Investing in staff and their skill development will achieve the same, if not better, results and should be the priority.
This a response to a recently published report in PLOS Medicine suggesting that implementation of universal third trimester ultrasound scanning in pregnancy improves outcomes for babies and mothers.Why use more retrospective data and modelling to support universal third trimester scanning when prospective data suggests the implementation of specialist vaginal breech birth teams is equally likely to impact outcomes? — The OptiBreech Project
Since the publication of the 2017 RCOG guidelines on the Management of Breech Presentation, mothers have, in theory, been given more choice in their options relating to mode of birth. Unfortunately, anecdotally this does not seem to be the case for all. Many units across the UK do not have dedicated services for mothers found to have a breech presentation at or near term. Therefore, they are potentially missing out on receiving balanced information regarding their choice of mode of birth. Finding out your baby is in a breech presentation at this late stage of pregnancy can be upsetting for some, birth plans have been discussed and made, excitement is building for the new arrival and then suddenly this seems to all be turned upside down. More decisions have to be made, that’s if the choices are offered to parents. Having a dedicated breech clinic, run by those knowledgeable and experienced in breech presentation, can help to allay some of the worries and concerns experienced by parents and ensure all evidence-based options are discussed in a balanced way. The clinic enables a two-way dialect between healthcare practitioner and mother in a supportive environment. In the current financial climate of the NHS it can be difficult to set up new services, however, the mother’s well-being must come first. Additionally, the skill of the practitioner is key to ensuring safety. The RCOG states:
“The presence of a skilled practitioner is essential for safe vaginal breech birth.”
“Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.”
But with the decline in the facilitation of vaginal breech birth over the past two decades how do we ensure as healthcare practitioners that we are skilled to facilitate such births? This post aims to describe one way to increase knowledge, skill and experience in this field and how to set up a breech service within an NHS Trust to ensure mothers really do have all the options open to them for mode of birth with a breech presentation.
The first step to gaining knowledge and experience is to become involved in teaching. This has many benefits including, increasing your comprehension and embedding that information so you can pass it on to others; enables people to recognise you as breech specialist and it helps to build confidence when discussing with colleagues and parents alike. The more you are teaching the greater your understanding and the more people will recognise you within this role as a breech specialist. It is vital to keep your own skills up to date if you are putting yourself forward as a specialist, teaching both locally and assisting with teaching through the Breech Birth Network, CIC will help you keep up to date with the latest evidence and move things forward within your own constabulary. The team at the Breech Birth Network, CIC are very keen to support others to teach on our Physiological Breech Birth courses. You can read the following blog post for more information on the benefits of teaching Physiological Breech Birth with the Breech Birth Network, CIC.
Other ways to get involved with teaching are within the University and to the students coming through the local hospitals, these are the midwives of the future and this is where the biggest change is going to come from. Likewise, speak with the lead Consultant Obstetrician for new doctors starting in your Trust to see if you can teach them a shorter session on their induction days. This enables the new doctors coming into the hospital an awareness of what will be expected of them in terms of offering choice and ensures they have an understanding of both the mechanisms of breech birth and recognising complications. Additionally, setting up a weekly morning teaching session for thirty minutes ideally after handover so those finishing the night shift and those starting the day shift can both attend. This can be done as a case discussion or a scenario using a breech birth video. You could even use a breech birth proforma (if you have one) and ask those attending to complete the proforma whilst watching a video to see if they understand about the timings for a physiological breech birth and when to intervene. Speak to the Practice Development team and ask if you can teach the breech sessions on the mandatory training days too – moral of the story…teach, teach, teach!!
Of course, with all this knowledge and skills you are teaching you need to put it into practice. Put yourself forward at every opportunity to attend breech births both to facilitate them yourself and to support others to gain confidence in facilitating vaginal breech births. Clinical experience is essential. Research has shown, to maintain skills and competence the breech specialist should attend between three to ten breech births every year (Walker, 2017; Walker et al, 2017; Walker et al, 2018). In some smaller units this may be difficult to achieve but by making yourself available to attend births you will have a far better chance at getting these numbers in practice. There is also evidence which suggests that you can create the same complex pattern recognition by watching videos of vaginal breech births, both normal and complicated, as you can by attending breech births in real-life (Walker et al, 2016). Watching videos has the added benefit that you can rewind and re-watch parts of the video to ensure understanding and further analysis.
Setting up a breech birth service would be an excellent next step. Firstly, find a Consultant Obstetrician who is supportive of physiological breech birth and who would help to lead on service development with you. This has to be a multi-disciplinary approach other wise it just won’t be sustainable or safe. The best way to move such services forward is with consultant support and input, don’t try and do it on your own. A breech birth clinic is a good starting point for any service development, this will provide midwife-led and consistent counselling for parents attending the clinic. Depending on the size of the hospital, running the clinic once a week should be adequate initially. Setting up a dedicated email address for all referrals to be sent to is a great way to ensure referrals are not missed and there is a clear pathway set out. The following is an example of such a pathway:
Referrals can be made by any healthcare practitioner, but it is a good idea to link in with the sonographers performing the ultrasound scans. They may be able to send the details of the mother via email immediately following the scan and give the parents an information leaflet. This avoids any delay with the referral being made by another healthcare practitioner and ensures the counselling remains consistent. Moreover, the development of ‘breech teams’ is supported in the literature to ensure there are breech specialist midwives and doctors on every shift, or on-call, to support the wider team to gain their clinical skills to facilitate vaginal breech births and increase safety for mother and baby.
To further develop the service and your own skills you could complete a midwife scanning course. This will enable you to scan mothers referred into the breech service to check presentation before sending for a detailed scan. The advantages of this is that mothers could be referred into the clinic earlier, from thirty-four weeks gestation based on identification on palpation. Research has shown mothers find it difficult making decisions about mode of birth for breech presentation so late in pregnancy and would benefit from earlier referral and discussion. Referrals made at thirty-four weeks gestation with a bedside midwife scan to assess presentation, would enable the counselling to begin sooner giving more time for decision-making. An additional advantage of being able to scan is following mothers up after successful external cephalic version (ECV). Seeing mothers, a week after successful ECV enables you to scan the mother to ensure the baby has remained in a head-down position avoiding unexpected breech births. An adjunct to the scanning course would be to learn to perform ECV’s. This enables a fully midwife-led service and research has indicated comparable rates of success for ECV’s performed by Midwives and those performed by Obstetricians. It is also cheaper for the Trust to have ECV’s performed by Midwives!
Governance and audit are the final steps to take to building the specialist breech midwife role and for service development. This is often seen as the mundane part of the job, but you will benefit greatly by doing this, not just from immersing yourself in all the research but by knowing your service inside and out. Knowing what needs to be changed and what has improved. The first step in governance change is to write the guidelines incorporating physiological breech birth, new evidence relating to breech presentation, service development, the breech clinic, referral pathways and training. An example of a current guideline can be found via this link. Develop an information leaflet to give to parents which contains the latest evidence in relation to breech birth options. It can be given to the mothers either by midwives in the clinic and/or by the sonographers after their ultrasound confirming breech presentation. The following can be used as an example and is editable for use in your organisation.
Finally, audit, audit, audit! Before, after and everything in between! This is your evidence that things need to change and, once the service is developed, the outcomes since you implemented all the aspects of the service. It will also act as evidence of safety which the governance team within the organisation will want to see. Audit rates of planned caesarean, emergency caesarean, planned VBB, successful VBB, neonatal outcomes, maternal outcomes, uptake of ECV, success rate of ECV etc. All before and after the service. It is also a good idea to obtain service user feedback. Developing a simple questionnaire such as this one enables you to easily send and receive feedback regarding the service. Feedback from service users is the most powerful way of moving services forward and supporting change within an organisation, it also enables you to develop the service dependent on the needs of the parents using it. The process of audit and user feedback is continuous throughout the time running the service. However, it is important analyse and present the result at regular opportunities such as at local level with clinical governance days and meetings and at a wider national level at conferences and in journals.
Whilst it can seem daunting and places you in a seemingly vulnerable position, starting your journey as breech specialist is an extremely rewarding one which will enable you to learn and develop new skills not just clinically but operationally and strategically. It will give you a stepping stone into research, audit and teaching, build your confidence as a practitioner and most of all, empower you to provide the best evidence-based care for those families who need that knowledge and support at a crucial time in their pregnancy to help them to make the right decision on mode of birth for them and their breech baby.
Following the implementation of all that has been discussed in this post, the results within the large teaching hospital I work are as follows:
- Planned caesarean section increased from 55.8% (n=43) to 62.9% (n=66);
- Unplanned caesarean section decreased from 42.9% (n=33) to 24.8% (n=26);
- Vaginal breech birth increased from 1.3% (n=1) to 12.3% (n=13)
All results are for those over thirty-six weeks gestation, there were no differences in neonatal mortality or morbidity prior to or following the implementation of the service. This is a positive change and shows how supporting vaginal breech birth in a safe environment can increase the normal birth rate. The results are after a year of implementing the service and will hopefully continue to improve as time goes on and more midwives and doctors become more confident to facilitate breech births.
Emma Spillane is seeking your thoughts on a new piece of research prior to its submission for ethics approval. If you have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, or you work with pregnant women in a non-medical capacity (e.g. doula, antenatal teacher, breastfeeding supporter, etc.), I would love to hear from you.
I am conducting research as part of my Masters exploring breech childbirth preferences of expectant parents to understand if there is demand for breech birth services within the NHS and explore the factors which influence parents decision-making. At this stage, I would like your feedback on the suggested design of the trial, to ensure that the information resulting from the research will be useful to those considering breech options. For those of you who would like to remain with the project I am forming a Breech Advisory Group provide feedback at further stages in the project such as analysing the results.
If you are interested in participating in my research in this way, please read the plain text summary of the project below and complete a short survey by following the link after the research summary.
Approximately 3-4% of babies at term present in the breech position (bottom or feet first) (Impey et al. 2017). The Royal College of Obstetricians and Gynaecologists’ (RCOG) most recent clinical guideline on Management of Breech Presentation recommends that pregnant women should be offered choice on mode of birth for breech presentation at term(after 37 weeks’ gestation) (Impey et al, 2017). Despite this recommendation, only 0.4% of all breech babies in the UK are born vaginally (Hospital Episode Statistics, 2017), and this figure includes pre-term breech births where breech presentation is more common (Impey et al. 2017). These statistics suggest that either the demand for vaginal breech birth is low, or the choice of mode of birth is not being consistently offered. This study aims to explore this enigma by providing empirical evidence necessary to inform maternity services on the requirement of breech birth services.
Current evaluations of demand for vaginal breech birth services have been limited by the quality and impartiality of information parents are able to access via their maternity services. For example, research has shown that women have difficulties finding information to support their choices and are pressured into making the decision based upon practitioner preference (Petrovska et al, 2016). An investigation carried out in the Netherlands, found that one third of parents would prefer to have their babies born vaginally (Kok, 2008). However, little is currently known about parents’ preferences in England.
This research will evaluate the extent of expectant parents’ preferences for vaginal breech birth prior to counselling, and the factors that influence these preferences, using personal interview surveys (Bhattacherjee, 2012). All women presenting with suspected breech presentation at a large London based teaching hospital – St George’s University Hospital NHS Foundation Trust – will be given information about this study along with their Trust approved mode of birth information leaflet during their routine antenatal appointment at 36 weeks of pregnancy. As per Trust clinical protocol, women with suspected breech presentation will be offered a referral for an Obstetric Ultrasound Scan (OUSS) for confirmation of fetal presentation. During this routine OUSS appointment, either prior to or following the scan taking place, parents will be approached by the researcher and invited to take part in an interview on their preferred mode of birth and the reasons behind these preferences. Both parents, if present, will be interviewed separately. Parents will already have been given information about the study in the form of a Participant Information Sheet PIS) by the clinician referring them for an OUSS. The timing of the interview has been chosen because it fits with the participating Trusts usual pathway of care. Parents are informed there may be long waiting times due to OUSS being arranged at short notice.
The findings from this research will provide evidence on the following:
- the demand for a vaginal breech birth service, based on written information prior to individualised counselling;
- the factors influencing this demand, which can be used to improve shared decision-making training and taken into account when planning future research; and
- a predicted service planning model for a fully integrated breech continuity team within the host Trust.
Data on parents’ preferences for mode of birth will be reported descriptively as a percentage. Qualitative data regarding parents’ reasons for their preferences of mode of birth will be analysed thematically.
A new SOGC Clinical Practice Guideline No. 384 — Management of Breech Presentation at term has been published. It echoes the latest RCOG guideline in promoting accurate and supportive informed consent discussions. One of the main authors, Andrew Kotaska, has written extensively about this before: Informed consent and refusal in obstetrics: a practical ethical guide.
The SOGC guideline frames counselling around mode of childbirth for a breech baby within the context of human rights, especially in the ‘Key Messages:’
A woman’s choice of delivery mode should be respected.
The risk of planned vaginal breech birth is acceptable to some women with a term singleton breech fetus.
Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should be provided with the best possible in-hospital care.
The summary of evidence related to safety is similar to that provided by the RCOG and a good reference for anyone counselling women about their breech childbirth options. A notable difference is the recommendation that,
Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour.
As with the RCOG guideline, the new SOGC guideline recognises the importance of skill and experience to the safety of vaginal breech births. One of the SOGC’s summary statements is:
Vaginal breech birth requires a high degree of skill and support. To avoid the increased risk of out-of-hospital vaginal breech birth, women who choose planned vaginal breech birth should be accommodated in-hospital. To facilitate this, referral to more experienced centres, back-up on-call arrangements, and continuing medical training in vaginal breech birth skills should be promoted (very low).
(Very low refers to the quality of evidence in relation to this recommendation.) The RCOG also recommends antenatal referral to a centre with more skill and experience if necessary. Later in the SOGC text, the authors point out:
Many newly qualified obstetricians do not have the experience necessary to supervise a breech TOL [trial of labour]. Mentoring by more senior colleagues will be necessary if they are to attain these skills. As women will continue to request planned VBB and precipitous breech births occur in all settings, theoretical and hands-on breech birth training using models should remain part of basic obstetrical and midwifery training and of traingin programs such as ALARM, ALSO, and MORE ob.
I am particulary interested in recommendations made regarding how to support breech skill development because Competence and Expertise in Physiological Breech Birth was the topic of my PhD.
In our integrative review of the Effectiveness of vaginal breech birth training strategies (2017), inclusion of breech birth as part of an obstetric emergencies training package without support in practice was negatively associated with subsequent attendance at vaginal breech births, meaning practitioners attended fewer breech births. None of the evaluations of training packages included clinical outcomes, so it was not possible to determine whether they had an effect on safety. But the evidence suggests that support and mentorship in practice is likely to be key to giving less experienced practitioners the confidence to support breech births and gain the skills in practice.
Research on Expertise in physiological breech birth and the Deliberate acquisition of competence in physiological breech birth suggest that mentorship is indeed very important, but that this does not always take the form of senior colleagues supporting newly qualified colleagues. Maintaining classical hierarchies — such as expecting senior obstetricians to have breech skills while younger colleagues, or midwives, not to — can promote a form of alienating authority, which inhibits the development of generative expertise. Among practitioners who had deliberately developed competence to support breech births, younger, highly motivated practitioners often had to leave their primary clinical setting to acquire knowledge, skills and new techniques, which they brought back with them. The fact that they needed to do this suggests that they had not been being mentored at home.
One of the things I love about working in the UK is the long history of multi-disciplinary working. Although some teams work more effectively than others, it means that a person wishing to birth their breech baby with an experienced midwife in attendance does not have to choose between a home birth and an obstetrically-managed hospital birth. The obstricians I work with recognise the skill with physiological birth that their midwifery colleagues bring into the room — and we are grateful for their skill with surgical and very complicated births. We keep each other safe.
Given that referral to experienced centres is recommended in both RCOG and SOGC guidelines, more research is needed about how this works in various settings. What happens if a woman is referred elsewhere, but that hospital cannot or will not accept her for care? What are the economic implications? What defines an ‘experienced centre?’ In some hospitals, such as in Frankfurt Germany, the vaginal breech birth rate can be as high as 6-11% of the total birth rate due to women travelling to experienced providers, compared to 0.4% of the total birth rate in the UK.
We also need to consider and study other potential solutions to skill redevelopment. For example, why expect women to travel away from their known and trusted care team — why not shift professionals instead? I am employed primarily by a university, but I have a contract with one NHS Trust and am completing a contract with another by request, so that I can support them to develop their breech services. Mobility of providers also happens when obstetric trainees rotate between training centres. Sadly, I have heard numerous stories from senior obstetric trainees who have acquired breech experience in one hospital, only to be blocked from using that experience by their senior colleagues in another, a case of hierarchical and alienating authority. Similarly, many midwives have spent time abroad and delivered dozens of breech babies, but have had to stand aside when a woman is diagnosed in labour with a breech because the woman is now considered ‘an obstetric case.’ Women are often not informed when skill and experience is available because these remain invisible and under-utilised, especially in midwives and younger obstetric colleagues.
Throughout the UK, many new breech services are being developed. Breech clinics, like the one at the Royal London, ensure women get consistent counselling by breech-experienced practitioners. They also provide an environment where trainees can learn this skill. Many hospitals are developing ‘breech teams‘ so that vaginal breech births and those attending them can be supported by confident and competent members of the team — this includes experienced midwives. Training activities to support these new teams emphasise the elements available literature suggests will be effective — repetition and reflection — especially using birth videos for team debrief and simulation training. Gradually, we are supporting each other to reintroduce breech skills and consider new ways of sustaining them in order to be able to offer the care our countries’ leading guidelines recommend.
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Training in Lewisham on November 12 — Book here.
“We believe that we do well what we do often.” – Caroline Daelemans
Contact Hōpital Erasme Clinique du Siège on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be.
This month I visited Hōpital Erasme, in Brussels, Belgium. Led by Lead Obstetrician Caroline Daelemans, Erasme began to offer a dedicated Breech Clinic in December 2015. Much of the organisation and development of the clinic has been done by Dr Sara Derisbourg, who continues to research the impact of instituting a dedicated breech service.
I came to Brussels to provide our usual physiological breech study day. The breech team has transitioned to using physiological methods, including upright maternal positions (Louwen et al 2016), after attending training in Norwich in 2017. They now needed the rest of the team to understand the philosophy behind this approach. But the day began with Caroline describing the impact of instituting a dedicated Breech Clinic, and this was particularly exciting for me.
My own research concerning the development of breech competence and expertise, and the recovery of these skills within a service, indicates that developing a core team with significant experience is the most effective method of safely offering a vaginal breech birth service (Walker et al 2016). This skilled and experienced core is more important than the ‘selection criteria’ that are used to predict the likelihood of a good outcome (but in fact are not very predictive). Skill and experience facilitate good outcomes and enable other colleagues to develop competence (Walker et al 2018). The Erasme team even encourage other health care professionals to come with their clients and attend them in labour with their support, to encourage the growth of breech skills.
The need for new ways of organising care has been emphasised in an on-line survey of Dutch gynaecologists just published by Post et al (2018, Does vaginal breech delivery have a future despite low volumes for training?): “Potential suggested alterations in organization are designated gynecologists within one centre, designated teams within one region or centralizing breech birth to hospitals with a regional referral status. Training should then be offered to residents within these settings to make the experience as wide spread as possible.”
Daelemans and Derisbourg began with a small team of 5 people. This has gradually expanded and now includes eight members who together provide 24/7 cover for all breech births within the hospital. Women with a breech presentation are referred by colleagues and increasingly by other women. The environment at Erasme is ideal because the hospital has a very positive approach to physiological birth in general, and a 15% overall caesarean section rate in 2017. This compares to 20.2% in Brussels and much higher in many places globally.
What has the Breech Clinic changed? Before the introduction of the clinic, the planned vaginal breech birth rate was 7.19%, and in just a few years this has climbed to 42.7% of all breech presentations. Neonatal outcomes have remained stable. Actual vaginal breech births have climbed from 4.2% to 35.96% of all breech presentations within the hospital. The success rate for planned vaginal breech birth is 76.3%, which suggests that within experienced teams, the emergency caesarean section rate is also reduced. (The RCOG guideline suggests about 40% of planned breech births end in CS.)
All of this is very impressive. The message is clear: a physiological approach and an organised care pathway, including a breech clinic and experienced on-call team, can reduce the caesarean section rate significantly without negatively impacting neonatal outcomes. We should all look out for Derisbourg’s papers when they are published.
If you are a woman seeking support for a physiological breech birth, or a health care professional looking to refer a woman to the breech clinic, they can be contacted on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be. Caroline Daelemans will be teaching with me in Lewisham, London, on 12 November.