Tag Archives: induction

New Canadian breech guidelines published

new guidelineA 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.

https://twitter.com/SisterShawnRM/status/1143838688637542400

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.

— Shawn

References

García Adánez J et al 2013. Recuperación del parto vaginal de nalgas y versión cefálica externa. Progresos Obstet. y Ginecol. 56, 248–253.

Hickland P et al 2018. A novel and dedicated multidisciplinary service to manage breech presentation at term; 3 years of experience in a tertiary care maternity unit. J. Matern. Neonatal Med. 31, 3002–3008.

Homer C S E et al 2015. Women’s experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 15, 89.

Kidd L et al 2014. Development of a dedicated breech service in a London teaching hospital. Arch. Dis. Child. – Fetal Neonatal Ed. 99, A20–A21.

Kotaska A 2017. Informed consent and refusal in obstetrics: A practical ethical guide. Birth 44, 195–199.

Kotaska A, Menticoglou S 2019. No. 384-Management of Breech Presentation at Term. J. Obstet. Gynaecol. Canada 41, 1193–1205.

Larsen J W, Pinger WA 2014. Primary cesarean delivery prevention: a collaborative model of care. Obstet. Gynecol. 123 Suppl, 152S.

Louwen F et al 2017. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans? Int. J. Gynecol. Obstet. 136, 151–161.

Maier B et al, 2011. Fetal outcome for infants in breech by method of delivery: experiences with a stand-by service system of senior obstetricians and women’s choices of mode of delivery. J Perinat Med 39, 385–390.

Marko K I et al 2015. Cesarean Delivery Prevention. Obstet. Gynecol. 125, 42S.

Petrovska K et al 2016. Supporting Women Planning a Vaginal Breech Birth: An International Survey. Birth 43, 353–357.

Reitter A et al 2018. Is it reasonable to establish an independent obstetric leadership in a small hospital and does it result in measurable changes in quality of maternity care? Z. Geburtshilfe Neonatol.

Walker S, Scamell M, Parker P 2016. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery 34, 7–14.

Walker S, Scamell M, Parker P 2016. Principles of physiological breech birth practice: A Delphi study. Midwifery 43, 1–6.

Walker S 2017. Competence and expertise in physiological breech birth. PhD Thesis. City, University of London.

Walker, S., Breslin, E., Scamell, M., Parker, P., 2017. Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth 44, 101–109.

Walker S, Scamell M, Parker P 2018. Deliberate acquisition of competence in physiological breech birth: A grounded theory study. Women and Birth 31, e170–e177.

Walker S, Parker P, Scamell M 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209.

Induction of labour and … everyone

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:

  1. 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 …
  2. 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.
  3. 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.
  4. 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.

Shawn

Why midwives are sceptical

This blog is Part 2 in a discussion about on-going RCTs looking at induction of labour (IOL) at various gestations: Why midwives are sceptical about research on medical interventions

In theory, research like this is done in order to support clinical decision-making and to enable informed consent for proposed interventions. If midwives seem dubious about the merits of research concerning medicalised birth, it is because our experience indicates that truly informed consent is a rare beast. Once an RCT has decided that a certain course of action results in less risk for baby, any woman who wants to take a different course will most likely have a fight on her hands, with most health professionals, family, friends, even her partner.

Because it is socially unacceptable to say – It is okay for a woman to choose an option which appears more risky for her baby. Women are not just baby carriers. They live complex physical and emotional lives in which other factors are important too. – midwives end up in the awkward position of trying to argue with The Truth of big science.

Soon, someone will get funding to do an RCT looking at whether the outcomes for babies are better for low-risk primips who undergo elective CS at 39 weeks, or normal labour. And my guess is CS will come out on top for the Big Ones – reduced morbidity and mortality. And then what? Will all primips be offered a CS at 39 weeks? And those who refuse?

I’d like to think we could use the information from these trials to truly offer women an induction of labour, acknowledging that it will not be right for everyone, but as a midwife I see every day what happens to women who decline the Recommended Treatment. Take for example this recent Tweet:

Screen Shot 2014-01-19 at 16.34.03

Is it really okay for an ‘anaesthesiologist’ and president of MSF-USA (Doctors Without Borders) to publicly discuss this tragic outcome, in a way which implies that a woman who declines a recommended CS is selfish, cold, heartless .. & uninformed (despite having definite, and accurate, reasons for refusing). Putting her own experience ahead of her baby’s life, as if losing a baby is ever a good experience, even for the most ambivalent. Are women who decline medical advice no longer entitled to respect and confidentiality? This so-called professional then used the MSF-USA twitter account to re-tweet this damning judgement to 361,500 followers. Midwives in the UK are struck off for less.

We need more research on how to increase the quality rather than the quantity of birth, and life in general; and the quality of women’s experiences will certainly improve with more compassion and less guilt-tripping. Childbirth is not a trip to Walmart.

I want women to have the choice of an early induction, or a CS, if research indicates it may benefit their baby. If they feel it is the best choice for them, so do I. But I want women who don’t want this to have their choices acknowledged as equally valid and equally supported. And I don’t have a lot of faith that will happen.

Finally, because it’s my blog: For me, going into labour was like falling in love. The agonising wait, wondering when it will happen. The brief period of terror when I realised it had. Followed by succumbing. Followed by a lot of hard work and ultimately, blessedly, joy. For me, it was worth waiting for.

Shawn

How the consent process introduces bias into RCTs

Part 1: Why I remain sceptical of RCTs concerning obstetric interventions in normal labour and birth

Another blog post in response to a Twitter debate .. this time concerning various RCTs currently evaluating IOL vs expectant management. We’ve been discussing three trials:

The questions are valid. We know stillbirth is increased, especially in certain populations, the longer a pregnancy continues. In order to make an informed decision, many women will want to know the most likely outcomes and effects of opting in or out of proposed interventions. RCTs are considered the most unbiased way of settling these issues, unsullied by the biases of women or health professionals.

The problem is, these interventions are eventually applied to a population that is, due to being human, inherently biased. Some women feel a strong preference in one direction, some in another; and some want their doctor to decide for them. Women need to consent to be randomised into RCTs, and women who are most averse to the proposed intervention simply decline consent. Therefore the population recruited becomes slightly biased towards a preference for the intervention being investigated.

Is this important? Does it matter? I don’t know. Recent research by Wu et al suggests that women with a strong preference for vaginal birth were more likely to have a vaginal birth. RCTs cannot tell us the effect of women’s preferences on the outcomes they measure. Yet in theory their results are used to offer women an option they will almost certainly have an opinion about.

If I were contributing to the design of these trials, I would want to collect observational data alongside the main trial data. Things like:

  • Why do women consent or decline to participate in the RCT? Are the women who declined to participate due to a strong preference against induction more or less likely to have a normal birth? Are the outcomes for their babies significantly different than those in either arm of the trial?
  • What are the long-term outcomes? Especially in the over-35 population, an increase stillbirth rate may be due to inherent weaknesses in the baby. Significant long-term differences are often not detectable until 2 years of age.
  • And finally .. would they do the again? Would they recommend it to a friend?

These are questions best answered using quantitative techniques, but women may have different questions or priorities, which we will only discover using qualitative investigations.

See Part 2: Why midwives are sceptical.

Shawn