Category Archives: Cultural

Avoiding ‘us versus them’ when breech births go wrong

This week, BBC News Northern Ireland reported on a coroner’s inquest concerning a breech birth:

“Baby death inquest hears breech delivery method very unusual practice.”
11 April 2024, Kelly Bonner, BBC News N I

In this blog, I reflect on how this inquest has been reported. I do so with the understanding that not everything that is reported is 100% accurate. But once it is in print, we must deal with it.

I acknowledge the significant grief and devastation the parents of Troy Brady have experienced; they deserve justice and clarity. I also acknowledge the trauma Dr Sharma and colleagues have experienced, as their undoubtedly best intentions fell short of the desired outcome. I will offer some alternative ways we can learn from this tragic event, in the hope that our professions can prevent similar avoidable harm in the future.

Claim: Upright maternal positions are ‘very unusual practice’ for breech births.

The article’s headline caption is that, “The delivery position used by a doctor for a baby boy who was in a breech position was a ‘very unusual practice’, an expert [consultant obstetrician] has told an inquest.” The obstetric consultant expert who made this claim also testified that she has ‘delivered 30 breeched [sic] babies in her career and does not consider herself experienced in breech delivery.’ Another consultant obstetrician, from Scotland, further testified: “Breech delivery on all fours isn’t something we do in Scotland. It’s simply not something we’re experienced in. We would normally deliver the baby in lithotomy position.”

Unusual practice for whom?

These witnesses have made a classic type II error – when one assumes that something does not exist or is uncommon simply because one has not encountered it. One only needs to do a basic literature search to uncover the evidence for how ‘usual’ or ‘unusual’ upright maternal positions are for vaginal breech births.

In fact, almost all (if not all) UK primary researc h concerning how to improve the safety of vaginal breech birth is being done by people who regularly practice upright breech birth. Research about caesarean section is NOT research about how to improve the safety of actual vaginal breech births. Research about identifying breech babies or trying to turn them head-down in pregnancy (external cephalic version) is NOT research about how to improve the safety of actual vaginal breech births.

PubMed Search: ((vaginal breech birth) AND (safety)) AND (UK)

Breech Birth Network’s Physiological Breech Birth training is the only training that has been evaluated in NHS hospitals that has demonstrated a change in knowledge and behaviour following training (2 017 & 202 1). The training includes how to safety assist upright breech births. Upright maternal position is taught as a “tool and not a rule” in a clinician’s vaginal breech birth skillset. Nonetheless, among a sample of clinicians who have experience facilitating vaginal breech births in BOTH supine/lithotomy and upright positions, the outcomes demonstrate a clear preference for upright positions once clinicians have received this training, with good outcomes compared to those who have not.

In 2022, Deputy Director of Midwifery Emma Spillane published her case control study covering eight years of vaginal breech births in a London teaching hospital (2012 – 2020). Neither she nor I worked at this site during the study period. In this sample of 45 births, 43% occurred in upright maternal birthing positions, and 56% were facilitated by midwives.

The OptiBreech feasibility studies and pilot trial are the only prospective observational studies of vaginal breech births to be conducted in the UK since the Term Breech Trial was published in 2000. Over 70% of OptiBreech births occurred in upright positions, when the births were attended by clinicians who had appropriate training to support women to birth in the birthing position of their choice. In qualitative studies with women, they also reported more balanced counsellin g, detailing the risks and benefits of all options, from breech specialist midwives working in OptiBreech clinics. (This was another concern in the Brady case.)

Who is ‘we’? And who decides what ‘we do’ in Scotland?

While no research has reported maternal birth positions for vaginal breech births in Scotland, it is categorically wrong to say that it is ‘not done’ in Scotland, let alone in Northern Ireland. The OptiBreech team recently published a birth stor y from a woman very keen to share her experience, specifically to raise awareness of the need to ensure more maternity care providers in Scotland have training in upright breech birth.

Within the past two years, Breech Birth Network has been commissioned to deliver the Physiological Breech Birth Study Da y in Kilmarnock, Glasgow and Dumfries. Within our training, we use videos provided by women who have given birth in upright positions in Scotland. Every time we do teach, we ask attendants about their prior experience. Upright breech birth experience is invariably reported in Scotland, as it is at all English, Welsh and Northern Irish hospitals where we teach. Multiple members of our teaching team are based in Scotland, where they practice – you guessed it! – upright breech birth.

From our training in Kilmarnock:

What was the most useful part of this training?
Excellent explanation of mechanisms of breech birth and the manoeuvres to assist if needed.
All content was excellent, including new videos not available on online course. But most useful part was tapping into [the instructor's] first hand experience, both of clinical VBB and of establishing breech service with shared expertise.
What is one thing you intend to change about your practice based on this training?
Knowing that breech babies need to be born quickly and not waiting hands off the breech if there isn't clear descent.
How would you like to see this training influence practice in your organisation?
We are already using some of content/resources in modified way to introduce physiological breech birth. I hope we can have formal in house study days and support to adopt the algorithm in our guideline in coming years.
Feedback from Breech Birth Network Physiological Breech Birth Study Day in Kilmarnock, 2023

It is true than many providers in Scotland, such as those that supported Sandy MacMillan’s birth, do not have formal training in upright breech birth. Despite clear demand from women for this option, upright breech-experienced clinicians who wish to introduce the fully-evaluated, evidence-based training available face resistance from decision-makers who keep repeating: “Breech delivery on all fours isn’t something we do in Scotland. It’s simply not something we’re experienced in. We would normally deliver the baby in lithotomy position.” And it becomes a self-fulfilling prophecy …

Upright breech-experienced providers who have been safely attending vaginal breech births over the past seven years have been writing to me over the past few days to ask for help in addressing the extraordinary resistance they are experiencing due to this sensationalised media, based on a statement made by a self-described non-breech-experienced obstetrician, about a birth that occurred in 2016. Let’s take a deep breath before a fear-driven reaction distracts from the very real issues raised in this case.

What does ‘slow and delayed’ mean?

Jane Brady told the inquest during her evidence that Troy was delivered up to his neck in the all-fours position and was “hanging there, just hanging there”.

Her husband John Brady described the labour as “shocking”.

“I was waiting for someone to step in and save the day. It seemed as if no-one knew what they were doing,” he said.
quoted in 11 April 2024, BBC News NI

The harrowing events described by Troy Brady’s parents are the most consequential issue in this case. We (Breech Birth Network and the OptiBreech Collaborative) have been raising awareness of the dangers of delay in vaginal breech birth s to the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives for a few years now.

*Impey L, Murphy D, Griffiths M, Penna L, on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation (Green-Top Guideline 20b). 2017*

It is important to remember that this birth occurred in 2016. While many providers of vaginal breech education had been teaching upright breech methods by that point, the majority of teaching focused heavily on a ‘Hands Off the Breech’ approach. In the early 2000’s, upright maternal positioning was taught almost as a panacea. Based on the belief that it was safer to avoid touching the baby, proponents advocating putting the woman in an all fours position so that gravity could help the baby be born without the need for hands-on manoeuvres. As result, many people tried this, and discovered that in fact, hands-on manoeuvres are often needed.

The RCOG first introduced guidance on timings in the 2017 update of their guidance, based on professional opinion. Prior to this, the approach emphasised ‘Hands Off the Breech,’ but with no guidance on indications to intervene, how to intervene in upright births, or optimal time intervals.

Our mutual observation that reluctance to intervene was resulting in avoidable adverse outcomes prompted Dr Anke Reitter and I to undertake our first video study. This attempted to accurately describe, for the first time, the ‘normal’ parameters for vaginal breech births, based on evidence rather than professional opinion. During the process of conducting this study, I systematised the approach we were then teaching into the first Physiological Breech Birth Algorithm, focusing on our recommendation that the birth should be complete within 7 minutes of rumping (both buttocks and anus visible on the perineum), 5 minutes of the birth of the fetal pelvis, and/or 3 minutes of the birth of the umbilicus.

“In my reading of the case, delivery was slow and delayed,” she said.

“Manoeuvres were not deployed by Dr Sharma and that made me feel that he didn’t have an awful lot of experience in this type of birth.

“When things went wrong it was obvious that Dr Sharma hadn’t been trained on how to manoeuvre the baby and there was a delay.”
Dr Alyson Hunter, quoted in 11 April 2024, BBC News N I

We first taught using the Physiological Breech Birth Algorithm at a study day in Belfast, Northern Ireland, in October 2017. This was the first study day in the world to introduce this algorithmic approach. Yes, we also introduced upright birthing positions and what manoeuvres are effective when using these positions. But after 14 years of doing research in this area, my strong opinion is this: While upright birthing positions are often preferred by the women and clinicians who use them, the biggest impact on the safety of vaginal breech birth comes from improvements to our understanding of what constitutes ‘normal’ progress, especially the normal time frames of emergence.

This sensationalised journalism will potentially result in a backlash against all those who have been using and teaching physiological breech birth methods. The most tragic outcome if this occurs is that women like Sandy MacMilla n will continue to request support for upright breech births, and well-intentioned clinicians like Dr Sharma will continue to support their reasonable request, but without access to high-quality training about how and when to intervene in these types of births. As a result, we will continue to have inquests that include testimony like that above. The solution to an adverse outcome based on lack of appropriate training in a widely used practice is NOT to restrict training and practice.

What about the placenta?

The paediatric pathologist and neonatologist expert in this inquest also described problems with the placenta that likely impacted this birth:

During the inquest hearing, experts told the court that Troy had a “smaller than usual” placenta and that it was not “operating as it should be”.

Dr Caroline Gannon, a paediatric and perinatal pathologist, said it is known that “placenta infection and placenta deficiency can cause brain damage”.

Consultant neonatologist Dr David Sweet told the inquest Troy’s reduced reserves meant he was “less able to deal with vaginal delivery”.

However, he said there was “no clue” there was a risk to Troy.

“No one could have known he had a deficient placenta,” he added.

“Having half a placenta is like having one lung instead of two – he’s going to get into difficulty quicker,” he said.
Baby death inquest hears breech delivery method very unusual practice, BBC News NI, 11 April 2024

I am absolutely in agreement with the neonatologist. Some breech babies are breech because there is an underlying problem, and unfortunately, we cannot always identify when this is the case. But it is MUCH more likely when a baby is premature, born at 33 weeks rather than about 40 weeks. In OptiBreech physiological breech birth practice, we teach that, exactly as the neonatologists describes, smaller babies are more likely to get into difficulty quicker. And therefore, attendants must be even more swift to assist the birth.

Again, the issue is not with the maternal position – all of us who practice upright breech birth regularly have attended multiple successful upright preterm breech births.

What is expertise, and who is an expert?

The obstetric consultant expert who made the headline claim also testified that she has ‘delivered 30 breeched [sic] babies in her career and does not consider herself experienced in breech delivery.’

My own credentials / expertise to comment are:

*Search conducted Sunday, 14 April 2024. To make it easy, I’ve circled the links to my work. The other two links are work by close colleagues.*

I am one of the most experienced vaginal breech birth attendants in the UK. I have attended well over 50 vaginal breech births (I stopped counting). I have also contributed to the safe care of at least double that number, because for many, an in-labour caesarean birth is the safest option when a deviation from normal occurs. Knowing how to identify this is part of the skill of an experienced vaginal breech birth attendant.
My experience includes management of complicated breech births (eg. needing to use hands-on manoeuvres to deliver the baby) where the woman is in an upright position, as well as those where the woman is in a supine position. To me personally, neither is ‘very unusual practice.’
I am the only clinician in the country who has led multi-centre studies of planned vaginal breech births. My OptiBreec h work included 13 NHS sites in England and Wales, 199 planned vaginal breech births, and 96 actual vaginal breech births.
I teach vaginal breech birth skills personally to over 1000 experienced maternity care providers each year, through a training course developed out of research and thoroughly evaluated. I lead a team of similarly experienced clinicians who help teach this course, and it is constantly developing based on our frequent reflections and the research.
I lead an international community of practice. My visibility in this arena means that I frequently debrief clinicians and women who have experienced poor outcomes with vaginal breech births. While this is one of the saddest and most difficult aspects of my role as a public expert, it also enables me to identify patterns across a wide range of practice cultures. This in turn helps me to focus my research on the areas most likely to impact safety if we improve them.
My PhD was titled, “Competence and Expertise in Physiological Breech Birt h,” giving me some confidence in my ability to identify this.
Finally, I continue to research the ‘problem’ of how to make vaginal breech birt h as safe as possible from a variety of perspectives, using multiple scientific methods. If you search ‘vaginal breech birth’ on any research database, you will find my work among the top 10 primary research publications. If you search ‘upright breech birth’ on ANY search engine, it would be impossible to miss my work in this area.

But I am a midwife. I am rarely called upon to provide formal ‘expert witness’ nationally or even locally, in risk management activities. This is likely due to what Diehl and Dzubinski describe as ‘Role Incredulity.’ People expect consultant obstetricians to be experts in vaginal breech birth, even when they are giving testimony that they are not. Whereas, due to the rarity with which midwives are perceived as clinical experts in complex births, a midwife who is an actual expert in vaginal breech birth will frequently face doubts about her capacity. This is my daily lived experience.

ROLE INCREDULITY

In a male-privileged culture, people may assume women are not in charge. Outsiders may mistake women in a stereotypically make role – leader, engineer, tech support, lawyer, physician – for a stereotypically female role, such as administrative support, court reporter, nurse, or wife. This mistaken assumption is called role incredulity, and even when others learn the woman’s actual role, the effects may linger in doubts about her capacity. (p 18)

What should we focus on?

In my expert opinion, focusing on the following information is most likely to impact the safety of future vaginal breech births, regardless of the maternal birthing position:

“In my reading of the case, delivery was slow and delayed,” she said.

“Manoeuvres were not deployed by Dr Sharma and that made me feel that he didn’t have an awful lot of experience in this type of birth.

“When things went wrong it was obvious that Dr Sharma hadn’t been trained on how to manoeuvre the baby and there was a delay.”
Dr Alyson Hunter, quoted in 11 April 2024, BBC News N I

Continuing to focus on the upright birthing position, with antagonism directed against those who support women’s choice to use this position, is a distraction from the real safety issue. That is, the continuing dogmatic, non-evidence-based belief that ‘hands off the breech’ until at least 5 minutes have passed from the birth of the pelvis (RCOG, 2017) will result in a ‘safer’ delivery. This is simply false, ignored by most experts, and dangerous when novices blindly follow it. But it continues to be taught, along with the promotion of lithotomy birthing positions, usually with much confidence and shroud-waving by people who have actually attended very few, if any, vaginal breech births.

Secondary analysis SPSS means table, 14 April 2024, of Spillane’s Optimal Time Intervals for Vaginal Breech Births dataset.

The table above was created from our archived dataset of Spillane’s Optimal Time Intervals for Vaginal Breech Births study. It demonstrates that in control cases (good outcomes), assistance is provided in all cases well before the 3 minutes from the umbilicus recommended in current RCOG guidance. There is less difference, and less ability to modify this difference, in the length of time taken to perform manoeuvres. Swifter intervention is a modifiable behavioural factor.

This is directly relevant to John Brady’s description of his baby being born up to the neck and then “hanging there, just hanging there.” Even an untrained parent can see that there is something very, very wrong with this approach. Please, listen to him!

For a cross-cultural comparison, the Danish national guideline has now eliminated the instruction to ‘let the baby hang’ after the birth of the arms, regardless of the position the mother is in. This is not helpful, as it does not result in head flexion. Only manual assistance can help flex the aftercoming head, and delaying this is potentially harmful.

While there is evidence to suggest swifter intervention results in better outcomes, especially when attendants are novices and less likely to perform manoeuvres confidently, this teaching continues to be attacked, disbelieved and dismissed in favour of ‘us versus them’-style debates about maternal birthing position. This is a hardship for those of us who are continually striving to improve the safety of vaginal breech birth and respect women’s right to give birth as they choose.

Meanwhile, babies are needlessly dying.

— Shawn

Secondary analysis SPSS means table, 14 April 2024, of Spillane’s Optimal Time Intervals for Vaginal Breech Births dataset. Compared to the differences between controls and cases (good and adverse outcomes), less obvious differences exist in time-to-intervention intervals between supine and upright births.

Reflections on the Ockenden Report in the context of breech presentation

2 Replies

The recent release of the final Ockenden Report has shed light on deeply painful experiences for the women, families and healthcare professionals involved. For those of us who have not been involved, the call to deep reflection can also be a painful experience, but a necessary one.

I have been asked by several people what I feel this means for vaginal breech birth. Will women still want one after this report, where promotion of vaginal breech birth against maternal request for a caesarean section was a contributing factor in some very sad outcomes? Will professionals be even more reluctant to support women who wish to choose a vaginal breech birth, for fear of being accused of zealous pursuit of normal birth at all costs?

My answer is this: I welcome this report because I see it as affirmation of the need for individualised care, the need to listen to women, the need to place their values and needs at the centre of care.

Women who want a caesarean section, regardless of their baby’s presentation, should have easy access to one. I counsel several women with a breech-presenting baby every week about their birth choices, and I encounter many women who appear to be somewhat relieved that their baby is breech. They do not want an attempt at baby turning (external cephalic version, ECV, to a head-down position). They want a caesarean section. And their baby being breech means they will have one without the need to justify their choice.

I stopped talking women into an attempt at baby turning (ECV) a decade ago because I audited the results of my first breech clinic. By introducing a breech specialist midwife pathway, I doubled the rate of ECV acceptance almost overnight. Women trusted me. For two women, I remember clearly convincing them that ECV was ‘best.’ I even said to one after a successful procedure, “Aren’t you glad you had a go?” One woman had a long, complicated induction that ended with an emergency caesarean section and massive obstetric haemorrhage (bleeding). The other had a failed attempt at suction cup delivery, failed attempt at forceps delivery and a caesarean section. I have also been present when an ECV attempt at 36 weeks led to an emergency caesarean section, in which we found the cord ended up in front of the baby’s head as it was trying to engage. I’m pretty sure none of these women ended up happy that someone convinced them to have an ECV rather than a planned CS. If this has been your experience, or similar, I am so deeply sorry.

But I also meet many women who decide that an attempt at baby turning is the best choice for them. They really want to try for what they see as a ‘normal birth,’ in a birth centre with midwives and access to the birth pool. They are prepared to accept the relatively small risks associated with ECV and vaginal birth — after all, I can remember these women as individuals after a decade of doing breech work — because they feel the potential benefits outweigh the risks. These women deserve to be offered this attempt, with experienced providers who have a consistently good success rate. And if adverse outcomes happen, they deserve NOT to be treated as if they made the wrong decision. None of us has a crystal ball.

It is my responsibility to explain why baby turning is the nationally recommended ‘treatment’ for breech presentation. When I explain this, I explain the potential benefits of and increased likelihood of having a straightforward vaginal birth, particularly in a first pregnancy. I also explain to every woman that, in 2022, by far the most likely outcome no matter what she chooses to do (ECV, VBB, CS) is that she and her baby will be well and safe following the birth. There are small differences in risk between each choice, but ultimately, with skilled support and a plan in place, the outcomes are very good for all choices. She should feel supported to make the choice that ‘feels’ right to her. We professionals should then do our best to make this choice as safe as possible, while continuing to communicate any changes to the risk profile she initially accepted.

I deeply feel that women who want a caesarean section should be able to have one, without judgement or difficulty. I am reassured by our qualitative data in the OptiBreech study, that the breech specialist midwives and breech clinic obstetricians providing counselling are all doing it in a way where women feel they have genuine choices but are not pressured in one direction in another. Participants say this repeatedly and express how much they value this balanced counselling.

I also deeply feel that women who want to attempt a physiological breech birth should have the best possible support for that option. They should also feel their choice is supported without judgement, shame or pressure. Part of enabling women to make this choice involves enabling healthcare professionals to develop skills and work in ways that make ‘a vaginal breech birth with skilled and experienced support’ – which the RCOG guideline tells us should be nearly as safe as a cephalic birth – possible. This is a win-win situation. By supporting the women who WANT to plan a physiological breech birth well, we also increase our skill level to support those rare occasions when there is no choice available due to the rapid progress of an early or unplanned breech labour. When this occurs in the context of rigorously governed research, we can be even more confident that this learning will occur.

Sadly, this is not possible for most women in the UK. Every meeting of our OptiBreech Patient and Public Involvement (PPI) group involves talking through some amount of trauma. Our research team includes women who have sadly lost their babies to poor care and want to preserve the choice with BETTER care and women who have experienced severe complications from caesarean sections they did not want. But almost ALL members of our group, including partners, have expressed trauma from being repeatedly blocked, judged and unable to access skilled, supportive care for a vaginal breech birth. They have read national guidelines that said this should be an option, then found that their local health services had zero commitment to delivering this; they effectively had no choice.

On the other hand, our PPI group has been adamant that they do not want research to demonstrate vaginal breech birth is BEST. They want research to demonstrate what the actual, current risks are for all choices, and to show us how we can help all women make the choice that is right for them.

The vaginal breech birth skill set has remained largely static since the 1970’s, with ‘put the woman in an upright position’ being virtually the only innovation in breech care – until recently. It is as if we have been managing shoulder dystocia with only McRoberts and Gaskin manoeuvres – of course we would expect bad outcomes. (shoulder dystocia = where the baby’s shoulders become stuck in a head-first birth; McRoberts = pulling the woman’s legs back to her abdomen to create space in the pelvis; Gaskin = turning the woman to a hands/knees position)

Yet many professionals trying very hard to do the research we need to improve outcomes for breech babies are also exposed to the trauma of incivility and lack of respect. There is a particular power dynamic that exists between obstetricians and midwives that can make uncooperative behaviour threatening and dangerous – because the best outcomes for planned vaginal breech births are achieved when there are skilled, trusted care providers and a low threshold for using interventions (such as caesarean section) when they are needed. If you are afraid to refer to a person who has previously spoken to you harshly, publicly criticised you or outright refused to have anything to do with a physiological breech birth, this can introduce hesitation where there should be none. Some midwives have also found it difficult to maintain engagement with some women because being called to repeatedly justify women’s choices to colleagues is very emotionally draining, leading to avoidance behaviour. This is neither healthy, nor safe.

Multiple obstetricians who have tried to progress OptiBreech research have also experienced blocking, incivility, and general lack of respect. Discussions have been shut down before they begin. Junior doctors who want to learn the skills find they have no support to do this and remain silent. This has led to communication breakdowns and undermined safety at a time when we all need to be working at our best to learn and improve.

Do I think there is a place for physiological breech birth post-Ockenden? The demand for skilled breech care continues, and we are contacted each week from across the UK by women who are looking for support. In our OptiBreech project, there have been exemplars of healthy communication and excellent teamwork to achieve good outcomes for mothers and babies, and we are focusing on these as the way forward. I am grateful for the warm and respectful interactions I have with many of my colleagues; these sustain us all in our challenging everyday work. Examples of successful co-operation are especially valuable given the extreme pressures staff have been facing with chronic under-staffing and pandemic conditions. And our learning about how to support breech births well is accelerating at light speed as we share our experiences through constant reflection among OptiBreech leads at active sites. We will persist for as long as we can.

Enabling physiological breech birth, and research about how to make it safer, is NOT about promoting natural birth at all costs, nor about promoting natural birth at all. It is about placing the women who use our services at the centre of all we do, bringing our best to meet them where they are at and constantly striving for better. Which is, in my opinion, what the Ockenden Report calls us to do.

This blog is the personal opinion of Dr Shawn Walker and not the NIHR, King’s College London or any NHS institution.

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