Author Archives: midwifeshawn

About midwifeshawn

Midwife with a special interest in complex normality, especially breech.

Visits and elective placements for students

Emma and I frequently receive requests for elective placements from students keen to experience midwifery practice related to breech birth. We wrote this post to provide some guidance into what you can do if you would like to gain more breech exposure.

Elective placements are tricky for a number of reasons:

  1. At the moment, COVID-19.
  2. A lot of administrative paperwork for a short placement.
  3. We need to prioritise students from our local universities.
  4. Direct work with women with a breech-presenting baby is only a small part of what we do.
  5. No guarantee there would be any breech births during this period and/or that permission would be given for you to attend.
  6. You will not be able to gain hands-on experience on an elective placement.

If you would like to spend your elective placement learning more about working with breech presentation, our on-line course is a great place to start. You will gain more exposure to the way breech births work, in a shorter period of time, than most midwives do in their careers. You will gain insight into how women and birthing people can be counselled to ensure informed decision-making. And you will learn how others have implemented change to the way breech works in their local hospitals.

You could structure your own elective placement, including the following:

  1. Completing the Physiological Breech Birth on-line training.
  2. Working with your local practice development midwives to attend any local training provided to qualified midwives, doctors or medical students, for example mandatory training activities.
  3. Arranging to observe local counselling for breech presentation in your antenatal clinic. This may require you to liaise with the Antenatal Clinic Matron to find out about the local breech care pathway.
  4. Attending presentation scans. You will need to find out where and by whom these are done in your local unit.
  5. Observing external cephalic versions. Where and by whom are these done in your local unit?
  6. Reading through publications related to physiological breech birth so you really understand the principals and evidence base.
  7. Make a video about some aspect of breech management. If we include it in our training, you get lifetime access for free! Think about what women you encounter need more information about. Or what your fellow students need to learn about breech that you have learned through your placement. Practice finding evidence-based answers to the questions posted to these forums.
  8. Hang out on-line in forums related to breech birth, such as Breech Birth Network’s FaceBook page and Instagram, Breech Birth UK, Breech Birth Australia and New Zealand, and the Coalition for Breech Birth. This will give you insight into women’s and providers’ concerns and experiences.
  9. Writing a commentary article for a midwifery practice journal, such as TPM’s Student Midwife, summarising your self-made elective placement and what you learned.

Finding out the answers to all of these questions and/or completing these activities will give you insight into how the breech care pathway works for the women you care for. In some locations, this care is provided through an organised clinic and the path is clear. In other sites, care is more fragmented, and it may be harder to determine what the pathway is. But this in itself is useful because you will be able to see the work that needs to be done!

Another benefit of crafting your own placement in your local setting is that, when your colleagues know of your interest in breech, you are more likely to be involved in actual breech births. This is called “attracting breeches,” and you can read more about it in this research.

We are very keen to support students but need to be realistic about how we might be able to do that at the moment.

— Shawn and Emma

Image: Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre

New training videos from the Hospital of Southern Denmark

The team at Sygehus Sønderjylland, the University Hospital of Southern Denmark, has created a wonderful new series of training videos for upright breech birth. We are thrilled to be able to share them with you!

The creation of the videos was led by obstetrician Kamilla Gerhard-Nielsen, who also led the implementation of the upright breech concept in the hospital and its introduction in Denmark.

They also host a FaceBook page. Image: Obstetricians Katrin Loeser and Kamilla Gerhard-Nielsen

Saturday at 2pm: Consultation on Draft NICE Antenatal Care Guideline

Update 17 March: This was our final submission.

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.

Josephine and Thiago talk about their experience of Ulysse’s breech birth at Erasme Hospital in Brussels

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:

  1. Help you understand what the guideline and evidence reviews are saying.
  2. Ask you how you feel about the recommendations.
  3. 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;
  • or leave a comment on our FaceBook group page, where we will post a link to this invitation.

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.

Meeting Details

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

Join Zoom Meeting
https://us02web.zoom.us/j/88695973178?pwd=U0k2MVg3cSs5eUd0Z29ONjJIbjIzZz09

Meeting ID: 886 9597 3178
Passcode: Zja8zR

Links to Draft Guidance

Breech Birth Network’s fully-evaluated, evidence-based Physiological Breech Birth training is now on-line! Including dozens of videos of real breech births. CPD certificate provided upon completion. Covering:

Simple Shoulder Press
  • types of breech presentation
  • maternal birth positions, normal mechanisms
  • normal timings of emergence
  • normal fetal characteristics during emergence
  • using maternal movement and effort to avoid delay
  • assisting newborn transition
  • delay on the perineum
  • assisting legs, arms and heads to be born
  • developing and sustaining local expertise
  • implementation examples
  • woman-centred counselling

What is ‘physiological breech birth?’

‘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.

Image from Dr Anke Reitter, 2019

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.

Permission to use this video for teaching purposes is granted. Just access this page and click the full screen icon.

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.

Permission granted to use for teaching purposes

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):

  1. 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.
  2. 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.
  3. 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.

In Summary

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?

Shawn

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 …”

Here’s some!

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.

Model of a breech baby sitting over the pelvis

Touch Surgery / Medtronic breech birth simulation app

Physiological breech birth training is now available via the Touch Surgery app. This 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.

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.)