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:
- do everything possible to ensure there is as much ‘skill and experience’ as possible in the room for every vaginal breech birth; and
- 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?
What is Physiological Breech Birth? Read more here: Walker S, Scamell M, Parker P (2016) Principles of physiological breech birth practice: A Delphi Study. Midwifery. 43:1-6. (Author version archived at City Research Online)