Category Archives: breech clinics

Seeking your thoughts on further research…

Image by Kate Evans

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.

Discussing breech birth in Ethiopia

STUDY 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:

  1. the demand for a vaginal breech birth service, based on written information prior to individualised counselling;
  2. the factors influencing this demand, which can be used to improve shared decision-making training and taken into account when planning future research; and
  3. 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.

https://www.surveymonkey.co.uk/r/8VR9J2K

Emma

New Canadian breech guidelines published

new guidelineA 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.

https://twitter.com/SisterShawnRM/status/1143838688637542400

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.

— Shawn

References

García Adánez J et al 2013. Recuperación del parto vaginal de nalgas y versión cefálica externa. Progresos Obstet. y Ginecol. 56, 248–253.

Hickland P et al 2018. A novel and dedicated multidisciplinary service to manage breech presentation at term; 3 years of experience in a tertiary care maternity unit. J. Matern. Neonatal Med. 31, 3002–3008.

Homer C S E et al 2015. Women’s experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 15, 89.

Kidd L et al 2014. Development of a dedicated breech service in a London teaching hospital. Arch. Dis. Child. – Fetal Neonatal Ed. 99, A20–A21.

Kotaska A 2017. Informed consent and refusal in obstetrics: A practical ethical guide. Birth 44, 195–199.

Kotaska A, Menticoglou S 2019. No. 384-Management of Breech Presentation at Term. J. Obstet. Gynaecol. Canada 41, 1193–1205.

Larsen J W, Pinger WA 2014. Primary cesarean delivery prevention: a collaborative model of care. Obstet. Gynecol. 123 Suppl, 152S.

Louwen F et al 2017. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans? Int. J. Gynecol. Obstet. 136, 151–161.

Maier B et al, 2011. Fetal outcome for infants in breech by method of delivery: experiences with a stand-by service system of senior obstetricians and women’s choices of mode of delivery. J Perinat Med 39, 385–390.

Marko K I et al 2015. Cesarean Delivery Prevention. Obstet. Gynecol. 125, 42S.

Petrovska K et al 2016. Supporting Women Planning a Vaginal Breech Birth: An International Survey. Birth 43, 353–357.

Reitter A et al 2018. Is it reasonable to establish an independent obstetric leadership in a small hospital and does it result in measurable changes in quality of maternity care? Z. Geburtshilfe Neonatol.

Walker S, Scamell M, Parker P 2016. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery 34, 7–14.

Walker S, Scamell M, Parker P 2016. Principles of physiological breech birth practice: A Delphi study. Midwifery 43, 1–6.

Walker S 2017. Competence and expertise in physiological breech birth. PhD Thesis. City, University of London.

Walker, S., Breslin, E., Scamell, M., Parker, P., 2017. Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth 44, 101–109.

Walker S, Scamell M, Parker P 2018. Deliberate acquisition of competence in physiological breech birth: A grounded theory study. Women and Birth 31, e170–e177.

Walker S, Parker P, Scamell M 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209.

Bruxelles et le siège

Training in Lewisham on November 12 — Book here.

“We believe that we do well what we do often.” – Caroline Daelemans

Drs Caroline Daelemas and Sara Derisbourg

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.

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

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.”

Daphne Lagrou of Médecins Sans Frontières demonstrates shoulder press

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.

Practising collaborative manoeuvres for resolving head extension at the inlet of the pelvis (elevate & rotate)

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.

— Shawn