Shawn talks about some of the challenges of improving the way we deliver care for mothers and their breech babies.
Yesterday was International Day of the Midwife. I saw but didn’t participate in the social media celebrations. Not because I wasn’t feeling it, but because my clinical academic midwife life was full to the brim. 931 more words
In the OptiBreech Care pathway, women with a breech-presenting baby at the end of pregnancy receive care primarily from a midwife with enhanced training and proficiency (a Breech Specialist Midwife). This begins in a dedicated clinic, where they are offered three options from the start:
vaginal breech birth, supported by the specialist midwife or another member of the OptiBreech team;
an attempt to turn the baby head-down (external cephalic version, ECV), performed by someone who does >20 procedures per year; or
a planned caesarean delivery around 39 weeks.
When women choose to plan a vaginal breech birth, term births are supported by the specialist midwife or OptiBreech team member. Standard labour care is provided by either the caseload midwife or a member of staff on duty. The OptiBreech team is there as an additional layer of support. Their skills and experience enable all staff to learn breech skills with a ‘safety net.’ This minimises the variability in skills and attitudes towards breech birth by making sure we get the right people in the right place at the right time.
But breech care led by a specialist midwife is a significant departure from business as usual in UK maternity care, where care for all vaginal breech births has customarily fallen to the on-call obstetric staff. Understandably, some obstetric colleagues have requested clarification about their role and lines of responsibility. The purpose of this post is to answer some important questions based on the OptiBreech Care Trial protocol.
I do not have experience or training supporting upright breech births. Will I be responsible for managing upright breech births for women on the trial?
Good question — the answer is No. We hope to determine the safety profile of a physiological approach to breech births, which includes upright maternal positioning where the birthing person chooses this. In order to test this, we need to ensure that these births are attended by professionals who have both training and experience in physiological breech birth, the OptiBreech team. The protocol, which has received ethics approval and is insured by clinical trials insurance, specifies that the OptiBreech team member is considered the clinical lead at all OptiBreech births, up until either forceps or caesarean delivery is indicated and care handed over.
What if an OptiBreech team member is not available?
OptiBreech participant information and verbal advice given during breech choices counselling inform women that there is never a 100% guarantee that an OptiBreech team member will be available, due to the unpredictable nature of labour. In the OptiBreech 1 observational study, as of March 2022, we have achieved this >94% of the time. There is a very good chance both women and staff can depend on OptiBreech support.
However, on the occasions that this is not possible, the person would receive ‘standard care’ led by the on-call senior obstetrician on labour ward, just as any other woman who planned a vaginal breech birth outside of the study, or had a breech presentation diagnosed in labour, would receive.
If an OptiBreech member is leading care, am I required to be there?
Vaginal breech births are still at higher risk of an adverse outcome than cephalic births, regardless of the mode of delivery. Safety depends on the team being prepared for this. Although the rate of instrumental delivery is lower than with cephalic birth, forceps may be needed for the after coming head. And when needed, although most caesarean births occur for non-urgent reasons such as obstruction during the first stage of labour, others are more urgent. Therefore, the OptiBreech model is one in which the multi-disciplinary team (MDT) works closely together. The OptiBreech team takes responsibility for physiological breech birth where this remains within clearly specified safety parameters, communicates frequently, escalates promptly and hands over care when the birth requires assistance with forceps or surgery.
The Royal College of Obstetricians and Gynaecologists provides clear guidance about the Roles and responsibilities of the consultant providing acute care in obstetrics and gynaecology. This specifies a list of “Situations in which the consultant must ATTEND unless the most senior doctor present has documented evidence as being signed off as competent. In these situations, the senior doctor and the consultant should decide in advance if the consultant should be INFORMED prior to the senior doctor undertaking the procedure.” (p14) Vaginal breech birth is included in this list.
Our friends at OLVG Amsterdam have created a video to review the procedure for applying forceps to the aftercoming head, for those rare occasions that it may be required. At OptiBreech sites, we have also worked with Practice Development teams to ensure forceps are available during mandatory training exercises so that obstetric staff have an opportunity for simulation practice.
Ideally, unless the birthing person requests differently, we encourage a member of obstetric staff to be quietly present at all births. This makes for a more seamless transition should help be required. And it leads to greater understanding of physiological breech birth across the maternity care team.
What if an adverse outcome occurs on labour ward when I am the consultant on-call. Won’t I be held responsible for it?
The clinician leading care is responsible for what they did or did not do. As this is a clinical trial, there are several additional layers of clinical governance and clinical trials insurance, which enable us to test a new care process with as much safety as possible for all involved. If your assistance is needed, you can be expected that this will be escalated to you in a timely manner. If it is not, the OptiBreech team member is responsible for that.
In a physiological breech birth approach, the OptiBreech team members are obligated to follow clear guidance, which was co-created with the wider OptiBreech Collaborative of midwife and obstetrician clinicians delivering the study across the UK. Key features are:
use of the physiological breech birth algorithm to ensure the birth proceeds spontaneously or is assisted within a timeframe based on previous research — this means, if your assistance with forceps is requested, we expect this to occur well before the baby has become compromised;
regular reflective seminars to support and share learning occurring within the study. Your local PI can tell you how to access these.
Why don’t women want obstetricians to be involved?
They do! They very much do. Essentially, women who plan a vaginal breech birth want the same thing as women who plan a head-first birth. They want to labour in as calm and relaxed a way as possible, knowing that their midwifery team is remaining quietly vigilant. And they want the obstetric team to be there if complications arise.
Our qualitative interviews with women indicate that positive and supportive interactions with an obstetric consultant enhance women’s experience of breech pregnancy and birth. They especially value consultant obstetrician input within a dedicated breech clinic. The interviews indicate that women in the study are receiving detailed, balanced counselling from breech specialist midwives, including detailed information about complications and how these might need to be managed. When their interactions with a knowledgeable and supportive consultant obstetrician are ‘singing from the same hymn sheet,’ women feel confident that the team is aligned and able to assist them if required.
On the other hand, when they encounter any member of staff who expresses judgement of their choice, suggests they do not have a choice or provides imbalanced counselling that exaggerates the risks involved in vaginal birth, women understandably become distrustful, of that individual and of the ability of the team to work cohesively. Many also become distrustful of themselves and request a caesarean delivery they do not really want out of fear and shame. Some also remain at home in labour much longer than would be advised, or refuse to give birth on the obstetric unit. While we support women’s informed choices about place of birth, we feel the safest outcomes for all can be achieved by creating a safe and welcoming space for women to give birth with the support of the entire MDT close at hand.
Personally, I feel incredibly grateful to have enjoyed some truly and supportive collaborative relationships with obstetric colleagues. It has helped me recognise the value of this when it is in place, and the significant risk to safety when it is not.
I have further questions or concerns. How can I share them?
If you are an obstetrician at a site participating in the OptiBreech Trial, we are very keen to hear from you. It is important to the success of the trial that we listen and respond to the views of all stakeholders. But we can only do this if you share them with us.
Members of our research team who are not involved in delivering OptiBreech care conduct interviews with health care professionals at participating sites. The transcripts from these interviews are then anonymised, so no one is able to identify you or where you work. They are then analysed by the research team, who are not involved in delivering OptiBreech care themselves. You can register your willingness to provide feedback in this way by completing the Interest and Proficiency Survey (password:5minutes), ticking only the box for consent to interview. You will then be contacted by the research team, and your views will become part of trial’s overall feasibility assessment.
You can place a comment on this page, which would be part of the public discussion. We have also added a feedback form below, where you can send questions and/or concerns to the research team.
The local Breech Lead makes a plan for how they will provide care for this birth. Ideally, someone who meets all of the OptiBreech Proficiency Criteria will attend the birth. Where this is not possible, the team will do their best to have someone attend the birth who has completed OptiBreech training.
How will they do that?
In this setting, ensuring experienced support is straightforward. The hospital employs a Consultant Midwife with a special interest in breech birth. She meets all of the Proficiency Criteria, and part of her job role is to attend planned vaginal breech births. While she is not paid for additional time on call, her Head of Midwifery has authorised her to claim time back for any birth she attends outside of her normal working hours.
In order to make the service sustainable, the Consultant Midwife will support the clinical staff caring for the woman to gain experience. Her role is to provide an additional layer of OptiBreech support and safety. Where possible, she will seek to involve another member of the OptiBreech team. This is the group of colleagues who expressed an interest in providing OptiBreech care, through the OptiBreech Interest and Proficiency Survey.
What if the Consultant Midwife can’t make it to the birth?
The expectation is that, where possible, a member of the OptiBreech team will be present for all of second stage at a minimum. For planned breech births, there is usually at least a few hours warning, time enough to sort out who is available to attend. All women are informed that there is not an absolute guarantee, and assisted to think through what might happen if no skilled and experienced practitioner is available.
If the Consultant Midwife can’t make it, she will liaise with her colleagues to determine whether someone else on the OptiBreech team is available. If no other skilled and experienced member of staff who has completed OptiBreech training is available, the woman will be informed of this. She will be counselled by the consultant obstetrician on-call and decide if she would like to proceed with a vaginal breech birth or have a caesarean section, just as she would if she were planning a VBB outside of the study.
If this occurs, and nobody who has completed OptiBreech training is available to attend the birth, this will be recorded on the Case Report Form. The research team will be monitoring this closely so that we can give women an accurate idea of how well they can depend on their birth being attended by someone with OptiBreech training.
There is no ‘penalty’ if a participating site is not able to get someone with the OptiBreech training to the birth. Part of what our feasibility testing will determine is how often this occurs. Women in our PPI group expressed understanding that it may be hard for Trusts to guarantee attendance, especially in the early days, but that they appreciated the willingness to try.
What will happen during the birth?
The OptiBreech team member who attends will lead the birth but liaise closely with the on-call consultant obstetrician, as an additional layer of safety. The team will ensure that the Pro Forma is completed, documenting the care around the time of birth.
What will happen after the birth?
The local Principal Investigator will gather the data from the birth and enter it onto a Case Report Form. This will be securely returned to the research team.
If the woman has consented to a follow-up interview or long-term outcome collection, the research team will be in touch as appropriate.