This year we honour midwives who continue to do the best job in the world under the most difficult of circumstances. Please enjoy this virtual International Day of the Midwife 2020 celebration from King’s College London student midwives, staff, alumni and collaborators. I’m so proud to be a part of this team!
And as always, we at Breech Birth Network honour the highly skilled midwives around the world who are working to make vaginal breech births safer and more accessible, for the women who choose them and for those who do not have a choice.
As part of the celebrations, I’ve made this video to explain the recent research that Dr Anke Reitter, Alex Halliday and I have done about what ‘normal for breech’ looks like. The video can be shared. Thank you to the women and professionals who have shared their intimate and vulnerable moments to make this possible.
The research is published open-access (FREE!) as part of a trio of breech articles by the journal Birth: Issues in Perinatal Care.
The Breech Birth Network are delighted to announce both Shawn and Emma have been shortlisted for awards at the International Maternity Expo Awards. We are both very honoured to have been shortlisted in the following categories:
Dr Shawn Walker – shortlisted for the Research Innovation Award and the Improving Safety Award
Dr Shawn Walker has been shortlisted for both the Research Innovation Award and the Improving Safety Award for her work in improving the knowledge, skills and training around Physiological Breech Birth. Shawn has published a number of research articles highlighting the importance of effective training, the development of experienced breech teams and pracical insights into upright breech birth. Shawn is currenty writing proposals for further essential research into Physiological Breech Birth to further improve safety and choice for mothers and their babies as well as practiotioners facilitating such births.
Emma has been shortlisted for the Practice Innovation Award for her work in setting up a breech birth service in the large London teaching hospital she works in. The service supports mothers in their choices regarding mode of birth for breech presentation at term. Emma is also completing her Masters research in Breech Childbirth Preferences of Parents to further support service provision and support for parents choices.
We would both like to thank those who nominated us. It is a privilege and an honour to have been recognised for the work we are both doing.
Emma Spillane is seeking your thoughts on a new piece of research prior to its submission for ethics approval. If you have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, or you work with pregnant women in a non-medical capacity (e.g. doula, antenatal teacher, breastfeeding supporter, etc.), I would love to hear from you.
I am conducting research as part of my Masters exploring breech childbirth preferences of expectant parents to understand if there is demand for breech birth services within the NHS and explore the factors which influence parents decision-making. At this stage, I would like your feedback on the suggested design of the trial, to ensure that the information resulting from the research will be useful to those considering breech options. For those of you who would like to remain with the project I am forming a Breech Advisory Group provide feedback at further stages in the project such as analysing the results.
If you are interested in participating in my research in this way, please read the plain text summary of the project below and complete a short survey by following the link after the research summary.
Approximately 3-4% of babies at term present in the breech position (bottom or feet first) (Impey et al. 2017). The Royal College of Obstetricians and Gynaecologists’ (RCOG) most recent clinical guideline on Management of Breech Presentation recommends that pregnant women should be offered choice on mode of birth for breech presentation at term(after 37 weeks’ gestation) (Impey et al, 2017). Despite this recommendation, only 0.4% of all breech babies in the UK are born vaginally (Hospital Episode Statistics, 2017), and this figure includes pre-term breech births where breech presentation is more common (Impey et al. 2017). These statistics suggest that either the demand for vaginal breech birth is low, or the choice of mode of birth is not being consistently offered. This study aims to explore this enigma by providing empirical evidence necessary to inform maternity services on the requirement of breech birth services.
Current evaluations of demand for vaginal breech birth services have been limited by the quality and impartiality of information parents are able to access via their maternity services. For example, research has shown that women have difficulties finding information to support their choices and are pressured into making the decision based upon practitioner preference (Petrovska et al, 2016). An investigation carried out in the Netherlands, found that one third of parents would prefer to have their babies born vaginally (Kok, 2008). However, little is currently known about parents’ preferences in England.
This research will evaluate the extent of expectant parents’ preferences for vaginal breech birth prior to counselling, and the factors that influence these preferences, using personal interview surveys (Bhattacherjee, 2012). All women presenting with suspected breech presentation at a large London based teaching hospital – St George’s University Hospital NHS Foundation Trust – will be given information about this study along with their Trust approved mode of birth information leaflet during their routine antenatal appointment at 36 weeks of pregnancy. As per Trust clinical protocol, women with suspected breech presentation will be offered a referral for an Obstetric Ultrasound Scan (OUSS) for confirmation of fetal presentation. During this routine OUSS appointment, either prior to or following the scan taking place, parents will be approached by the researcher and invited to take part in an interview on their preferred mode of birth and the reasons behind these preferences. Both parents, if present, will be interviewed separately. Parents will already have been given information about the study in the form of a Participant Information Sheet PIS) by the clinician referring them for an OUSS. The timing of the interview has been chosen because it fits with the participating Trusts usual pathway of care. Parents are informed there may be long waiting times due to OUSS being arranged at short notice.
The findings from this research will provide evidence on the following:
the demand for a vaginal breech birth service, based on written information prior to individualised counselling;
the factors influencing this demand, which can be used to improve shared decision-making training and taken into account when planning future research; and
a predicted service planning model for a fully integrated breech continuity team within the host Trust.
Data on parents’ preferences for mode of birth will be reported descriptively as a percentage. Qualitative data regarding parents’ reasons for their preferences of mode of birth will be analysed thematically.
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
Clinicians should counsel women in an unbiased way that ensures a proper understanding ofthe 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.
We are seeking your thoughts on two new pieces of research currently in the development stage. If you have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, or you work with pregnant women in a non-medical capacity (e.g. doula, antenatal teacher, breastfeeding supporter, etc.), we would love to hear from you.
Emma Spillane would like your feedback on an Information Leaflet for people pregnant with breech-presenting babies. The leaflet will be used in research to determine an approximate level of demand for vaginal breech birth, with balanced counselling and adequate support.
Talking through elevate and rotate
Shawn Walker is preparing an application for a large grant to fund a pilot randomised controlled trial. No term breech trials have been published since 2000 (Hannah et al). The team around this project would like to gather a Breech Advisory Group composed of people who have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, and non-medical birth workers, such as doulas and antenatal teachers. At this stage, we would like your feedback on the suggested design of the trial, to ensure that the information resulting from the research will be useful to those considering breech options. For those of you who would like to remain with the project if funding is obtained, we will send regular updates with opportunities to provide feedback at stages like final project design, advertising the trial and analysing the results.
If you are interested in participating in our research in this way, please complete the form below and one of us will be in touch.
Last Tuesday, 14th October 2014, obstetricians and midwives from around the world converged in the basement of the Royal College of Obstetricians and Midwives (RCOG) in London for a study day on Management of the Term Breech (#RCOGbreech). The day was originally planned to correspond with the publication of the new RCOG guideline, last published in 2006. However, the re-write has been delayed, understandably. Across the country, more and more units are not only raising the level of support for breech, they are supporting women to birth their breech babies in upright positions, something the current guideline recommends women are advised not to do.
The update authors face some tough choices: 1) continue to advise against an increasingly popular practice, alienating many of the few professionals currently supporting breech births; or 2) turn the current state of affairs upside down by … guess we’ll see when it’s published! The RCOG day was opened by the rather marvellous Mr Lawrence Impey, Oxford Consultant in Obstetrics and Fetal Medicine and co-author (with Justus Hofmeyr) of the 2006 guideline, and Mrs Anita Hedditch, Delivery Suite Senior Midwife and ECV Midwife, also at Oxford. Impey acknowledged the sense of anticipation and slight tension in the room by instructing delegates: “No heckling, and no snorting!”
However, Professor Deirdre Murphy from Dublin created little controversy with her fair and balanced evaluation of the evidence. Although her analysis was much more nuanced, following discussions, the take-home message was: With experienced support, the short-term risks for breech babies (neonatal mortality, serious morbidity) are probably not significantly greater than those for cephalic babies. Both breech and cephalic babies have increased short-term risks compared to a planned caesarean section (CS). For breech babies, the available evidence indicates that by two years of age, no significant difference in primary adverse outcomes (death and neuromotor delay) is apparent between babies born after planned CS and babies born after planned vaginal breech delivery (PVD). But babies born following planned CS face some increased risk of other medical problems.
Murphy was followed by Mich Mohajer of the Royal Shrewsbury, who presented evidence from her telephone survey about what exactly is happening around the UK for breech. ECV appears to be almost universally offered throughout England and Wales at the moment, although she found significant variations in models of care, with some units offering dedicated breech clinics and other units offering an ad hoc service on delivery suite. She found even more variations in levels of support for vaginal breech birth, with only 27% of units in England and Wales supporting VBD. Mohajer also acknowledged the importance of involving midwives with breech skills, as the facilitation of breech births has always been considered part of midwives’ expertise. These two themes: the importance of a specialist approach through dedicated clinics and ‘breech teams,’ and the value of multi-professional collaboration, were echoed frequently throughout the week.
After a brief break, Dr Leonie Penna from King’s in London presented on ‘pitfalls and pearls’ in delivering the vaginal breech. She summarised a number of common errors and helpful hints, bringing the focus onto the real gap in clinical skills which will need to be closed or bridged in order to reintroduce systematic support for planned breech births. Penna was also very upfront in discussing the reluctance of the obstetric profession to shift away from women on their backs, even with strong evidence of how helpful it is. She drew parallels with fetal blood sampling, which it is now recommended to perform with women in left lateral. With Penna’s talk, it became clear that the discussion is finally shifting away from an assumption of vaginal breech DELIVERY and towards and understanding of vaginal breech BIRTH. Finally, Penna as well emphasised the important role midwives have always played in supporting breech births at King’s.
After this, Dr Anke Reitter presented on her experience of being a part of the now-famous breech clinic in Frankfurt, and her MRI data demonstrating how significantly maternal movement affects the dimensions of the bony pelvis. Reitter (@OB_Anke) also discussed how our current understanding of helpful manoeuvres for upright breech birth – especially the first principle of rotation by the shoulder girdle rather than the pelvis – is not new. She showed captivating drawings from historic German and Australian textbooks showing nuchal arms and how to resolve the problem. Thankfully, Reitter will be returning to the UK in June to share her hands-on skills at one of our Breech Birth Network Physiological Breech Study Days.
Visiting speaker Thomas van den Akker, obstetrician and researcher from the Netherlands, reminded the audience of the RCOG’s responsibility to the developing world. In less resource-rich countries, CS presents a much higher risk to women and their future children than it does in the UK. But the world follows the RCOG’s example and demands the highest standard of care, even when it is inappropriate in that context. Van den Akker also presented data from follow-up studies by the Vlemmix team which demonstrate that per 10,000 babies delivered by CS for breech (compared to planned VBD), there were 26 neonates saved in the first pregnancy (19/7442). However, there were 27 neonates (18/6689) lost in subsequent pregnancies in a policy of trial of labour. Can we continue to recommend that first time mothers avoid a vaginal breech birth, while encouraging them to plan a vaginal breech birth after caesarean section (VBAC) in their next pregnancies?
Over lunch, Jane Evans gave a presentation of the mechanisms of breech labour, and strategies to help when help is needed. She brought along her slide show and doll and pelvis, for those who wanted to make the most of every minute available to learn breech skills.
Deirdre Murphy, Anke Reitter, Mich Mohajer, Thomas van den Akker, Leonie Penna
After lunch, the morning speakers engaged in a panel discussion about how the term breech should be managed. The relaxed mood and support for the option of vaginal breech birth was clearly emotive for some. One obstetric delegate stood up and shared how he had become a pariah among his colleagues for continuing to facilitate vaginal breech birth (VBB), and how he hoped the new guideline would be more clear about how important and appropriate it is to support VBB.
This was followed by talks by Impey and Hedditch about the evidence base, practice and their clinical experience of external cephalic version (ECV). Like many other professionals, I have made a pilgrimage to Oxford to visit their renowned clinic and learn from them and their community midwife colleague, Pauline Ellaway. They presented their most recent statistics, which like others’ (see Grootscholten et al, 2008) show a higher rate of interventions and adverse outcomes for post-ECV babies than babies who spontaneously assumed a head-first position (neonatal mortality = 0.9/1000; not significantly different from 1.3/1000, the neonatal mortality for planned VBD in the Netherlands reported in Vlemmix et al). This is a video from a Dutch team which also use a two-person approach.
This then opened up the discussion in the final afternoon panel to a point I had not previously hoped was possible: The genuine suggestion that perhaps dedicated ECV services should become dedicated Breech services, where women’s individual clinical situations are evaluated and those felt to be good candidates are offered a VBB, while those who are not felt to be good candidates are encouraged to consider ECV. (Selection criteria remain controversial, but this openness is a very good start.) The strong message was that women should have access to a high-quality, experienced ECV service, but this should not be the only alternative to CS.
Dr Joris Hemelaar also presented about rates of undiagnosed breech in Oxford, which are over 20% like most places in the UK which do not do routine third trimester scans (which are not recommended by Cochrane. Hemelaar’s point in presenting this information alongside reports on breech/ECV clinics is that we cannot offer women an ECV or detailed counselling about VBB if we do not detect the breech antenatally. However, and my view differs somewhat, as we do not yet have any evidence that the undiagnosed breech is at greater risk in the UK. Most of the available evidence indicates that the undiagnosed breech is far more likely to be born vaginally, at no increased risk. The situation is unlikely to change until more than 27% of UK units support a planned VBB, and until that time, obstetric and midwifery-led units would be wise to put a proactive plan in place so that these births can be managed with a calm, team approach.
Shawn Walker, Ethel Burns, Anita Hedditch, Andrew Bisits, Lawrence Impey, Anke Reitter, Betty-Anne Daviss
As if the RCOG conference was not exciting enough, Senior Midwifery Lecturer Ethel Burns of Oxford Brookes University made the most of international visitors to host a conference on “Breech Birth: Sharing what we know and do, and exploring best practice for the future,” on Saturday, 18th October 2014 (#Oxfordbreech). The day included repeat presentations (for a new audience) from Anke Reitter and Anita Hedditch, and Jane Evans again presented her slides, mechanisms and manoeuvres over lunch; but there were some additions.
This day kicked off with Lawrence Impey presenting the evidence base for breech birth, emphasising some of the themes from the previous Tuesday’s conference:
In selected women with high quality care baby mortality is probably little different from cephalic presentation, but is higher than ELCS
However, there may be a higher risk of obesity, asthma and other serious problems following elective CS
Maternal mortality and morbidity is dependent on emergency CS rate but unless this is >50% is likely to be increased with a polity of elective CS. This is particularly important in the developing world.
In the long term, there is a small increase in risk of mortality and morbidity to future babies through unexplained stillbirth and uterine scars.
Lost skills will mean a higher complication rate for unplanned breech deliveries, be these CS or vaginal
Impey was followed by Ruth Sloman, who has recently completed her Masters in Midwifery at Oxford Brookes. Sloman used focus groups to look at midwives’ knowledge and experience of breech births. I really enjoyed this presentation, and some of Ruth’s themes resonated with my own research, especially the value of video footage in helping professionals to learn when hands-on experience is difficult to come by, and midwives frustration at witnessing vaginal breech deliveries poorly managed and the lack of choice available to many women.
After the break, the conference continued with Dr Andrew Bisits, FRANZCOG of Sydney, Australia. Bisits’ sensitivity to women’s experiences has made him beloved of women and midwives across the globe, and his long-term commitment to supporting vaginal breech births has gained him knowledge and experience exceeding most obstetricians working in 2014. Crucial to Bisits’ talk was a recognition of how important the experience of attempting a vaginal breech birth is to some women. He also encouraged us to recognise that moderate risk-taking confers psychological benefits. Although Bisits’ talk included much more than I can summarise here, a final important point concerned the ‘atomic reaction’ which usually follows adverse outcomes in breech births, and knee-jerk responses usually preclude any genuine learning from these events. If we are to improve the safety of breech birth, it is vitally important that we learn from adverse outcomes by reflecting on them in an open and enquiring, rather than punitive way.
Reitter and Bisits are of course not only two of the most highly experienced breech practitioners in the world, they are passionate advocates for the use of upright positioning. Reitter’s clients birth mostly in all fours/kneeling positions, and Bisits’ clients commonly use a birthing stool. Their view is that it is not so much the position, as the ability of women to move spontaneously and assume the position of her choice, which matters most. The mood of both days indicated that this point has been well and truly made and heard by those writing the new guideline. The question became not so much whether upright positioning would be acknowledged as a legitimate approach, but whether or not it will continue to be considered in any way ‘alternative’ in the new guideline.
Betty-Anne Daviss visited from Ontario, presenting an encapsulated history of the women’s movement in Canada, and how this has influenced the progress they have made with breech birth. She explained the way in which the Canadian-born Coalition for Breech Birth worked with sympathetic doctors and midwives to reintroduce the choice of VBB. Remarkably, Daviss has succeeded in gaining privileges to attend VBBs in her local hospitals, and currently supports approximately 1-3 women per month to achieve their goal.
I also presented my current research concerning how practitioners learn breech skills. We need to accelerate this process if we are going to increase support for planned vaginal breech birth within the current risk-adverse maternity care culture. I’m looking forward to sharing more of this in publications as the research progresses, so watch this space! My presentation also highlighted the standard of care when it comes to maternal birth position for healthy women. NICE’s evidence-based and woman-centred approach is clear:
Women should be discouraged from lying supine or semi-supine in the second stage of labour and should be encouraged to adopt any other position that they find most comfortable. (1.7.7, current Intrapartum Care guideline)
If policy-makers are now acknowledging that VBB carries a similar risk to cephalic birth in experienced hands, then those who continue to advocate a maternal birth position (lithotomy) which deviates from the current standard of care should present evidence as to why they are doing this, rather than the other way around. Experience alone may be enough to explain it for those who have continued to safely facilitate VBDs, but the next generation and those who have taken a 14-year hiatus would do well to learn the new upright techniques as part of their standard training.
If the authors of the new RCOG guideline walk the walk as well as they have talked the talk in the past week, some major changes are a-foot. But policy changes are only a small part of what happens on the ground, evidenced by the fact that the RCOG has recommended the choice of VBD be offered to women since 2006, something that is clearly not happening universally in the UK. A major cultural shift is required, but these two events suggest that the shifting has indeed begun.
Well done you if you’ve read all the way to end of this post, and join the breech activist club! If you found other aspects of the day important and informative, please do highlight them in the comments below.