Midwives’ views, experiences and feelings of confidence surrounding vaginal breech birth: A qualitative study

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.

Advanced midwifery practice: A scoping review

PROBLEM

There is no international standard for advanced midwifery scope of practice.

BACKGROUND

Globally, there is variance in how scope of midwifery practice is determined and regulated, with no consensus on extended or advanced scope. This can lead to under-utilised staff potential, un-met consumer need, and loss of professional skill.

AIMS

The aim of this scoping review was to synthesise and map what is reported in the international literature on the advanced scope of midwifery practice.

METHODS

A systematic scoping review methodology was adopted utilising Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A full search was conducted of databases including MEDLINE, CINAHL, Scopus, Google. Publications from 2019 to August 2022 that met criteria were included. Reported skills were mapped to the International Confederation of Midwives (ICM) competencies of pre-conception, antenatal, labour and birth, postnatal plus globally identified areas for midwifery investment.

FINDINGS

28 articles met inclusion criteria. Reported skills included abortion care (n = 6), prescribing (n = 7), ultrasound (n = 2), advanced practice skills (n = 7), midwifery-led skills, primary health, post-graduate education, HIV/AIDS testing, advocacy, and acupressure (all n = 1).

DISCUSSION

This review presents a synopsis of publications describing what has been defined as advanced midwifery scope of practice in international contexts.

CONCLUSION

Establishing evidence of midwives working to the peak of professional scope is important to continue to develop professional capacity and support contemporary practice, regulation, governance, and policy while improving consumer access to equitable care. Findings aid service development, provision, and professional planning.

What are women's experiences of seeking to plan a vaginal breech birth? A systematic review and qualitative meta-synthesis

Background

Guidelines for breech management at term emphasise choice and informed decision-making. Despite this, the choice of vaginal breech birth (VBB), is not always available or accessible. We aimed to describe the experiences of women seeking a VBB as reported in primary research and to offer strategies for improving this experience that are grounded in evidence.

Methods

We conducted a systematic review and qualitative meta-synthesis of the results, using grounded theory analysis methods (PROSPERO registration CRD42021262380), with literature published between January 2000 and February 2022. Seven databases were searched. Our review included literature about women with breech presentation, who sought a planned or unplanned VBB. Studies considering only experiences of alternative management (e.g. caesarean, external cephalic version), and those investigating healthcare workers' experiences were excluded. Covidence systematic review software was used for screening and quality assessment. Qualitative data were extracted using NVivo software (20.5.0). Data were analysed through an iterative process based on constant comparison methods, with an iterative and reflexive code generation process. Codes were then arranged into 'categories of experience', which gave rise to over-arching themes.

Results

Our review included 19 studies. We present one overarching theory: 'Women who wish to plan a vaginal breech birth seek connected autonomy'. Our schematic, depicting this theory, includes seven main categories of experience: paternalistic healthcare; emotional turmoil; judgement and self-doubt; mother vs society: refusing to conform; isolated but united by breech; welcomed direction; and supported self-determination and self-efficacy.

Conclusions

Women seeking to plan a VBB feel vulnerable and wish to connect with capable and confident healthcare providers. To meet their needs, services should be designed so that they can connect with clinicians who are willing and able to support their autonomy. Services should also seek to limit their exposure to disrespectful and judgemental interactions with healthcare providers.

Factors associated with birth asphyxia among term singleton births at two referral hospitals in Northern Uganda: a cross sectional study

Background

Birth asphyxia is one of the leading causes of neonatal mortality worldwide. In Uganda, it accounts for 28.9% of all neonatal deaths. With a view to inform policy and practice interventions to reduce adverse neonatal outcomes, we aimed to determine the prevalence and factors associated with birth asphyxia at two referral hospitals in Northern Uganda.

Methods

This was a cross-sectional study, involving women who gave birth at two referral hospitals. Women in labour were consecutively enrolled by the research assistants, who also attended the births and determined Apgar scores. Data on socio-demographic characteristics, pregnancy history and care during labour, were obtained using a structured questionnaire. Participants were tested for; i) malaria (peripheral and placental blood samples), ii) syphilis, iii) white blood cell counts (WBC), and iv) haemoglobin levels. The prevalence of birth asphyxia was determined as the number of newborns with Apgar scores < 7 at 5 min out of the total population of study participants. Factors independently associated with birth asphyxia were determined using multivariable logistic regression analysis and a p-value < 0.05 was considered statistically significant.

Results

A total of 2,930 mother-newborn pairs were included, and the prevalence of birth asphyxia was 154 [5.3% (95% confidence interval: 4.5- 6.1)]. Factors associated with birth asphyxia were; maternal age ≤ 19 years [adjusted odds ratio (aOR) 1.92 (1.27–2.91)], syphilis infection [aOR 2.45(1.08–5.57)], and a high white blood cell count [aOR 2.26 (1.26–4.06)], while employment [aOR 0.43 (0.22–0.83)] was protective. Additionally, referral [aOR1.75 (1.10–2.79)], induction/augmentation of labour [aOR 2.70 (1.62–4.50)], prolonged labour [aOR 1.88 (1.25–2.83)], obstructed labour [aOR 3.40 (1.70–6.83)], malpresentation/ malposition [aOR 3.00 (1.44–6.27)] and assisted vaginal delivery [aOR 5.54 (2.30–13.30)] were associated with birth asphyxia. Male newborns [aOR 1.92 (1.28–2.88)] and those with a low birth weight [aOR 2.20 (1.07–4.50)], were also more likely to develop birth asphyxia.

Conclusion

The prevalence of birth asphyxia was 5.3%. In addition to the known intrapartum complications, teenage motherhood, syphilis and a raised white blood cell count were associated with birth asphyxia. This indicates that for sustained reduction of birth asphyxia, appropriate management of maternal infections and improved intrapartum quality of care are essential.

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.

Physiological breech birth training: An evaluation of clinical practice changes after a one-day training program

BACKGROUND

The "physiological breech birth" one-day training program is based on evidence about the physiology of breech births and how clinicians learn breech skills. Previous evaluations have demonstrated positive effects on confidence and knowledge, but the training's effect on clinical practice and outcomes is unknown.

METHODS

A mixed-methods evaluation was conducted in eight National Health Service hospitals in England and Northern Ireland. Changes in confidence and knowledge were assessed using pretraining and post-training surveys. Mode of birth and maternal birth positions were evaluated using audit data covering one year before the training and one year after, for all singleton vaginal breech births at term.

FINDINGS

A total of 263 participants completed the surveys. Confidence in managing breech births in both upright and supine positions significantly increased, as did participant knowledge. Audited data for 1402 women were collected. Overall vaginal birth rates remained similar in both periods. Among singleton vaginal breech births >37 weeks, the use of upright birthing positions increased significantly (P = .002). The study was not powered to detect differences in other outcomes, but pilot data were collected to inform the design of future studies.

CONCLUSIONS

Increase in use of upright birthing positions suggests that physiological breech birth training is likely to lead to clinical practice changes, which may help support maternal choice in line with current guidance. However, provision of a one-day training program did not change overall vaginal breech birth rates. Adequately powered research is needed to determine effects of clinical practice changes on clinical outcomes.

Breech presentation management: A critical review of leading clinical practice guidelines

PROBLEM

Clinical practice guidelines are designed to guide clinicians and consumers of maternity services in clinical decision making, but recommendations are often consensus based and differ greatly between leading organisations.

BACKGROUND

Breech birth is a divisive clinical issue, however vaginal breech births continue to occur despite a globally high caesarean section rate for breech presenting fetuses. Inconsistencies are known to exist between clinical practice guidelines relating to the management of breech presentation.

AIM

The aim of this review was to critically evaluate and compare leading obstetric clinical practice guidelines related to the management of breech presenting fetuses.

METHODS

Leading obstetric guidelines were purposively obtained for review. Analysis was conducted using the International Centre for Allied Health Evidence (iCAHE) Guideline Quality Checklist and reviewing the content of each guideline.

FINDINGS

Antenatal care recommendations and indications for Caesarean Section were relatively consistent between clinical guidelines. However, several inconsistencies were found among the other recommendations in terms of birth mode counselling, intrapartum management and the basis for recommendations.

DISCUSSION

Inconsistencies noted in the clinical practice guidelines have the potential to cause issues related to valid consent and create confusion among clinicians and maternity consumers.

CONCLUSION

Clinical practice guidelines, which focus on the risks of a Vaginal Breech Birth without also discussing the risks of a Caesarean Section when a breech presentation is diagnosed, has the potential to sway clinician attitudes and impact birth mode decision-making in maternity consumers. To respect pregnant women's autonomy and fulfil the legal requirements of consent, clinicians should provide balanced counselling.