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.
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.
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.
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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!
‘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.
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.
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.
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):
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.
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.
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.
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?
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 …”
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.
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 (firstname.lastname@example.org), 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 email@example.com 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.
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.
% studies reported
APGAR score at 5 minutes
Perinatal or neonatal mortality
Admission to neonatal intensive care unit (NICU)
Neonatal birth trauma/morbidity
Brachial plexus injury / peripheral nerve injury
Low umbilical artery pH
Hematoma (cephalic or subdural)
Post-partum haemorrhage (PPH)
PPH requiring blood transfusion
Other serious maternal morbidity/other complications
This year we honour midwives who continue to do the best job in the world under the most difficult of circumstances. Please enjoy this virtual International Day of the Midwife 2020 celebration from King’s College London student midwives, staff, alumni and collaborators. I’m so proud to be a part of this team!
And as always, we at Breech Birth Network honour the highly skilled midwives around the world who are working to make vaginal breech births safer and more accessible, for the women who choose them and for those who do not have a choice.
As part of the celebrations, I’ve made this video to explain the recent research that Dr Anke Reitter, Alex Halliday and I have done about what ‘normal for breech’ looks like. The video can be shared. Thank you to the women and professionals who have shared their intimate and vulnerable moments to make this possible.
The research is published open-access (FREE!) as part of a trio of breech articles by the journal Birth: Issues in Perinatal Care.
“Practical insight into upright breech birth from birth videos: a structured analysis” is now available on-line! (Reitter, Halliday and Walker, 2020, Birth – https://doi.org/10.1111/birt.12480) This paper represents a few years of hard work by Anke Reitter, me and our Research Assistant, Alexandra Halliday. It contains insights into birth timings and the mechanisms as observed in upright breech birth videos. The Physiological Breech Birth Algorithm is also included.
We look forward to much debate and discussion! Please share with anyone concerned about safe vaginal breech birth.
Traduit par: Isabelle Brabant et Caroline Daelmans
The Breech Birth Network are delighted to announce both Shawn and Emma have been shortlisted for awards at the International Maternity Expo Awards. We are both very honoured to have been shortlisted in the following categories:
Dr Shawn Walker – shortlisted for the Research Innovation Award and the Improving Safety Award
Dr Shawn Walker has been shortlisted for both the Research Innovation Award and the Improving Safety Award for her work in improving the knowledge, skills and training around Physiological Breech Birth. Shawn has published a number of research articles highlighting the importance of effective training, the development of experienced breech teams and pracical insights into upright breech birth. Shawn is currenty writing proposals for further essential research into Physiological Breech Birth to further improve safety and choice for mothers and their babies as well as practiotioners facilitating such births.
Emma has been shortlisted for the Practice Innovation Award for her work in setting up a breech birth service in the large London teaching hospital she works in. The service supports mothers in their choices regarding mode of birth for breech presentation at term. Emma is also completing her Masters research in Breech Childbirth Preferences of Parents to further support service provision and support for parents choices.
We would both like to thank those who nominated us. It is a privilege and an honour to have been recognised for the work we are both doing.
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.
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.
Providing evidence-based information to parents throughout the pregnancy, birth and post-partum journey is an essential part of the role of all healthcare professionals working in maternity services. However, evidence suggests in some areas of maternity, such as the highly politicised area of vaginal breech birth, the information provided to parents is biased towards that of what the system supports or the individual healthcare professional providing the counselling prefers. A compelling ethical and legal requirement exists to provide the evidence to parents which they have a right to receive, as discussed by Kotaska et al (2007).
An international qualitative survey by Petrovska et al (2017) surveyed women who had a breech presentation and were seeking support for their choice of mode of birth. Petrovska et al (2017) examines how mothers found inadequate system and clinical support for vaginal breech birth which impeded their access to unbiased information on their options for mode of birth and the care they received. In a paper written by Powell et al (2015) they also found that parents were often given unbalanced information. This lack of balanced information was a motivating factor in developing an information leaflet for parents identified with a breech presentation at or near the end of their pregnancy. The development of an information leaflet is supported by many papers such as that by Guittier et al (2011) and Sloman et al (2016) who also found parents were often provided with biased information. We hope the development and provision of useful, unbiased information material will assist with decision making and enable parents to make an informed choice of their options with a breech presentation.
Clinicians should counsel women in an unbiased way that ensures a proper understanding ofthe absolute as well as relative risks of their different options. [New 2017]
It is alarming that despite this guidance, and in light of more recent evidence which has emerged on the suitability of vaginal breech birth for selective pregnancies, that parents are still not being given all their options and more importantly the impact it is having on their future pregnancies.
The information leaflet has been developed in response to the acknowledged lack of balanced information available to parents. To ensure the information is evidence-based it includes data from the RCOG (2017) guidelines as well as other research sources such as that from Louwen et al (2016) and the NICE Caesarean Section Guideline (2013). The information leaflet was circulated to healthcare professionals of all grades (midwives, SHO’s, Registrars and Consultants) as well as parents who had experienced a breech presentation previously. They were asked to comment via a SurveyMonkey on the information which was provided in the leaflet to ensure it was easy to understand, informative, evidence-based and unbiased. The leaflet is provided below in both PDF leaflet form as well as an MS Word format, so healthcare professionals are able to download and edit for use in their own healthcare organisation.
Providing this readily available resource for parents and healthcare professionals is invaluable for ensuring the correct information is easily accessible and shared to not only support parents in making an informed choice about their options, but also for assisting with the counselling healthcare professionals provide to those in their care. If you have any questions or comments about the information leaflet, please do not hesitate to contact us on the contact form provided below.