David Coggin-Carr is a UK+US dual-certified obstetrician, Maternal-Fetal Medicine subspecialist and early career physician-scientist at the University of Vermont (UVM). He practices full-spectrum MFM in Vermont and upstate New York and additionally serve as Associate Medical Director of the Birthing Center and Associate Director of Quality for Obstetrics at UVM Medical Center. In recent years he has developed a strong interest in physiological breech birth in response to the local community’s desire for greater autonomy around their birth choices amidst a near-total lack of trained/experienced providers in the region. Accordingly, he now regularly provides consultations and intrapartum support for planned vaginal breech birth.
Image: Book of Traceable Heraldic Art
All births have the potential for injury, whether this be facial markings from forceps delivery or lacerations from a caesarean birth. Vaginal breech birth has its own variations. This webinar will explore how vaginal breech birth affects neonatal genitals, both normal variations in appearance from being born bottom-first, to potential injuries.
There should be no requirement to report genital injury as a separate category in ALL effectiveness studies of breech birth at term, although it may be reported in some. It should not be included in the Breech-COS composite measure of severe morbidity.
or
The incidence of significant genital injury, defined as one that is likely to have long-term, life-altering consequences, should be reported as a separate category in ALL effectiveness studies of breech birth at term. Significant genital injury should be included in the Breech-COS composite measure of severe neonatal morbidity associated with vaginal breech birth.
For all sites that have expressed an interest in our planned stepped wedge trial of OptiBreech collaborative care: please include your name and hospital in the chat, and we will award one site selection point for every site that participates.
Women with breech presentation at term should now be offered the choice of a vaginal or caesarean birth, benefits and risks of both for her individually, and the implications for future pregnancies (RCOG, 2017). Vaginal breech birth and vaginal twin birth are both made safer by the attendance of specialist, skilled practitioners (Su et al, 2003; Barrett et al, 2013). When it comes to the combination of vaginal breech and twin births, there remains a lack of professional consensus on the safety of vaginal birth compared to planned caesarean. This is particularly true of breech presenting twins, where the first twin is breech at term, compared to twins in a vertex-breech order, which has been subject to more research.
RCOG breech guidance (2017) recommends planned caesarean in cases where the first twin is breech, but not in the case of twins where the second twin is breech. This recommendation is influenced by the Hogle et al paper (2003), which found lower Apgar scores at five minutes for breech-first twins born vaginally. However, the paper did not find any other significant negative outcomes for these babies, such as neonatal unit admissions, need for resuscitation or increased mortality. Women considering a vaginal breech birth are now routinely informed that following a vaginal breech birth, babies are more likely to have lower Apgar scores, but that this does not translate into severe illness or long-term health consequences. Therefore, breech lead twins behave similarly to singleton breech babies who are born vaginally, meaning they should also be suitable for vaginal birth depending on maternal choice.
As with many areas of breech, research studies are mostly retrospective and often reporting on small numbers. Nonetheless, evidence dating from 1998-2022 suggests no significant difference in neonatal morbidity or mortality for lead breech twins born vaginally or by caesarean, or any difference in outcomes for breech lead twins compared to cephalic lead twins (Grisaru et al, 2000). In 2020, Korb et al published their secondary analysis of the JUMODA twin study, which concluded that planned vaginal birth with a breech twin first is not associated with higher neonatal mortality or morbidity for either twin. In their systematic review, Steins Bisschop et al (2012) found no difference in neonatal outcomes between vaginal or caesarean birth for breech first or second twin. Several authors stress the value of practitioners and centres having exposure to and skills in facilitating vaginal breech and vaginal twin birth.
Where caesarean is recommended (Nassar et al, 2005; Hogle et al, 2003), these papers appear to generalize the singleton findings of the Term Breach Trial (Hannah et al, 2000), which have since been called into question. Bourtembourg et al (2012) recommend caesarean for nulliparous clients, but this is based on likelihood of vaginal birth, rather than negative impact on mother or baby. The RCOG breech guideline (2017) mentions the risk of interlocking when the first twin is breech, but the only available evidence on this is from Cohen et al in 1965; none of the studies analysed in this review cited interlocking of twins to be a significant labour complication.
The impact on maternal health was not included in many of these studies, but where this was considered, findings suggest either no difference to maternal morbidity (Bats et al, 2006); a greater incidence of postpartum haemorrhage following planned caesarean (Ghesquière, 2022); or an increased incidence of deep vein thrombosis and pulmonary embolism (Sentilhes, 2007) following planned caesarean. These findings should be incorporated into consultations on the benefits and risks of modes of birth.
According to the evidence reviewed, planning a vaginal birth with breech-presenting twins is a reasonable choice and should be approached in a similar way to singleton breech birth. However, the birth must be facilitated in a unit with staff skilled and experienced in vaginal breech and vaginal twin birth.
Are there any additional considerations?
Estimated fetal weight should be considered. Blickstein et al (2000) found benefits from planned caesarean in cases when the breech twin weighed less than 1500g. As is often the case in breech, babies weighing over 3800g were recommended for caesarean section in many studies, which means they are omitted from the current evidence base.
Should we screen for nuchal cord using ultrasound when a woman is planning a vaginal breech birth? and
What should we do with the information if we do identify a nuchal cord on ultrasound?
‘Nuchal cord’ means that one or more loops of umbilical cord are wrapped around the baby’s neck, during pregnancy or birth. Checking for nuchal cord prior to external cephalic version (ECV) or during risk assessment prior to a vaginal breech birth (VBB) is both common and controversial.
cord-leg entanglement, image: Dr Pricilla Ribeiro-Huguet
What is known:
Nuchal cords are common, especially for breech presentation. For example, in this study (Wong & Ludmir, 2006), where someone specifically looked for a nuchal cord prior to an attempt at ECV, 34/75 (45.3%) babies were spotted wearing their cord as a necklace. They attempted the ECVs without this information. More babies with nuchal cords had transient (temporary) heart rate abnormalities, and their ECVs were less likely to be successful. But none of them had an emergency caesarean birth because of the way their heart rate was affected by attempting ECV.
It may cause problems in some pregnancies and/or births, but visual assessment by ultrasound does NOT help us to predict which ones. (… in general. Unless, as in this paper by Hinkson et al 2019, there are 6 loops of nuchal cord visible. Wow!)
double nuchal cord, image: Shawn Walker
What is not known: Does a nuchal cord increase the risk associated with an ECV or vaginal breech birth? We just don’t know if, or by how much, presence of a nuchal cord increases the risk. This is one reason neither of the RCOG guidelines (ECV, Management of Breech) indicate nuchal cord should be identified, or used as an exclusion criteria, for either of these. In fact, they don’t mention ‘nuchal cord’ or ‘cord around the neck’ at all.
When there is clinical uncertainty, we just say … there is clinical uncertainty. We can’t guarantee it won’t be a problem, but we have no clear evidence that it is likely to cause a problem.
Other guidelines often do say something like, “exclude nuchal cord.” This means, “Look for it with ultrasound to make sure it isn’t there.” But it’s not clear what one is supposed to do if you identify it IS there. And if a clinician has not looked for it, or has not spotted it, and it ends up being there and causing a problem during birth, have they been negligent? It’s a slippery slope.
cord-leg entanglement, image: Dr Anke Reitter
In my own clinical experience, breech babies born vaginally quite often have one or sometimes two loops of nuchal cord around their neck at birth. My gut feeling is that these babies more often needed help to flex the head, for example with a shoulder press, but that this was not more difficult than when the cord is not there.
I also checked our video study (Reitter, Halliday & Walker 2020) database of 42 breech births with ‘good’ outcomes. Among these, 8/42 (19%) had a cord wrapped at least once around the neck. Among these 8, 5/8 had help with the arms, and 6/8 had help to flex the head. This was slightly higher than the overall averages in the whole dataset. In the dataset, there were also 2 cases of leg entanglement, 1 case of arm entanglement, and 1 cord prolapse, where the cord comes out first.
It seems plausible that cord entanglement, whether around the neck or another body part, could interfere with the normal mechanisms of a vaginal breech birth. These babies may then require more assistance to be born safely, which is not itself a problem, as long as that assistance is provided in a timely fashion. It also seems plausible that in some case, a tight or short cord entanglement could cause problems that would put the baby at risk. But the kind of potential problems Peesay describes are all very likely to be picked up with the kind of close monitoring (growth scans, fetal heart rate monitoring, etc.) that every known breech baby received antenatally and/or in labour.
I’ve also added a ‘cord’ tag to several videos in our video library. If you’ve taken our Physiological Breech Birth course, you can search the library to watch several videos where cord entanglements feature and are resolved.
In summary, these are my recommendations:
Don’t routinely go looking for a nuchal cord in otherwise uncomplicated pregnancies.
If you do spot a nuchal cord, explain the clinical uncertainty with regard to its implications.
Offer and attempt ECV if the person chooses this.
Offer and support a VBB if the person chooses this.
When attending a VBB with a known/suspected nuchal cord in labour:
interpret fetal heart monitoring in light of this;
interpret descent in light of this;
anticipate the cord could interfere with the mechanisms, which may require your assistance; and
review all of your tools for assisting the head to flex.
I’d love to know others’ thoughts and experiences?
Shawn
This is really interesting. My breechy had the cord x3 round her neck then looped under her arm. Straight forward home birth. When chatting to midwife after we thought if she'd been cephalic the length of cord left may not have allowed her to descend, as bum first fine! Anecdata!
— Ellie Garlick RN MSCN 💙 (@EllieGarlick) June 2, 2021
Another NICE Guideline that mentions care for breech presentation has been put out for comment. This time it is Inducing Labour. Many fine colleagues are collating responses to the guideline in general, but I would like views on the specific section related to induction of labour in breech presentation.
I have prepared a response, based on previous feedback from women and birthing people. Please let us know how you feel about this, and whether you would word anything differently.
Induction of labour is controversial, and even more controversial for breech presentation. I have tried to word the response in such a way that reflects the need for more informed choice, rather than more induction per se.
p.10, line 6 “Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]” Cannot locate evidence for this recommendation in evidence review. This statement is vague. Not generally recommended by who? Why? Induction of labour for breech presentation is common outside of the UK.
p.10, line 14 “Discuss the possible risks of induction with the woman.” Also vague. What are the risks? A systematic review has been done, so women can be offered evidence-based information rather than general reluctance. https://www.ejog.org/article/S0301-2115(17)30578-X/fulltext
p.10, line 5 Suggest the section on ‘Breech Presentation’ is re-written to reflect the ethos of informed choice and discussion, in a similar manner to the section on ‘Previous caesarean birth.’ Otherwise, the service is inequitable. A guideline on IOL with breech presentation is only applicable to women who have chosen to plan a vaginal breech birth. The guideline should reflect and respect this, using neutral, non-judgemental language.
For example:
1.2.19 Advise women with a baby in the breech position, who have chosen to plan a vaginal breech birth, that:
induction of labour could lead to an increased risk of emergency caesarean birth, compared to spontaneous breech labour
induction of labour could lead to an increased risk of neonatal intensive care unit admission for the baby, compared to spontaneous breech labour
the methods used for induction of labour will be guided by the need to reduce these risks. See the recommendations on Methods for inducing labour.
1.2.20 If delivery is indicated, offer women who have a baby in the breech position a choice of:
an attempt at external cephalic version, immediately followed by induction of labour if successful
caesarean birth or
induction of labour in breech presentation
Take into account the woman’s circumstances and preferences. Advise women that they are entitled to decline the offer of treatment such as external cephalic version, induction of labour or caesarean birth, even when it MAY benefit their or their baby’s heath.
Current wording in Draft Guideline is:
Breech presentation
1.2.19 Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]
1.2.20 Consider induction of labour for babies in the breech position if:
delivery is indicated and
external cephalic version is unsuccessful, declined or contraindicated and
the woman chooses not to have an elective caesarean birth.
Discuss the possible risks associated with induction with the woman. [2008, amended 2021]
You are invited to an open discussion about the Draft of the new NICE Antenatal Care Guideline. Breech Birth Network would like to collect the views of families who have experienced a breech presentation at term and care providers on the draft guidance.
Josephine and Thiago talk about their experience of Ulysse’s breech birth at Erasme Hospital in Brussels
The NICE Antenatal Care Guideline covers the detection of breech presentation (how midwives and obstetricians pick up that your baby is breech) and how a known breech presentation at term should be managed by your care providers.
The recommendations are based on outcomes that are considered ‘critical’ and ‘important.’ A discussion of how the committee has prioritised outcomes and decided upon a recommendation is included in the Evidence Reviews.
This is a first meeting. A second will be held in March to review the results of this meeting and any written responses Breech Birth Network has received, before the deadline at the end of March. At the meeting we will:
Help you understand what the guideline and evidence reviews are saying.
Ask you how you feel about the recommendations.
Ask you if you would like to provide any feedback to the committee, which we will include in a collective response.
If you are unable to attend this meeting, you are also welcome to:
engage in this discussion by posting a comment on this blog page;
contact us using the e-mail form below to provide non-public feedback;
or leave a comment on our FaceBook group page, where we will post a link to this invitation.
Note: We have observed that some of the women we work with have experienced distress or sometimes trauma in their breech pregnancies. If your experience makes it uncomfortable to participate in a group event, and you would like to have a 1:1 meeting with someone from the Breech Birth Network, please contact us using the e-mail form below.
Meeting Details
Shawn Walker is inviting you to a scheduled Zoom meeting.
Topic: Consultation on draft NICE Antenatal Guideline Time: Feb 13, 2021 02:00 PM London
Thank you to the woman who provided permission to re-post this exchange, in case others are looking for similar information. Emma and I respond to many requests for information like this. Hoping that sharing this response helps others looking & those who are caring for them. Shawn’s replies in blue.
I’m P2+0, ventouse in first and normal birth on the second. In all of my pregnancies I’ve had Gestational diabetes and been induced. I’ve been well controlled on insulin with no complications for the babies either antenatally or in the neonatal period. Same is the plan for this one. Previous two babies weighed 2.8kg And 2.82kg. All went well for both mother and babies on both births.
Sounds good.
This time round I’m currently 34+4 weeks and baby is firmly breech for the last 8 weeks. So far I’ve tried spinning babies, homeopathy, acupuncture and moxa sticks to encourage baby to turn. Not budging one bit. I know there is still time for it to turn but I’m getting myself educated as to options.
ECV is a potential option at 37 weeks and if that fails obstetrician has suggested that I go for an induction of labour with breech as he knows I really don’t want a c/s.
He has said himself as I’m a midwife I know what’s involved, I don’t have big babies and there is only 18mths between each of my babies so I should labour well.
Agreed.
Only breech births I’ve seen over my career are either second twins or unexpected fully dilated breech in labour on arrival. I’ve never seen one induced.
Yes, this is one of the things that causes problems for planned breech births. Most people are most familiar with the ones what progress quickly and ‘just fall out’ before a CS can be performed. This can give a false impression, and though people may be ‘experienced,’ they may lack experience of more challenging breech births that take a little longer, such as people giving birth for the first time and inductions. [See No more ‘hands off the breech.’]
I’ve been doing reading & research on the topic but it’s hard to find current evidence. As you know historically from previous research c/s has been recommended instead of induction. I have found some more current evidence suggesting that with the right maternal candidate induction is possible and long term outcomes for both mother and baby are of no significant difference to those that have elective c/s. Am I right in this?
In experienced centres, the balance of evidence does not indicate increased risk from induction compared to spontaneous breech birth. In fact, in experienced centres, induction is sometimes used to increase the likelihood of a good outcome by ensuring a birth occurs when significant experience is available – not ideal, but nothing to do with vaginal breech birth is currently ideal.
One of my talented midwifery students just repeated this review with the addition of the most recent evidence, and the results showed not one significant difference. However, all of these studies would have been done in centres that are experienced enough to be confident inducting breech births. Given what I have said above, I feel it is likely that in centres who do not regularly do this, there is some increased risk. But this would be more applicable to people giving birth for the first time, in my opinion.
Also my baby is currently in a complete breech position flexed knees and feet above the buttock. Again I know this could change but I have read conflicting information on if this is a suitable position for induction of breech.
Breech babies dance until they can’t dance no more. So the position could change to head down or feet up or knees down or something else at the time of labour or even in labour. Non-frank breech presentations are at slightly higher risk of cord prolapse, so you may want to consider labouring with a cannula if this is the case at the time of induction. I have no further research-based information to offer.
It’s hard to find current information for parents on options using recent research so that is why I am contacting yourself. I’ve been following your twitter and some of the work the breech team is doing. I think as a midwife it’s a great idea and desperately needed to give real options to parents and expand skill set in health professionals. Do you have any patient information that you give to parents on induction of breech that I might benefit from reading?
Agreed, it’s hard. We have a leaflet, developed by Emma Spillane, which was developed based on the current RCOG guidelines. https://breechbirth.org.uk/2019/07/18/new-information-leaflet/ Because the RCOG guidelines currently ‘do not recommend’ induction of labour for breech births, we have chosen not to go there. Working in a controversial area like breech birth, one has to choose one’s battles. I’m very happy to support this as an individual choice myself, but in the wider context of re-establishing effective breech services, it hasn’t been the priority. Given increases in induction across the service, and evidence of the potential benefits of offering induction, this will eventually need to be addressed in any contemporary breech service. ‘Not going into labour,’ either by the date considered optimal, or following waters breaking, is the biggest reason that people who plan a vaginal breech birth do not end up having one.
Finally – Would you be happy for me to publish this e-mail exchange as a blog, with names and any other identifiable information removed, or not if you prefer? It helps me to be able to provide a link when people ask similar questions, which I expect will happen more with this topic.
Next month, I will be a Visiting Scholar at the University of British Columbia. This will include a workshop on my research and physiological breech birth practice, delivered alongside Andrew Kotaska, lead author of the Canadian breech guideline, and a highly respected obstetric and midwifery faculty.
Please share this information with any Canadian OBs and Residents who want to extend their skills to facilitate safe vaginal breech births. The course is accredited for MOC 3. Bookings can be made on-line.
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.
Emma Spillane is seeking your thoughts on a new piece of research prior to its submission for ethics approval. If you have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, or you work with pregnant women in a non-medical capacity (e.g. doula, antenatal teacher, breastfeeding supporter, etc.), I would love to hear from you.
I am conducting research as part of my Masters exploring breech childbirth preferences of expectant parents to understand if there is demand for breech birth services within the NHS and explore the factors which influence parents decision-making. At this stage, I would like your feedback on the suggested design of the trial, to ensure that the information resulting from the research will be useful to those considering breech options. For those of you who would like to remain with the project I am forming a Breech Advisory Group provide feedback at further stages in the project such as analysing the results.
If you are interested in participating in my research in this way, please read the plain text summary of the project below and complete a short survey by following the link after the research summary.
Discussing breech birth in Ethiopia
STUDY SUMMARY
Approximately 3-4% of babies at term present in the breech position (bottom or feet first) (Impey et al. 2017). The Royal College of Obstetricians and Gynaecologists’ (RCOG) most recent clinical guideline on Management of Breech Presentation recommends that pregnant women should be offered choice on mode of birth for breech presentation at term(after 37 weeks’ gestation) (Impey et al, 2017). Despite this recommendation, only 0.4% of all breech babies in the UK are born vaginally (Hospital Episode Statistics, 2017), and this figure includes pre-term breech births where breech presentation is more common (Impey et al. 2017). These statistics suggest that either the demand for vaginal breech birth is low, or the choice of mode of birth is not being consistently offered. This study aims to explore this enigma by providing empirical evidence necessary to inform maternity services on the requirement of breech birth services.
Current evaluations of demand for vaginal breech birth services have been limited by the quality and impartiality of information parents are able to access via their maternity services. For example, research has shown that women have difficulties finding information to support their choices and are pressured into making the decision based upon practitioner preference (Petrovska et al, 2016). An investigation carried out in the Netherlands, found that one third of parents would prefer to have their babies born vaginally (Kok, 2008). However, little is currently known about parents’ preferences in England.
This research will evaluate the extent of expectant parents’ preferences for vaginal breech birth prior to counselling, and the factors that influence these preferences, using personal interview surveys (Bhattacherjee, 2012). All women presenting with suspected breech presentation at a large London based teaching hospital – St George’s University Hospital NHS Foundation Trust – will be given information about this study along with their Trust approved mode of birth information leaflet during their routine antenatal appointment at 36 weeks of pregnancy. As per Trust clinical protocol, women with suspected breech presentation will be offered a referral for an Obstetric Ultrasound Scan (OUSS) for confirmation of fetal presentation. During this routine OUSS appointment, either prior to or following the scan taking place, parents will be approached by the researcher and invited to take part in an interview on their preferred mode of birth and the reasons behind these preferences. Both parents, if present, will be interviewed separately. Parents will already have been given information about the study in the form of a Participant Information Sheet PIS) by the clinician referring them for an OUSS. The timing of the interview has been chosen because it fits with the participating Trusts usual pathway of care. Parents are informed there may be long waiting times due to OUSS being arranged at short notice.
The findings from this research will provide evidence on the following:
the demand for a vaginal breech birth service, based on written information prior to individualised counselling;
the factors influencing this demand, which can be used to improve shared decision-making training and taken into account when planning future research; and
a predicted service planning model for a fully integrated breech continuity team within the host Trust.
Data on parents’ preferences for mode of birth will be reported descriptively as a percentage. Qualitative data regarding parents’ reasons for their preferences of mode of birth will be analysed thematically.
Warrnambool Dreaming Weaving Panel, Lightning Ridge, Boolarng Nangamai Aboriginal Art and Culture Studio — from a previous breech-related trip to Australia
On Sunday, I am heading off to New Zealand (Christchurch & Auckland), where doctors and midwives are keen to learn more about physiological breech birth. From there it’s on to Sydney for the Normal Birth Conference 2016, where I’m excited to be giving an oral presentation about my research into how professionals develop skills to support breech birth. This is my first Normal Birth Conference, and I can’t wait to soak up the influence of so many birth researchers, including the team from Sydney currently publishing some groundbreaking papers about breech (more below). You can follow the conference on Twitter at #NormalBirth16.
I am often asked by students with a budding interest in breech birth and a requirement to write a dissertation, if I can recommend any good/important breech research papers. Why, yes, I can.
The easy and Kuhnian answer to this question is: As it happens, I’ve published a good handful of peer-reviewed research and professional publications concerning breech presentation and breech birth! History may or may not deem them to be important, but if you want to know what I think is important, the reference lists will reveal all.
Read the Term Breech Trial. Read all of it, including all of the follow-up studies written by people who weren’t named Hannah. Critique the research and form your own opinions about if/how it is relevant to contemporary practice. Until you have completed this task, resist the urge to claim publicly that the TBT has been ‘disproven’ or ‘debunked.’ It hasn’t. It is still a powerful force, and in fact contains many relevant lessons. Finally, read the critiques of the TBT.
Now do the same for PREMODA, and if you are reading this in a few months’ time, the Frankfurt studies. At this point it will start to become interesting if you compare the reference lists of the different ‘camps’ of breech thought.
When I was starting my PhD, I did a PubMed search on ‘breech presentation,’ which returned over 4000 results. I read all of the abstracts related to management of breech presentation, and all of the articles where the abstract looked interesting/relevant. It took me about 6 months. My PhD supervisors suggested this strategy might be ‘inefficient.’ Fair point. However, it’s one of the best things I ever did, as I feel confident that I have a broad understanding of research related to breech. However, I’ve muted this suggestion, as it may not fit the time constraints of the pre-registration students. It’s just to say — there is no shortcut if you want to thoroughly understand the research base in your area of practice.
Finally, keep an eye on the group in Sydney who are currently publishing some very important papers. Mixing qualitative and quantitative methods, and focusing on the experiences of women and health care professionals, this team is producing research which complements the observational studies which have predominated in the past 15 years. Although each piece of research contains its own question, underlying them all, the wider questions are lurking: How did we get in such a muddle about breech? And how can we get out of it?
Remembering the last visit! Westmead Consultant Midwife Michelle Underwood, Obstetrician Anke Reitter, (me) Shawn Walker, and Lactation Consultant/Conference Organiser Barbara Glare
I will link a few of the Sydney papers below. Looking forward to seeing several members of this team at #NormalBirth16.
Catling, C., Petrovska, K., Watts, N., Bisits, A., Homer, C.S.E., 2015. Barriers and facilitators for vaginal breech births in Australia: Clinician’s experiences. Women Birth 29, 138–143. doi:10.1016/j.wombi.2015.09.004 — A qualitative study of interviews with 9 breech-experienced professionals (midwives and obstetricians) exploring what helped and hindered their ability to provide women with the option of a vaginal breech birth.
Catling, C., Petrovska, K., Watts, N.P., Bisits, A., Homer, C.S.E., 2016. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery 34, 111–116. doi:10.1016/j.midw.2015.12.008 — Additional analysis from the qualitative study above, exploring how these professionals provide care during the decision-making phase, when women are choosing mode of childbirth for a breech-presenting baby.
Homer, C.S.E., Watts, N.P., Petrovska, K., Sjostedt, C.M., Bisits, A., 2015. Women’s experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 15, 1–8. doi:10.1186/s12884-015-0521-4 — A large qualitative study exploring women’s experiences and what women want when planning mode of breech childbirth. Open access too.
Petrovska, K., Watts, N.P., Catling, C., Bisits, A., Homer, C.S.E., 2016. Supporting Women Planning a Vaginal Breech Birth: An International Survey. Birth. doi:10.1111/birt.12249 — An international survey exploring the support women received when planning a breech birth. The researchers found that women were generally happy with their decision to plan a breech birth and would do it again in another pregnancy. However, lack of support from their primary care providers often made this difficult to achieve.
Watts, N.P., Petrovska, K., Bisits, A., Catling, C., Homer, C.S.E., 2016. This baby is not for turning: Women’s experiences of attempted external cephalic version. BMC Pregnancy Childbirth 16, 248. doi:10.1186/s12884-016-1038-1 — Oh, thank goodness for this. The rhetoric around external cephalic version (ECV) is so strong, it almost feels a sacrilege to question it. Despite the Cochrane Review stating clearly that the evidence does not indicate that ECV improves neonatal outcomes, women are constantly told that ECV is ‘best for babies.’ Which says a lot about how reluctant to engage with the option of vaginal breech birth their providers are. This study of women’s experiences is a welcome balance to the dominant view that vaginal breech birth is only something to be considered after ECV has failed. ECV is a good option for many women, and a safe procedure in experienced hands. But it is not for everyone.
Andrew Bisits and Anke Reitter demonstrate breech skills
Borbolla Foster, A., Bagust, A., Bisits, A., Holland, M., Welsh, A., 2014. Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study. Aust. N. Z. J. Obstet. Gynaecol. 54, 333–9. doi:10.1111/ajo.12208 — Technically from another team, with one cross-over member, inspirational obstetrician Andrew Bisits. This observational study helps to shed light on the clinical context surrounding these researchers. Although the article makes no mention of use of upright positioning for labour and birth, Dr Bisits is well-known for his use of a birthing stool for breech birth. You can read more about this in a previous blog, Bottoms Down Under.
Andrew Bisits performing a gentle ECV
I may have missed something, or a new study may have been published while I am writing this. (I have updated the post with some recent editions.) Best to keep a look out yourself.
