Since the publication of the 2017 RCOG guidelines on the Management of Breech Presentation, mothers have, in theory, been given more choice in their options relating to mode of birth.  Unfortunately, anecdotally this does not seem to be the case for all.  Many units across the UK do not have dedicated services for mothers found to have a breech presentation at or near term.  Therefore, they are potentially missing out on receiving balanced information regarding their choice of mode of birth.  Finding out your baby is in a breech presentation at this late stage of pregnancy can be upsetting for some, birth plans have been discussed and made, excitement is building for the new arrival and then suddenly this seems to all be turned upside down.  More decisions have to be made, that’s if the choices are offered to parents.  Having a dedicated breech clinic, run by those knowledgeable and experienced in breech presentation, can help to allay some of the worries and concerns experienced by parents and ensure all evidence-based options are discussed in a balanced way.  The clinic enables a two-way dialect between healthcare practitioner and mother in a supportive environment.  In the current financial climate of the NHS it can be difficult to set up new services, however, the mother’s well-being must come first.  Additionally, the skill of the practitioner is key to ensuring safety.  The RCOG states:

“The presence of a skilled practitioner is essential for safe vaginal breech birth.”

And

“Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.”

But with the decline in the facilitation of vaginal breech birth over the past two decades how do we ensure as healthcare practitioners that we are skilled to facilitate such births?  This post aims to describe one way to increase knowledge, skill and experience in this field and how to set up a breech service within an NHS Trust to ensure mothers really do have all the options open to them for mode of birth with a breech presentation.

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.

Emma