Category Archives: Breech Teams

Becoming a Breech Specialist and Setting up a Breech Service within the NHS

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.”

And

“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.

Teaching physiological breech birth at City, University of London

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, 2017Walker et al, 2017Walker 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:

Breech service referral process at St George’s University Hospital NHS Foundation Trust

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.

Breech information leaflet developed by the Breech Birth Network, CIC

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

International Maternity Expo Award Nominees

The Breech Birth Network are delighted to announce both Shawn and Emma have been shortlisted for awards at the International Maternity Expo Awards. We are both very honoured to have been shortlisted in the following categories:

Dr Shawn Walker – shortlisted for the Research Innovation Award and the Improving Safety Award

 

Dr Shawn Walker has been shortlisted for both the Research Innovation Award and the Improving Safety Award for her work in improving the knowledge, skills and training around Physiological Breech Birth. Shawn has published a number of research articles highlighting the importance of effective training, the development of experienced breech teams and pracical insights into upright breech birth. Shawn is currenty writing proposals for further essential research into Physiological Breech Birth to further improve safety and choice for mothers and their babies as well as practiotioners facilitating such births.

 

Emma Spillane – shortlisted for the Practice Innovation Award

Emma has been shortlisted for the Practice Innovation Award for her work in setting up a breech birth service in the large London teaching hospital she works in. The service supports mothers in their choices regarding mode of birth for breech presentation at term. Emma is also completing her Masters research in Breech Childbirth Preferences of Parents to further support service provision and support for parents choices.

We would both like to thank those who nominated us. It is a privilege and an honour to have been recognised for the work we are both doing.

Shawn and Emma

Stockholm and the breech

This weekend, I have been lucky enough to visit Stockholm, Sweden, at the invitation of the Södersjukhuset (BB SÖS), with Dr Andrew Kotaska, author of the 2019 Canadian breech guideline. We delivered training in breech research and practice to obstetricians and midwives from across Stockholm, a contribution to their recent effort to establish city-wide guidelines.

Breech Team Leader Tove Wallström and Breech Midwife Monica Berggren

The day was organised by senior obstetrician Julia Savchenko (pictured with Andrew above). Julia and fellow senior consultant Tove Wallström lead the Labour Ward and the SÖS breech team. These inspirational women presented their local audit results, showing how their vaginal breech births have increased from 9 in 2014 to 50 so far in 2019. Almost all women give birth in an upright position, and all births are attended by a breech-experienced obstetrician and a breech-experienced midwife from the breech team.

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

It was exciting to see a ‘Breech Team‘ service working so well in the largest maternity hospital in Stockholm. The team are able to take referrals for women pregnant with a breech-presenting baby at term who wish to give birth at SÖS. They can also provide training for other teams in Sweden who wish to improve the safety and delivery of their own services, using their own resources and presentation materials provided by the Breech Birth Network.

To ask about referral or training, please contact Julia and Tove using the form below.

Typical Swedish post-birth meal — a step up from British tea and toast!

Each family places a pin in the board to celebrate their birth as she leaves SÖS

Busy hospital!

For more information about training outside of Sweden, please see our Booking a Study Day page.

For information about training or referrals for a vaginal breech birth in Sweden, contact Julia and Tove:

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.

Breech Team Lanyard Pins!

We are thrilled at the interest these pins are receiving. We have created them to make it easy to identify people who have attended our Physiological Breech Birth study day and are either on a breech team or working with Breech Birth Network to create a breech team in their work setting. More information below, with the form to request pins at the bottom of this post. We are going to maintain this criteria strictly so that it is meaningful, but we will consider additional designs in the future.

In a few weeks, we will receive our new breech team pins from @madebycooper, based on our Breech Birth Network training booklet cover image by Merlin Strangeway (Drawn to Medicine).

We have created these pins because my research (Walker et al 2018open access version) indicates that the three elements which develop and sustain expertise in breech birth are:

  • affinity
  • visibility
  • relationship

Expertise is generative — it generates comparatively good outcomes, and confidence and competence among colleagues. The role of a breech team is to develop expertise in order to support the entire team to support vaginal breech births safely.

Breech teams enable the development of expertise within organisation because team members  work flexibly to attend breech births when they occur, enabling them to acquire clinical experience. Once new team members develop their own skill and experience, they continue to attend births as an extra layer of support for the wider maternity care team, maintaining their own expertise while promoting confidence and safety.

Walker S, Parker P, Scamell M, 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209. https://doi.org/10.1111/birt.12326

Some Trusts have a specific on-call system. But most find that making their breech team visible is enough to introduce cultural change supporting the development of expertise. One simple way to do this is to designate a breech team (including obstetricians and midwives) and post a list of people and how to contact them in a prominent position on the labour ward. Make it an expectation, backed up by the Trust guideline where possible, that someone from this team is involved in any episode of breech care wherever possible. Sometimes it is not possible. But most of the time it is, even without a rigid on-call system.

A team member should be involved from the moment a term breech is diagnosed, whether antenatally or in labour. Individuals who have developed generative expertise counsel very differently from those who are still developing their skills or are not keen on breech birth. “Facilitating an informed consent discussion that demonstrates respect for maternal intelligence and autonomy, while being realistic about the inability to guarantee a perfect outcome” is also a skill that develops with practice (Walker et al 2016, p11 — open access version).

Walker S, Parker P, Scamell M, 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209. https://doi.org/10.1111/birt.12326

These pins will increase the visibility of breech teams by reminding women that physiological breech births are supported, countering negative portrayals in the media and social discourses of risk, and remind maternity staff that involvement of the breech team is available and expected.

Breech team lanyard pins will be available for FREE from the Breech Birth Network, CIC. To wear the pins:

  • Each member of your team who wears a pin must have attended one of our Physiological Breech Birth study days. If this hasn’t happened yet, you can easily book a study day at your hospital.
  • Your team must contain at least one person who has taught breech skills with us on our Physiological Breech Birth study days (more information on how to do this is on the page). The network pays your expenses to do this, but we need to confirm we are on the same page with the skills and content. Teaching is also one of the mechanisms through which breech expertise develops.

To order pins for your team, contact us using the form below.

Love,

Shawn