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.
Since the publication of the 2017 RCOG guidelines on the Management of Breech Presentation, mothers have, in theory, been given more choice in their options relating to mode of birth. Unfortunately, anecdotally this does not seem to be the case for all. Many units across the UK do not have dedicated services for mothers found to have a breech presentation at or near term. Therefore, they are potentially missing out on receiving balanced information regarding their choice of mode of birth. Finding out your baby is in a breech presentation at this late stage of pregnancy can be upsetting for some, birth plans have been discussed and made, excitement is building for the new arrival and then suddenly this seems to all be turned upside down. More decisions have to be made, that’s if the choices are offered to parents. Having a dedicated breech clinic, run by those knowledgeable and experienced in breech presentation, can help to allay some of the worries and concerns experienced by parents and ensure all evidence-based options are discussed in a balanced way. The clinic enables a two-way dialect between healthcare practitioner and mother in a supportive environment. In the current financial climate of the NHS it can be difficult to set up new services, however, the mother’s well-being must come first. Additionally, the skill of the practitioner is key to ensuring safety. The RCOG states:
“The presence of a skilled practitioner is essential for safe vaginal breech birth.”
“Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.”
But with the decline in the facilitation of vaginal breech birth over the past two decades how do we ensure as healthcare practitioners that we are skilled to facilitate such births? This post aims to describe one way to increase knowledge, skill and experience in this field and how to set up a breech service within an NHS Trust to ensure mothers really do have all the options open to them for mode of birth with a breech presentation.
The first step to gaining knowledge and experience is to become involved in teaching. This has many benefits including, increasing your comprehension and embedding that information so you can pass it on to others; enables people to recognise you as breech specialist and it helps to build confidence when discussing with colleagues and parents alike. The more you are teaching the greater your understanding and the more people will recognise you within this role as a breech specialist. It is vital to keep your own skills up to date if you are putting yourself forward as a specialist, teaching both locally and assisting with teaching through the Breech Birth Network, CIC will help you keep up to date with the latest evidence and move things forward within your own constabulary. The team at the Breech Birth Network, CIC are very keen to support others to teach on our Physiological Breech Birth courses. You can read the following blog post for more information on the benefits of teaching Physiological Breech Birth with the Breech Birth Network, CIC.
Other ways to get involved with teaching are within the University and to the students coming through the local hospitals, these are the midwives of the future and this is where the biggest change is going to come from. Likewise, speak with the lead Consultant Obstetrician for new doctors starting in your Trust to see if you can teach them a shorter session on their induction days. This enables the new doctors coming into the hospital an awareness of what will be expected of them in terms of offering choice and ensures they have an understanding of both the mechanisms of breech birth and recognising complications. Additionally, setting up a weekly morning teaching session for thirty minutes ideally after handover so those finishing the night shift and those starting the day shift can both attend. This can be done as a case discussion or a scenario using a breech birth video. You could even use a breech birth proforma (if you have one) and ask those attending to complete the proforma whilst watching a video to see if they understand about the timings for a physiological breech birth and when to intervene. Speak to the Practice Development team and ask if you can teach the breech sessions on the mandatory training days too – moral of the story…teach, teach, teach!!
Of course, with all this knowledge and skills you are teaching you need to put it into practice. Put yourself forward at every opportunity to attend breech births both to facilitate them yourself and to support others to gain confidence in facilitating vaginal breech births. Clinical experience is essential. Research has shown, to maintain skills and competence the breech specialist should attend between three to ten breech births every year (Walker, 2017; Walker et al, 2017; Walker et al, 2018). In some smaller units this may be difficult to achieve but by making yourself available to attend births you will have a far better chance at getting these numbers in practice. There is also evidence which suggests that you can create the same complex pattern recognition by watching videos of vaginal breech births, both normal and complicated, as you can by attending breech births in real-life (Walker et al, 2016). Watching videos has the added benefit that you can rewind and re-watch parts of the video to ensure understanding and further analysis.
Setting up a breech birth service would be an excellent next step. Firstly, find a Consultant Obstetrician who is supportive of physiological breech birth and who would help to lead on service development with you. This has to be a multi-disciplinary approach other wise it just won’t be sustainable or safe. The best way to move such services forward is with consultant support and input, don’t try and do it on your own. A breech birth clinic is a good starting point for any service development, this will provide midwife-led and consistent counselling for parents attending the clinic. Depending on the size of the hospital, running the clinic once a week should be adequate initially. Setting up a dedicated email address for all referrals to be sent to is a great way to ensure referrals are not missed and there is a clear pathway set out. The following is an example of such a pathway:
Referrals can be made by any healthcare practitioner, but it is a good idea to link in with the sonographers performing the ultrasound scans. They may be able to send the details of the mother via email immediately following the scan and give the parents an information leaflet. This avoids any delay with the referral being made by another healthcare practitioner and ensures the counselling remains consistent. Moreover, the development of ‘breech teams’ is supported in the literature to ensure there are breech specialist midwives and doctors on every shift, or on-call, to support the wider team to gain their clinical skills to facilitate vaginal breech births and increase safety for mother and baby.
To further develop the service and your own skills you could complete a midwife scanning course. This will enable you to scan mothers referred into the breech service to check presentation before sending for a detailed scan. The advantages of this is that mothers could be referred into the clinic earlier, from thirty-four weeks gestation based on identification on palpation. Research has shown mothers find it difficult making decisions about mode of birth for breech presentation so late in pregnancy and would benefit from earlier referral and discussion. Referrals made at thirty-four weeks gestation with a bedside midwife scan to assess presentation, would enable the counselling to begin sooner giving more time for decision-making. An additional advantage of being able to scan is following mothers up after successful external cephalic version (ECV). Seeing mothers, a week after successful ECV enables you to scan the mother to ensure the baby has remained in a head-down position avoiding unexpected breech births. An adjunct to the scanning course would be to learn to perform ECV’s. This enables a fully midwife-led service and research has indicated comparable rates of success for ECV’s performed by Midwives and those performed by Obstetricians. It is also cheaper for the Trust to have ECV’s performed by Midwives!
Governance and audit are the final steps to take to building the specialist breech midwife role and for service development. This is often seen as the mundane part of the job, but you will benefit greatly by doing this, not just from immersing yourself in all the research but by knowing your service inside and out. Knowing what needs to be changed and what has improved. The first step in governance change is to write the guidelines incorporating physiological breech birth, new evidence relating to breech presentation, service development, the breech clinic, referral pathways and training. An example of a current guideline can be found via this link. Develop an information leaflet to give to parents which contains the latest evidence in relation to breech birth options. It can be given to the mothers either by midwives in the clinic and/or by the sonographers after their ultrasound confirming breech presentation. The following can be used as an example and is editable for use in your organisation.
Finally, audit, audit, audit! Before, after and everything in between! This is your evidence that things need to change and, once the service is developed, the outcomes since you implemented all the aspects of the service. It will also act as evidence of safety which the governance team within the organisation will want to see. Audit rates of planned caesarean, emergency caesarean, planned VBB, successful VBB, neonatal outcomes, maternal outcomes, uptake of ECV, success rate of ECV etc. All before and after the service. It is also a good idea to obtain service user feedback. Developing a simple questionnaire such as this one enables you to easily send and receive feedback regarding the service. Feedback from service users is the most powerful way of moving services forward and supporting change within an organisation, it also enables you to develop the service dependent on the needs of the parents using it. The process of audit and user feedback is continuous throughout the time running the service. However, it is important analyse and present the result at regular opportunities such as at local level with clinical governance days and meetings and at a wider national level at conferences and in journals.
Whilst it can seem daunting and places you in a seemingly vulnerable position, starting your journey as breech specialist is an extremely rewarding one which will enable you to learn and develop new skills not just clinically but operationally and strategically. It will give you a stepping stone into research, audit and teaching, build your confidence as a practitioner and most of all, empower you to provide the best evidence-based care for those families who need that knowledge and support at a crucial time in their pregnancy to help them to make the right decision on mode of birth for them and their breech baby.
Following the implementation of all that has been discussed in this post, the results within the large teaching hospital I work are as follows:
- Planned caesarean section increased from 55.8% (n=43) to 62.9% (n=66);
- Unplanned caesarean section decreased from 42.9% (n=33) to 24.8% (n=26);
- Vaginal breech birth increased from 1.3% (n=1) to 12.3% (n=13)
All results are for those over thirty-six weeks gestation, there were no differences in neonatal mortality or morbidity prior to or following the implementation of the service. This is a positive change and shows how supporting vaginal breech birth in a safe environment can increase the normal birth rate. The results are after a year of implementing the service and will hopefully continue to improve as time goes on and more midwives and doctors become more confident to facilitate breech births.
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 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.
Shawn and Emma
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.
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.
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.
It was exciting to see a ‘Breech Team‘ service working so well in the largest maternity hospital in Stockholm. The team are able to take referrals for women pregnant with a breech-presenting baby at term who wish to give birth at SÖS. They can also provide training for other teams in Sweden who wish to improve the safety and delivery of their own services, using their own resources and presentation materials provided by the Breech Birth Network.
To ask about referral or training, please contact Julia and Tove using the form below.
For more information about training outside of Sweden, please see our Booking a Study Day page.
For information about training or referrals for a vaginal breech birth in Sweden, contact Julia and Tove:
In December 2017, Breech Birth Network was incorporated as a Community Interest Company. This means the company is a not-for-profit, constituted to benefit the community and is asset-locked. Profits are channelled back into the activities in the community interest. The Intellectual Property, such as teaching presentations and videos created from those donated by women and practitioners, belongs to the CIC, and if the company dissolves must be donated to one of two designated charities.
This month, Breech Birth Network, Community Interest Company, submitted its first accounts to Companies House, via our accountant. In the interests of transparency, we are sharing our accounting reports here, along with the description of CIC activities we have provided to Companies House. Thank you to those who have paid to attend our study days during this period. As you can see, sharing these skills and information requires substantial funding. You enable us to do what we do.
Trading and Profit and Loss Account for the Period 1 December 2017 to 31 December 2018
Shawn Walker was the only named Director of the CIC during this period. Emma Spillane was appointed a Director in May 2019.
Cost of sales £8,115
Purchases £2,252 — This includes purchases of teaching equipment and printing of training manuals.
Sub contractors £1,563 — This includes fees paid to collaborators, such as consultant obstetricians who teach on our study days, and illustrators.
Teaching fees £4,300 — This includes a set daily rate paid to Shawn Walker and Emma Spillane for each complete day of teaching. A total of 35 complete days and many more shorter conference presentations were delivered by Shawn and Emma during this accounting period.
GROSS PROFIT £11,246
Insurance £373 — We are required to have insurance to meet NMC requirements while teaching in a professional capacity.
Conference costs £99
Post and stationery £25
Travelling £5,870 — This includes expenses related to travel for Shawn, Emma, collaborators and clinical skills trainers who are developing their skills to disseminate training locally.
Repairs and maintenance £149
Research £303 — This includes fees paid to Research Assistants to help with the before-and-after study of the Physiological Breech Birth Training Package.
Computer costs £894 — This includes IT fees related to maintaining the Vimeo site where our teaching resource videos are shared, this blog and other software required to create the resources we use.
Sundry expenses £62
Accountancy £493 — We felt this needed to be done properly now that the company is registered as a CIC, to ensure we are not in breach of any legal standards. We are midwives, not accountants.
Depreciation of tangible fixed assets
Plant and machinery £92
Computer equipment £386 — Shawn and Emma both carry an encrypted laptop to transport the sensitive birth videos we use to teach. Our presentations are too large to transport on a data stick because of the number of images and videos.
Entertainment £419 — When we meet in the evening for a planning meeting or after a training day with guests.
Bank charges £852
NET PROFIT £866
PART 1 – GENERAL DESCRIPTION OF THE COMPANY’S ACTIVITIES AND IMPACT
In the space provided below, please insert a general account of the company’s activities in the financial year to which the report relates, including a description of how they have benefited the community.
Breech Birth Network, Community Interest Company, was incorporated as a CIC on 1 December 2017. During the period from 1/12/17 to 31/12/18, Breech Birth Network provided 35 days of physiological breech birth training, within the UK and other parts of Europe. This enabled the training to reach approximately 1500 health care professionals. We provided printed training manuals and an on-line video database containing breech birth videos and recorded training presentations, made available for on-going revision to each of these health care professionals. We reimbursed travel expenses for 19 different clinical skills trainers, to enable them to gain confidence teaching alongside the Director, Shawn Walker, and Training Co-ordinator, Emma Spillane, in order to disseminate the training in their local settings. We donated two doll and pelvis models to the Fernandez Institute in Hyderabad, India, to support their efforts to develop a breech birth service. We funded a before-and-after evaluation of the breech training package, which is currently being analysed, and other small research-related expenses. And we provided free advice and support to women seeking support for a vaginal breech birth and health services seeking to provide better support, including reflective supervision of other health care professionals attending vaginal breech births.
PART 2 – CONSULTATION WITH STAKEHOLDERS
Please indicate who the company’s stakeholders are; how the stakeholders have been consulted and what action, if any, has the company taken in response to feedback from its consultations? If there has been no consultation, this should be made clear.
Our stakeholders include service user advocates, such as women who have experienced a breech pregnancy, and health care professionals who may attend vaginal breech births. Health care professionals complete a feedback form following each training day, and results are incorporated into on-going iterations of the training package. The Director, Shawn Walker, and the Training Co-ordinator, Emma Spillane, have both undertaken PPI (Patient and Public Involvement) activities concerning their breech-related research projects.
PART 3 – DIRECTORS’ REMUNERATION
The accounts indicate that £4300 was paid in teaching fees for the provision of 35 days of teaching. The Director, Shawn Walker, was paid £3200 of this amount, in addition to travel expenses. There were no other transactions or arrangements in connection with the remunerations of directors, or compensation for director’s loss of office, which require to be disclosed.
PART 4 – TRANSFERS OF ASSETS OTHER THAN FOR FULL CONSIDERATION
No transfer of assets other than for full consideration has been made.
A new SOGC Clinical Practice Guideline No. 384 — Management of Breech Presentation at term has been published. It echoes the latest RCOG guideline in promoting accurate and supportive informed consent discussions. One of the main authors, Andrew Kotaska, has written extensively about this before: Informed consent and refusal in obstetrics: a practical ethical guide.
The SOGC guideline frames counselling around mode of childbirth for a breech baby within the context of human rights, especially in the ‘Key Messages:’
A woman’s choice of delivery mode should be respected.
The risk of planned vaginal breech birth is acceptable to some women with a term singleton breech fetus.
Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should be provided with the best possible in-hospital care.
The summary of evidence related to safety is similar to that provided by the RCOG and a good reference for anyone counselling women about their breech childbirth options. A notable difference is the recommendation that,
Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour.
As with the RCOG guideline, the new SOGC guideline recognises the importance of skill and experience to the safety of vaginal breech births. One of the SOGC’s summary statements is:
Vaginal breech birth requires a high degree of skill and support. To avoid the increased risk of out-of-hospital vaginal breech birth, women who choose planned vaginal breech birth should be accommodated in-hospital. To facilitate this, referral to more experienced centres, back-up on-call arrangements, and continuing medical training in vaginal breech birth skills should be promoted (very low).
(Very low refers to the quality of evidence in relation to this recommendation.) The RCOG also recommends antenatal referral to a centre with more skill and experience if necessary. Later in the SOGC text, the authors point out:
Many newly qualified obstetricians do not have the experience necessary to supervise a breech TOL [trial of labour]. Mentoring by more senior colleagues will be necessary if they are to attain these skills. As women will continue to request planned VBB and precipitous breech births occur in all settings, theoretical and hands-on breech birth training using models should remain part of basic obstetrical and midwifery training and of traingin programs such as ALARM, ALSO, and MORE ob.
I am particulary interested in recommendations made regarding how to support breech skill development because Competence and Expertise in Physiological Breech Birth was the topic of my PhD.
In our integrative review of the Effectiveness of vaginal breech birth training strategies (2017), inclusion of breech birth as part of an obstetric emergencies training package without support in practice was negatively associated with subsequent attendance at vaginal breech births, meaning practitioners attended fewer breech births. None of the evaluations of training packages included clinical outcomes, so it was not possible to determine whether they had an effect on safety. But the evidence suggests that support and mentorship in practice is likely to be key to giving less experienced practitioners the confidence to support breech births and gain the skills in practice.
Research on Expertise in physiological breech birth and the Deliberate acquisition of competence in physiological breech birth suggest that mentorship is indeed very important, but that this does not always take the form of senior colleagues supporting newly qualified colleagues. Maintaining classical hierarchies — such as expecting senior obstetricians to have breech skills while younger colleagues, or midwives, not to — can promote a form of alienating authority, which inhibits the development of generative expertise. Among practitioners who had deliberately developed competence to support breech births, younger, highly motivated practitioners often had to leave their primary clinical setting to acquire knowledge, skills and new techniques, which they brought back with them. The fact that they needed to do this suggests that they had not been being mentored at home.
One of the things I love about working in the UK is the long history of multi-disciplinary working. Although some teams work more effectively than others, it means that a person wishing to birth their breech baby with an experienced midwife in attendance does not have to choose between a home birth and an obstetrically-managed hospital birth. The obstricians I work with recognise the skill with physiological birth that their midwifery colleagues bring into the room — and we are grateful for their skill with surgical and very complicated births. We keep each other safe.
Given that referral to experienced centres is recommended in both RCOG and SOGC guidelines, more research is needed about how this works in various settings. What happens if a woman is referred elsewhere, but that hospital cannot or will not accept her for care? What are the economic implications? What defines an ‘experienced centre?’ In some hospitals, such as in Frankfurt Germany, the vaginal breech birth rate can be as high as 6-11% of the total birth rate due to women travelling to experienced providers, compared to 0.4% of the total birth rate in the UK.
We also need to consider and study other potential solutions to skill redevelopment. For example, why expect women to travel away from their known and trusted care team — why not shift professionals instead? I am employed primarily by a university, but I have a contract with one NHS Trust and am completing a contract with another by request, so that I can support them to develop their breech services. Mobility of providers also happens when obstetric trainees rotate between training centres. Sadly, I have heard numerous stories from senior obstetric trainees who have acquired breech experience in one hospital, only to be blocked from using that experience by their senior colleagues in another, a case of hierarchical and alienating authority. Similarly, many midwives have spent time abroad and delivered dozens of breech babies, but have had to stand aside when a woman is diagnosed in labour with a breech because the woman is now considered ‘an obstetric case.’ Women are often not informed when skill and experience is available because these remain invisible and under-utilised, especially in midwives and younger obstetric colleagues.
Throughout the UK, many new breech services are being developed. Breech clinics, like the one at the Royal London, ensure women get consistent counselling by breech-experienced practitioners. They also provide an environment where trainees can learn this skill. Many hospitals are developing ‘breech teams‘ so that vaginal breech births and those attending them can be supported by confident and competent members of the team — this includes experienced midwives. Training activities to support these new teams emphasise the elements available literature suggests will be effective — repetition and reflection — especially using birth videos for team debrief and simulation training. Gradually, we are supporting each other to reintroduce breech skills and consider new ways of sustaining them in order to be able to offer the care our countries’ leading guidelines recommend.
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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.
Since setting up a breech service within the Trust I work I have seen the difference in counselling techniques and the information provided to parents. As part of my clinical role I meet parents for birth options discussions, often parents seeking support to use a Birth Centre for labour and birth despite having either medical or obstetric complexities which means the recommendation would be to labour and birth on the obstetric unit. Many of these discussions are with mothers who have had a previous caesarean section often for breech presentation in their first pregnancy. In nearly all of these cases the parents say they were never given the option to have a vaginal breech birth and yet the NMC Code states:
2.3 encourage and empower people to share in decisions about their treatment and care
2.4 respect the level to which people receiving care want to be involved in decisions about their own health, wellbeing and care
2.5 respect, support and document a person’s right to accept or refuse care and treatment
6 Always practise in line with the best available evidence
To achieve this, you must:
6.1 make sure that any information or advice given is evidence-based including information relating to using any health and care products aor servicesNursing and Midwifery Council, The Code
Having not been given the option of a vaginal breech birth the practitioners counselling them were breaching the NMC Code. Furthermore, the RCOG (2017) Management of Breech Presentation Guidelines state:
Clinicians should counsel women in an unbiased way that ensures a proper understanding of the 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.
This week, I ventured into a Twitter discussion around routine induction of labour for everyone at 39 weeks, initiated by obstetrician Ed Prosser-Snelling with this tweet, if you want to check out the thread:
Because this is the place I collect my controversial thoughts, and because this obviously affects the extremely narrow window of possibility for vaginal breech birth, here are my thoughts:
I actually think it’s not a bad idea to enable women who want it to have access to elective IOL from 39 weeks, regardless of their risk level (or indeed fetal presentation). The research is pretty clear that it does not increase CS rates. It appears to reduce perinatal mortality but increase neonatal admissions (Stocks et al 2012). My main, deep and passionate commitment is for women to be in control of their mode of birth and birth experiences as much as possible.
My biggest concern about committing services to making more medical options more easily accessible is that, at the moment, accessing the most evidence-based care for optimal physiological birth is not easy. Providing more medical interventions will divert resources and attention from achieving this. Not every woman has continuity of midwifery care, an intervention backed up by multiple systematic reviews, which also reduces preterm birth, total fetal loss and neonatal death (see Sands statement on Continuity of Carer). Midwifery CoC is a government-backed, national priority (see Better Births) and is requiring major reorganisation of services everywhere. Sometimes, to do things properly, concentrating on one big change at a time does help. It also helps when trying to determine which intervention is responsible for any observed changes.
Similarly, women who would like to plan a vaginal breech birth are not provided with care that the evidence base says will give them the best chance of a good outcome — an experienced attendant — effectively making this choice unavailable in most locations. And women who would like to await spontaneous labour past the locally decided date for routine IOL face judgement and resistance — not from all health care professionals, but from many.
I spend a good deal of my professional life supporting women who are actively seeking help to plan a birth that clearly involves more risk than awaiting spontaneous labour after 39 weeks. I know plenty of women are prepared to accept some element of increased neonatal risk in their holistic assessment of what is right for them, but that they are easily shamed into changing their minds. (If anyone is asking themselves why they don’t meet them, bear in mind most of them will stop talking about what they really want when they pick up on judgmental attitudes about their choices. Then they will seek support elsewhere, or just accept what’s on offer. It is emotionally exhausting for them and for those midwives and obstetricians who try to help them pick up the pieces.)
Midwives everywhere will also be worrying about the ever-narrowing window of normality during childbirth. What exactly will be a midwife’s sphere of practice in a world of routine induction at 39 weeks? Most guidelines indicate we’re not supposed to perform a cervical sweep on a nullip until after 40 weeks and a multip after 41? Who will give birth in midwife-led units? Home birth? Will it be reasonable to plan anything other than an OU birth? Midwives will also be concerned about hidden costs they can’t quite put into words (or a cost-utility analysis), things like the time spent scheduling and rescheduling IOL, time spent counselling women who are upset about ‘having to be induced,’ time spent scheduling additional appointments with consultant midwives or consultant obstetricians for women who have declined induction, time spent debriefing women who feel traumatised by an IOL process that felt out of control, etc.
Expanding the offer of IOL to 39 weeks requires careful, multi-professional collaboration because it has massive implications for women, the service, and the role of the midwife. What women need to have a satisfying induction (Coates et al 2019) is not something that can be provided for all women currently undergoing induction now — how will we provide it for more? The history of obstetrics is replete with well-meaning people implementing plausibly beneficent interventions ASAP, but also many instances in which unanticipated harms are discovered as consequences late in the day. I want world in which birthing families have more options, not less. But I would like to take things slowly, carefully so that we:
- Research the effects of implementing this policy thoroughly. Let’s do thorough PPI work to ensure all of the outcomes that all stakeholders are worried about are eventually accounted for. Let’s ensure midwives are part of the team that designs rather than just delivers the research, so they can take an equal part in confidently implementing & disseminating it. Ten years later, let’s look back and be able to confidently say, “Look what we’ve done!” with one tone of voice or another …
- Co-design an information and consent process with women who have had positive and negative experiences of IOL. Women would be informed at 37 weeks that the risk of stillbirth increases from 39 weeks with clear, consistent information, including infographics. They would be offered a scheduled induction, and if they decline, neither them nor their midwife (if otherwise low-risk) would be required to justify this decision.
- Co-design services which give women maximum control over the timing of their induction. Have some ‘scheduled’ slots for women who prefer that and some for arising medical indications. And tell everyone else that they can put themselves on the waiting list for medical induction whenever they want to after 39 weeks, to be seen on a first-come-first-serve basis. If we have capacity to do this many IOL, we ought to have capacity to offer greater flexibility. One of the things women regret losing with scheduled IOL is the ability to trust their instincts as they are becoming parents. Ensure at each visit women know how to access IOL if they want it, but don’t hound women who choose not to join this queue.
- See this as a ‘choice’ issue and not a stillbirth reduction ‘target.’ Targets which require everyone accept the intervention in order to achieve the target outcome will reduce, rather than expand, choice.
Finally, I feel that midwives need to lead on research that contributes to our knowledge about IOL, rather than seeing it as ‘the realm of the abnormal,’ and thus obstetric territory. If we are offering IOL closer and closer to 39 weeks, this is more ‘normal’ than ‘abnormal,’ especially as we know outcomes for live babies are best after 39 weeks. For example, we have Cochrane Reviews on cervical sweeps and nipple stimulation (see Evidence-Based Birth blogs on membrane sweeps and breast stimulation to stimulate labour).
Many women would like the ability to request a sweep earlier than 40 weeks, and they certainly will want this if induction at 39 weeks is routine. Might this help, or harm, or are there trade-offs? Might pumping breast milk after 38 weeks improve spontaneous birth and breastfeeding rates? Might these traditional midwifery approaches have potential to help women retain more control over initiation of their labour and consequently their choice of birth setting? Researching and changing midwifery practice related to cervical ripening for women at term who wish this would, in my opinion, be a more manageable and likely more widely acceptable first step than scheduling more hospital-based inductions. It would also dovetail nicely if a policy of offering induction at 39 or 40 weeks does become routine.