Tag Archives: evidence-based practice

New Information Leaflet

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 services

Nursing 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.

— Emma

 

Moxibustion: A Smoke Screen?

Screen Shot 2014-06-13 at 01.38.38Professionals: Concerned about women waving giant sticks of burning wacky weed around their wee toes in a desperate attempt to turn their breech babies?! Take action NOW! Ensure that these women can access support for a vaginal breech birth with an experienced, trusted professional, and you will no longer have to busy yourself trying to root out such madness!

Screen Shot 2014-06-13 at 06.51.12Last week the results of a trial (Coulon et al 2014) were released which appeared to show moxibustion with acupuncture ineffective in causing more babies to turn head-down. The trial had its good points. A reasonable number of women randomised (328) at the appropriate point in pregnancy (33+4 – 35+4) to use moxibustion for maximum effectiveness. This in itself was impressive, as most centres do not bother about breech presentation until 36 weeks, making recruitment for studies during this time period difficult. The team looked at the percentage of babies who remained breech at 37+2, the point when ECV (a procedure to manually try to turn the baby in the uterus to a head-down position) would be offered, and found that 72% who had the treatment were still breech, compared with 63.4% who had the placebo. They reported this was not statistically different, but superficially it looks like the treatment had the opposite of the desired effect.

Screen Shot 2014-06-13 at 01.38.58On the other hand, they appear to have used actual needles, heated with moxibustion, rather than the method most commonly used in UK-based moxibustion practices, which involves using the heated sticks only. Also, the intervention and placebo were applied for only six sessions. Generally, women using moxibustion in the UK are usually taught to home-administer (usually with the help of her partner) and then instructed to follow a ten-day course, applying moxibustion twice a day, and continuing whether the baby turns or not. The ten-day, moxibustion-only practice follows a less treat-to-cure, and more treat-to-nourish philosophy, the idea being that the moxibustion nourishes the energy of the womb and promotes optimal positioning. (No swearing until I’ve finished the article, please!)

Screen Shot 2014-06-13 at 01.39.14I’m a fan of observing responses to research on Twitter. (See this previous discussion on hypnosis for childbirth.) And Twitter did not disappoint. The Green Journal announced the Coulon study, and obstetricians celebrated their vindication for having dismissed the practice years ago. There’s nothing like the joy of scientific confirmation of one’s deeply held beliefs. It was as if somebody walked into a room full of midwives and said, “Hey, guess what? Continuity of carer improves outcomes for everybody!” (By the way, it does.)

Screen Shot 2014-06-13 at 02.12.23But then a woman who had actually experienced a breech pregnancy pointed out the obvious: What are the alternatives? Generally, women are highly motivated to give birth vaginally (Raynes-Greenow et al 2004Guittier et al 2011). They instinctively feel what the research tells us – that  a normal birth, wherever possible, is beneficial for both babies and women. There are many hospitals throughout the Western world, including some in the UK, where women cannot even access an ECV, let alone a vaginal breech birth. I’ve had phone conversations where I’ve asked to speak with the person who performs ECVs and been told, “We don’t do that here for liability reasons.” Folks, it’s 2014.

Screen Shot 2014-06-13 at 01.38.22With evidence-based counselling based on the outcomes of the Term Breech Trial, Kok et al 2008 found at least 35% of women preferred to plan a vaginal breech birth. Evidence-based counselling includes the lack of evidence of any difference between two-year outcomes whether an elective caesarean section or a vaginal breech birth is planned (Whyte et al 2004). We can reasonably conclude that if approximately 1/3 of women are not planning a vaginal breech birth in a given setting, then they are probably being directively counselled towards a caesarean section. This would include feeling forced to choose a caesarean section because no plan will be put in place to ensure attendance at a vaginal breech birth by an experienced and supportive professional.

Screen Shot 2014-06-13 at 01.41.57Women resort to practices such as moxibustion and handstands in the swimming pool because they are constantly given the message that breech presentation is ‘wrong’ and should be corrected, with very few alternatives. Whereas the evidence indicates that turning babies, even with ECV, does not improve outcomes for those babies, though it certainly improves the chances of a vaginal birth in settings with minimal support for vaginal breech birth (Hofmeyr and Kulier, 2012 – Cochrane Review). I am increasingly uncomfortable with the current situation, where women do things they do not actually want to do because they cannot access a vaginal breech birth at all, or will not be supported to choose that option until they have done everything else (especially ECV).

Screen Shot 2014-06-13 at 01.40.36Personally, I have no strong opinion on the use of moxibustion itself, as I generally prefer to leave the use of complementary therapies up to what works for individual women, as long as they do not pose a threat to her or her baby. I have taken training to be able to offer women advice, and I have supported women through the use of moxibustion. (We usually spend the ‘treatment’ time talking through the issues around breech birth.) When I speak publicly about breech management, someone usually asks me why I have not included moxibustion. And I tend to dodge the question, not so much because I am convinced of its efficacy or not, but because I believe it is professionals’ attitudes towards breech presentation and not the breech itself that needs to be ‘corrected.’

Screen Shot 2014-06-13 at 06.19.23Let me propose this radical solution: Why don’t we channel some of that indignation over moxibustion practices into ensuring that breech services improve to a point where women will not need to look elsewhere? Let’s ensure every woman has access to a well-supported vaginal breech birth, an ECV attempted by a highly experienced practitioner, and/or a woman-centred caesarean section as late in her pregnancy as she wishes to plan it, including in early labour. Let’s ensure that women have sympathetic, experienced counselling and continuity from a midwife while they navigate these choices, and the attendance of a highly experienced consultant, ready to step up and be that expert in complications of childbirth, backing up the team at birth.

No Re-tweet, sadly ;-)

No Re-tweet, sadly 😉

While we must always make room for those who choose a different path, I suspect that if we got a bit more comfortable with breech in general, the debate over whether moxibustion has a place in the mainstream or not would fade into the distance. Stop blaming pregnant women for their misled attempts to avoid a caesarean section, and the sympathetic midwives who are desperate to help them, and sort out primary breech services.

Shawn

 

 

 

 

 

Choice 1 Choice 2 Choice 3

 

 

 

[Note: I can only access the abstract to Coulon et al at the moment, as it has been posted ahead-of-print. I’ll update the post when it’s published, if there’s anything more to say.]