Category Archives: Research

How much does breech experience matter?

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Some friends of mine at the Coalition for Breech Birth (a consumer advocacy organisation) have been discussing the role of practitioner experience in reducing risk associated with vaginal breech birth. My response is a bit longer than Facebook will permit, so I’m putting it here.

The study I find most useful in this discussion is here:

Su M, McLeod L, Ross S, Willan A, Hannah WJ, Hutton E, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol. 2003 Sep;189(3):740-5. PubMed PMID: 14526305. Epub 2003/10/04. eng.

Overall, the team found very few factors associated with an increase or reduction of risk of adverse perinatal outcome. They did find a dose-reponse relationship between amount of labour and adverse outcome. In other words, a pre-labour CS seemed to afford the most benefit, followed by early labour CS. By the time you are in active labour (>3 cm), there is no longer a statistically significant difference between CS and vaginal birth. So I get particularly annoyed when this study is used to tell women who arrive in advanced labour with an undiagnosed breech that a CS is the safest option.

They also found, contrary to popular belief, that big babies (>3500g) fared no worse than more averaged weight babies, but small babies (<2800g) did. Makes sense to me. Generally but not always, babies who are very small at term may already be slightly compromised; labour may be an additional stress. On the other hand, if a chunky 9-pounder folded in half can fit both his abdomen and his legs through your pelvis, chances are his head is going to fit, especially if you are with someone who knows how to help it into an optimal position.

He also needs to fit without help, because the study also revealed that using augmentation to enhance a labour which is not progressing well enough on its own was associated with over twice the risk of labours which proceeded spontaneously. Similarly, longer second stages increased the risk, so our baby needs to be descending fairly easily in the second stage, without help, or a CS may be the better option.

But the only factor shown to reduce the risk associated with a vaginal breech birth (by over 2/3) is the presence of an experienced clinician at the birth. This person need not be a licensed obstetrician, and the years of experience did not make a difference either – the TBT team specifically looked at these factors. The risk reduction occurred only when ‘an experienced clinician was defined as a clinician who judged him or herself to be skilled at vaginal breech delivery, confirmed by the Head of Department.’ Midwives were among those included in this definition.

Although we do not (yet) have any research (get back to me in a decade or so) which looks at the results of spontaneous breech birth with experienced clinicians at term, this analysis of the TBT suggests that this scenario is significantly less risky than many of the births included in the trial which were responsible for adverse outcomes. Add to that the further benefits we are seeing emerge with upright breech (reduction in need for manoeuvres and the minor injuries these can sometimes cause), and vaginal breech birth is a realistic option for many women.

One further comment on the research: Many are frustrated because the results of retrospective observational studies overwhelmingly indicate similar outcomes for vaginal breech birth and planned CS. These have comparatively little influence on guidelines because they are considered ‘biased.’ However, understanding why they are biased is sometimes useful. Retrospective studies are most often done by experienced practitioners who feel their own results conflict with the lowest common denominator represented by a large multi-centre RCT like the TBT. They present these results to illustrate that a comparatively safe vaginal breech service is possible, despite the fact that breech is often grossly mismanaged in many areas. Retrospective studies do not necessarily represent the ‘norm.’ But they do suggest, along with the TBT’s own data, that if your provider feels confident supporting you to have a vaginal breech birth, you can probably feel pretty confident as well.

Update 2015: A meta-analysis of observational studies indicates significantly better short-term outcomes when CS is planned than when VBB is planned. However, the rate of complications following planned VBB is much less than reported in the Term Breech Trial and similar to the results when a cephalic birth is planned. Read Berhan et al 2015 by clicking the link.

Shawn

Hypnosis for childbirth: medical or social intervention?

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fundingI’m feeling slightly bemused again by the obstetric interest in whether hypnosis for childbirth has been shown to ‘work’ via randomised controlled trial (RCT), following the on-line advanced publication of another large RCT in the BJOG (Cyna et al 2013). They’ve flown straight into the hen house again, stirring up a lively Twitter debate, made more timely because the Duchess of Cambridge apparently used hypnobirthing in the successful birth of her first child.

EBM labour coping

But was she following evidence based medicine (EBM)? No, she was not. Women do not follow EBM when it comes to labour coping strategies. They follow social medicine. They look around for women who they feel are ‘like’ themselves, women who share the same philosophy towards birth as they do, women who have experienced birth in the way they hope to. They explore available coping strategies and pick a few which are in tune with the coping strategies they use outside of the microcosmic birth world. And of course, they look to their midwives on the day.

in and out of NHS

Our risk-focused maternity culture is particularly poor at sending the message to women: “Your body was designed to do this. You can do this, you are strong, and you will cope. And if you need help, it will be there.” Instead we give women the message that they will need to ‘do’ something extra in order to be able to birth normally. When it comes to pharmacological pain relief, many would rather have ‘nothing,’ and hypnosis is about as close to nothing as you can get. Apparently the data back me up.

yoga

My major problem with Cyna et al’s study is that it takes what seems to work in a social setting, e.g. a group of women who share similar beliefs and are looking for similar things out of childbirth, and a facilitator who nurtures self-belief and enhances new and familiar coping strategies over a period of time, and they medicalise it. The 3 hypnosis sessions in this study were delivered by a doctor trained in hypnosis, only 50% attended all three sessions, and some allocated to the training even chose to attend a different hypnosis training group outside of the intervention. This suggests to me that the intervention was not very appealing on a social level. Every article published seems to acknowledge that the pared down version used in an RCT isn’t quite like what is practised in today’s hypnobirthing and natal hypnotherapy classes which are so popular with women, where women receive on-going support from their classmates and instructors.

blinding and biasAdditionally, these researchers blinded health professionals involved to group allocation, a fault I have discussed the last time this debate flew up (although in the Cyna study it is difficult to imagine how health professionals remained blinded to allocation when some groups were asked to use a CD in labour and others were not). Again, my issue is with the medicalisation of a social art. Part of my job as a midwife is to facilitate an environment which supports a woman’s natural coping skills. If I do not know what coping strategies she is using, I am much less likely to get that right. Blinding in a trial like this is neither possible nor desirable.

questions

With various types of research trials turning up conflicting information, the pragmatic in me deals with this by imagining how certain conversations might play out.

Woman: Does hypnobirthing work?

Me: It depends on what you mean by ‘work’ (and what you mean by ‘hypnobirthing,’ but that’s more complicated so I’m not going to say it out loud – yet).

If by ‘work,’ you mean you want it to relieve your labour pain, in a general population it has not been shown to be as effective as water or Entonox.

If by ‘work,’ you mean you are hoping to avoid unnecessary interventions such as instrumental or surgical delivery, in a general population hypnobirthing has not been shown to do that. Home birth and continuity have both been shown to do that very effectively. If your Trust is not practising evidence based medicine by ensuring you have access to these, having another woman support you and your partner during labour is also helpful. She need not have special training. Someone just being there the whole time will have the same effect.

If by ‘work,’ you mean you will look back on your childbirth experience and decide that was effective for you, the answer is, “Many women feel hypnobirthing has been effective for them, but whether it will be for you is down to many individual factors. I suggest you follow your instincts on this one.”

*****

Woman: My friend recommended this hypnobirthing class to me, but I don’t really like it. What do you think? I really want a natural birth.

Me: I think you ought to spend the evenings out doing something lovely with your partner instead. Your body was designed to give birth, you will be able to do it when the time comes, and we will do our best to support you. If you need help, we will be here. (See also above suggestions re: ‘working.’)

*****

Woman: I started doing a hypnobirthing class, which I really like, but when I talked about it with my consultant, he said it was quackery. What do you think?

Me: If you can’t be a bit quacky in labour, when can you? He may have never watched someone use hypnobirthing effectively in labour. I think you ought to follow your instincts on this one and do what gives you confidence. We will support you.

*****

Commissioner: Should we fund hypnosis antenatal classes for the women using our maternity services?

Me: No. We should not fund complementary therapies which have not been proven effective, but we should educate midwives in appropriately supporting women who choose to use them. We should also stop funding unnecessary extra ultrasounds which are requested against available evidence of their lack of effectiveness in improving outcomes, and significant effectiveness in increasing unnecessary interventions, incurring further associated costs. We should then channel the money we have saved into a more reliable home birth service (which has been proven to be the least costly option with no change in outcomes for multips, and a significant decrease in interventions) and more continuity services (also proven to improve outcomes), targeted first at those who need them most. Midwives should then use their clinical judgement and experience to support the individual women in their care, rather than referring them all to bare bones antenatal classes.

(Or some such similar argument, depending on which non-evidence-based intervention is currently most overused while many midwives run around like headless chickens trying to provide evidence based one-to-one care, desperately clinging to techniques like hypnosis which might help more women to do it by themselves when midwives cannot be at their sides providing individualised care.)

Upcoming study day: Promoting Normal Birth & Hypnobirthing Conference, 19/6/14

Listen to midwives, listen to women

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I always smile when people say, “It’s all well and good to support natural breech birth, but what happens if the head gets stuck?” Those of us who are supporting woman-centred, modern breech birth take an equally realistic view about the need to intervene in a skilled and confident manner when help is needed, although we are probably more realistic about the frequency with which such intervention is required. We also obsess about creating trusting relationships and environments which facilitate more spontaneous, easier births, with the end result that we need to use our skills less often.

However we sometimes rely on these skills to achieve a safe outcome. Therefore we share our experiences with others, for when they might be needed. And we know that supporting others to confidently support more breech births will create new knowledge which will in turn help us to improve our own practice.

Where does this knowledge come from? Hint: not Randomised Controlled Trials. One of the many ways midwives create knowledge about practice is by listening to each other and listening to women. For example, in the training aid linked above, one of the options involves assisting a woman who is on all fours to become straight upright on her knees, and applying suprapubic pressure. This is how my own personal learning about that happened (participants not identified to maintain confidentiality):

The baby’s head was hyperextended at the time of delivery, but not before. Woman on all fours, no progress with the next contraction, no spontaneous movements from the baby to assist his own flexion. Neither the midwife managing nor the Registrar who was supporting could reach the baby’s chin, just what felt like a bird beak (the lower jaw bone) pointed up to the sky, so Mariceau-Cronk was not an option. All present were fairly inexperienced, and no training aids were available, so the decision to get the woman upright was instinctive. The decision to apply suprapubic pressure while doing so was based on RCOG guidelines about how to help when the woman is in lithotomy, transcribed to the current situation. The occiput was felt during suprapubic pressure. Then suddenly the baby’s head dropped into the pelvis, and was immediately born wearing his placenta like a hat. Several minutes of resuscitation were required. Baby recovered quickly and well.

Following on from this story, I returned to the sources I use over and over again. Anne Frye’s Holistic Midwifery described how some midwives get the woman upright (for breech and shoulder dystocia) because this tightens the abdominal muscles, promoting head flexion. So someone else has a theory for how it works. There is also increasing radiological evidence that when upright or prone (e.g. shoulders, pelvis and knees in a straight line), the pelvic inlet is largest, while squatting significantly enlarges the mid-pelvis and pelvic outlet. The strategy of assisting the woman to move into an upright posture and use suprapubic pressure may have resulted in an even better outcome if performed earlier, as soon as the dystocia was identified.

Once you begin to see the patterns, they emerge in the stories you immerse yourself in. Reading Jennie Clegg’s story about her ‘Breech VBAC at home,’ I found this:

The next push I gave it everything I had and rumping happened very quickly followed by the body; the relief of the pressure was immense. Two sharp sensations happened which were the legs releasing, I remember looking through my legs and seeing a little body! Then there were a few sharp uncomfortable movements which were caused by the baby wriggling its arms out. My contractions at this point had stopped.

Debs could see no chin on the chest to examined me and found the head to be extended. An ambulance was called and Debs started manoeuvres to birth the baby. No movement was felt so I was encouraged to change position and Michelle tried nipple stimulation to get contractions coming. Michelle and James helped me to stand, Debs attempted head flexion, movement was felt and I was encouraged to push, baby was born immediately followed by the placenta! (Midwifery Matters, ISSUE 135, Winter 2012)

This scenario was slightly different, but maternal movement was again helpful. Jane Evans, a midwife with many years of breech experience, writes and talks about how her understanding of the physiology of breech birth has been informed by listening to and close observation of women (Evans 2012a, Evans 2012b).

Listen to women. Listen to midwives. Share your stories. Share your skills.

Feel free to share your own stories in the comments below. Community support for breech professionals is available via a Breech Birth Network Facebook group.

References

Michel, S. C., Rake, A., Treiber, K., Seifert, B., Chaoui, R., Huch, R., . . . Kubik-Huch, R. A. (2002). MR obstetric pelvimetry: effect of birthing position on pelvic bony dimensions. AJR Am J Roentgenol, 179(4), 1063-1067. doi: 10.2214/ajr.

Anne Frye’s Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice, Vol II is now available to download as a PDF, you lucky ducks! My father still complains about having to transport the heavy tome across London on the underground when he brought it to me from America one Christmas.

When the science of midwifery undermines the art

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Self-hypnosis for pain relief in labour

Obstetrician and canoeist through the thick waters of controversy Jim Thornton drew my attention to this recent trial, published by the BJOG in February (Werner et al 2013, read it here), through his blog (read his post here, always though-provoking). Jim calls the trial ‘lovely,’ but I can’t agree. Rather, I think it illustrates how research, if not appropriately designed, can potentially cause more harm than good.

This study was well-conducted in randomised controlled trial (RCT) terms, so we can depend on the results: Take a group of women who are up for it and randomly allocate them to a short course on either self-hypnosis, relaxation, or standard antenatal care. They then give birth supported by a midwife who is not allowed to know how they prepared to self-manage pain in labour. You will find that no one education intervention results in more or less pain, more or less need for epidurals, nor any noticeable difference in satisfaction with their childbirth experience. I’m not surprised.

I was pleased to see the authors shared many of my concerns in retrospect and can only imagine it was over-confidence in a technique they had observed many women use with great satisfaction that led them to proceed with a trial design which featured some predictable flaws. One of my biggest concerns was that staff were blinded about the woman’s allocation. Effect: most of the time the midwives could not guess correctly which group the woman belonged to. This was a piece of midwifery research, but it effectively disabled midwives from practicing their art, sympathetically enhancing the woman’s coping techniques using knowledge gained about that woman through their relationship.

This debate was bugging me until I picked up the latest issue of The Practising Midwife and read midwifery lecturer Charlotte Kenyon’s very sensible piece on ‘Clinical hypnosis for labour and birth: a consideration.’ She discusses the difficulties with conducting research in this area (I refer you to her article for a fuller account; TPM is digitally lacking, so visit your library), but most importantly she points out, “No recent studies could be found which employed individualised hetero-hypnosis” (Kenyon 2013, p12).

‘Individualised hetero-hypnosis’ is what you get when you give midwives a set of tools (along with women) and enable them to use them to support women on an individualised basis, according to the woman’s needs and values, enhancing the woman’s own coping skills. Delivering individualised care, sympathetically combining experience- and evidence-based knowledge, is the art of midwifery. In contrast – “Where research is undertaken using formulaic scripts, results may be affected by the use of a one size fits all approach to a therapy which by its nature is individualised” (Kenyon 2013, p12). Yep.

Soo Downe is currently conducting an RCT (registered here) on the use of self-hypnosis with a mixed methods design that appropriately includes other strands of contextualising data collection such as interviews, focus groups, logs and questionnaires. Importantly, the midwives supporting women in labour will not be blinded; therefore, the conduct of the trial itself presents an opportunity to expand the practice of midwives providing individualised care. This sounds like a study which will pragmatically improve our understanding of how women use self-hypnosis and how midwives can enhance women’s own efforts, as well as whether or not there is a quantifiable difference in outcomes which would justify increased investment to integrate such services into the NHS. Can’t wait for the results.

So what harm can come from poorly designed research? Well, I wouldn’t have liked a positive outcome for the Werner trial to lead us down a path of advising all women they will have a better time if they use self-hypnosis (without a greater understanding of who it is most likely to help, how and why). But I also don’t like the idea that on the back of this large RCT some individual women’s use of self-hypnosis will inevitably be dismissed by some professionals as ‘not evidence-based,’ rather than respected and appropriately supported. This could undermine a woman’s confidence and feeling of being supported in her chosen coping strategies. For what? Because we know better?

Declaring my personal biases (because it’s my blog): I have never been drawn to using hypnosis (self-administered or otherwise) while giving birth, despite having four home births. If you told me I would never have to listen to a hypnosis CD throughout a night of someone else’s labour again, I wouldn’t complain; they make me feel like I’ve just had a lobotomy. My personal birth mix included Nina Simone, Herbie Hancock, and Madonna’s ‘Like a Virgin,’ just to lighten the mood while I swore like a trucker. But I trust women. Having listened to many women describe how hypnosis-related techniques and programmes helped them feel more confident and in control, and having watched them give birth, I am siding with those who insist their experience be properly accounted for before we close the book on the hypnosis for childbirth debates.

Reference

Kenyon C (2013) Clinical hypnosis for labour and birth: a consideration. The Practising Midwife. 16(5):10-13.

Update 2015 – You can read Downe et al 2015 by following the link.

BJOG. 2015 Aug;122(9):1226-34. doi: 10.1111/1471-0528.13433. Epub 2015 May 11. Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness. Downe S, Finlayson K, Melvin C, Spiby H, Ali S, Diggle P, Gyte G, Hinder S, Miller V, Slade P, Trepel D, Weeks A, Whorwell P, Williamson M.

Heads Up! International Breech Conference

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Washington, DC – November 9-12, 2012

Conference report.

Driven by consumers, sponsored by the Society of Obstetricians and Gynecologists of Canada and attended by obstetricians and midwives from 15 different countries, the third International Breech Conference convened in Washington, DC, from November 9-11.

The highlight of the conference was soon-to-be-published data from observational studies in Frankfurt and Sydney, representing nearly 800 planned vaginal births, presented by obstetricians Andrew Bisits, FRANZCOG, and Anke Reitter, FRCOG, along with Frankfurt team researchers, midwife Betty-Anne Daviss and epidemiologist Ken Johnson. Fellow conference presenter Sophie Alexander (MD, PhD, and co-author of the PREMODA study )1 summarised by pointing out, “These results are consistent with all of the large studies done since the Term Breech Trial. Everyone except Hannah has observed a small increase in low Apgars and non-significant birth injuries for vaginally born breech babies, with no difference in mortality rates or long-term morbidity.”2

The current state of breech research was summarised by Prof Marek Glezerman, MD, Chairman of the team which contributed results from Israeli institutions to the Term Breech Trial, and author of the significant 2006 re-evaluation of the same study which concluded that due to serious flaws in the research and the simplications of standardising its recommendations, the results of the study should be withdrawn.3 Glezerman presented research from further studies, which demonstrate, as Dr Alexander pointed out, that where vaginal breech birth is well supported, it can be a safe option.4,5 Additionally, Glezerman pointed out that we need to be less precious in our initial evaluation of significant morbidity: “A low Apgar at 1 minute means nothing in 2 hours or 2 years; it only serves to make you alert to the baby.” Bisits also participated in the original TBT and shared Glezerman’s and others’ skepticism about whether the trial design was appropriate to measure what it intended to measure.6

Significantly, Anke Reitter, Andrew Bisits and Betty-Anne Daviss are experts in the use of upright techniques for breech delivery, along with Reitter’s Frankfurt colleague Professor Frank Louwen. A majority of the births in each location took place in upright positions, with the woman on hands/knees or a birthing stool. In both settings, they have observed an increased need for manoeuvres or forceps and an increase in birth injuries when the mothers have been in lithotomy position, and these obstetricians are now keen to share their data so that other clinicians can learn safer ways to facilitate vaginal breech births.

This stance was well-received by the many midwives in the audience, many of whom have been advocating upright delivery techniques for vaginal breech birth for some time. One of the foremost breech midwives is Jane Evans, SCM, SRN, a UK Independent Midwife, who presented her recently published descriptions of the mechanisms of a normal breech birth,7,8 the result of decades of close observation. Although one panel featured a lively debate about whether breech presentation should be viewed as an abnormality or an unusual variation of normal, all agreed that a thorough understanding of the parameters of normal specific to breech birth is a prerequisite for a safe service. Knowing the mechanisms allows a practitioner to understand when progress has deviated from normal and intervention is indicated, and when to refrain from potentially harmful manipulations when these are not required.

The varied conference contributions made two points very clear. Firstly, knowledge about breech birth is evolving far beyond what research done over a decade ago can address, with so much more to learn about how to make breech birth as safe as possible. Secondly, moving breech knowledge forward will require genuine multi-disciplinary openness and skill-sharing, exemplified by the humbleness of the expert obstetricians and midwives who acknowledged the many sources of their knowledge.

Following on from three days of intense discussion, a post-conference practical session on November 12 was dedicated to hands-on, practical learning with simulated breech births, guided by several of the experienced obstetric and midwife practitioners. This included two new manoeuvres, the Louwen Manoeuvre for assisting the birth of fetal arms in an upright delivery through rotation (a variation of Lovset’s), and Frank’s Nudge, used to promote flexion and birth of an extended fetal head. Detailed descriptions of these manoeuvres will be published alongside the Frankfurt data early next year, but they are already being taught in several UK hospitals which incorporate upright techniques into annual mandatory breech updates.

Throughout the three-day conference, we also heard from women who spoke very movingly about their experiences of breech pregnancy and attempts to secure support for their choice of a vaginal breech birth. Evident in these stories was the fear and resistance their providers felt, which prevented them from providing appropriate, woman-centred care, and the long-term effects this had on each woman’s wellbeing. A panel discussion dedicated to this topic included Benna Waites, a UK clinical psychologist whose own experience prompted her to gather the available evidence into her very thorough book, Breech Birth,9 essential reading for any breech practitioner. As Waites passionately summarised in her own story: “I was angry, not just scientifically disappointed. Providers need to know: your fear and your ignorance cannot be the reason for our lack of choice.”

The conference was designed to tackle this fear and resistance head-on with expert-led discussions of what is required to change the current situation, in which a caesarean section is either the most often only option when a baby presents breech, or is promoted as the best option due to providers’ lack of familiarity with current breech research since or lack of confidence in their own skills to safely deliver a breech baby. Glezerman argued that to reinstate breech skills, we must standardise assessments of competency with theoretical and practical tests, and while this must be combined with hands-on experience, standardisation cannot be based on numbers alone.10

This is partially because large numbers of breech births are simply not available to today’s trainee obstetricians and midwives. Recent research into the breech experience of obstetricians training in the UK show remarkably little experience, compared to what obstetric trainees would have experienced a few decades ago.11 The need to measure breech competency independent of birth numbers also results from the influence of personal skill sets on the ability of breech attendants, including confidence and motivation to develop expertise, which requires additional on-call commitments.12 Several speakers, obstetricians and midwives, spoke movingly of how breech birth attendance is an art, like many aspects of our professions, which some are simply more drawn to than others.

This viewpoint is consistent with the secondary analysis of the TBT results, which demonstrated that a clinician’s own evaluation of his/herself as “skilled and experienced,” when confirmed by their Head of Department, was more strongly associated with good outcomes than when the attendant was defined as a registered obstetrician or by number of years of experience.13 It also mirrors the Canadian recommendations that on-call specialist teams be established.14 In a move which reflects growing institutional support for practitioners who are willing to acquire the necessary experience to support breech birth safely, we heard how one hospital in Canada has recently abolished a mandatory transfer-of-care from midwives to obstetricians when women labouring with breech-presenting babies enter the hospital. It seems likely that, while universal training for doctors and midwives in emergency breech delivery remains required on safety grounds, planned breech births will increasingly be managed by breech specialists. In which case, more of us are needed.

Three days of presentations and discussions ended with a panel dedicated to exploring the legal and ethical dimensions of supporting a woman’s choice to birth her breech baby within today’s risk-adverse and minimally experienced services. As well as legal experts, the panel included obstetricians who facilitated planned breech births, as well as those who were prevented from doing so by their hospital’s policies, which made for an interesting discussion around the ethical dilemma resulting from the professional obligation to respect clients’ informed refusal (eg. of a caesarean section) amidst active obstruction from risk management policies. The discussion made clear that in order to provide the woman-centred service that clients want and many providers want to provide, there are many obstacles which need to be overcome, not all of these are apparent or clearly defined, so they remain difficult to tackle.

Although over the course of the conference we heard from a few American obstetricians who were preserving breech skills in isolated pockets (with positive outcomes, similar to their European counterparts), the medicolegal panel was the only portion of the conference attended by a representative of the ACOG (Dr Constance Bohon), despite repeated invitations. This was a great disappointment to the organisers from the Coalition for Breech Birth, who chose the Washington DC location for this international conference particularly to support the American chapters, who are struggling to open up lines of dialogue between consumers wanting more options and providers and their professional organisations. Listening closely to women’s concerns and extending an olive branch, Bohon suggested, “Perhaps it is time to set up a task force.”

While we in the UK are often not as circumscribed by actual legal constraints limiting woman-centred practice, a well-supported vaginal breech birth is still not easy to come by. The conference organisation team included a UK Coalition for Breech Birth user representative, student midwife Ruth Mace-Tessler, and was attended by several UK midwives and an obstetrician, but again no RCOG representative despite repeated invitations. Maybe the time has come for us to set up a similar task force in the UK?

Shawn

References

1. Goffinet F, Carayol M, Foidart J-M, Alexander S, Uzan S, Subtil D & Bréart G (for the PREMODA Study Group) 2006. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology, 194: 1002-1011. 1. Daviss, B. A., Johnson, K. C. & Lalonde, A. B. 2010. Evolving evidence since the term breech trial: Canadian response, European dissent, and potential solutions. J Obstet Gynaecol Can, 32, 217-24.

2. Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., Willan, A. R. & Term Breech Trial Collaborative, G. 2000. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet, 356, 1375-1383.

3. Glezerman M. 2006. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol, 194, 20-5.

4. Toivonen, E., Palomäki, O., Huhtala, H. & Uotila, J. 2012. Selective vaginal breech delivery at term – still an option. Acta Obstetricia Et Gynecologica Scandinavica, 91, 1177-1183.

5. Hauth, J. C. & Cunningham, F. G. 2002. Vaginal breech delivery is still justified. Obstet Gynecol, 99, 1115-6.

6. Kotaska, A. 2004. Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery. BMJ, 329, 1039-42.

7. Evans, J. 2012a. Understanding physiological breech birth. Essentially MIDIRS, 3, 17-21.

8. Evans, J. 2012b. The final piece of the breech birth jigsaw? Essentially MIDIRS, 3, 46-49.

9. Waites B. 2003. Breech Birth, London, Free Association Books.

10. Glezerman M. 2012. Planned Vaginal Breech Delivery: Current Status and the Need to Reconsider. Expert Review of Obstetrics & Gynecology., 7, 159-166.

11. Dhingra, S. & Raffi, F. 2010. Obstetric trainees’ experience in VBD and ECV in the UK. Journal of Obstetrics and Gynaecology, 30, 10-12.

12. Kotaska, A. 2009. Breech birth can be safe, but is it worth the effort? J Obstet Gynaecol Can, 31, 553-554.

13. Su, M., Mcleod, L., Ross, S., Willan, A., Hannah, W. J., Hutton, E., Hewson, S., Hannah, M. E. & Term Breech Trial Collaborative, G. 2003. Factors associated with adverse perinatal outcome in the Term Breech Trial. American Journal of Obstetrics and Gynecology, 189, 740-745.

14. Daviss, B. A., Johnson, K. C. & Lalonde, A. B. 2010. Evolving evidence since the term breech trial: Canadian response, European dissent, and potential solutions. J Obstet Gynaecol Can, 32, 217-24.