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.
This Monday, we held a training day at St. Mary’s Hospital in Paddington, London, to support the Imperial OptiBreech Team, led by Consultant Obstetrician Sabrina Das.
OptiBreech Just Giving Page
We will be donating 10% of any revenue obtained from this and all future study days to the OptiBreech Just Giving page, which is raising money to provide sites with extra support so that team members can continue to be on-call for women planning a vaginal breech birth.
We would be incredibly grateful if you would join us in this support by donating if you can and sharing the link with your social networks.
Below is some recent research to demonstrate how we are helping to make breech services better and safer for all families:
First OptiBreech results poster! Walker, S., Dasgupta, T., Hunter, S., Reid, S., Shennan, A., Sandall, J., Davies, S., 2022. Preparing for the OptiBreech Trial: a mixed methods implementation and feasibility study. BJOG An Int. J. Obstet. Gynaecol. 129, 70. https://epostersonline.com/rcog2022/node/4909
Spillane E, Walker S, McCourt C, 2022. Optimal time intervals for vaginal breech births: a case-control study. NIHR Open Res. 2, 45.https://doi.org/10.3310/nihropenres.13297.1
Walker S, Dasgupta T, Halliday A, Reitter A, 2021. Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS): A systematic review on variations in outcome reporting. Eur. J. Obstet. Gynecol. Reprod. Biol. 263, 117–126. https://doi.org/10.1016/j.ejogrb.2021.06.021
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
What can a dedicated breech clinic and team do for your service? This Brussels hospital increased term breech births from 4.3% to 43.5%, with no change in neonatal outcomes (non-significant ⬇️ in NNU admissions) https://t.co/jgeCjM9Jnu
Further research about obstetric breech training and willingness to attend breech births:
Rattray et al (2019) — Only 36% of medical officers who attended training in Australia had facilitated > 5 breech births. Suggests specialist teams and/or centres of excellence.
Post et al (2018) — Does vaginal breech delivery have a future despite low volumes for training? Results of a questionnaire. Among sixth year residents, 65% were not yet confident to personally guide VBDs. 13% of the 294 residents and new obstetrician gynaecologists had performed less than 3 VBDs. Suggested specialist teams and/or centres of excellence as potential solutions.
(This list is not exhaustive, but what I have time for. Before you assume that things are different where you are from, do a similar anonymous survey in your own unit.)
Providing advanced training to a core breech clinical teaching team is potentially more efficient and effective than training the entire maternity care team using traditional methods. The theory is strong, but rigorous research needs to be done.
Traditional training, looks something like this: Participants take time away from clinical commitments to attend a dedicated training session, ranging in length from a few hours to a whole day or more.
Challenges for this approach in the context of breech birth
1. It’s expensive
While preparing the research proposal for the #termbreech2020 Physiological Breech Trial, I worked closely with NHS Research & Development Finance specialists. Using the Agenda for Change pay scales, we calculated that providing 1 day of physiological breech birth training to 5 obstetricians and 5 senior midwives will cost the service £2,442 just to release them from clinical work. Multiplying this to cover the whole staff will obviously increase the cost exponentially. And then there is the cost of paying the trainers.
This is why most training programmes, like PROMPT, use a ‘train the trainers’ approach. It is a more efficient and effective way to disseminate training throughout an organisation. [PROMPT is a great multi-professional training package, but unfortunately, they excluded outcomes for breech births from their evaluation (Draycott et al 2006). So this training has not yet been evaluated for vaginal breech birth.]
2. The effects of training wear off before most people will have a chance to use it
Our systematic review of the effectiveness of breech training strategies showed that breech training can improve objectively assessed skill and knowledge, but that these effects wear off quickly, sometimes within 6 weeks, sometimes within 72 hours. A bigger concern was that, in some cases, confidence increased but objectively assessed skill did not. Training alone is likely not sufficient to improve breech skills, but for those who have some clinical experience, it may extend current understanding.
If you train a staff of 40 (or more) in a service that has only 1 breech birth per month, most of them will not have a chance to consolidate their learning in clinical practice. And if you do not have a plan for ensuring that someone who has attended enhanced training will attend the vaginal breech births that do occur, the enhanced training will not contribute to improvement in outcomes.
3. Clinical support in practice appears to make the biggest behavioural change
A surprising finding from our systematic review was that attendance at an obstetric emergencies-type training course was inversely associated with attendance at vaginal breech births, unless a system was in placed to provide clinical support in practice. This means that clinicians attended fewer vaginal breech births after taking breech training as part of an obstetric emergencies package. Although no quantitative evaluation was done, the studies that reported increase in breech births attended all had a model for ensuring experienced support in practice.
Conclusion
Implementing a breech clinical teaching team is a way of ‘training everyone.’ The model just differs from traditional ‘training day’ methods, which have not proven effective on their own in sustaining safe vaginal breech services.
Paying a few people who want to support breech births to be on-call occasionally and to cascade training is likely less expensive than providing enhanced training to the entire maternity care team, or even the entire senior team. But we need to implement the model and evaluate it in a systematic way in order to determine cost effectiveness. This is why experienced health economists are central to the #termbreech2020 Physiological Breech Trial and helped develop the design.
According to the evidence, breech clinical teaching team is also likely to result in greater availability of the option of vaginal breech birth for women who want them. This was a central concern of the women who participated in #termbreech2020 Physiological Breech Trial public engagement work.
But! Isn’t experienced senior clinical support what consultant obstetricians do? … Good question. We’ll discuss that next …
Explanation of the Proficiency Criteria used in the OptiBreech study
The setting of proficiency criteria for those attending vaginal breech births in the OptiBreech Study is a quality assurance mechanism. The potential risks of participating in research need to be mitigated as much as possible. Defining a set of minimum training and experience criteria for those attending vaginal breech births in the feasibility study is one way of doing this.
The Merriam-Webster Dictionary defines proficient (adv.) as: well advanced in art, occupation or branch of knowledge. Proficiency lies somewhere between basic competence, which all professionals are expected to have in order to practice safely, and expertise, which only a few may acquire. Using the term ‘breech expert’ may also suggest that all risks can be eliminated as a consequence, and unfortunately this is never true with birth.
participated in 6 hours of evaluated physiological breech birth training;
attended at least 10 vaginal breech births, including resolution of complications using manual manoeuvres;
experience of 3 vaginal breech births (attended or taught with simulation) within the past year; and
delivered physiological breech birth training at least once within the past year, including reflective reviews of births attended.
The evidence that has contributed to these criteria is referenced below, but they are also the result of much involvement from professionals currently trying to implement physiological breech birth services in a responsible manner.
The drawback of using proficiency criteria during a trial is that results will only be generalisable to settings which apply a similar set of criteria. After 10 years of studying how centres have re-introduced thriving vaginal breech birth services where little or no service existed, I have observed that almost all those that succeed use some form of a ‘breech team’ strategy. This is rarely reported because it is usually informal, and that may be one reason great services are sometimes not sustained as key individuals retire or leave the service.
I actually believe that the idea of a ‘golden age’ of universal breech skill is a bit of a myth. I think that adverse outcomes used to be more common and more tolerated. And I think that certain individuals have always had an affinity with breech birth, leading to them being called in to help their colleagues more often. Breech clinical teaching teams just make this mechanism visible and systematic.
Follow-on question from a consultant: Are the numbers meant for proficiency realistic?
A breech clinical teaching team can realistically achieve the numbers required to maintain proficiency if the team is not larger than the number of births occurring. If the numbers of vaginal breech births are small, the breech clinical teaching team needs to be smaller. If the unit is functioning as a centre of excellence and attracting additional breech births, the team can and will expand.
The important lessons we have learnt from working with centres that have implemented a good physiological breech training service are:
Do not change a whole organisation’s approach to breech birth unless everyone has received the same training and has been supported to apply it in practice. Just because a unit has hosted a study day doesn’t mean the unit is now a centre of excellence. Training, skill and experience lie with individuals, not institutions. If you haven’t been trained to do something new (e.g. upright breech birth), don’t do it. Use a breech clinical teaching team to help new skills embed into the wider service.
Do not become complacent once a service embeds and becomes the ‘norm’ in a unit. Be cautious when new members of staff join a service, including as part of training rotation or locum/bank. They are likely not to have a similar level of training and experience.
Follow-on question: Does this mean we should not attend physiological breech births if we have not achieved these criteria? And what if we do not have enough people who have achieved the criteria to cover the service?
The criteria are not meant to prohibit breech births from occurring without them. But if we consider this the benchmark ideal for physiological breech birth, our counselling can include how close we are to achieving this, or not. We can help women make informed decisions by clearly defining ‘skill and experience,’ and explaining that where this is not available, it may introduce some increased risk.
Even in the OptiBreech Study, we may need to be flexible in the early stages, being open and honest with the women who participate. But setting the criteria and attempting to achieve them will enable us to answer important questions, like How often were we able to get a breech team member to the birth? Did it require us to put people on-call? If so, how often? If we weren’t able to do it from the start, how long did it take to establish a proficient team? How much effort did it take from the team, and how do they feel about it? How do the rest of the team feel about the team’s involvement? Answering these questions will enable us to refine the design of the study even further if it proceeds to a substantial trial.
Follow-on questions: The study design and criteria seems to direct towards selective group. And what if I feel skilled and experienced to attend breech births but do not meet all of the criteria?
The criteria are based on the best available evidence. Participation in a breech clinical teaching team may be perceived as a privilege, but it will also require effort from those involved. It is open to anyone with an interest who puts in that effort.
The OptiBreech Study is in the early stages of feasibility testing. Professionals should go on using the same standards of competence recommended in local and national guidelines outside of the feasibility trial.
Walker S, Reading C, Silverwood-Cope O, Cochrane V (2017) Physiological breech birth: Evaluation of a training programme for birth professionals. The Practising Midwife. 20(2): 25-8. (Extended Author Version)
Use of breech clinical teaching teams is a pragmatic mechanism for delivering the only intervention associated in a randomised trial with an improvement in neonatal outcomes: the presence of a ‘skilled and experienced’ practitioner.
Su et al (2003) performed a secondary analysis of Term Breech Trial (Hannah et al, 2000) data to identify factors associated with adverse perinatal outcomes. The presence of an experienced clinician was the only factor associated with a reduced risk of adverse perinatal outcome in a vaginal breech birth (OR: 0.30 [95% CI: 0.13-0.68], P=.004). Compare this to the reduction of risk associated with a cesarean section during active labour in the same trial (OR: 0.57 [95% CI: 0.32-1.02, P=.06), or the reduction of risk associated with planned cesarean section overall in the trial (RR: 0.33 [95% CI: 0.19-0.56, P=<0.0001).
It is noteworthy that having an experienced clinician at the birth was associated with a reduced risk of adverse perinatal outcome, only when an experienced clinician was defined as a clinician who judged him or herself to be skilled and experienced at vaginal breech delivery, confirmed by the Head of Department. When an experienced clinician was defined as a licensed obstetrician or as a clinician with more than 10 or 20 years of vaginal breech delivery experience, there was no subsequent reduction in risk of adverse perinatal outcome. Thus, our analysis suggests that a clinician’s self-assessment of his or her own skill and experience may be a more valid measure of clinical experinece than either the completion of a training program in obstetrics and gynecology, or having many years of attending to vaginal breech deliveries.
If we take the lessons of the Term Breech Trial seriously, and I think we should, then evidence-based practice would be to:
do everything possible to ensure there is as much ‘skill and experience’ as possible in the room for every vaginal breech birth; and
incorporate the availability of this skill and experience into the counselling women receive.
What can a dedicated breech clinic and team do for your service? This Brussels hospital increased term breech births from 4.3% to 43.5%, with no change in neonatal outcomes (non-significant ⬇️ in NNU admissions) https://t.co/jgeCjM9Jnu
The findings of the Term Breech Trial resonate with the Public and Patient Involvement (PPI) work I have done to explore the feasibility of a physiological breech trial (#termbreech2020). Women also find the availability of a skilled and experienced attendant fundamentally important to their decision-making around whether or not to plan a vaginal breech birth. Consultant Midwife Emma Spillane and I have published two case studies that explore how this works in practice and what it means to women (2019 & 2020).
Finally, my own theory-building research suggests that breech clinical teaching teams are potential solutions to the pragmatic problem of providing ‘skill and experience.’ This consensus-development research with experienced obstetricians, midwives and service user representatives, to determine the standards for practitioners attending upright breech births, recommended ‘specialist’ breech teams. These collaborative recommendations have shaped the development of the ‘physiological breech birth’ intervention in the #termbreech2020 feasibility study.
Given the general depletion of VBB skills and opportunities, one of the hospital-based panel members suggested a ‘specialist’ breech team in every labour setting with at least one member on each shift (or on-call) would be advantageous, and this statement met consensus-level agreement (87%). However, the panel agreed the role of ‘specialists’ is to mentor and support breech skills development throughout the entire maternity care team, rather than functioning as experts of an exclusive skill set.
In summary, the status of the evidence is: Breech clinical teaching teams are a potential mechanism for providing an intervention we know reduces the risk of adverse perinatal outcomes in vaginal breech births: a ‘skilled and experienced’ attendant. And their use is recommended by professionals experienced with physiological breech birth. Now physiological breech birth team care needs to be tested. The #termbreech2020 Physiological Breech Study will explore the feasibility of doing that in a randomised trial.
Coming soon … how is ‘skill and experience’ defined?
I am incredibly grateful for the time my senior obstetric and midwifery colleagues have taken to read and engage with the plans for the #termbreech2020Physiological Breech Trial. If feasible, this will be the first trial of term breech birth in over 20 years. Multi-disciplinary involvement in the trial design is essential to its success. This will be the first in a series of blogs addressing some potential barriers identified. The purpose is to 1) involve others in the discussion and reflection; 2) invite further feedback; and 3) share the learning with colleagues who are planning to implement a Breech Team, within the feasibility study or independently.
‘Breech Team’ is a succinct term for a Breech Clinical Teaching Team.
A Breech Clinical Teaching Team is a multi-disciplinary group of clinicians within a maternity care team who are proficient in facilitating physiological breech births, leading on breech training within the institution and attending vaginal breech births regularly in their clinical teaching role.
What does this look like?
In the #termbreech2020 feasibility study, we will start by providing Physiological Breech Birth training to five consultant obstetricians and five senior midwives.* These 10 initial Breech Team members will organise themselves to cover the service. The team has autonomy over determining how this will work, but support from the institution is essential. The role needs to be recognised so that, at a minimum, team members can be released from other duties temporarily when required to attend a breech birth, or given time back if they have attended a birth outside their normally scheduled hours.
What can a dedicated breech clinic and team do for your service? This Brussels hospital increased term breech births from 4.3% to 43.5%, with no change in neonatal outcomes (non-significant ⬇️ in NNU admissions) https://t.co/jgeCjM9Jnu
The core team should include clinicans who 1) spend a lot of time on the Labour Ward; 2) enjoy teaching; and 3) have skill and experience attending vaginal breech births.
When attending a breech birth, the role of a Breech Team member is to 1) support the attending clinicians to develop their own physiological breech birth skill set; 2) to maintain safety while this occurs; and 3) to continue their own learning. Following each breech birth attended, the Breech Team member shares the learning from that birth by providing a brief reflective account and simulation if appropriate, or supporting the attending clinican to do so, for other members of the maternity care team who did not attend the birth.
The Breech Team also collaborates and leads on breech guidelines and education within the institution. This promotes a consistent approach and dissemination throughout the wider maternity care team.
What a Breech Team is not: A small group of clinicians who are the only people allowed to attend breech births. The role is an additional safety and training mechanism.
Do you have a breech team in operation within your unit? Is it formally set up or informally arranged on a per-woman basis? I would love to hear your thoughts and experiences.
Shawn
from the intro to Løvset’s original publication of his rotational manoeuvre, 1937 BJOG 44(4): 696-701
When a Breech Team member supports a breech birth, who is legally responsible?
Isn’t counselling the biggest issue? Why can’t we just improve counselling to make sure every woman is able to make an informed choice?
How much will it cost?
* All breech training is provided free of charge for the institutions that are participating in #termbreech2020. The feasibility study includes a budget for the release of time for the initial 10 Breech Team members. Breech Team members will then lead on education within the insitution, but training materials (videos, presentations, etc.) and support will be provided. Institutions can request further free training at any time.
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, 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:
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.
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.
