Tag Archives: experience

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

 

How much does breech experience matter?

Some friends of mine at the Coalition for Breech Birth (a consumer advocacy organisation) have been discussing the role of practitioner experience in reducing risk associated with vaginal breech birth. My response is a bit longer than Facebook will permit, so I’m putting it here.

The study I find most useful in this discussion is here:

Su M, McLeod L, Ross S, Willan A, Hannah WJ, Hutton E, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol. 2003 Sep;189(3):740-5. PubMed PMID: 14526305. Epub 2003/10/04. eng.

Overall, the team found very few factors associated with an increase or reduction of risk of adverse perinatal outcome. They did find a dose-reponse relationship between amount of labour and adverse outcome. In other words, a pre-labour CS seemed to afford the most benefit, followed by early labour CS. By the time you are in active labour (>3 cm), there is no longer a statistically significant difference between CS and vaginal birth. So I get particularly annoyed when this study is used to tell women who arrive in advanced labour with an undiagnosed breech that a CS is the safest option.

They also found, contrary to popular belief, that big babies (>3500g) fared no worse than more averaged weight babies, but small babies (<2800g) did. Makes sense to me. Generally but not always, babies who are very small at term may already be slightly compromised; labour may be an additional stress. On the other hand, if a chunky 9-pounder folded in half can fit both his abdomen and his legs through your pelvis, chances are his head is going to fit, especially if you are with someone who knows how to help it into an optimal position.

He also needs to fit without help, because the study also revealed that using augmentation to enhance a labour which is not progressing well enough on its own was associated with over twice the risk of labours which proceeded spontaneously. Similarly, longer second stages increased the risk, so our baby needs to be descending fairly easily in the second stage, without help, or a CS may be the better option.

But the only factor shown to reduce the risk associated with a vaginal breech birth (by over 2/3) is the presence of an experienced clinician at the birth. This person need not be a licensed obstetrician, and the years of experience did not make a difference either – the TBT team specifically looked at these factors. The risk reduction occurred only when ‘an experienced clinician was defined as a clinician who judged him or herself to be skilled at vaginal breech delivery, confirmed by the Head of Department.’ Midwives were among those included in this definition.

Although we do not (yet) have any research (get back to me in a decade or so) which looks at the results of spontaneous breech birth with experienced clinicians at term, this analysis of the TBT suggests that this scenario is significantly less risky than many of the births included in the trial which were responsible for adverse outcomes. Add to that the further benefits we are seeing emerge with upright breech (reduction in need for manoeuvres and the minor injuries these can sometimes cause), and vaginal breech birth is a realistic option for many women.

One further comment on the research: Many are frustrated because the results of retrospective observational studies overwhelmingly indicate similar outcomes for vaginal breech birth and planned CS. These have comparatively little influence on guidelines because they are considered ‘biased.’ However, understanding why they are biased is sometimes useful. Retrospective studies are most often done by experienced practitioners who feel their own results conflict with the lowest common denominator represented by a large multi-centre RCT like the TBT. They present these results to illustrate that a comparatively safe vaginal breech service is possible, despite the fact that breech is often grossly mismanaged in many areas. Retrospective studies do not necessarily represent the ‘norm.’ But they do suggest, along with the TBT’s own data, that if your provider feels confident supporting you to have a vaginal breech birth, you can probably feel pretty confident as well.

Update 2015: A meta-analysis of observational studies indicates significantly better short-term outcomes when CS is planned than when VBB is planned. However, the rate of complications following planned VBB is much less than reported in the Term Breech Trial and similar to the results when a cephalic birth is planned. Read Berhan et al 2015 by clicking the link.

Shawn