The recent release of the final Ockenden Report has shed light on deeply painful experiences for the women, families and healthcare professionals involved. For those of us who have not been involved, the call to deep reflection can also be a painful experience, but a necessary one.
I have been asked by several people what I feel this means for vaginal breech birth. Will women still want one after this report, where promotion of vaginal breech birth against maternal request for a caesarean section was a contributing factor in some very sad outcomes? Will professionals be even more reluctant to support women who wish to choose a vaginal breech birth, for fear of being accused of zealous pursuit of normal birth at all costs?
My answer is this: I welcome this report because I see it as affirmation of the need for individualised care, the need to listen to women, the need to place their values and needs at the centre of care.
Women who want a caesarean section, regardless of their baby’s presentation, should have easy access to one. I counsel several women with a breech-presenting baby every week about their birth choices, and I encounter many women who appear to be somewhat relieved that their baby is breech. They do not want an attempt at baby turning (external cephalic version, ECV, to a head-down position). They want a caesarean section. And their baby being breech means they will have one without the need to justify their choice.
I stopped talking women into an attempt at baby turning (ECV) a decade ago because I audited the results of my first breech clinic. By introducing a breech specialist midwife pathway, I doubled the rate of ECV acceptance almost overnight. Women trusted me. For two women, I remember clearly convincing them that ECV was ‘best.’ I even said to one after a successful procedure, “Aren’t you glad you had a go?” One woman had a long, complicated induction that ended with an emergency caesarean section and massive obstetric haemorrhage (bleeding). The other had a failed attempt at suction cup delivery, failed attempt at forceps delivery and a caesarean section. I have also been present when an ECV attempt at 36 weeks led to an emergency caesarean section, in which we found the cord ended up in front of the baby’s head as it was trying to engage. I’m pretty sure none of these women ended up happy that someone convinced them to have an ECV rather than a planned CS. If this has been your experience, or similar, I am so deeply sorry.
But I also meet many women who decide that an attempt at baby turning is the best choice for them. They really want to try for what they see as a ‘normal birth,’ in a birth centre with midwives and access to the birth pool. They are prepared to accept the relatively small risks associated with ECV and vaginal birth — after all, I can remember these women as individuals after a decade of doing breech work — because they feel the potential benefits outweigh the risks. These women deserve to be offered this attempt, with experienced providers who have a consistently good success rate. And if adverse outcomes happen, they deserve NOT to be treated as if they made the wrong decision. None of us has a crystal ball.
It is my responsibility to explain why baby turning is the nationally recommended ‘treatment’ for breech presentation. When I explain this, I explain the potential benefits of and increased likelihood of having a straightforward vaginal birth, particularly in a first pregnancy. I also explain to every woman that, in 2022, by far the most likely outcome no matter what she chooses to do (ECV, VBB, CS) is that she and her baby will be well and safe following the birth. There are small differences in risk between each choice, but ultimately, with skilled support and a plan in place, the outcomes are very good for all choices. She should feel supported to make the choice that ‘feels’ right to her. We professionals should then do our best to make this choice as safe as possible, while continuing to communicate any changes to the risk profile she initially accepted.
I deeply feel that women who want a caesarean section should be able to have one, without judgement or difficulty. I am reassured by our qualitative data in the OptiBreech study, that the breech specialist midwives and breech clinic obstetricians providing counselling are all doing it in a way where women feel they have genuine choices but are not pressured in one direction in another. Participants say this repeatedly and express how much they value this balanced counselling.
I also deeply feel that women who want to attempt a physiological breech birth should have the best possible support for that option. They should also feel their choice is supported without judgement, shame or pressure. Part of enabling women to make this choice involves enabling healthcare professionals to develop skills and work in ways that make ‘a vaginal breech birth with skilled and experienced support’ – which the RCOG guideline tells us should be nearly as safe as a cephalic birth – possible. This is a win-win situation. By supporting the women who WANT to plan a physiological breech birth well, we also increase our skill level to support those rare occasions when there is no choice available due to the rapid progress of an early or unplanned breech labour. When this occurs in the context of rigorously governed research, we can be even more confident that this learning will occur.
Sadly, this is not possible for most women in the UK. Every meeting of our OptiBreech Patient and Public Involvement (PPI) group involves talking through some amount of trauma. Our research team includes women who have sadly lost their babies to poor care and want to preserve the choice with BETTER care and women who have experienced severe complications from caesarean sections they did not want. But almost ALL members of our group, including partners, have expressed trauma from being repeatedly blocked, judged and unable to access skilled, supportive care for a vaginal breech birth. They have read national guidelines that said this should be an option, then found that their local health services had zero commitment to delivering this; they effectively had no choice.
On the other hand, our PPI group has been adamant that they do not want research to demonstrate vaginal breech birth is BEST. They want research to demonstrate what the actual, current risks are for all choices, and to show us how we can help all women make the choice that is right for them.
The vaginal breech birth skill set has remained largely static since the 1970’s, with ‘put the woman in an upright position’ being virtually the only innovation in breech care – until recently. It is as if we have been managing shoulder dystocia with only McRoberts and Gaskin manoeuvres – of course we would expect bad outcomes. (shoulder dystocia = where the baby’s shoulders become stuck in a head-first birth; McRoberts = pulling the woman’s legs back to her abdomen to create space in the pelvis; Gaskin = turning the woman to a hands/knees position)
Yet many professionals trying very hard to do the research we need to improve outcomes for breech babies are also exposed to the trauma of incivility and lack of respect. There is a particular power dynamic that exists between obstetricians and midwives that can make uncooperative behaviour threatening and dangerous – because the best outcomes for planned vaginal breech births are achieved when there are skilled, trusted care providers and a low threshold for using interventions (such as caesarean section) when they are needed. If you are afraid to refer to a person who has previously spoken to you harshly, publicly criticised you or outright refused to have anything to do with a physiological breech birth, this can introduce hesitation where there should be none. Some midwives have also found it difficult to maintain engagement with some women because being called to repeatedly justify women’s choices to colleagues is very emotionally draining, leading to avoidance behaviour. This is neither healthy, nor safe.
Multiple obstetricians who have tried to progress OptiBreech research have also experienced blocking, incivility, and general lack of respect. Discussions have been shut down before they begin. Junior doctors who want to learn the skills find they have no support to do this and remain silent. This has led to communication breakdowns and undermined safety at a time when we all need to be working at our best to learn and improve.
Do I think there is a place for physiological breech birth post-Ockenden? The demand for skilled breech care continues, and we are contacted each week from across the UK by women who are looking for support. In our OptiBreech project, there have been exemplars of healthy communication and excellent teamwork to achieve good outcomes for mothers and babies, and we are focusing on these as the way forward. I am grateful for the warm and respectful interactions I have with many of my colleagues; these sustain us all in our challenging everyday work. Examples of successful co-operation are especially valuable given the extreme pressures staff have been facing with chronic under-staffing and pandemic conditions. And our learning about how to support breech births well is accelerating at light speed as we share our experiences through constant reflection among OptiBreech leads at active sites. We will persist for as long as we can.
Enabling physiological breech birth, and research about how to make it safer, is NOT about promoting natural birth at all costs, nor about promoting natural birth at all. It is about placing the women who use our services at the centre of all we do, bringing our best to meet them where they are at and constantly striving for better. Which is, in my opinion, what the Ockenden Report calls us to do.
This blog is the personal opinion of Dr Shawn Walker and not the NIHR, King’s College London or any NHS institution.
