Providing advanced training to a core breech clinical teaching team is potentially more efficient and effective than training the entire maternity care team using traditional methods. The theory is strong, but rigorous research needs to be done.
Traditional training, looks something like this: Participants take time away from clinical commitments to attend a dedicated training session, ranging in length from a few hours to a whole day or more.
Challenges for this approach in the context of breech birth
1. It’s expensive
While preparing the research proposal for the #termbreech2020 Physiological Breech Trial, I worked closely with NHS Research & Development Finance specialists. Using the Agenda for Change pay scales, we calculated that providing 1 day of physiological breech birth training to 5 obstetricians and 5 senior midwives will cost the service £2,442 just to release them from clinical work. Multiplying this to cover the whole staff will obviously increase the cost exponentially. And then there is the cost of paying the trainers.
This is why most training programmes, like PROMPT, use a ‘train the trainers’ approach. It is a more efficient and effective way to disseminate training throughout an organisation. [PROMPT is a great multi-professional training package, but unfortunately, they excluded outcomes for breech births from their evaluation (Draycott et al 2006). So this training has not yet been evaluated for vaginal breech birth.]
2. The effects of training wear off before most people will have a chance to use it
Our systematic review of the effectiveness of breech training strategies showed that breech training can improve objectively assessed skill and knowledge, but that these effects wear off quickly, sometimes within 6 weeks, sometimes within 72 hours. A bigger concern was that, in some cases, confidence increased but objectively assessed skill did not. Training alone is likely not sufficient to improve breech skills, but for those who have some clinical experience, it may extend current understanding.
If you train a staff of 40 (or more) in a service that has only 1 breech birth per month, most of them will not have a chance to consolidate their learning in clinical practice. And if you do not have a plan for ensuring that someone who has attended enhanced training will attend the vaginal breech births that do occur, the enhanced training will not contribute to improvement in outcomes.
3. Clinical support in practice appears to make the biggest behavioural change
A surprising finding from our systematic review was that attendance at an obstetric emergencies-type training course was inversely associated with attendance at vaginal breech births, unless a system was in placed to provide clinical support in practice. This means that clinicians attended fewer vaginal breech births after taking breech training as part of an obstetric emergencies package. Although no quantitative evaluation was done, the studies that reported increase in breech births attended all had a model for ensuring experienced support in practice.
Implementing a breech clinical teaching team is a way of ‘training everyone.’ The model just differs from traditional ‘training day’ methods, which have not proven effective on their own in sustaining safe vaginal breech services.
Paying a few people who want to support breech births to be on-call occasionally and to cascade training is likely less expensive than providing enhanced training to the entire maternity care team, or even the entire senior team. But we need to implement the model and evaluate it in a systematic way in order to determine cost effectiveness. This is why experienced health economists are central to the #termbreech2020 Physiological Breech Trial and helped develop the design.
According to the evidence, breech clinical teaching team is also likely to result in greater availability of the option of vaginal breech birth for women who want them. This was a central concern of the women who participated in #termbreech2020 Physiological Breech Trial public engagement work.
But! Isn’t experienced senior clinical support what consultant obstetricians do? … Good question. We’ll discuss that next …
Dr Anke Reitter and Dr Shawn Walker of the Breech Birth Network will teach together in Barcelona on 23 April at Hospital de la Santa Creu i Sant Pau. Please share with your obstetric and midwifery colleagues. Materials will be translated into Spanish for participants. Click the image below for more information on how to register.
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.
This weekend, I have been lucky enough to visit Stockholm, Sweden, at the invitation of the Södersjukhuset (BB SÖS), with Dr Andrew Kotaska, author of the 2019 Canadian breech guideline. We delivered training in breech research and practice to obstetricians and midwives from across Stockholm, a contribution to their recent effort to establish city-wide guidelines.
Breech Team Leader Tove Wallström and Breech Midwife Monica Berggren
The day was organised by senior obstetrician Julia Savchenko (pictured with Andrew above). Julia and fellow senior consultant Tove Wallström lead the Labour Ward and the SÖS breech team. These inspirational women presented their local audit results, showing how their vaginal breech births have increased from 9 in 2014 to 50 so far in 2019. Almost all women give birth in an upright position, and all births are attended by a breech-experienced obstetrician and a breech-experienced midwife from the breech team.
Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre
After training with the Breech Birth Network, Isabelle Brabant gave us her feedback from her first training session teaching midwives in the far North of Canada:
“I have to tell you a bit about Maternity up North. There are seven villages on the Hudson Bay Coast (just about 1200km long!). There’s a maternity service in three of the biggest villages: Salluit, Puvirnituq and Inukjuak. There is no road to get there, you can only go by plane or by cargo – if you have a couple of weeks to spare for the trip. The Inukjuak maternity services have around 40 births per year, and if a baby remains breech in the pregnancy they would offer an external cephalic version, but if unsuccessful the woman would be sent to services further south (to Montreal!) to have her baby – alongside the other approximately 15% of women who are referred for medical reasons. If ever a woman needs to be transferred in labour it takes no less than 8 hours as there is no plane in the village itself – yes 8 hours! In an undiagnosed breech situation the decision would be made to transfer, but the chances are that the baby would be born before transfer. This explains the interest and need for Breech Birth training with the midwives being very interested in the training – of course they have a small volume of births, but the possibility remains of having an undiagnosed breech birth at any time.
The training was given to a small group of enthusiastic midwives in Inukjuak, where we started the day with what is normal for Breech which the midwives enjoyed alongside teaching essential skills and manoeuvres. I will be delivering this training three times to Quebec midwives in May and June.”
There are three more training sessions planned in Canada throughout May and June and the details are as follows:
6th May 2019: MdN de l’Estrie, Sherbrooke
31st May 2019: MdN Mimosa, Lévis
13th June 2019: Montréal (lieu à déterminer selon la taille du groupe)
You and your colleagues may be interested in these two upcoming conferences, led by obstetricians. First, a two-day breech conference in Denmark featuring a number of internationally known teachers and researchers:
And in November, Breech Birth Network will be offering physiological breech training alongside the British Intrapartum Care Society Conference in Leicester.
“We believe that we do well what we do often.” – Caroline Daelemans
Drs Caroline Daelemas and Sara Derisbourg
Contact Hōpital Erasme Clinique du Siège on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be.
This month I visited Hōpital Erasme, in Brussels, Belgium. Led by Lead Obstetrician Caroline Daelemans, Erasme began to offer a dedicated Breech Clinic in December 2015. Much of the organisation and development of the clinic has been done by Dr Sara Derisbourg, who continues to research the impact of instituting a dedicated breech service.
I came to Brussels to provide our usual physiological breech study day. The breech team has transitioned to using physiological methods, including upright maternal positions (Louwen et al 2016), after attending training in Norwich in 2017. They now needed the rest of the team to understand the philosophy behind this approach. But the day began with Caroline describing the impact of instituting a dedicated Breech Clinic, and this was particularly exciting for me.
Josephine and Thiago talk about their experience of Ulysse’s breech birth at Erasme
My own research concerning the development of breech competence and expertise, and the recovery of these skills within a service, indicates that developing a core team with significant experience is the most effective method of safely offering a vaginal breech birth service (Walker et al 2016). This skilled and experienced core is more important than the ‘selection criteria’ that are used to predict the likelihood of a good outcome (but in fact are not very predictive). Skill and experience facilitate good outcomes and enable other colleagues to develop competence (Walker et al 2018). The Erasme team even encourage other health care professionals to come with their clients and attend them in labour with their support, to encourage the growth of breech skills.
The need for new ways of organising care has been emphasised in an on-line survey of Dutch gynaecologists just published by Post et al (2018, Does vaginal breech delivery have a future despite low volumes for training?): “Potential suggested alterations in organization are designated gynecologists within one centre, designated teams within one region or centralizing breech birth to hospitals with a regional referral status. Training should then be offered to residents within these settings to make the experience as wide spread as possible.”
Daphne Lagrou of Médecins Sans Frontières demonstrates shoulder press
Daelemans and Derisbourg began with a small team of 5 people. This has gradually expanded and now includes eight members who together provide 24/7 cover for all breech births within the hospital. Women with a breech presentation are referred by colleagues and increasingly by other women. The environment at Erasme is ideal because the hospital has a very positive approach to physiological birth in general, and a 15% overall caesarean section rate in 2017. This compares to 20.2% in Brussels and much higher in many places globally.
Practising collaborative manoeuvres for resolving head extension at the inlet of the pelvis (elevate & rotate)
What has the Breech Clinic changed? Before the introduction of the clinic, the planned vaginal breech birth rate was 7.19%, and in just a few years this has climbed to 42.7% of all breech presentations. Neonatal outcomes have remained stable. Actual vaginal breech births have climbed from 4.2% to 35.96% of all breech presentations within the hospital. The success rate for planned vaginal breech birth is 76.3%, which suggests that within experienced teams, the emergency caesarean section rate is also reduced. (The RCOG guideline suggests about 40% of planned breech births end in CS.)
All of this is very impressive. The message is clear: a physiological approach and an organised care pathway, including a breech clinic and experienced on-call team, can reduce the caesarean section rate significantly without negatively impacting neonatal outcomes. We should all look out for Derisbourg’s papers when they are published.
If you are a woman seeking support for a physiological breech birth, or a health care professional looking to refer a woman to the breech clinic, they can be contacted on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be. Caroline Daelemans will be teaching with me in Lewisham, London, on 12 November.
Emma Spillane, Training Co-ordinator at the Breech Birth Network, has attended six breech births in the last six months in an NHS hospital. Rebuilding breech skill is possible, guided by evidence about how breech competence develops. Emma writes about how she gained confidence in teaching and attending physiological breech births by assisting at Physiological Breech Birth study days.
In January 2017 I attended a Physiological Breech Birth study day in Norwich by Dr Shawn Walker and Dr Anke Reitter. Breech birth had always interested me from my first breech birth as a newly qualified midwife. I didn’t understand the physiology of breech birth at this time, it had always been taught as something abnormal, an obstetric emergency. I could never understand though, how breech birth could be so abnormal if babies were on occasion born like this. My interest had been piqued, and so a few years later, and a few more breech births later, I found myself on the study day to develop my knowledge and skills in vaginal breech birth.
The study day taught me the tools required for supporting women to have a physiological breech birth and to resolve possible complications whilst supporting physiology. Following the training I went and introduced myself to Shawn and told her of my interest in breech birth, I felt so inspired to start a breech birth service within the trust I work. On my return to work I started putting plans in place to develop a service within the trust. Shawn contacted me a few days later and invited me to help teach the hands on clinical skills on her next Physiological Breech Birth training day in South Wales. I jumped at the chance to attend and found it so useful to listen to the day again and then help with the hands on teaching. It helped to embed what I had already learnt previously and give me the confidence to teach the skills within my own trust.
I started talking about breech, a lot! Shawn continued to invite me to help on training days and with each one my confidence grew. I started viewing the videos differently. Instead of looking for what was ‘normal’ and ‘abnormal’ I started analysing them with a deeper understanding of the physiology. Shawn also encouraged me to start teaching parts of the presentation. Admittedly I was more than a little ropey to begin with but with Shawn’s nurturing and encouragement and the more I learnt from each training day, each time I attended my confidence grew. Eventually I was able to transfer this new knowledge, understanding and confidence into practice. I was asked to attend a breech birth!
I supported a woman with a physiological breech birth, along with a consultant obstetrician colleague and one other midwife. An arm complication occurred with the birth, and I was able to resolve using the manoeuvres I had learnt and taught on the course. The baby was born in good condition, and I felt relieved and elated! I immediately contacted Shawn to tell her about the birth but it had also sparked an interest in the consultant obstetrician who had attended. We debriefed from the birth and I spoke about the Breech Birth Network and the training it offers. I took the opportunity to ask if my obstetric colleague would like to be the lead consultant in my quest to set up a breech birth service, to which they agreed. It had taken me nine months – the length of a full term pregnancy – from when I first attended the training until this physiological breech birth. It was the birth of an exciting change in knowledge and culture.
Claire Reading, Emma Spillane and Shawn Walker
Attending training days has not only helped to embed my own learning but it has given me the skills and confidence to set up a service within the trust I work, support women who choose to have a vaginal breech birth and support colleagues to facilitate breech births themselves. I have found repeating the information and skills has been the key to my learning and enabling change within practice. It has given me the confidence to attend births and increased the number of breech births within the trust by instilling confidence in others. If you would like to build your confidence in vaginal breech birth, develop a service within your trust and teach others I highly recommend coming along and helping at future training days. You can view a list of upcoming opportunities to help deliver training here. Please let us know by getting in contact via email or the contact form.