Touch Surgery / Medtronic breech birth simulation app

Physiological breech birth training is now available via the Touch Surgery app. The QR code will take you to a page where you can download the app.

FREE to use and distribute. The training is based on research about physiological breech birth and the methods we teach in our one-day course.

Thank you to the artists and technicians at Touch Surgery, who developed this resource to help improve the safety of vaginal breech birth.

Help Breech Birth Network improve the safety of vaginal breech birth

The Breech Birth Network would like to employ an administrative assistant, for 5-10 hours per week at £10/hour. We are a small social enterprise, in which all profits are re-invested in the objectives: to improve the safety of vaginal breech birth. But Shawn and Emma cannot keep up with the admin demands of running a small community interest company and their day jobs as midwives.

Join our team …

We need someone who:

  • is UK-based;
  • is passionate about making vaginal breech birth a safe and accessible choice;
  • can reliably devote 5-10 hours per week to our projects;
  • is able to be proactive and self-guided in organising workload and learning needs; and
  • is familiar with or willing to learn accounting software (Xero), video editing and WordPress.

Professional qualifications and/or registration are not required for this role. We would be equally happy with someone who is mainly at home with children but possesses the admin skills required and would like to devote some spare time to the Breech Birth Network.

If you are interested, please send a CV and short statement about why you would like this role to shawn (at) breechbirth.org.uk

Teaching breech in Ethiopia

Breech birth videos

There is a small revolution happening around vaginal breech birth, and this is due in large part to the miracles of modern technology, especially videos. Watching many breech births via video enables midwives and obstetricians to develop pattern recognition — what is normal, what is not, when it is time to intervene — without having to attend many breech births. And it enables this to happen more quickly than it would normally happen, over decades of practice. Birth videos also enable us to study the features of breech births in a systematic way in research.

Birth videos will never entirely replace clinical practice, but they can accelerate the learning process. We are incredibly grateful to the women who are enabling this to happen. This blog is addressed to health care providers who may want to ask for permission to film births to support skill development throughout their clinical team.

Permission and the Law

The content of medical care is confidential to the patient, not the health care provider. This means that women have a right to film their births, which are part of their private lives, if they want to. It is, however, respectful to ask for permission.

The GMC provides guidance on the recording of patients, and the principles of informed consent apply. Your employing Trust will also have guidance and forms that can be used to obtain consent, which are usually available from the Medical Illustration Department or similar. You should speak with your managers and team as well. In the Breech Birth Network, we use our own consent form, which you are welcome to use. It allows people to choose from different levels of consent, e.g. just for teaching in person, on-line teaching with restricted access, unrestricted on-line access. It is best practice to take the final consent after filming so that she can identify anything she would like edited out, e.g. if her name is audible or her face is visible., or change her mind.

A copy of any videos should be given to the woman and placed in the woman’s hospital notes.

Access the BBN film agreement here.

Equipment

You will need a good quality video camera. Most phones contain a decent video camera these days, and most of our videos were taken on phones. But something like a GoPro is designed to adjust with movement. GoPros also take in a wider angle than standard phones.

GoPro Chesty

You will need something to hold the camera and ideally, be able to move to get a good angle — so not a static mount. In some videos, it seems as though people are staying ‘out of the way’ in order to enable the camera to get a good shot. This is not a good idea; you want the primary attendant fully focused on the birth and disregarding the camera. In the Hospital of Southern Denmark, filming is the job of the Junior Doctor, who is learning about breech births but not yet managing them.

POV necklace mount

The other alternative is a POV (point-of-view) mount. GoPro make a special chest mount, but … let’s just say they are not designed for women. It’s called a ‘Chesty,’ and that’s exactly how I felt while wearing one. I prefer something called a necklace mount, which keeps the camera closer to where your eyes naturally are and is much more comfortable to wear (IMHO).

I hope this is helpful!

Shawn

Inviting your views … — The OptiBreech Project

From Tisha Dasgupta, OptiBreech Research Assistant, re-blog from The OptiBreech Project: We would like to invite women, birthing people and their families who have experienced a breech pregnancy at term to attend an online focus group discussion on Thursday 10th December 10.30-11.30am to be conducted via Microsoft Teams.  Anyone with an interest and experience of breech pregnancy can participate.

The purpose of this meeting will be to get your perspective on the following issues: 

A core outcome set is a minimum set of outcomes that should be collected in every study about a topic, in this case vaginal breech birth at term. Making these consistent means that we can better compare and combine studies, and ensure research meets the needs of those who use it.

To develop a core outcomes set, we have conducted a systematic review of the available literature relevant to this project (brief summary below). However, we need your input to determine if these outcomes are important to the people who will use the results of research to make decisions, and how important each is. Does this meet all your informational needs or are there outcomes that have not been identified, which you think is important to record? 

Do you think it is important to include salutogenically focused outcomes that emphasize positive well-being of the mother and newborn such as maternal satisfaction, relationship with baby etc.? If so, which factors would you like to see and how important do you think these are? 

The next stage will be to ask both professionals and service users to rate the importance of the outcomes to be included in the core outcome set. But before we do this, we want to insure all of the outcomes important to you are included.

You are welcome to share your feedback directly during the focus group meeting or by emailing Tisha Dasgupta (tisha.dasgupta@kcl.ac.uk), the OptiBreech Research Assistant, at any point. If you are unable to make it and would like to contribute, or have further feedback after the session, please also contact Tisha.

While we do not require written consent for your participation in the meeting, it is important to let you know that the session will be recorded. We intend to take the feedback you provide into consideration while designing the next stage of this project: a multinational Delphi study. No identifiable information will be used such as direct quotes or anecdotes, and we will only report summary data.  

Thank you very much for your consideration. Please could you send your RSVP to tisha.dasgupta@kcl.ac.uk by Monday, 7th December to confirm your attendance at the session? She will be in touch thereafter to provide you access to the online meeting.

More information:

The COMET Database

The CROWN initiative

We’d also love to hear your views on the information presented on the OptiBreech website!


Overall summary of the Systematic Review

A systematic review of all relevant literature was conducted to identify outcomes, definitions and measurements previously reported in effectiveness studies of breech births at term. 108 studies were identified comprising of systematic reviews, randomised controlled trials and comparative observational studies, with full-text available in English. Below are the most common outcome measures, with a percentage of how many studies reported them. These are the top 10 most frequently reported measures in each category grouped by neonatal, maternal, features of labour, and long-term maternal outcomes respectively.

Neonatal outcomes

Outcome measure% studies reported
APGAR score at 5 minutes78.7
Perinatal or neonatal mortality68.5
Admission to neonatal intensive care unit (NICU)59.3
Neonatal birth trauma/morbidity53.7
Brachial plexus injury / peripheral nerve injury38.0
Low umbilical artery pH35.2
Bone fracture33.3
Neonatal seizures/convulsions31.5
Intubation/ventilation29.6
Hematoma (cephalic or subdural)20.4

Maternal outcomes

Maternal mortality24.1
Post-partum haemorrhage (PPH) 16.7
PPH requiring blood transfusion14.8
Other serious maternal morbidity/other complications14.8
Genital tract trauma13.0
Wound infection requiring prolonged hospital stay/re-admission12.0
Deep vein thrombosis (DVT) requiring anticoagulant therapy10.2
Prolonged hospital stay9.3
Hysterectomy8.3
Anaemia7.4

Features of labour

Vaginal Delivery97.2
Emergency Caesarean88.0
Elective caesarean80.6
Induction of labour24.1
Instrumental vaginal delivery18.5
Manoeuvres used17.6
Regional anaesthesia15.7
Trial of labour14.8
Actual mode of birth13.9
Duration of delivery/second stage13.9

Long-term maternal outcomes

Urinary incontinence6.5
Breastfeeding complications5.6
Faecal incontinence5.6
Postnatal depression5.6
CS in subsequent delivery5.6
Long term abdominal pain4.6
Dyspareunia4.6
Flatus incontinence4.6
Relationship with partner4.6
Long term perineal pain3.7

Normalising breech birth at the European Congress on Intrapartum Care, 2021

Physiological breech birth will be one of the key topics at next year’s ECIC in Belgrade, Serbia. See information below for booking and consider submitting an abstract.

ECIC 2021

5th ECIC: European Congress on Intrapartum Care
Making Birth Safer

27-29 May 2021 · Belgrade, Serbia

Be one of the first 300 to registerRegister as early as today to take advantage of the discounted fee – available only to the first 300 participants!

Here are some good reasons why you should attend the 5th ECIC in 2021:

  • ECIC is a unique opportunity to learn standard obstetric skills
  • ECIC gives you knowledge and confidence in obstetrics
  • A congress where women in labour are the focus of midwives and obstetricians
  • Scientific and clinical challenges of intrapartum care on debate
  • Positive childbirth experience combined with the best available technology

REGISTER AND SAVE

PRELIMINARY PROGRAMME
ABSTRACT SUBMISSION
CONGRESS COMMITTEES

We look forward to meeting you in Belgrade!
info@eciccongress.eu
eciccongress.eu
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Interesting follow up discussion on Twitter! …

Induction of breech labour?

Thank you to the woman who provided permission to re-post this exchange, in case others are looking for similar information. Emma and I respond to many requests for information like this. Hoping that sharing this response helps others looking & those who are caring for them. Shawn’s replies in blue.

I’m P2+0, ventouse in first and normal birth on the second. In all of my pregnancies I’ve had Gestational diabetes and been induced. I’ve been well controlled on insulin with no complications for the babies either antenatally or in the neonatal period. Same is the plan for this one. Previous two babies weighed 2.8kg And 2.82kg. All went well for both mother and babies on both births.

Sounds good.

This time round I’m currently 34+4 weeks and baby is firmly breech for the last 8 weeks. So far I’ve tried spinning babies, homeopathy, acupuncture and moxa sticks to encourage baby to turn. Not budging one bit. I know there is still time for it to turn but I’m getting myself educated as to options. 

ECV is a potential option at 37 weeks and if that fails obstetrician has suggested that I go for an induction of labour with breech as he knows I really don’t want a c/s. 

He has said himself as I’m a midwife I know what’s involved, I don’t have big babies and there is only 18mths between each of my babies so I should labour well.

Agreed.

Only breech births I’ve seen over my career are either second twins or unexpected fully dilated breech in labour on arrival. I’ve never seen one induced.

Yes, this is one of the things that causes problems for planned breech births. Most people are most familiar with the ones what progress quickly and ‘just fall out’ before a CS can be performed. This can give a false impression, and though people may be ‘experienced,’ they may lack experience of more challenging breech births that take a little longer, such as people giving birth for the first time and inductions. [See No more ‘hands off the breech.’]

I’ve been doing reading & research on the topic but it’s hard to find current evidence. As you know historically from previous research c/s has been recommended instead of induction. I have found some more current evidence suggesting that with the right maternal candidate induction is possible and long term outcomes for both mother and baby are of no significant difference to those that have elective c/s. Am I right in this?

In experienced centres, the balance of evidence does not indicate increased risk from induction compared to spontaneous breech birth. In fact, in experienced centres, induction is sometimes used to increase the likelihood of a good outcome by ensuring a birth occurs when significant experience is available – not ideal, but nothing to do with vaginal breech birth is currently ideal.

Most recent published systematic review is Sun et al (2017) in EJOG. https://www.ejog.org/article/S0301-2115(17)30578-X/fulltext

One of my talented midwifery students just repeated this review with the addition of the most recent evidence, and the results showed not one significant difference. However, all of these studies would have been done in centres that are experienced enough to be confident inducting breech births. Given what I have said above, I feel it is likely that in centres who do not regularly do this, there is some increased risk. But this would be more applicable to people giving birth for the first time, in my opinion.

Also my baby is currently in a complete breech position flexed knees and feet above the buttock. Again I know this could change but I have read conflicting information on if this is a suitable position for induction of breech.

Breech babies dance until they can’t dance no more. So the position could change to head down or feet up or knees down or something else at the time of labour or even in labour. Non-frank breech presentations are at slightly higher risk of cord prolapse, so you may want to consider labouring with a cannula if this is the case at the time of induction. I have no further research-based information to offer. 

It’s hard to find current information for parents on options using recent research so that is why I am contacting yourself. I’ve been following your twitter and some of the work the breech team is doing. I think as a midwife it’s a great idea and desperately needed to give real options to parents and expand skill set in health professionals. Do you have any patient information that you give to parents on induction of breech that I might benefit from reading?

Agreed, it’s hard. We have a leaflet, developed by Emma Spillane, which was developed based on the current RCOG guidelines.  https://breechbirth.org.uk/2019/07/18/new-information-leaflet/ Because the RCOG guidelines currently ‘do not recommend’ induction of labour for breech births, we have chosen not to go there. Working in a controversial area like breech birth, one has to choose one’s battles. I’m very happy to support this as an individual choice myself, but in the wider context of re-establishing effective breech services, it hasn’t been the priority. Given increases in induction across the service, and evidence of the potential benefits of offering induction, this will eventually need to be addressed in any contemporary breech service. ‘Not going into labour,’ either by the date considered optimal, or following waters breaking, is the biggest reason that people who plan a vaginal breech birth do not end up having one.

Finally – Would you be happy for me to publish this e-mail exchange as a blog, with names and any other identifiable information removed, or not if you prefer? It helps me to be able to provide a link when people ask similar questions, which I expect will happen more with this topic.

Wishing you all the best,

Shawn

Consultant obstetricians at vaginal breech births: The key to safety?

A common finding in reviews of deaths and adverse outcomes following vaginal breech births is that a consultant obstetrician was not in attendance. For example, coroners have ordered reviews of services nationally after tragic deaths where skill and experience has been an issue, such as this one in 2012, and another in 2015, recommending that a consultant obstetrician always be present at vaginal breech births. A review of NHS cerebral palsy claims (Magro 2017) from 2012-2016 found that breech births represent 12% of all litigation costs despite representing only 0.4% of all NHS births. In five out of six of these births, the breech presentation was diagnosed late in labour. And in five out of six, the births were attended by a trainee (registrar) without a consultant present. This review also recommended increased senior support.

But this assumes that all consultant obstetricians do themselves have significant skill, confidence and experience with vaginal breech birth. The evidence does not indicate that this is the case.

In Dhingra and Raffi’s 2009 survey, 80 obstetric trainees on a labour ward advanced skill training course provided information about the amount of training and experience in vaginal breech delivery they had. Most (80%) were ST4-5, but others were ST1-3 or newly appointed consultants. In this survey, 63% had attended more than 10 vaginal breech births, 66% report having had supervision in practice and 80% of them felt ‘happy to perform and offer VBD.’ The vaginal breech birth rate has declined since 2009, so these numbers are unlikely to have improved.

This means that approximately 1:3 obstetricians at the point of qualification would not meet the physiological breech birth proficiency criteria. Approximately 1:3 of them will have not had supervision in clinical practice. And 1:5 of them would not be happy to perform or offer a VBD. And this is a self-selected sample of trainee obstetricians keen to acquire advanced labour ward skills, which is likely to differ from the general population of trainees and consultants (some of whom specialise in gynaecological oncology).

My own experience does not suggest that these figures are inaccurate. I have attended over 20 vaginal breech births in at least 5 hospitals, and a consultant obstetrician has only been present for one of them. This was despite engagement ranging from inviting them to attend, to emergency escalation. Usually, the role of senior clinician has been delegated to one of the trainees matching the above profile. My distinct impression is that a significant portion of obstetric consultants do not want to be responsible for attending vaginal breech births.

Often at this point someone starts arguing that the reluctant participants need to be ‘trained’ or ‘educated,’ that it is part of their job. I am not convinced that this is the safest or most compassionate approach. Often, my obstetric colleagues have privately shared with me their trauma and grief after difficult breech births. Their reluctance is understandable, especially within a work culture that does not make personal vulnerability easy and does not have a mechanism for offering consultant obstetricians support for developing their own breech clinical skill levels.

“You talk about providing support, but let me ask you: Who supports you? I have never delivered a breech baby’s head without using forceps.”

How much I respect the obstetrician who was willing to say this out loud at a meeting! And how much I respect that skill with forceps and surgery. These are outside of my scope of practice, and I do not have the hubris to assume I will never need them. But I am fairly certain my presence in a room makes the need to use forceps significantly less likely, and I have supported several professionals to deliver the aftercoming head without them for the first time. Bringing both skill sets into the clinical picture is what the breech clinical teaching team is all about.

Shawn

Further research about obstetric breech training and willingness to attend breech births:

Rattray et al (2019) — Only 36% of medical officers who attended training in Australia had facilitated > 5 breech births. Suggests specialist teams and/or centres of excellence.

Post et al (2018) — Does vaginal breech delivery have a future despite low volumes for training? Results of a questionnaire. Among sixth year residents, 65% were not yet confident to personally guide VBDs. 13% of the 294 residents and new obstetrician gynaecologists had performed less than 3 VBDs. Suggested specialist teams and/or centres of excellence as potential solutions.

(This list is not exhaustive, but what I have time for. Before you assume that things are different where you are from, do a similar anonymous survey in your own unit.)

Breech training: time for a new approach?

Providing advanced training to a core breech clinical teaching team is potentially more efficient and effective than training the entire maternity care team using traditional methods. The theory is strong, but rigorous research needs to be done.

Traditional training, looks something like this: Participants take time away from clinical commitments to attend a dedicated training session, ranging in length from a few hours to a whole day or more.

Challenges for this approach in the context of breech birth

1. It’s expensive

While preparing the research proposal for the #termbreech2020 Physiological Breech Trial, I worked closely with NHS Research & Development Finance specialists. Using the Agenda for Change pay scales, we calculated that providing 1 day of physiological breech birth training to 5 obstetricians and 5 senior midwives will cost the service £2,442 just to release them from clinical work. Multiplying this to cover the whole staff will obviously increase the cost exponentially. And then there is the cost of paying the trainers.

This is why most training programmes, like PROMPT, use a ‘train the trainers’ approach. It is a more efficient and effective way to disseminate training throughout an organisation. [PROMPT is a great multi-professional training package, but unfortunately, they excluded outcomes for breech births from their evaluation (Draycott et al 2006). So this training has not yet been evaluated for vaginal breech birth.]

2. The effects of training wear off before most people will have a chance to use it

Our systematic review of the effectiveness of breech training strategies showed that breech training can improve objectively assessed skill and knowledge, but that these effects wear off quickly, sometimes within 6 weeks, sometimes within 72 hours. A bigger concern was that, in some cases, confidence increased but objectively assessed skill did not. Training alone is likely not sufficient to improve breech skills, but for those who have some clinical experience, it may extend current understanding.

If you train a staff of 40 (or more) in a service that has only 1 breech birth per month, most of them will not have a chance to consolidate their learning in clinical practice. And if you do not have a plan for ensuring that someone who has attended enhanced training will attend the vaginal breech births that do occur, the enhanced training will not contribute to improvement in outcomes.

3. Clinical support in practice appears to make the biggest behavioural change

A surprising finding from our systematic review was that attendance at an obstetric emergencies-type training course was inversely associated with attendance at vaginal breech births, unless a system was in placed to provide clinical support in practice. This means that clinicians attended fewer vaginal breech births after taking breech training as part of an obstetric emergencies package. Although no quantitative evaluation was done, the studies that reported increase in breech births attended all had a model for ensuring experienced support in practice.

Conclusion

Implementing a breech clinical teaching team is a way of ‘training everyone.’ The model just differs from traditional ‘training day’ methods, which have not proven effective on their own in sustaining safe vaginal breech services.

Paying a few people who want to support breech births to be on-call occasionally and to cascade training is likely less expensive than providing enhanced training to the entire maternity care team, or even the entire senior team. But we need to implement the model and evaluate it in a systematic way in order to determine cost effectiveness. This is why experienced health economists are central to the #termbreech2020 Physiological Breech Trial and helped develop the design.

According to the evidence, breech clinical teaching team is also likely to result in greater availability of the option of vaginal breech birth for women who want them. This was a central concern of the women who participated in #termbreech2020 Physiological Breech Trial public engagement work.

But! Isn’t experienced senior clinical support what consultant obstetricians do? … Good question. We’ll discuss that next …

Shawn

Walker S, Breslin E, Scamell M, Parker P (2017) Effectiveness of vaginal breech birth training strategies: an integrative review of the literatureBirth. 44(2):101-9. (Author version archived at City Research Online)

What are the physiological breech birth proficiency criteria?

Explanation of the Proficiency Criteria used in the OptiBreech study

The setting of proficiency criteria for those attending vaginal breech births in the #termbreech2020 Physiological Breech Trial is a quality assurance mechanism. The potential risks of participating in research need to be mitigated as much as possible. Defining a set of minimum training and experience criteria for those attending vaginal breech births in the feasibility study is one way of doing this.

The Merriam-Webster Dictionary defines proficient (adv.) as: well advanced in art, occupation or branch of knowledge. Proficiency lies somewhere between basic competence, which all professionals are expected to have in order to practice safely, and expertise, which only a few may acquire. Using the term ‘breech expert’ may also suggest that all risks can be eliminated as a consequence, and unfortunately this is never true with birth.

A professional is considered currently proficient in physiological breech birth if they have:

  • participated in 6 hours of evaluated physiological breech birth training;
  • attended at least 10 vaginal breech births, including resolution of complications using manual manoeuvres;
  • experience of 3 vaginal breech births (attended or taught with simulation) within the past year; and
  • delivered physiological breech birth training at least once within the past year, including reflective reviews of births attended.

The evidence that has contributed to these criteria is referenced below, but they are also the result of much involvement from professionals currently trying to implement physiological breech birth services in a responsible manner.

The drawback of using proficiency criteria during a trial is that results will only be generalisable to settings which apply a similar set of criteria. After 10 years of studying how centres have re-introduced thriving vaginal breech birth services where little or no service existed, I have observed that almost all those that succeed use some form of a ‘breech team’ strategy. This is rarely reported because it is usually informal, and that may be one reason great services are sometimes not sustained as key individuals retire or leave the service.

I actually believe that the idea of a ‘golden age’ of universal breech skill is a bit of a myth. I think that adverse outcomes used to be more common and more tolerated. And I think that certain individuals have always had an affinity with breech birth, leading to them being called in to help their colleagues more often. Breech clinical teaching teams just make this mechanism visible and systematic.

Follow-on question from a consultant: Are the numbers meant for proficiency realistic?

A breech clinical teaching team can realistically achieve the numbers required to maintain proficiency if the team is not larger than the number of births occurring. If the numbers of vaginal breech births are small, the breech clinical teaching team needs to be smaller. If the unit is functioning as a centre of excellence and attracting additional breech births, the team can and will expand.

The important lessons we have learnt from working with centres that have implemented a good physiological breech training service are:

  • Do not change a whole organisation’s approach to breech birth unless everyone has received the same training and has been supported to apply it in practice. Just because a unit has hosted a study day doesn’t mean the unit is now a centre of excellence. Training, skill and experience lie with individuals, not institutions. If you haven’t been trained to do something new (e.g. upright breech birth), don’t do it. Use a breech clinical teaching team to help new skills embed into the wider service.
  • Do not become complacent once a service embeds and becomes the ‘norm’ in a unit. Be cautious when new members of staff join a service, including as part of training rotation or locum/bank. They are likely not to have a similar level of training and experience.

Follow-on question: Does this mean we should not attend physiological breech births if we have not achieved these criteria? And what if we do not have enough people who have achieved the criteria to cover the service?

The criteria are not meant to prohibit breech births from occurring without them. But if we consider this the benchmark ideal for physiological breech birth, our counselling can include how close we are to achieving this, or not. We can help women make informed decisions by clearly defining ‘skill and experience,’ and explaining that where this is not available, it may introduce some increased risk.

Even in the termbreech2020 Physiological Breech Trial, we may need to be flexible in the early stages, being open and honest with the women who participate. But setting the criteria and attempting to achieve them will enable us to answer important questions, like How often were we able to get a breech team member to the birth? Did it require us to put people on-call? If so, how often? If we weren’t able to do it from the start, how long did it take to establish a proficient team? How much effort did it take from the team, and how do they feel about it? How do the rest of the team feel about the team’s involvement? Answering these questions will enable us to refine the design of the study even further if it proceeds to a substantial trial.

Follow-on questions: The study design and criteria seems to direct towards selective group. And what if I feel skilled and experienced to attend breech births but do not meet all of the criteria?

The criteria are based on the best available evidence. Participation in a breech clinical teaching team may be perceived as a privilege, but it will also require effort from those involved. It is open to anyone with an interest who puts in that effort.

The #termbreech2020 Physiological Breech Trial is in the early stages of feasibility testing. Professionals should go on using the same standards of competence recommended in local and national guidelines outside of the feasibility trial.

Shawn

References:

What is Physiological Breech Birth? Read more here: Walker S, Scamell M, Parker P (2016) Principles of physiological breech birth practice: A Delphi StudyMidwifery. 43:1-6. (Author version archived at City Research Online)

6 hours of evaluated breech birth training

Attended at least 10 vaginal breech births, including resolution of complications using manual manoeuvres

Experience of 3 vaginal breech births (attended or taught with simulation) within the past year

Delivered physiological breech birth training at least once within the past year, including reflective reviews of births attended

What is the evidence for breech teams?

Use of breech clinical teaching teams is a pragmatic mechanism for delivering the only intervention associated in a randomised trial with an improvement in neonatal outcomes: the presence of a ‘skilled and experienced’ practitioner.

Su et al (2003) performed a secondary analysis of Term Breech Trial (Hannah et al, 2000) data to identify factors associated with adverse perinatal outcomes. The presence of an experienced clinician was the only factor associated with a reduced risk of adverse perinatal outcome in a vaginal breech birth (OR: 0.30 [95% CI: 0.13-0.68], P=.004). Compare this to the reduction of risk associated with a cesarean section during active labour in the same trial (OR: 0.57 [95% CI: 0.32-1.02, P=.06), or the reduction of risk associated with planned cesarean section overall in the trial (RR: 0.33 [95% CI: 0.19-0.56, P=<0.0001).

It is noteworthy that having an experienced clinician at the birth was associated with a reduced risk of adverse perinatal outcome, only when an experienced clinician was defined as a clinician who judged him or herself to be skilled and experienced at vaginal breech delivery, confirmed by the Head of Department. When an experienced clinician was defined as a licensed obstetrician or as a clinician with more than 10 or 20 years of vaginal breech delivery experience, there was no subsequent reduction in risk of adverse perinatal outcome. Thus, our analysis suggests that a clinician’s self-assessment of his or her own skill and experience may be a more valid measure of clinical experinece than either the completion of a training program in obstetrics and gynecology, or having many years of attending to vaginal breech deliveries.

Su et al for the Term Breech Trial Collaborative Group (2003) AJOG 189(3): 740-745

If we take the lessons of the Term Breech Trial seriously, and I think we should, then evidence-based practice would be to:

  1. do everything possible to ensure there is as much ‘skill and experience’ as possible in the room for every vaginal breech birth; and
  2. incorporate the availability of this skill and experience into the counselling women receive.

The findings of the Term Breech Trial resonate with the Public and Patient Involvement (PPI) work I have done to explore the feasibility of a physiological breech trial (#termbreech2020). Women also find the availability of a skilled and experienced attendant fundamentally important to their decision-making around whether or not to plan a vaginal breech birth. Consultant Midwife Emma Spillane and I have published two case studies that explore how this works in practice and what it means to women (2019 & 2020).

Finally, my own theory-building research suggests that breech clinical teaching teams are potential solutions to the pragmatic problem of providing ‘skill and experience.’ This consensus-development research with experienced obstetricians, midwives and service user representatives, to determine the standards for practitioners attending upright breech births, recommended ‘specialist’ breech teams. These collaborative recommendations have shaped the development of the ‘physiological breech birth’ intervention in the #termbreech2020 feasibility study.

Given the general depletion of VBB skills and opportunities, one of the hospital-based panel members suggested a ‘specialist’ breech team in every labour setting with at least one member on each shift (or on-call) would be advantageous, and this statement met consensus-level agreement (87%). However, the panel agreed the role of ‘specialists’ is to mentor and support breech skills development throughout the entire maternity care team, rather than functioning as experts of an exclusive skill set.

Walker, Scamell & Parker (2016) Midwifery 34:7-14

In summary, the status of the evidence is: Breech clinical teaching teams are a potential mechanism for providing an intervention we know reduces the risk of adverse perinatal outcomes in vaginal breech births: a ‘skilled and experienced’ attendant. And their use is recommended by professionals experienced with physiological breech birth. Now physiological breech birth team care needs to be tested. The #termbreech2020 Physiological Breech Study will explore the feasibility of doing that in a randomised trial.

Coming soon … how is ‘skill and experience’ defined?

Shawn

What is Physiological Breech Birth? Read more here: Walker S, Scamell M, Parker P (2016) Principles of physiological breech birth practice: A Delphi StudyMidwifery. 43:1-6. (Author version archived at City Research Online)