Thinking through the practicalities of breech advocacy.
Midwives and obstetricians who would like give women with breech presenting babies more support to plan a vaginal breech birth (VBB) need to think through the wider picture of how this happens in order to become effective advocates. In my experience of doing breech advocacy throughout the post-Term Breech Trial era, women often get in touch after 38 or 39 weeks to try to organise support for a VBB. Achieving this requires quite a bit of discussion and negotiation in quite a short period of time.
This post makes visible some ‘common experiences’ in women’s vaginal breech birth journeys. Services differ in every area, so it won’t be every woman’s experience. And increasingly, forward-thinking NHS Trusts are working with advocacy organisations (such as the Coalition for Breech Birth, Breech Birth UK and BBANZ) to develop woman-centred care pathways which meet women’s needs rather than restrict their choices, like this team in Sheffield.
| Common experience | Other possibilities | |
| 33 weeks | Antenatal clinic visit. Midwife or woman suspects breech. Woman told not to worry, most babies will turn. | Informed about / referred for moxibustion treatment. Not associated with risk of harm. Shown to reduce breech and CS when used with acupuncture. Shown to reduce use of syntocinon before and during labour regardless of presentation. (Coyle et al, Cochrane Review, 2012) |
| 36 weeks | Palpation in antenatal clinic. Midwife suspects breech and refers for USS. Woman receives counselling re: ECV, to return at a later date. Is told discussion re: mode of birth will occur after unsuccessful ECV. | One-stop shop breech clinic. Scan, counselling and ECV performed by a midwife or doctor with specialist training. If unsuccessful/declined, mode of birth preference documented. To return for further counselling. |
| 37 weeks | Counselling repeated by a different professional, who may have different personal preferences. External cephalic version attempted. If unsuccessful, asked to return for counselling re: mode of birth in consultant clinic. | Returns to breech clinic for second attempt at ECV. Sees same practitioner, who is also part of the breech birth team. After unsuccessful/declined second attempt, confirms choice of mode of birth. Wider team made aware of planned VBB. |
| 38 weeks | Returns to antenatal clinic and sees another consultant or registrar. Majority of UK hospitals reluctant to support planned VBB. Advised to have CS. In some cases, a managed breech delivery in lithotomy is offered. | Woman and her birth partner prepare for the up-coming birth. |
| 39 weeks + | After a return visit to antenatal clinic to attempt to negotiate support for an active VBB, meeting yet another consultant, and lots of research on the internet, woman seeks out external sources of support for VBB. Advocate (Supervisor of Midwives, doula, independent midwife) attempts to liaise with hospital staff, who ask, “Why do they all leave it to the last minute? There’s no time to put a plan in place now!” | Returns to breech clinic at 41 weeks to revisit choice of mode of birth, taking factors such as fetal growth and length of pregnancy into consideration. Talks to the same or another experienced member of the breech team. |
Questions for reflection:
- Consider your current work setting. If a woman tells you she would like to consider a VBB but is not receiving support to plan one, what can you do?
- Who needs to be involved in her plan?
- Who will support you to support her? To what extent are you comfortable being involved?
- How can you build a local breech team, who can be ready to meet this need when it arises?
- Consider working with your team to develop an informational resource for women, like this leaflet from King’s College Hospital.
Please share your positive experiences and good examples of breech teams in the comments.
Shawn
References:
Beuckens, A., Rijnders, M., Verburgt-Doeleman, G., Rijninks-van Driel, G., Thorpe, J., Hutton, E., 2016. An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives. BJOG An Int. J. Obstet. Gynaecol. 123, 415–423. doi:10.1111/1471-0528.13234
Catling, C., Petrovska, K., Watts, N.P., Bisits, A., Homer, C.S.E., 2015. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery. doi:10.1016/j.midw.2015.12.008
Coyle ME Peat B, S.C.A., 2012. Cephalic version by moxibustion for breech presentation (Review). Cochrane Database Syst. Rev. doi:10.1002/14651858.CD003928.pub3
Walker, S., Perilakalathil, P., Moore, J., Gibbs, C.L., Reavell, K., Crozier, K., 2015. Standards for midwife practitioners of external cephalic version: A Delphi study. Midwifery 31, e79–e86. doi:10.1016/j.midw.2015.01.004