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.
A professional is considered currently proficient in physiological breech birth if they have:
- 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.
Shawn
References:
What is Physiological Breech Birth? Read more here: Walker S, Scamell M, Parker P (2016) Principles of physiological breech birth practice: A Delphi Study. Midwifery. 43:1-6. (Author version archived at City Research Online)
6 hours of evaluated breech birth training
- Walker S, Breslin E, Scamell M, Parker P (2017) Effectiveness of vaginal breech birth training strategies: an integrative review of the literature. Birth. 44(2):101-9. (Author version archived at City Research Online)
- Walker S, Reading C, Silverwood-Cope O, Cochrane V (2017) Physiological breech birth: Evaluation of a training programme for birth professionals. The Practising Midwife. 20(2): 25-8. (Extended Author Version)
- Walker S, Scamell M, Parker P (2016) Standards for maternity care professionals attending planned upright breech births. Midwifery. 34:7-14. (Author version archived at City Research Online)
Attended at least 10 vaginal breech births, including resolution of complications using manual manoeuvres
- Walker S, Scamell M, Parker P (2016) Standards for maternity care professionals attending planned upright breech births. Midwifery. 34:7-14. (Author version archived at City Research Online)
- Walker S, Scamell M, Parker P (2018) Deliberate acquisition of competence in physiological breech birth: A grounded theory study. Women & Birth 31(3):e170-e177.
Experience of 3 vaginal breech births (attended or taught with simulation) within the past year
- Walker S, Scamell M, Parker P (2016) Standards for maternity care professionals attending planned upright breech births. Midwifery. 34:7-14. (Author version archived at City Research Online)
- Walker S, Parker P, Scamell M (2018) Expertise in physiological breech birth: A mixed methods study. Birth. 45(2):202-209.
Delivered physiological breech birth training at least once within the past year, including reflective reviews of births attended
- Walker S, Scamell M, Parker P (2016) Standards for maternity care professionals attending planned upright breech births. Midwifery. 34:7-14. (Author version archived at City Research Online)