Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field

Consensus-based recommendations for the care of women with a breech presenting fetus

OBJECTIVE

To establish consensus related to aspects of breech presentation and care.

DESIGN

A multinational, three round e-Delphi study.

PARTICIPANTS

A panel of 15 midwives, four obstetricians and an academic with knowledge and/or experience of caring for women with a breech presenting fetus.

METHODS

An initial survey of 45 open-ended questions. Answers were coded and amalgamated to form 448 statements in the second round and three additional statements in the third round. Panellists were asked to provide their level of agreement for each statement using a 5-point Likert scale. Consensus was deemed met if 70% of panellists responded with strongly agree to somewhat agree, or strongly disagree to somewhat disagree after the second round.

FINDINGS

Results led to the development of a consensus-based care pathway for women with a breech presenting fetus and a skills development framework for clinicians.

KEY CONCLUSIONS

A cultural shift is beginning to occur through the provision of physiological breech workshops offered by various organisations and may result in greater access to skilled and experienced clinicians for women desiring a vaginal breech birth, ultimately improving the safety of breech birth.

IMPLICATIONS FOR PRACTICES

The care pathway and skills development framework can be used by services wishing to make changes to their current practices related to breech presentation and increase the level of skill in their workforce.

Women's experiences with planned singleton upright breech birth - A phenomenological study

OBJECTIVE

To explore the experience of primi- and multiparous women with planned singleton upright breech births.

METHOD

We conducted face-to-face, in-depth interviews with five primiparous and five multiparous women who underwent a physiological breech birth at one hospital in Norway and analyzed the data using Giorgi's descriptive phenomenological method.

RESULTS

The phenomenon of women's experiences with physiological breech birth yielded four main constituents: "Mental preparedness and control", "The importance of shared decision-making and sufficient information", "Trust and the many 'faces' of birthing staff", and "'I actually did it!': Coping and control in the upright breech position". The significance of readiness, the influence of previous experiences and information, and the establishment of trust in midwives and gynecologists emerge as dominant themes. The sense of co-determination, control, and mastery is also highlighted.

CONCLUSIONS

Our findings underscore the pivotal role of personal attributes in fostering mental preparedness when confronted with unforeseen aspects of childbirth. Notably, women's experiences with upright breech birth vary; while some perceive it as an ideal birth, others find it more challenging. Factors such as unpreparedness, lack of information, diminished co-determination, and loss of control negatively impact birth experiences. This study's findings underscore the significance of tailoring maternity care to individual needs and improving information sharing. These measures are paramount for optimizing women's experience during upright breech births.

Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS)—an international multi-stakeholder Delphi study: study protocol

Background

Women pregnant with a breech-presenting foetus at term are at increased risk of adverse pregnancy outcomes. The most common intervention used to improve neonatal outcomes is planned delivery by caesarean section. But this is not always possible, and some women prefer to plan a vaginal birth. A number of providers have proposed alternative interventions, such as delivery protocols or specialist teams, but heterogeneity in reported outcomes and their measurements prevents meaningful comparisons. The aim of this paper is to present a protocol for a study to develop a Breech Core Outcome Set (Breech-COS) for studies evaluating the effectiveness of interventions to improve outcomes associated with term breech birth.

Methods

The development of a Breech-COS includes three phases. First, a systematic literature review will be conducted to identify outcomes previously used in effectiveness studies of breech birth at term. A focus group discussion will be conducted with the study’s pre-established Patient and Public Involvement (PPI) group, to enable service user perspectives on the results of the literature review to influence the design of the Delphi survey instrument. Second, an international Delphi survey will be conducted to prioritise outcomes for inclusion in the Breech-COS from the point of view of key stakeholders, including perinatal care providers and families who have experienced a term breech pregnancy. Finally, a consensus meeting will be held with stakeholders to ratify the Breech-COS and disseminate findings for application in future effectiveness studies.

Discussion

The expectation is that the Breech-COS will always be collected in all clinical trials, audits of practice and other forms of observation research that concern breech birth at term, along with other outcomes of interest. This will facilitate comparing, contrasting and combining studies with the ultimate goal of improved maternal and neonatal outcomes.

Trial registration

Core Outcome Measures in Effectiveness Trials (COMET) #1749

Women’s experiences of breech birth decision making: An integrated review

INTRODUCTION

Currently, caesarean section is the primary mode of birth for a breech presenting fetus, leading to a deskilling of clinicians and limitation of birth choices for women. The aim of this review is to present a synthesized summary of existing literature related to women’s experiences of breech birth mode decision-making.

METHODS

A systematic search of the literature was conducted in April 2021, utilizing five databases to identify and obtain peer-reviewed articles meeting the predetermined selection criteria.

RESULTS

Four major categories were synthesized from the integrated review: 1) Women who desire a vaginal birth may experience a range of negative emotions such as feelings of disempowerment, loss, uncertainty and a sense of isolation; 2) Women who experience a breech presentation at term experience significant pressures to conform to expectations of medical professionals and their families due to perceptions of risk related to breech birth; 3) Breech birth decision-making in a limiting system; and 4) Overall satisfaction with the decision to plan a vaginal breech birth.

CONCLUSION

Women with a breech presenting fetus at term experience a complex range of emotions and internal and external pressures due to perceptions of risk around breech birth. Midwives were seen as helpful throughout the breech experience. The reduced caesarean section rate for breech, observed in studies exploring specialized care pathways or dedicated services, could reduce the incidence of Severe Acute Maternal Morbidity.

Women's Selection of Mode of Birth for their Breech Presentation

OBJECTIVE

Many studies since the Term Breech Trial have demonstrated the safety of vaginal breech birth (VBB), and today it is an option for breech presentation at term. However, women with breech presentation often face a difficult decision regarding mode of birth, especially when planned cesarean was the standard of care in the not-so-distant past. We aim to clarify the decision-making process and barriers women face when making this decision.

METHODS

Between January and April 2016, women who delivered with breech presentation were approached during their postpartum hospital stay to obtain consent for the study. The follow-up, semi-structured interview probed the woman's acquisition of knowledge and supports and barriers to her choices leading up to delivery. The responses were recorded and transcribed for analysis, and themes were identified for reporting.

RESULTS

Of the 95 women who completed the interview, 21 preferred VBB but only 1 had a VBB. Most unplanned cesarean deliveries were performed for obstetrical indications, but 5 women expressed a lack of support for VBB or did not recall being provided options. Themes were identified with respect to the influences the women experienced, including passive external, provider-based, evidence-based, and internal.

CONCLUSION

Despite the availability of options for breech pregnancy, the majority of women continue to have planned cesarean deliveries. The retrospective process reveals that women did not fully understand the eligibility criteria for VBB and all available options (including external cephalic version). Shared decision-making and continuity of care should remain a priority during the counselling process and delivery of care.

Endocrine Cephalic Phase Responses to Food Cues: A Systematic Review

Cephalic phase responses (CPRs) are conditioned anticipatory physiological responses to food cues. They occur before nutrient absorption and are hypothesized to be important for satiation and glucose homeostasis. Cephalic phase insulin responses (CPIRs) and pancreatic polypeptide responses (CPPPRs) are found consistently in animals, but human literature is inconclusive. We performed a systematic review of human studies to determine the magnitude and onset time of these CPRs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to develop a search strategy. The terms included in the search strategy were cephalic or hormone response or endocrine response combined with insulin and pancreatic polypeptide (PP). The following databases were searched: Scopus (Elsevier), Science Direct, PubMed, Google Scholar, and The Cochrane Library. Initially, 582 original research articles were found, 50 were included for analysis. An insulin increase (≥1μIU/mL) was observed in 41% of the treatments (total n = 119). In 22% of all treatments the increase was significant from baseline. The median (IQR) insulin increase was 2.5 (1.6-4.5) μIU/mL, 30% above baseline at 5± 3 min  after food cue onset (based on study treatments that induced ≥1 μIU/mL insulin increase). A PP increase (>10 pg/mL) was found in 48% of the treatments (total n = 42). In 21% of the treatments, the increase was significant from baseline. The median (IQR) PP increase was 99 (26-156) pg/mL, 68% above baseline at 9± 4 min  after food cue onset (based on study treatments that induced ≥1 μIU/mL insulin increase). In conclusion, CPIRs are small compared with spontaneous fluctuations. Although CPPPRs are of a larger magnitude, both show substantial variation in magnitude and onset time. We found little evidence for CPIR or CPPPR affecting functional outcomes, that is, satiation and glucose homeostasis. Therefore, CPRs do not seem to be biologically meaningful in daily life.

Face-to-pubes rotational maneuver for bilateral nuchal arms in a vaginal breech birth, resolved in an upright maternal position: A case report

BACKGROUND

A physiological breech birth is one in which the woman is encouraged to remain active throughout her labor and able to assume the position of her choice for the birth. Use of this strategy within the United Kingdom National Health Service has led to the use of innovative maneuvers to relieve obstruction when women give birth in upright positions, for example, kneeling or standing. This includes use of the face-to-pubes rotational maneuver to relieve extended nuchal arm(s). In this paper, we report a case where the face-to-pubes rotational maneuver was used to relieve bilateral nuchal arm entrapment in a breech birth.

METHODS

Single-case study. We aimed to generate an in-depth understanding of how this maneuver works and how professionals decide to use it by exploring its use in a real-life context.

RESULTS

The face-to-pubes rotational maneuver appears to be an effective method of relieving nuchal arm entrapment when used by experienced hands. In cases of bilateral nuchal arm entrapment, elevation to a higher station may be necessary to dis-impact the arms above the pelvic inlet before the fetus can be rotated. After face-to-pubes rotation and release of arms, the head should be realigned in an occiput anterior position for delivery.

CONCLUSION

The face-to-pubes rotational maneuver can be taught for resolution of nuchal arms in an upright position. Parents should be informed of the availability or not of a specialist midwife trained in physiological breech birth, as this may be important to their decision-making.

Conceptual and ethical problems underpinning calls to abandon vaginal breech birth

The view that vaginal breech birth is unjustifiable due to neonatal safety concerns has resulted in continued calls for breech pregnancies to be managed via a policy of planned caesarean birth. Vaginal breech birth has of course always occurred, but women with term breech pregnancies who seek to have a vaginal birth often face coercive pressures to have a caesarean birth instead. In this paper I argue that even if there is population level evidence that vaginal birth is relatively riskier for the breech presenting fetus, implementing a policy of planned caesarean birth would essentially be an unjustified attempt at forced medical intervention upon women. Advocates of a policy of planned caesarean birth often conflate the acceptability of allocating participants to a treatment group (policy) within the context of a randomized controlled trial with the justifiability of doing that as part of individual health care. Calls for obstetricians to "abandon vaginal breech birth" mistakenly position vaginal breech birth itself as a form of medical intervention that can simply be removed as an option for women by obstetricians. In reality, abandoning vaginal breech birth would entail abandoning women by denying them access to healthcare options that are otherwise available to any woman having a vaginal birth.

A quantitative investigation into women's basic beliefs about birth and planned birth choices

OBJECTIVE

Perceptions about the nature of the birth process are important in determining women's birth choices regarding labour and delivery but are scarcely the subject of empirical research. The aim of the current study was to assess women's beliefs about birth as a natural and safe or medical and risky process and study the associations of these beliefs with fear of childbirth and planned birth choices.

DESIGN

An observational study using self-administered questionnaires during pregnancy.

SETTING

1. Community women's health centres in a metropolitan area in Israel; 2. Purposeful sampling of women who plan to birth naturally, through home midwives and targeted internet forums.

PARTICIPANTS

746 women with a singleton pregnancy in their second and third trimester.

MEASUREMENTS

Beliefs about birth as a natural and a medical process, fear of childbirth, and a range of natural birth choices.

FINDINGS

The birth beliefs were associated with women's birth intentions. The more women believed birth to be natural and the less they believed it to be medical, the more likely they were to make more natural birth-related choices. In the presence of the birth beliefs, fear of childbirth no longer had an independent association with birth choices. The beliefs interacted with each other, revealing a stronger association of viewing birth as natural with planning more natural choices among women who did not view birth as very medical.

KEY CONCLUSION

It is important to recognize women's beliefs about birth and how they may affect their fear of childbirth and birth intentions. Further studies on the origin of such beliefs and their development are needed.

IMPLICATIONS FOR PRACTICE

Women should be allowed to choose how they would like to birth in accordance with their beliefs. At the same time, strengthening women's belief in the natural birth process and their body's ability to perform it, could help lower fear of childbirth and medical intervention rates.

This baby is not for turning: Women's experiences of attempted external cephalic version

BACKGROUND

Existing studies regarding women's experiences surrounding an External Cephalic Version (ECV) report on women who have a persistent breech post ECV and give birth by caesarean section, or on women who had successful ECVs and plan for a vaginal birth. There is a paucity of understanding about the experience of women who attempt an ECV then plan a vaginal breech birth when their baby remains breech. The aim of this study was to examine women's experience of an ECV which resulted in a persistent breech presentation.

METHODS

A qualitative descriptive exploratory design was undertaken. In-depth semi-structured interviews were conducted and analysed thematically.

RESULTS

Twenty two (n = 22) women who attempted an ECV and subsequently planned a vaginal breech birth participated. Twelve women had a vaginal breech birth (55 %) and 10 (45 %) gave birth by caesarean section. In relation to the ECV, there were five main themes identified: 'seeking an alternative', 'needing information', 'recounting the ECV experience', 'reacting to the unsuccessful ECV' and, 'reflecting on the value of an ECV'.

CONCLUSIONS

ECV should form part of a range of options provided to women, rather than a default procedure for management of the term breech. For motivated women who fit the safe criteria for vaginal breech birth, not being subjected to a painful experience (ECV) may be optimal. Women should be supported to access services that support vaginal breech birth if this is their choice, and continuity of care should be standard practice.