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.)

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