  2. Blanket caesarean section policy following the publication of the Term Breech Trial
  3. A recognition in more recent guidelines that vaginal breech birth should remain an option for women
  4. Increasing demand from women for more choice and involvement in decision-making around how they birth their breech babies

As a result, health care providers are needing to re-skill in the facilitation of breech birth, and in a way which matches women’s expectations. This requires introducing entirely new skills to manage breech births when the mother is upright and active, as women who choose to birth vaginally usually expect to be.

But transitions can be de-stabilising. Doing things ‘as they are always done’ provides some protection because team members are familiar with their roles. Each professional knows her/his place on the team. They are familiar with the range of events that might happen in this scenario, and they know by repetitive practice exactly how they will need to communicate and respond. The emergency caesarean section for the undiagnosed breech discovered at 9 cm – the team has been here before many times, and swings comfortably into action.

In contrast, a planned breech birth is novel territory. This is even more the case if the woman has planned to be upright and active, as many teams will have rehearsed emergency breech drills with the mannequin in a lithotomy position (legs in stirrups). Therefore, teams supporting this choice will need to employ different strategies to ensure effective teamwork around the time of birth.

Identify your breech birth dream team

(These suggestions apply to a planned breech birth which occurs in a hospital setting, particularly one where a planned breech service is being introduced.)Breech Dream Team

Ideally, the entire second stage and the birth of this breech baby will be primarily supported by three people. These three should be familiar with and aligned with the woman’s birth plan and each other, as any task or relational conflict will compromise decision-making ability (de Wit et al 2013, Puck & Pregernig 2014). They should each have a clear understanding of what their role in the team will be, and they should have rehearsed together the management of some common emergencies. They should have clear eye contact with each other throughout the birth, in order to confirm in an unobtrusive way the on-going evaluation that the birth is going well, or to prepare each other for the possibility that it might not be.

Each team member has a different primary responsibility:

1)   Management – This person is primarily responsible for facilitating the birth, and may be an experienced midwife or an obstetrician. Ideally, this person will be known to the woman and have experience with breech birth in general (and the type of birth the woman has requested). The birth facilitator will be intimately familiar with the woman and her wishes, as well as the mechanics of breech birth, how to anticipate possible problems, and how to assist when required. They are responsible for co-ordinating care and preparing the rest of the team to assist when required.

2)   Support – This person, usually a senior midwife, is responsible for taking over monitoring of the woman’s and baby’s well-being throughout the second stage, frequently relaying this information to the rest of the team and reassuring the woman. Positioned beside the woman, they are an important communication bridge, especially when the woman is in a kneeling position, facing away from the person managing the birth. In this position, the support professional is also placed to assist with applying suprapubic pressure and/or change of maternal position.

3)   Perspective – This person is responsible for documenting the birth and providing a second evaluation of progress. This role requires breech experience because in order to document appropriately and accurately, the person needs to understand what they are seeing. Similarly, in order to assist with the evaluation of progress, this person needs to be familiar with normal progress in a breech birth. Because of their perspective, this person is also an important communication bridge with the rest of the team outside the door (eg calling for further help, alerting paediatricians to possible complications, etc.), and may alert the managing professional to potential problems. Therefore, this role is often taken by the most experienced person in the room, such as the obstetrician or the experienced midwife who is supporting another midwife to develop her skills.

The triangle: nature’s most powerful structure

Most normal births are attended by two midwives, and this is more than adequate. But a breech birth is not an everyday occurrence. Documentation will need to be of a gold star standard. Yet in most hospitals, each person in the room will still be developing their skills with breech and will therefore need to concentrate on the task at hand, making attendance to paperwork tricky. It is also easy to become enthralled with the beauty of an unfolding breech birth.Team Triangle

Therefore, supporting breech births with a primary team of three strengthens a situation made vulnerable by its novelty. A triangle is one of nature’s strongest structures; this mini-team is strengthened, given a base by the addition of perspective. Given the importance of documentation in any higher-risk birth, triangulation of data (eg strengthening the accuracy by using different sources) also makes practical sense. The triangulated team increases everyone’s safety in a novel situation.

Interestingly, many women instinctively form their own triangles, involving two supporters. The third person in this triangle also provides additional support, strength and perspective for both her and her partner.

Continuity: the way forward

Continuity of carer – ensuring a woman knows the professional who will be facilitating her birth, and ideally the entire team – has known, evidenced benefits. Fewer interventions, greater satisfaction. Knowing who else will be in the room, and what their role will be, will also help the woman to feel more relaxed and reassured about the upcoming birth.

Continuity has benefits for providers as well, especially when it comes to facilitating non-standard care. A number of sources have suggested on-call teams for breech births as the way forward (Kotaska 2009Daviss et al 2010) and on-call midwives are a middle ground. Especially when experience is minimal, preparation is key. Where an on-call team is not available, the entire team who will be attending the birth should be identified when the woman is admitted to hospital, and again at handover if appropriate. This team should have a thorough discussion about roles and responsibilities, and a run-through of the ‘fire drill’ if things do not go as planned, well before second stage requires the additional team members to attend.

The team should meet afterwards to review the birth and identify if any group work issues have been identified that can be improved for future births. This review should involve the obstetric labour lead, a midwifery manager and/or risk management midwife if the breech service is new to the maternity team. A reflective approach in the early stages will pay off in increased safety and a more confident, united team in the long run.

Further information and inspiration for your dream team

Teamwork is crucial to the safety of breech births. Michael West has written extensively about the characteristics of ‘real teams,’ as opposed to ‘pseudo teams.’ Real teams have clear, shared team objectives; role interdependence and role clarity; and they meet regularly to review and improve performance (West, 2014). If we are to successfully change the culture of breech birth, and support women as safely as possible as we develop our skills and experience, we must function as real teams.

West, M.A., & Lyubovnikova, J. (2013). Illusions of Team Working in Health Care. Journal of Health Organization and Management, 27(1), 134-142. (more from West)

You may also be interested in this article: Plested M, Walker S. Building confident ways of working around higher risk birth choices. Essentially MIDIRS 5(9)13-16.

How have you prepared your teams to support planned breech births?

Shawn

6 thoughts on “Breech birth team work

  1. Denise Hynd

    Please can you add some discussion/consideration of how to enhance the labour hormones for Babies coming Breech so the Fetus Ejection Reflex is driving these births?? Perhaps Mary Cronk or others (eg Michel Odent) could write about this??

    Reply
    1. midwifeshawn

      Good morning, Denise. This is the place for discussion & I’m always interested in anything Mary Cronk or Michel Odent has to say. Betty-Anne Daviss, a midwife with many years experience facilitating home births as well as introducing physiological breech births to a hospital setting, is addressing the intricacies of bringing the benefits of home births into hospital settings at the upcoming Midwifery Today Conference (http://www.midwiferytoday.com/conferences/UK2014/) .. I hope to learn more from her there.

      From my point of view, thoughtful team work contributes to an oxytocin-enhancing environment. Knowing who is responsible for what means no one is walking in during that crucial expulsive stage asking, “What do you need me to do?” .. breaking everyone’s concentration on the task at hand. Team members who feel confident about their role and their own support system will also have lower levels of adrenalin to pass on to the labouring woman. Identifying exactly who will be in the room ahead of time means they do not have to introduce themselves at a crucial moment, and sends the message to other staff that it will not be okay to knock on the door and ask to watch as the baby is being born.

      Maintaining good eye contact means team members can collaborate on the assessment of progress without having to say out loud, “I’m not sure this is going well, what do you think?” .. or ring the bell for further assistance from people who may be strangers to the woman. When all goes well, three people seems unnecessary .. and the extra two can slip quietly out of the room as soon as the baby is crying, reassuring the paediatrician waiting outside the door as they pass. But when things are not straightforward, decision-making around when to be hands-on in a planned hands-off birth is a remarkably tricky skill to acquire. When I have been providing ‘prospective,’ I have needed to encourage others that intervention is required, now .. because it is all too easy to think that things will resolve with the next contraction and lose precious minutes which may compromise the baby. When I have been providing ‘management,’ I have needed both encouragement & reassurance from the person providing ‘perspective.’ Sometimes it is the encouragement that yes, indeed, we need to move (giving me the courage to perform manoeuvres decisively); sometimes it is reassurance that progress has been good enough .. we can relax and go with this as long as baby continues to do well.

      The person providing ‘support’ cannot provide ‘perspective’ from their position alongside the woman. And when the woman is facing away from you (as in an all fours birth), the person providing ‘management’ has to move away from their baby-receiving position in order to monitor mother and baby; the extra ‘support’ means the person facilitating the birth can concentrate on the birth. (Midwives do this for obstetricians all the time, but sometimes roles can get confused when midwives are undertaking the ‘management’ role.)

      Introducing more people into the room has the potential to inhibit the fetal ejection reflex by making the woman feel more observed, and Michel has written extensively about this. However, the right combination of people may foster a feeling of safety which actually enhances the flow of oxytocin. She is, after all, choosing to have a hospital birth for her breech baby, due to the increased potential for complications. If the team is in alignment – with her and with ourselves – we will be more likely to provide the physical and emotional safety she requires.

      Shawn

      Reply
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