25th June 1.30pm – The ‘Dropped Foot’ Baby in Labour
2nd July 1.30pm – Nuchal cords and vaginal breech births
14th July 6.30pm – ‘Buttock Lift’ for the birth of the fetal buttocks
To join one of the seminars listed above or any other which will be run over the course of the year, please see open the course in which you are enrolled.
Breech Birth Network, CIC is dedicated to training Midwives and Obstetricians of all levels in physiological breech birth and developing research exploring key breech birth issues. As well as running full days face-to-face training on physiological breech birth, our well attended and evaluated course is now available online. The course has been developed directly from research about physiological breech birth and can be accessed via this link.
To support the learning and development following completion of the online course, Breech Birth Network, CIC are now running live reflective sessions with an instructor. These group sessions will be run virtually and provide an opportunity to discuss important issues and clinical situations related to physiological breech birth. The sessions will be held on Zoom and facilitated by Dr Shawn Walker and Emma Spillane. The seminars are a chance for those who have attended the Breech Birth Network online training course to discuss issues related to practice, further understand some more unique scenarios and how to manage these in practice.
The seminars are an opportunity for healthcare professionals to come together and discuss all things breech! Each seminar will have a main topic or theme, but the conversation will be led by those attending. You can ask questions; discuss births you have attended and reflect on scenarios in practice.
A common finding in reviews of deaths and adverse outcomes following vaginal breech births is that a consultant obstetrician was not in attendance. For example, coroners have ordered reviews of services nationally after tragic deaths where skill and experience has been an issue, such as this one in 2012, and another in 2015, recommending that a consultant obstetrician always be present at vaginal breech births. A review of NHS cerebral palsy claims (Magro 2017) from 2012-2016 found that breech births represent 12% of all litigation costs despite representing only 0.4% of all NHS births. In five out of six of these births, the breech presentation was diagnosed late in labour. And in five out of six, the births were attended by a trainee (registrar) without a consultant present. This review also recommended increased senior support.
But this assumes that all consultant obstetricians do themselves have significant skill, confidence and experience with vaginal breech birth. The evidence does not indicate that this is the case.
In Dhingra and Raffi’s 2009 survey, 80 obstetric trainees on a labour ward advanced skill training course provided information about the amount of training and experience in vaginal breech delivery they had. Most (80%) were ST4-5, but others were ST1-3 or newly appointed consultants. In this survey, 63% had attended more than 10 vaginal breech births, 66% report having had supervision in practice and 80% of them felt ‘happy to perform and offer VBD.’ The vaginal breech birth rate has declined since 2009, so these numbers are unlikely to have improved.
This means that approximately 1:3 obstetricians at the point of qualification would not meet the physiological breech birth proficiency criteria. Approximately 1:3 of them will have not had supervision in clinical practice. And 1:5 of them would not be happy to perform or offer a VBD. And this is a self-selected sample of trainee obstetricians keen to acquire advanced labour ward skills, which is likely to differ from the general population of trainees and consultants (some of whom specialise in gynaecological oncology).
My own experience does not suggest that these figures are inaccurate. I have attended over 20 vaginal breech births in at least 5 hospitals, and a consultant obstetrician has only been present for one of them. This was despite engagement ranging from inviting them to attend, to emergency escalation. Usually, the role of senior clinician has been delegated to one of the trainees matching the above profile. My distinct impression is that a significant portion of obstetric consultants do not want to be responsible for attending vaginal breech births.
Often at this point someone starts arguing that the reluctant participants need to be ‘trained’ or ‘educated,’ that it is part of their job. I am not convinced that this is the safest or most compassionate approach. Often, my obstetric colleagues have privately shared with me their trauma and grief after difficult breech births. Their reluctance is understandable, especially within a work culture that does not make personal vulnerability easy and does not have a mechanism for offering consultant obstetricians support for developing their own breech clinical skill levels.
“You talk about providing support, but let me ask you: Who supports you? I have never delivered a breech baby’s head without using forceps.”
How much I respect the obstetrician who was willing to say this out loud at a meeting! And how much I respect that skill with forceps and surgery. These are outside of my scope of practice, and I do not have the hubris to assume I will never need them. But I am fairly certain my presence in a room makes the need to use forceps significantly less likely, and I have supported several professionals to deliver the aftercoming head without them for the first time. Bringing both skill sets into the clinical picture is what the breech clinical teaching team is all about.
Further research about obstetric breech training and willingness to attend breech births:
Rattray et al (2019) — Only 36% of medical officers who attended training in Australia had facilitated > 5 breech births. Suggests specialist teams and/or centres of excellence.
Post et al (2018) — Does vaginal breech delivery have a future despite low volumes for training? Results of a questionnaire. Among sixth year residents, 65% were not yet confident to personally guide VBDs. 13% of the 294 residents and new obstetrician gynaecologists had performed less than 3 VBDs. Suggested specialist teams and/or centres of excellence as potential solutions.
(This list is not exhaustive, but what I have time for. Before you assume that things are different where you are from, do a similar anonymous survey in your own unit.)
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 …
The setting of proficiency criteria for those attending vaginal breech births in the OptiBreech Study is a quality assurance mechanism. The potential risks of participating in research need to be mitigated as much as possible. Defining a set of minimum training and experience criteria for those attending vaginal breech births in the feasibility study is one way of doing this.
The Merriam-Webster Dictionary defines proficient (adv.) as: well advanced in art, occupation or branch of knowledge. Proficiency lies somewhere between basic competence, which all professionals are expected to have in order to practice safely, and expertise, which only a few may acquire. Using the term ‘breech expert’ may also suggest that all risks can be eliminated as a consequence, and unfortunately this is never true with birth.
participated in 6 hours of evaluated physiological breech birth training;
attended at least 10 vaginal breech births, including resolution of complications using manual manoeuvres;
experience of 3 vaginal breech births (attended or taught with simulation) within the past year; and
delivered physiological breech birth training at least once within the past year, including reflective reviews of births attended.
The evidence that has contributed to these criteria is referenced below, but they are also the result of much involvement from professionals currently trying to implement physiological breech birth services in a responsible manner.
The drawback of using proficiency criteria during a trial is that results will only be generalisable to settings which apply a similar set of criteria. After 10 years of studying how centres have re-introduced thriving vaginal breech birth services where little or no service existed, I have observed that almost all those that succeed use some form of a ‘breech team’ strategy. This is rarely reported because it is usually informal, and that may be one reason great services are sometimes not sustained as key individuals retire or leave the service.
I actually believe that the idea of a ‘golden age’ of universal breech skill is a bit of a myth. I think that adverse outcomes used to be more common and more tolerated. And I think that certain individuals have always had an affinity with breech birth, leading to them being called in to help their colleagues more often. Breech clinical teaching teams just make this mechanism visible and systematic.
Follow-on question from a consultant: Are the numbers meant for proficiency realistic?
A breech clinical teaching team can realistically achieve the numbers required to maintain proficiency if the team is not larger than the number of births occurring. If the numbers of vaginal breech births are small, the breech clinical teaching team needs to be smaller. If the unit is functioning as a centre of excellence and attracting additional breech births, the team can and will expand.
The important lessons we have learnt from working with centres that have implemented a good physiological breech training service are:
Do not change a whole organisation’s approach to breech birth unless everyone has received the same training and has been supported to apply it in practice. Just because a unit has hosted a study day doesn’t mean the unit is now a centre of excellence. Training, skill and experience lie with individuals, not institutions. If you haven’t been trained to do something new (e.g. upright breech birth), don’t do it. Use a breech clinical teaching team to help new skills embed into the wider service.
Do not become complacent once a service embeds and becomes the ‘norm’ in a unit. Be cautious when new members of staff join a service, including as part of training rotation or locum/bank. They are likely not to have a similar level of training and experience.
Follow-on question: Does this mean we should not attend physiological breech births if we have not achieved these criteria? And what if we do not have enough people who have achieved the criteria to cover the service?
The criteria are not meant to prohibit breech births from occurring without them. But if we consider this the benchmark ideal for physiological breech birth, our counselling can include how close we are to achieving this, or not. We can help women make informed decisions by clearly defining ‘skill and experience,’ and explaining that where this is not available, it may introduce some increased risk.
Even in the OptiBreech Study, we may need to be flexible in the early stages, being open and honest with the women who participate. But setting the criteria and attempting to achieve them will enable us to answer important questions, like How often were we able to get a breech team member to the birth? Did it require us to put people on-call? If so, how often? If we weren’t able to do it from the start, how long did it take to establish a proficient team? How much effort did it take from the team, and how do they feel about it? How do the rest of the team feel about the team’s involvement? Answering these questions will enable us to refine the design of the study even further if it proceeds to a substantial trial.
Follow-on questions: The study design and criteria seems to direct towards selective group. And what if I feel skilled and experienced to attend breech births but do not meet all of the criteria?
The criteria are based on the best available evidence. Participation in a breech clinical teaching team may be perceived as a privilege, but it will also require effort from those involved. It is open to anyone with an interest who puts in that effort.
The OptiBreech Study is in the early stages of feasibility testing. Professionals should go on using the same standards of competence recommended in local and national guidelines outside of the feasibility trial.
Use of breech clinical teaching teams is a pragmatic mechanism for delivering the only intervention associated in a randomised trial with an improvement in neonatal outcomes: the presence of a ‘skilled and experienced’ practitioner.
Su et al (2003) performed a secondary analysis of Term Breech Trial (Hannah et al, 2000) data to identify factors associated with adverse perinatal outcomes. The presence of an experienced clinician was the only factor associated with a reduced risk of adverse perinatal outcome in a vaginal breech birth (OR: 0.30 [95% CI: 0.13-0.68], P=.004). Compare this to the reduction of risk associated with a cesarean section during active labour in the same trial (OR: 0.57 [95% CI: 0.32-1.02, P=.06), or the reduction of risk associated with planned cesarean section overall in the trial (RR: 0.33 [95% CI: 0.19-0.56, P=<0.0001).
It is noteworthy that having an experienced clinician at the birth was associated with a reduced risk of adverse perinatal outcome, only when an experienced clinician was defined as a clinician who judged him or herself to be skilled and experienced at vaginal breech delivery, confirmed by the Head of Department. When an experienced clinician was defined as a licensed obstetrician or as a clinician with more than 10 or 20 years of vaginal breech delivery experience, there was no subsequent reduction in risk of adverse perinatal outcome. Thus, our analysis suggests that a clinician’s self-assessment of his or her own skill and experience may be a more valid measure of clinical experinece than either the completion of a training program in obstetrics and gynecology, or having many years of attending to vaginal breech deliveries.
If we take the lessons of the Term Breech Trial seriously, and I think we should, then evidence-based practice would be to:
do everything possible to ensure there is as much ‘skill and experience’ as possible in the room for every vaginal breech birth; and
incorporate the availability of this skill and experience into the counselling women receive.
The findings of the Term Breech Trial resonate with the Public and Patient Involvement (PPI) work I have done to explore the feasibility of a physiological breech trial (#termbreech2020). Women also find the availability of a skilled and experienced attendant fundamentally important to their decision-making around whether or not to plan a vaginal breech birth. Consultant Midwife Emma Spillane and I have published two case studies that explore how this works in practice and what it means to women (2019 & 2020).
Finally, my own theory-building research suggests that breech clinical teaching teams are potential solutions to the pragmatic problem of providing ‘skill and experience.’ This consensus-development research with experienced obstetricians, midwives and service user representatives, to determine the standards for practitioners attending upright breech births, recommended ‘specialist’ breech teams. These collaborative recommendations have shaped the development of the ‘physiological breech birth’ intervention in the #termbreech2020 feasibility study.
Given the general depletion of VBB skills and opportunities, one of the hospital-based panel members suggested a ‘specialist’ breech team in every labour setting with at least one member on each shift (or on-call) would be advantageous, and this statement met consensus-level agreement (87%). However, the panel agreed the role of ‘specialists’ is to mentor and support breech skills development throughout the entire maternity care team, rather than functioning as experts of an exclusive skill set.
In summary, the status of the evidence is: Breech clinical teaching teams are a potential mechanism for providing an intervention we know reduces the risk of adverse perinatal outcomes in vaginal breech births: a ‘skilled and experienced’ attendant. And their use is recommended by professionals experienced with physiological breech birth. Now physiological breech birth team care needs to be tested. The #termbreech2020 Physiological Breech Study will explore the feasibility of doing that in a randomised trial.
Coming soon … how is ‘skill and experience’ defined?
I am incredibly grateful for the time my senior obstetric and midwifery colleagues have taken to read and engage with the plans for the #termbreech2020Physiological Breech Trial. If feasible, this will be the first trial of term breech birth in over 20 years. Multi-disciplinary involvement in the trial design is essential to its success. This will be the first in a series of blogs addressing some potential barriers identified. The purpose is to 1) involve others in the discussion and reflection; 2) invite further feedback; and 3) share the learning with colleagues who are planning to implement a Breech Team, within the feasibility study or independently.
‘Breech Team’ is a succinct term for a Breech Clinical Teaching Team.
A Breech Clinical Teaching Team is a multi-disciplinary group of clinicians within a maternity care team who are proficient in facilitating physiological breech births, leading on breech training within the institution and attending vaginal breech births regularly in their clinical teaching role.
What does this look like?
In the #termbreech2020 feasibility study, we will start by providing Physiological Breech Birth training to five consultant obstetricians and five senior midwives.* These 10 initial Breech Team members will organise themselves to cover the service. The team has autonomy over determining how this will work, but support from the institution is essential. The role needs to be recognised so that, at a minimum, team members can be released from other duties temporarily when required to attend a breech birth, or given time back if they have attended a birth outside their normally scheduled hours.
The core team should include clinicans who 1) spend a lot of time on the Labour Ward; 2) enjoy teaching; and 3) have skill and experience attending vaginal breech births.
When attending a breech birth, the role of a Breech Team member is to 1) support the attending clinicians to develop their own physiological breech birth skill set; 2) to maintain safety while this occurs; and 3) to continue their own learning. Following each breech birth attended, the Breech Team member shares the learning from that birth by providing a brief reflective account and simulation if appropriate, or supporting the attending clinican to do so, for other members of the maternity care team who did not attend the birth.
The Breech Team also collaborates and leads on breech guidelines and education within the institution. This promotes a consistent approach and dissemination throughout the wider maternity care team.
What a Breech Team is not: A small group of clinicians who are the only people allowed to attend breech births. The role is an additional safety and training mechanism.
Do you have a breech team in operation within your unit? Is it formally set up or informally arranged on a per-woman basis? I would love to hear your thoughts and experiences.
When a Breech Team member supports a breech birth, who is legally responsible?
Isn’t counselling the biggest issue? Why can’t we just improve counselling to make sure every woman is able to make an informed choice?
How much will it cost?
* All breech training is provided free of charge for the institutions that are participating in #termbreech2020. The feasibility study includes a budget for the release of time for the initial 10 Breech Team members. Breech Team members will then lead on education within the insitution, but training materials (videos, presentations, etc.) and support will be provided. Institutions can request further free training at any time.