You are invited to an open discussion about the Draft of the new NICE Antenatal Care Guideline. Breech Birth Network would like to collect the views of families who have experienced a breech presentation at term and care providers on the draft guidance.
The NICE Antenatal Care Guideline covers the detection of breech presentation (how midwives and obstetricians pick up that your baby is breech) and how a known breech presentation at term should be managed by your care providers.
The recommendations are based on outcomes that are considered ‘critical’ and ‘important.’ A discussion of how the committee has prioritised outcomes and decided upon a recommendation is included in the Evidence Reviews.
This is a first meeting. A second will be held in March to review the results of this meeting and any written responses Breech Birth Network has received, before the deadline at the end of March. At the meeting we will:
Help you understand what the guideline and evidence reviews are saying.
Ask you how you feel about the recommendations.
Ask you if you would like to provide any feedback to the committee, which we will include in a collective response.
If you are unable to attend this meeting, you are also welcome to:
engage in this discussion by posting a comment on this blog page;
contact us using the e-mail form below to provide non-public feedback;
Note: We have observed that some of the women we work with have experienced distress or sometimes trauma in their breech pregnancies. If your experience makes it uncomfortable to participate in a group event, and you would like to have a 1:1 meeting with someone from the Breech Birth Network, please contact us using the e-mail form below.
Shawn Walker is inviting you to a scheduled Zoom meeting.
Topic: Consultation on draft NICE Antenatal Guideline Time: Feb 13, 2021 02:00 PM London
‘Physiological breech birth’ is an approach to care informed by evidence about the physiological processes of vaginal breech births, and an approach to clinical education based on evidence about how professionals learn to facilitate breech births.
I spend a lot of time communicating about vaginal breech birth, and equally importantly, a lot of time listening to how other people communicate about vaginal breech birth. Lately, I have become aware that many people misunderstand what ‘physiological breech birth’ is. This causes difficulties in communication and prevents current research evidence from improving the safety of vaginal breech birth as quickly as it could.
It’s my job to help clarify so that research can be used to improve safety and choice, as it is intended. Let’s start with what physiological breech birth is NOT:
Physiological breech birth is NOT ‘upright breech birth,’ ‘standing breech,’ or ‘all fours breech.’ Upright maternal birth positions are a TOOL and not a RULE of physiological breech birth. The reference standard is that, in a normally progressing birth, the woman or birthing person should give birth in the position of their preference. For many women having an unmedicated birth, particularly in midwife-led settings, this will be an upright position. Therefore, the logic goes, a ‘normal breech birth’ is one in which the woman is enabled to give birth in the position of her choice. Requiring supine positioning is an intervention.
How does this fit with the RCOG guideline (2017)? This states: “Either a semi-recumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant. If the latter position is used, women should be advised that recourse to the semi-recumbent position may become necessary.”
The RCOG supports the use of upright positioning, but suggests this should be dependent on maternal preference and the experience of the attendant. Our recent analysis of video evidence (2020) showed that conversion to supine maternal position occurs within 10 seconds when use of supine manoeuvres is required. Therefore, the most recent evidence indicates that, while providers should continue to inform women that they may need them to turn over if the birth is very complicated, the experience of the attendant does not need to influence a woman’s initial choice of birthing position. Even if the attendant knows only supine manoeuvres.
Where it is possible and safe to support a woman’s liberty in her birthing process, that’s what we should be doing, right? There is no evidence to indicate that use of supine birthing position improves outcomes for mothers and/or babies compared to enabling upright positioning. There is also no evidence to support the use of some manoeuvres over others; only things, like pulling, we know are dangerous. If a local guideline stipulates that women should be asked to assume a supine position to birth, this is out of line with both current RCOG guidance and the principles of woman-centred care.
Physiological breech birth is NOT, “It’s just hands off the breech. Just breathe, wait for the next contraction.”
The penny dropped for me after hearing two different midwives in two different cities describe to two other people what ‘physiological breech birth is’ using exactly this phrase, word for word. And then participating in risk management reviews following adverse outcomes, where midwives had document that they were practising ‘hands off the breech.’ And then attending multiple births (and videos), where midwives were instructing women to ‘just breathe, wait for the next contraction,’ even when there was concern about fetal condition and the situation was becoming urgent. Because this is what they had been taught.‘Hands off the breech’ has become a dogma with unintended consequences. Instructing someone to avoid pushing when they feel the urge is an INTERVENTION. It has no evidence to back it up, nor any good theoretical basis other than preventing people from pulling when they don’t know what else to do.
It’s not surprising that some senior managers are cautious about enabling ‘physiological breech birth,’ if this is what they understand it to be, especially if they have participated in adverse outcome reviews where this sort of practice has been described.
But, due to science, we know how to do better. Our video analysis showed that in a sample of 42 births, the birth was complete within 2:46 of the birth of the pelvis in 75% of cases. Regarding birth intervals, the RCOG guideline states that breech births should be assisted if there is delay of more than 5 minutes from the buttocks to the head. We are in the same ballpark of the RCOG’s recommendation based on expert opinion. But now we know that if you wait this long to assist, you are already outside the normal reference range.
Physiological breech birth is not contradicting our already strong, evidence-based guideline. Rather, current, living, emerging evidence is refining it.
Historical use of the phrase ‘physiological breech birth’
Midwife Jane Evans used the phrase ‘physiological breech birth’ in her 2012 article, Understanding Physiological Breech Birth. In it, Evans shares her insights and descriptions of the mechanisms based upon her observations in clinical practice. Those of use who use this phrase in our research have continued in this tradition, using systematic, planned observational and other research methods. Many of her observations we have confirmed; some have been modified.
How to let the evidence help you
Let’s say you are a Practice Development Midwife. You teach the breech birth update in a 40-minute slot, using materials commonly used in other obstetric emergencies training programmes. You’d like to ensure the update is as informed by up-to-date evidence* but don’t want to blow people’s minds apart with variations from what they already know, especially now. Good idea.
These are my top 3 tips for making sure the training you deliver evolves with the current evidence base (as of January 2021):
Explain that the RCOG guideline recognises and supports women to adopt an upright position if that is their preference. Explain that the evidence indicates it takes less than 10 seconds to convert from upright to supine position. So even if providers are only experienced in supine complications, women should be supported to adopt the position of their choice. Although ‘lithotomy’ is not necessary, run through what conversion would look like in practice with your team if this helps people envision what is possible. Show them the video above if you are able.
Recommend the use of maternal movement and effort if any delay is identified. Delay is defined as no progress for 90 seconds at any point once the baby begins to emerge. Our video research indicated that maternal movement (#giveitawiggle) and effort (gentle encouragement to “push”) alone is often effective, without the risk of iatrogenic damage from hasty manoeuvres, but it is not always used. Instead, women are often instructed to breathe through a contraction and resist the urge to push. Because time is of the essence, and contractions may be 5 minutes apart in 2nd stage, this is a safety risk. Even in supine births with an epidural in situ, simply asking the woman to push will also work in this situation if there is no obstruction. At this point, the uterus is almost entirely empty; a contraction creates the urge to push, but maternal effort does the job. The use of maternal agency to facilitate the birth is a first principle of physiological breech birth – it’s not all about the position.
Teach shoulder press alongside MSV. Our video research found this simple manoeuvre was used in 57% of the upright breech births in our sample. Start by explaining the principle: elevating the occiput and flexing the fetal head, so that the smallest diameter delivers. When a woman is supine it is done like this … MSV. When a woman is upright, this works too … shoulder press. But the principle is the same. Then invite people to practice the one they are most likely to use. This flexible approach, recognising the variety of practice contexts, also reduces the risk an out-of-hospital midwife will ask a woman to lie down on the floor so she can perform MSV. This is a safety risk as it automatically deflexes the head.
Sure, the physiological breech birth evidence base covers a lot more. Our full training package (study day or on-line) goes into less common complications and their solutions, more about the research, and how to use the Algorithm to guide decision-making. A feasibility study is currently being conducted, hoping to trial a new care pathway based on physiological breech birth. But it is possible RIGHT NOW to use the available evidence to update current practice in a safer direction, without making major changes to what you are already doing.
Lastly, if one can point out a single maxim in breech deliveries, take heed of the results of the experienced country midwife and doctor. They are usually very good, and their results are obtained by a policy of non-intervention. Do not interfere unless it is necessary, but when it is necessary interfere quickly and with certainty.
Ian Donald, 1956, Practical Obstetric Problems
The careful, systematic study of vaginal breech births that has taken place in the physiological breech birth tradition reflects this maxim. Do not intervene, not by dictating a birth position, not by instructing someone not to push, not at all, unless it is necessary. Due to a lack of exposure, many health care professionals just do not know how to recognise ‘when it is necessary’ and therefore cannot act quickly and with certainty, through no fault of their own. Due to physiological breech birth research, ‘when it is necessary’ can now be defined and described much more precisely. Therefore, it can be taught. And it can be tested.
But if the available research indicates simply stopping untested but commonly applied interventions may reduce identifiable risks, do we really need to wait for an RCT?
P.S. A note on *up-to-date evidence. When preparing to write this blog, I did a brief literature search to find others (e.g. not ‘physiological breech’) who are publishing research related to the clinical practice of vaginal breech birth in the UK. The last I could find were Sloman et al 2016 and Pradhan et al 2005. Many of Sloman’s findings are consistent with those of other physiological breech researchers. I am keen to hear if anyone else in the UK is producing evidence concerning the clinical practice of vaginal breech birth at the moment — breech birth itself, not ECV or decision-making. Because it’s starting to feel surreal when people say, “We don’t teach/do physiological breech birth because it’s not evidence based …”
Jan, H., Guimicheva, B., Gosh, S., Hamid, R., Penna, L. and Sarris, I. (2014), Evaluation of healthcare professionals’ understanding of eponymous maneuvers and mnemonics in emergency obstetric care provision. International Journal of Gynecology & Obstetrics, 125: 228-231. https://doi.org/10.1016/j.ijgo.2013.12.011 — And one of the co-authors (L Penna) is also a co-author of the RCOG guideline. This is the reason we do not use eponyms when teaching skills on physiological breech birth study days.
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.
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.
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.
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).
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 (email@example.com), 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 firstname.lastname@example.org 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.
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.
% studies reported
APGAR score at 5 minutes
Perinatal or neonatal mortality
Admission to neonatal intensive care unit (NICU)
Neonatal birth trauma/morbidity
Brachial plexus injury / peripheral nerve injury
Low umbilical artery pH
Hematoma (cephalic or subdural)
Post-partum haemorrhage (PPH)
PPH requiring blood transfusion
Other serious maternal morbidity/other complications
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.
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.
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.
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.
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.
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.)
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.
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 …
The setting of proficiency criteria for those attending vaginal breech births in the OptiBreech Study 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.
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 OptiBreech Study, 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 OptiBreech Study 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.