Category Archives: Research

Reflections on International Day of the Midwife, 2022

Yesterday was International Day of the Midwife. I saw but didn’t participate in the social media celebrations. Not because I wasn’t feeling it, but because my clinical academic midwife life was full to the brim. This included:

This is the dress I made for Professor Jim Thornton’s retirement party, which I couldn’t attend due to another breech birth!
  • Supporting a planned OptiBreech vaginal breech birth through the night and until the birth occurred in the morning;
  • Conducting two interviews for the Wellcome Biomedical Vacation Scholarship at 9.30 and 11.00 — amazing candidates this year!;
  • Receiving the news that the OptiBreech team has been awarded a £15k ESRC Impact Acceleration Grant;
  • Receiving and responding to the news that both my funder and my employer have received complaints that the OptiBreech Project is ‘promoting vaginal breech birth;’
  • Being a keynote speaker in the Virtual International Day of the Midwife 2022 conference at 2 pm;
  • Allowing my little dog to take me for a walk to support my physical and mental health;
  • Taking a massive nap; and
  • Spending a wild evening in on my sofa, knitting a jumper for my son Waldo the Stonemason and listening to a Miss Marple audio book.

If you feel exhausted just reading that list, you’re as human as me!

A team is not a group of people that work together. A team is a group of people that trust each other.

– Simon Sinek, shared by Céline, an attendee at my VIDM presentation

OptiBreech

This feasibility study is undoubtedly the most challenging and most rewarding thing I have ever done in my life. Being a research leader means being a change leader, and change is never easy. The OptiBreech Project is proposing a paradigm change in the way we support vaginal breech birth. This means a change from promoting caesarean section (CS) to supporting each individual women’s choice of mode of birth, in line with NICE Guidance. And it means a change from using unreliable ‘selection criteria,’ which are also inconsistent with the concept of individual choice, to relying on specialist expertise to respond to unfolding and infinitely unique circumstances.

When I sit down to eat some dark chocolate and peanut butter because I’ve worked my butt off today …

Being a breech specialist is not easy. In addition to a lot of time spent on-call, it’s not like working in a low-risk midwifery setting, where you can anticipate 90% of women will have the normal birth that they want. Many women are heart-broken when they find out their baby is breech. We can support them to plan an elective CS, and some women are happy about this, but many are very disappointed, even when they feel this is the best option for them and their baby. For those who want to plan a vaginal birth, but only if the baby is head-down, baby turning (ECV, external cephalic version) is only successful up to 50% of the time. We are still there for women when it does not work.

For those who want to plan a vaginal breech birth, the barriers sometimes seem impossible. It’s not uncommon for women to make an informed decision to plan a physiological breech birth (PBB) and return to clinic in tears because of the way someone has spoken to them, be that another health care professional, a friend or family member, or an unkind stranger on social media with opinions about the wisdom of their choice. The criticism, judgement and stigma can feel very heavy at such a vulnerable time. Our interviews with women on the study indicate they have felt supported to change their minds and plan an elective CS in these circumstances. Of course we can and do facilitate women changing their minds, but we can’t take away the hurt women feel when they wished for more support to make a different choice.

Birthing people who stick with their choice to birth vaginally despite such ubiquitous doubt frequently want reassurance that everything will be okay. Of course, we can never guarantee a perfect outcome. We can only guarantee that we are doing our best to increase the chances we will get professionals with enhanced training and experience to their birth. We believe this will improve outcomes for these births (that is the premise of the research), but we will not know until many OptiBreech births have occurred. And we all have to be prepared for a higher need for intrapartum CS to achieve a safe outcome for breech babies, even when trying for a vaginal birth.

Those of us supporting women who choose physiological breech births face similar criticism and judgement on a regular basis. Sometimes the lack of respect and unkindness feels overwhelming, and it is tempting to succumb to despair. I find it helps to remember that behaviour like this comes from a place of fear, a belief that doing things differently could have disastrous outcomes. Nobody wants this, and nobody wants to be responsible for it. In difficult times, I lean into the support I feel from many wonderful midwifery and obstetric colleagues, who help bring me back to a place of compassionate understanding. Only by opening to understanding each other can we move towards trust and safety — physical, emotional and spiritual safety in each others’ hands.

Listening to my ‘Joy and Love’ playlist helps too. Here’s a mini playlist of my favourite Resistance Revival Chorus songs, for anyone who needs them today.

Continuous cyclic pushing: a non-invasive approach to optimising descent in vaginal breech births — The OptiBreech Project

Shawn Walker, RM PhD, King’s College London and Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex Hospital Sabrina Das, MB ChB, MRCOG, Imperial College Healthcare NHS Foundation Trust, Queen Charlottes & Chelsea Hospital Emma Spillane, RM MSc, Kingston Hospital NHS Foundation Trust Amy Meadowcroft, RM, Northern Care Alliance NHS Foundation Trust Background In the […]

Continuous cyclic pushing: a non-invasive approach to optimising descent in vaginal breech births — The OptiBreech Project

Reflections on the Ockenden Report in the context of breech presentation

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.

Breech-COS international study

Round 1 of the international multi-stakeholder Delphi study, Development of a Core Outcome Set for Effectiveness Studies of Breech Birth at Term (Breech-COS) is now open. We invite the involvement of anyone from the following stakeholder groups, who has experience of care for women having vaginal breech births:

QR code for Breech-COS Round 1
  • obstetrician
  • midwife
  • service users (you or your partner have had a breech-presenting baby within the last 5 years)
  • neonatologist
  • researcher
  • health services manager
  • healthcare commissioner
  • health economist
  • statistician
  • support group representative
  • other relevant roles

You can read more information about the research and participate using the link or the QR code below. You are welcome to share this post or forward to your stakeholder associates.

Participation Linkhttps://qualtrics.kcl.ac.uk/jfe/form/SV_b4uw2QJxcTC8oZM

This consensus-building activity follows on from our systematic review, including Patient and Public Involvement (PPI) activity, Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS): A systematic review on variations in outcome reporting.

Shawn Walker, on behalf of the OptiBreech team

student midwife literature reviews

My name is …, I’m a third year student midwife at X University and I am about to begin my literature review, I have decided to focus on vaginal breech birth. I haven’t finalised my question yet as I feel I need to read some more research to be able to word it correctly but I’m really interested in vaginal breech birth and practictoner skill. I’m ambitiously hoping my review might encourage the trust I work in to trial a breech birth team. I was wondering if you might be able to point me in the direction of any research regarding practitioner skill or breech birth teams? I understand we need much more research, but in your opinion is there any particular area that is really lacking in research that would support a move towards normalising vaginal breech births? I appreciate this is a very busy time for everyone having to work from home and understand you may not have time to respond to me at the moment but I’m so excited at the idea that don’t want to leave any stone unturned, any advice you have would be very appreciated.  

Hope to hear from you soon!

(Thank you for permission to share this exchange.)

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

Hello, 

Thank you for your message and your interest.

I write about this topic constantly https://breechbirth.org.uk/publications/. My PhD thesis contains a section on it, although this is a few years old now. Reference lists to our publications will help get you started. We also include information on building competence in the Breech Birth Network on-line training.

You could do a review on breech teams, breech clinics or midwife involvement in breech care. We need someone to lead some sort of consensus project to produce something like this for breech midwives: https://www.networks.nhs.uk/nhs-networks/diabetes-midwives/documents/NHSDAKC%20Midwives%20Standards.pdf That is a long-term project that will require funding, support and networking with key stakeholders, such as the RCM and RCOG. But it starts with a literature review.

You could do a literature review around midwives’ roles, any literature about competencies already out there, any evidence about the roles that midwives are taking, any evidence about outcomes associated with midwife-attended breech births (there is some in one of the TBT follow-up studies, I think by Su?).

My advice would be, whatever you do, treat it as a first step in becoming an expert in this area yourself. While it is great to try to convince your Trust they can do this, eventually, someone is going to need to actually put themselves on call and attend the births. So while you understandably feel at the beginning of a journey, see yourself as starting and committing to that journey, rather than trying to convince someone else to 😊 It may take years, but the breech revolution is a looooong-term game, requiring all of us to take small steps, with patience, but continuing to move forward, inch by inch. You will be constantly running into a wall. We turn to each other for support, do not give in to despair, and keep going. Eventually, enough of us running into the same wall will knock it down.

Another option is to do a review of outcomes associated with breech clinics and breech teams. This would be very valuable, but it will require a ‘no stone unturned’ approach indeed. This is because content about clinics and teams is usually embedded in articles, rather than listed as a key word. So you would have to do a general search on ‘breech presentation’ after 2000, eliminate obviously irrelevant articles and duplicates, then do searches on the words ‘team’, ‘clinic’ and ‘specialist’ and other related words such as ‘on-call’ and ‘stand-by,’ within the abstract and text of the articles themselves. It’s not as simple as a PICO search on randomised controlled trials, but it would pull together the general trends associated with clinics and teams (for ECV as well as VBB results), demonstrating a need for further research focusing on these as interventions themselves. (Here’s an example to get you started.)

To that end, make sure you are using a Reference Management Software programme. I use Mendeley. If you are going to become a breech specialist yourself, you will need to be very familiar with the literature and have it easy to hand when you want to apply for funding or write up your work. Do that now and begin to build your library of evidence, organised to help you make your arguments. Reference Management Software will also help you search the text.

Be sure to check the reference lists of any articles that qualify and our publications.

And choose a topic that you are interested in going on to do further research about because a literature review is the first step. Aim to write a literature review that you can publish, even in a student midwife journal, but ideally more. You are not doing a ‘student midwife literature review.’ You are doing a literature review. There’s no reason your first go need be any less worthy than any medical or post-graduate student doing a literature review for the first time, many of which get published. Your work and your mind are just as worthy, and when you spend time doing something properly, you have insight others can learn from.

Once you graduate, begin to identify sources of funding for the next stages. Research/breech practice is a great combination because it gives you some flexibility (e.g. not responsible for as many clinics/shifts) and helps move practice forward.

If you’ve done our on-line training, you can begin to become involved in assisting with training through BBN. Continual review and engagement is the best way to continually develop your confidence. We have on-line seminars frequently.

Join the community of practice: Have you found really good breech team / breech clinic references for your literature review? Post them below in the comments to help others get started.

I am very happy to provide specific advice and guidance as an external supervisor for students who are intending to follow through, taking their project to publication. We need more voices contributing to this effort.

Best wishes,

Shawn

Update: I just undertook a mini literature review due to a student reporting how difficult it was to find qualifying papers. First: sympathy. Yes it is. Second: Unfortunately, there is no shortcut for very thorough understanding and overview of a topic in which you would like to gain expertise.

But how exciting! Every time I do this, I learn more, from discovering more qualifying papers to other topics that people have looked into. I could spend all day lost in these papers, connecting one to the other, piecing the jigsaw together. However, I need to get on with other things. First, some more tips:

  1. Frankfurt. This group publish under FRABAT. You could make an argument for this being a dedicated centre, and all of the subsequent publications would qualify for inclusion. The group challenges many strongly-held assumptions about ‘exclusion criteria,’ which may not be as useful in an experienced centre.
  2. Do you speak/read Spanish? Garcia Adanez et al 2013
  3. Do you speak/read French? Marzouk et al 2011

Training evaluation published

Breech Birth Network are pleased to announce the publication of an evaluation of our physiological breech birth training, conducted in eight NHS hospitals across England and Northern Ireland. Click on the image below to read the full evaluation.

Highlights

  • Multi-disciplinary training, involving NHS midwives and obstetricians
  • Only training to have demonstrated an increase, rather than a decrease, in vaginal breech births following delivery of the training package, although this was not statistically significant
  • Use of upright positions at birth increased significantly
  • Pilot data: no adverse outcomes among births attended by someone who had completed the training, compared to a background rate of 7%
  • Pilot data: perineal outcomes similar to cephalic births

Congratulations to midwife Stella Mattiolo, who collected and analysed this data as part of her Masters in Research.

PhD Fellowship Opportunity

This week, the NIHR (UK based) announced a PhD Fellowship opportunity. A Fellowship is designed to support a researcher to gain experience and training in doing research, and to support the research itself. It’s a great opportunity. Advertisement pasted below.

If you are reading this after any of these calls have closed, the same organisations may have a more recent call.

NIHR-Wellbeing of Women Doctoral Fellowships (Round 6)

Provide the opportunity to undertake exciting and impactful research that will underpin a researcher’s development as an independent future leader. The Doctoral Fellowship funds researchers to undertake a PhD

Wellbeing of Women is delighted to have partnered with the National Institute for Health Research (NIHR) to jointly fund one Charity Partnership Doctoral Fellowship.

All NIHR Fellowships provide the opportunity to undertake exciting and impactful research that will underpin a researcher’s development as an independent future leader. The Doctoral Fellowship funds researchers to undertake a PhD.

NIHR Charity Partnership Fellowships offer researchers the opportunity to be part of an active and supportive community, drawing on the enormous benefits and opportunities of cross-sector working.

For more details please see: https://www.wellbeingofwomen.org.uk/funding-opportunities/nihr-wellbeing-of-women-doctoral-fellowships

Update: Here’s another

HEE/NIHR ICA Clinical Doctoral Research Fellowship

The Clinical Doctoral Research Fellowship (CDRF) funds health and social care professionals to undertake a PhD and professional development in parallel, alongside continued professional practice.

The scheme is part of the HEE/NIHR Integrated Clinical Academic (ICA) Programme.

CDRFs are available to health and social care professionals (excluding doctors or dentists) who are registered with an ICA eligible regulatory body.

For more details please see: https://www.nihr.ac.uk/funding/heenihr-ica-clinical-doctoral-research-fellowship/27181?source=chainmail

If you are considering training to be a researcher and/or clinical academic who does breech research, we would love to hear from you. There are many challenges in breech research. For example, variations in when the breech is diagnosed make recruitment challenging. Sometimes dramatic variations exist between centres in external cephalic version success rates, vaginal breech birth experience and whether or not breech presentation has a dedicated care pathway. This can make recruiting sites difficult, and it is difficult to reach an adequate sample size within single-centre studies. But we have experience in navigating some of these challenges and are keen to collaborate with others.

For example, in the OptiBreech Project, we are building a database designed to support a large, multi-site observational cohort study with multiple embedded trials along the breech care pathway. Some of the questions women or potential researchers have told us would be useful to answer include:

  • Does moxibustion work in a UK context, and what does it cost? This could be tested as a trial within the cohort.
  • Rebozo sifting / positional exercises / homeopathy / hypnosis — do they influence the rate at which babies turn head-down, or the success rate of external cephalic version? This could be tested as a trial within the cohort.
  • Does provision of an ECV service by a Breech Specialist Midwife change the outcomes of the service? And what does it cost compared to an obstetric service? This could be tested as a trial within the cohort.
  • Should we offer cervical sweeps to women with breech-presenting babies? Are they helpful? Safe? From when should we offer them? This could be tested as a trial within the cohort.
  • Does offering induction of labour for women with a breech-presenting baby who desire a vaginal breech birth affect modes of birth and/or outcomes? This could be tested as a trial within the cohort

If you’d like to consider applying for this or another source of funding for breech research, you are welcome to be in touch to discuss!

Shawn

What is ‘physiological breech birth?’

‘Physiological breech birth’ is an approach to care informed by evidence about the physiological processes of vaginal breech births, and an approach to clinical education based on evidence about how professionals learn to facilitate breech births.

I spend a lot of time communicating about vaginal breech birth, and equally importantly, a lot of time listening to how other people communicate about vaginal breech birth. Lately, I have become aware that many people misunderstand what ‘physiological breech birth’ is. This causes difficulties in communication and prevents current research evidence from improving the safety of vaginal breech birth as quickly as it could.

Image from Dr Anke Reitter, 2019

It’s my job to help clarify so that research can be used to improve safety and choice, as it is intended. Let’s start with what physiological breech birth is NOT:

Physiological breech birth is NOT ‘upright breech birth,’ ‘standing breech,’ or ‘all fours breech.’ Upright maternal birth positions are a TOOL and not a RULE of physiological breech birth. The reference standard is that, in a normally progressing birth, the woman or birthing person should give birth in the position of their preference. For many women having an unmedicated birth, particularly in midwife-led settings, this will be an upright position. Therefore, the logic goes, a ‘normal breech birth’ is one in which the woman is enabled to give birth in the position of her choice. Requiring supine positioning is an intervention.

How does this fit with the RCOG guideline (2017)? This states: “Either a semi-recumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant. If the latter position is used, women should be advised that recourse to the semi-recumbent position may become necessary.”

The RCOG supports the use of upright positioning, but suggests this should be dependent on maternal preference and the experience of the attendant. Our recent analysis of video evidence (2020) showed that conversion to supine maternal position occurs within 10 seconds when use of supine manoeuvres is required. Therefore, the most recent evidence indicates that, while providers should continue to inform women that they may need them to turn over if the birth is very complicated, the experience of the attendant does not need to influence a woman’s initial choice of birthing position. Even if the attendant knows only supine manoeuvres.

Permission to use this video for teaching purposes is granted. Just access this page and click the full screen icon.

Where it is possible and safe to support a woman’s liberty in her birthing process, that’s what we should be doing, right? There is no evidence to indicate that use of supine birthing position improves outcomes for mothers and/or babies compared to enabling upright positioning. There is also no evidence to support the use of some manoeuvres over others; only things, like pulling, we know are dangerous. If a local guideline stipulates that women should be asked to assume a supine position to birth, this is out of line with both current RCOG guidance and the principles of woman-centred care.

Physiological breech birth is NOT, “It’s just hands off the breech. Just breathe, wait for the next contraction.”

The penny dropped for me after hearing two different midwives in two different cities describe to two other people what ‘physiological breech birth is’ using exactly this phrase, word for word. And then participating in risk management reviews following adverse outcomes, where midwives had document that they were practising ‘hands off the breech.’ And then attending multiple births (and videos), where midwives were instructing women to ‘just breathe, wait for the next contraction,’ even when there was concern about fetal condition and the situation was becoming urgent. Because this is what they had been taught. ‘Hands off the breech’ has become a dogma with unintended consequences. Instructing someone to avoid pushing when they feel the urge is an INTERVENTION. It has no evidence to back it up, nor any good theoretical basis other than preventing people from pulling when they don’t know what else to do.

It’s not surprising that some senior managers are cautious about enabling ‘physiological breech birth,’ if this is what they understand it to be, especially if they have participated in adverse outcome reviews where this sort of practice has been described.

But, due to science, we know how to do better. Our video analysis showed that in a sample of 42 births, the birth was complete within 2:46 of the birth of the pelvis in 75% of cases. Regarding birth intervals, the RCOG guideline states that breech births should be assisted if there is delay of more than 5 minutes from the buttocks to the head. We are in the same ballpark of the RCOG’s recommendation based on expert opinion. But now we know that if you wait this long to assist, you are already outside the normal reference range.

Physiological breech birth is not contradicting our already strong, evidence-based guideline. Rather, current, living, emerging evidence is refining it.

Permission granted to use for teaching purposes

Historical use of the phrase ‘physiological breech birth’

Midwife Jane Evans used the phrase ‘physiological breech birth’ in her 2012 article, Understanding Physiological Breech Birth. In it, Evans shares her insights and descriptions of the mechanisms based upon her observations in clinical practice. Those of use who use this phrase in our research have continued in this tradition, using systematic, planned observational and other research methods. Many of her observations we have confirmed; some have been modified.

How to let the evidence help you

Let’s say you are a Practice Development Midwife. You teach the breech birth update in a 40-minute slot, using materials commonly used in other obstetric emergencies training programmes. You’d like to ensure the update is as informed by up-to-date evidence* but don’t want to blow people’s minds apart with variations from what they already know, especially now. Good idea.

These are my top 3 tips for making sure the training you deliver evolves with the current evidence base (as of January 2021):

  1. Explain that the RCOG guideline recognises and supports women to adopt an upright position if that is their preference. Explain that the evidence indicates it takes less than 10 seconds to convert from upright to supine position. So even if providers are only experienced in supine complications, women should be supported to adopt the position of their choice. Although ‘lithotomy’ is not necessary, run through what conversion would look like in practice with your team if this helps people envision what is possible. Show them the video above if you are able.
  2. Recommend the use of maternal movement and effort if any delay is identified. Delay is defined as no progress for 90 seconds at any point once the baby begins to emerge. Our video research indicated that maternal movement (#giveitawiggle) and effort (gentle encouragement to “push”) alone is often effective, without the risk of iatrogenic damage from hasty manoeuvres, but it is not always used. Instead, women are often instructed to breathe through a contraction and resist the urge to push. Because time is of the essence, and contractions may be 5 minutes apart in 2nd stage, this is a safety risk. Even in supine births with an epidural in situ, simply asking the woman to push will also work in this situation if there is no obstruction. At this point, the uterus is almost entirely empty; a contraction creates the urge to push, but maternal effort does the job. The use of maternal agency to facilitate the birth is a first principle of physiological breech birth – it’s not all about the position.
  3. Teach shoulder press alongside MSV. Our video research found this simple manoeuvre was used in 57% of the upright breech births in our sample. Start by explaining the principle: elevating the occiput and flexing the fetal head, so that the smallest diameter delivers. When a woman is supine it is done like this … MSV. When a woman is upright, this works too … shoulder press. But the principle is the same. Then invite people to practice the one they are most likely to use. This flexible approach, recognising the variety of practice contexts, also reduces the risk an out-of-hospital midwife will ask a woman to lie down on the floor so she can perform MSV. This is a safety risk as it automatically deflexes the head.

Sure, the physiological breech birth evidence base covers a lot more. Our full training package (study day or on-line) goes into less common complications and their solutions, more about the research, and how to use the Algorithm to guide decision-making. A feasibility study is currently being conducted, hoping to trial a new care pathway based on physiological breech birth. But it is possible RIGHT NOW to use the available evidence to update current practice in a safer direction, without making major changes to what you are already doing.

In Summary

Lastly, if one can point out a single maxim in breech deliveries, take heed of the results of the experienced country midwife and doctor. They are usually very good, and their results are obtained by a policy of non-intervention. Do not interfere unless it is necessary, but when it is necessary interfere quickly and with certainty.

Ian Donald, 1956, Practical Obstetric Problems

The careful, systematic study of vaginal breech births that has taken place in the physiological breech birth tradition reflects this maxim. Do not intervene, not by dictating a birth position, not by instructing someone not to push, not at all, unless it is necessary. Due to a lack of exposure, many health care professionals just do not know how to recognise ‘when it is necessary’ and therefore cannot act quickly and with certainty, through no fault of their own. Due to physiological breech birth research, ‘when it is necessary’ can now be defined and described much more precisely. Therefore, it can be taught. And it can be tested.

But if the available research indicates simply stopping untested but commonly applied interventions may reduce identifiable risks, do we really need to wait for an RCT?

Shawn

P.S. A note on *up-to-date evidence. When preparing to write this blog, I did a brief literature search to find others (e.g. not ‘physiological breech’) who are publishing research related to the clinical practice of vaginal breech birth in the UK. The last I could find were Sloman et al 2016 and Pradhan et al 2005. Many of Sloman’s findings are consistent with those of other physiological breech researchers. I am keen to hear if anyone else in the UK is producing evidence concerning the clinical practice of vaginal breech birth at the moment — breech birth itself, not ECV or decision-making. Because it’s starting to feel surreal when people say, “We don’t teach/do physiological breech birth because it’s not evidence based …”

Here’s some!

Jan, H., Guimicheva, B., Gosh, S., Hamid, R., Penna, L. and Sarris, I. (2014), Evaluation of healthcare professionals’ understanding of eponymous maneuvers and mnemonics in emergency obstetric care provision. International Journal of Gynecology & Obstetrics, 125: 228-231. https://doi.org/10.1016/j.ijgo.2013.12.011 — And one of the co-authors (L Penna) is also a co-author of the RCOG guideline. This is the reason we do not use eponyms when teaching skills on physiological breech birth study days.

Inviting your views … — The OptiBreech Project

From Tisha Dasgupta, OptiBreech Research Assistant, re-blog from The OptiBreech Project: We would like to invite women, birthing people and their families who have experienced a breech pregnancy at term to attend an online focus group discussion on Thursday 10th December 10.30-11.30am to be conducted via Microsoft Teams.  Anyone with an interest and experience of breech pregnancy can participate.

The purpose of this meeting will be to get your perspective on the following issues: 

A core outcome set is a minimum set of outcomes that should be collected in every study about a topic, in this case vaginal breech birth at term. Making these consistent means that we can better compare and combine studies, and ensure research meets the needs of those who use it.

To develop a core outcomes set, we have conducted a systematic review of the available literature relevant to this project (brief summary below). However, we need your input to determine if these outcomes are important to the people who will use the results of research to make decisions, and how important each is. Does this meet all your informational needs or are there outcomes that have not been identified, which you think is important to record? 

Do you think it is important to include salutogenically focused outcomes that emphasize positive well-being of the mother and newborn such as maternal satisfaction, relationship with baby etc.? If so, which factors would you like to see and how important do you think these are? 

The next stage will be to ask both professionals and service users to rate the importance of the outcomes to be included in the core outcome set. But before we do this, we want to insure all of the outcomes important to you are included.

You are welcome to share your feedback directly during the focus group meeting or by emailing Tisha Dasgupta (tisha.dasgupta@kcl.ac.uk), the OptiBreech Research Assistant, at any point. If you are unable to make it and would like to contribute, or have further feedback after the session, please also contact Tisha.

While we do not require written consent for your participation in the meeting, it is important to let you know that the session will be recorded. We intend to take the feedback you provide into consideration while designing the next stage of this project: a multinational Delphi study. No identifiable information will be used such as direct quotes or anecdotes, and we will only report summary data.  

Thank you very much for your consideration. Please could you send your RSVP to tisha.dasgupta@kcl.ac.uk by Monday, 7th December to confirm your attendance at the session? She will be in touch thereafter to provide you access to the online meeting.

More information:

The COMET Database

The CROWN initiative

We’d also love to hear your views on the information presented on the OptiBreech website!


Overall summary of the Systematic Review

A systematic review of all relevant literature was conducted to identify outcomes, definitions and measurements previously reported in effectiveness studies of breech births at term. 108 studies were identified comprising of systematic reviews, randomised controlled trials and comparative observational studies, with full-text available in English. Below are the most common outcome measures, with a percentage of how many studies reported them. These are the top 10 most frequently reported measures in each category grouped by neonatal, maternal, features of labour, and long-term maternal outcomes respectively.

Neonatal outcomes

Outcome measure% studies reported
APGAR score at 5 minutes78.7
Perinatal or neonatal mortality68.5
Admission to neonatal intensive care unit (NICU)59.3
Neonatal birth trauma/morbidity53.7
Brachial plexus injury / peripheral nerve injury38.0
Low umbilical artery pH35.2
Bone fracture33.3
Neonatal seizures/convulsions31.5
Intubation/ventilation29.6
Hematoma (cephalic or subdural)20.4

Maternal outcomes

Maternal mortality24.1
Post-partum haemorrhage (PPH) 16.7
PPH requiring blood transfusion14.8
Other serious maternal morbidity/other complications14.8
Genital tract trauma13.0
Wound infection requiring prolonged hospital stay/re-admission12.0
Deep vein thrombosis (DVT) requiring anticoagulant therapy10.2
Prolonged hospital stay9.3
Hysterectomy8.3
Anaemia7.4

Features of labour

Vaginal Delivery97.2
Emergency Caesarean88.0
Elective caesarean80.6
Induction of labour24.1
Instrumental vaginal delivery18.5
Manoeuvres used17.6
Regional anaesthesia15.7
Trial of labour14.8
Actual mode of birth13.9
Duration of delivery/second stage13.9

Long-term maternal outcomes

Urinary incontinence6.5
Breastfeeding complications5.6
Faecal incontinence5.6
Postnatal depression5.6
CS in subsequent delivery5.6
Long term abdominal pain4.6
Dyspareunia4.6
Flatus incontinence4.6
Relationship with partner4.6
Long term perineal pain3.7

Normalising breech birth at the European Congress on Intrapartum Care, 2021

Physiological breech birth will be one of the key topics at next year’s ECIC in Belgrade, Serbia. See information below for booking and consider submitting an abstract.

ECIC 2021

5th ECIC: European Congress on Intrapartum Care
Making Birth Safer

27-29 May 2021 · Belgrade, Serbia

Be one of the first 300 to registerRegister as early as today to take advantage of the discounted fee – available only to the first 300 participants!

Here are some good reasons why you should attend the 5th ECIC in 2021:

  • ECIC is a unique opportunity to learn standard obstetric skills
  • ECIC gives you knowledge and confidence in obstetrics
  • A congress where women in labour are the focus of midwives and obstetricians
  • Scientific and clinical challenges of intrapartum care on debate
  • Positive childbirth experience combined with the best available technology

REGISTER AND SAVE

PRELIMINARY PROGRAMME
ABSTRACT SUBMISSION
CONGRESS COMMITTEES

We look forward to meeting you in Belgrade!
info@eciccongress.eu
eciccongress.eu
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Interesting follow up discussion on Twitter! …