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Schafer R, Bovbjerg ML, Cheyney M, Phillippi JC. Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study. PLoS One 2024; 19:e0305587. [PMID: 39037977 PMCID: PMC11262641 DOI: 10.1371/journal.pone.0305587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 06/01/2024] [Indexed: 07/24/2024] Open
Abstract
OBJECTIVE Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling). DESIGN Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats). SETTING Planned community birth (homes and birth centers), United States. SAMPLE Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset. METHODS Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes. MAIN OUTCOME MEASURES Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death. RESULTS One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after congenital anomalies were excluded. CONCLUSIONS All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.
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Affiliation(s)
- Robyn Schafer
- Division of Advanced Nursing Practice, School of Nursing, Rutgers University, Newark, NJ, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States of America
| | - Marit L. Bovbjerg
- Epidemiology Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States of America
| | - Melissa Cheyney
- Department of Anthropology, Oregon State University, Corvallis, OR, United States of America
| | - Julia C. Phillippi
- School of Nursing, Vanderbilt University, Nashville, TN, United States of America
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Schafer R, Dietrich MS, Kennedy HP, Mulvaney S, Phillippi JC. "I had no choice": A mixed-methods study on access to care for vaginal breech birth. Birth 2024; 51:413-423. [PMID: 37968839 DOI: 10.1111/birt.12797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth. METHODS We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care. RESULTS Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system. CONCLUSION Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.
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Affiliation(s)
- Robyn Schafer
- Division of Advanced Nursing Practice, School of Nursing, Rutgers University, Newark, New Jersey, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Mary S Dietrich
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | | | - Shelagh Mulvaney
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
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Morris S, Geraghty S, Sundin D. Consensus-based recommendations for the care of women with a breech presenting fetus. Midwifery 2024; 130:103916. [PMID: 38241800 DOI: 10.1016/j.midw.2024.103916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 10/31/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024]
Abstract
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.
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Affiliation(s)
- Sara Morris
- Lecturer at Edith Cowan University, Clinical Nurse Midwife at King Edward Memorial Hospital, Western Australia.
| | - Sadie Geraghty
- Head of Midwifery at Notre Dame University, Western Australia
| | - Deborah Sundin
- Senior Lecturer at Edith Cowan University, Western Australia
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Lindtveit T, Malin Skeie C, Oommen HL, Eline Ween-Velken M, Sandhaug Nygaard B, Røseth I. Women's experiences with planned singleton upright breech birth - A phenomenological study. SEXUAL & REPRODUCTIVE HEALTHCARE 2024; 39:100952. [PMID: 38341936 DOI: 10.1016/j.srhc.2024.100952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024]
Abstract
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.
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Affiliation(s)
- Tone Lindtveit
- Centre for Women's, Family and Child Health, Faculty of Health and Social Sciences, University of South-Eastern Norway (USN), Post office box 4, 3199 Borre, Norway
| | - Connie Malin Skeie
- Centre for Women's, Family and Child Health, Faculty of Health and Social Sciences, University of South-Eastern Norway (USN), Post office box 4, 3199 Borre, Norway
| | - Hanna-Leena Oommen
- Centre for Women's, Family and Child Health, Faculty of Health and Social Sciences, University of South-Eastern Norway (USN), Post office box 4, 3199 Borre, Norway; Department of Obstetrics and Gynecology, Sørlandet Hospital Kristiansand, Kristiansand, Norway
| | - Marte Eline Ween-Velken
- Department of Obstetrics and Gynecology, Sørlandet Hospital Kristiansand, Kristiansand, Norway
| | | | - Idun Røseth
- Centre for Women's, Family and Child Health, Faculty of Health and Social Sciences, University of South-Eastern Norway (USN), Post office box 4, 3199 Borre, Norway; Department of child and adolescent mental health, Telemark Hospital Trust, PO Box 2900 Kjørbekk, 3710 Skien, Norway.
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Walker S, Spillane E, Stringer K, Trepte L, Davies SM, Bresson J, Sandall J, Shennan A. OptiBreech collaborative care versus standard care for women with a breech-presenting fetus at term: A pilot parallel group randomised trial to evaluate the feasibility of a randomised trial nested within a cohort. PLoS One 2023; 18:e0294139. [PMID: 37967120 PMCID: PMC10650999 DOI: 10.1371/journal.pone.0294139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 10/18/2023] [Indexed: 11/17/2023] Open
Abstract
OptiBreech collaborative care is a multi-disciplinary care pathway for breech presentation at term, with continuity from a breech specialist midwife, including where chosen, for vaginal breech birth (VBB). Pilot randomised trial using unblinded 1:1 parallel group allocation to OptiBreech versus standard care, within a cohort. Participants were women with a breech-presenting fetus > 33 weeks, at four sites in England, January-June 2022. A two-stage consent process was used. Participants consented to undergo random selection to be offered a 'new care process', with a choice to accept it, or not. Primary objectives were to identify recruitment, acceptance, and attrition rates. Randomisation procedures and potential primary outcomes for a substantive study were also feasibility-tested. 68 women were randomised between January-June 2022. The consent process was acceptable to participants, but randomisation was unacceptable to women who specifically sought OptiBreech care. Two women withdrew due to concerns about sharing personal information. More women planned a VBB when randomised to OptiBreech Care (23.5% vs 0, p = .002, 95% CI = 9.3%,37.8%). Women randomised to OptiBreech care had: lower rates of cephalic presentation at birth (38.2% vs 54.5%), higher rates of vaginal birth (32.4% vs 24.2%), lower rates of in-labour caesarean birth (20.6% vs 36.4%), lower rates of neonatal intensive care (5.9% vs 9.1%), and lower rates of severe neonatal morbidity (2.9% vs 9.1%). Randomisation was stopped on the advice of the steering committee before the planned sample of 104, as lack of access to VBB within standard care prohibited comparison of outcomes. Demand for VBB is sufficient for a cohort study, but comparison of outcomes by 1:1 randomisation is not feasible. OptiBreech care would be best evaluated using stepped wedge cluster randomisation. Funded by the United Kingdom National Institute for Health and Care Research (NIHR300582). Clinical trial registration: ISRCTN 14521381.
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Affiliation(s)
- Shawn Walker
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
- Women’s and Children’s Services, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Emma Spillane
- Kingston Maternity, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, Surrey, United Kingdom
| | - Kate Stringer
- Women’s Services, Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, United Kingdom
| | - Lauren Trepte
- Women’s and Children’s Services, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Siân M. Davies
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Jacana Bresson
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Jane Sandall
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Andrew Shennan
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
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Dasgupta T, Hunter S, Reid S, Sandall J, Shennan A, Davies SM, Walker S. Breech specialist midwives and clinics in the OptiBreech Trial feasibility study: An implementation process evaluation. Birth 2023; 50:596-605. [PMID: 36288483 DOI: 10.1111/birt.12685] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/03/2022] [Accepted: 10/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Attendance of skilled and experienced professionals at breech births has been associated with a reduction in adverse perinatal outcomes. We aimed to determine whether United Kingdom National Health Service (NHS) sites could reliably provide attendants with OptiBreech training and/or advanced proficiency (intervention feasibility) and consistent care (fidelity) that meets women's needs (acceptability), with low neonatal admission rates (safety) and recruitment adequate to support a clinical trial (trial feasibility). METHODS Mixed methods implementation evaluation was used. Settings were 13 services in England and Wales. Participants were 82 women requesting support for a vaginal breech birth (VBB) at term. Outcomes were descriptively analyzed. Twenty-one women were interviewed, and transcripts were analyzed using the Theoretical Framework of Acceptability. Iterative analysis informed subsequent interviews and the ongoing process of implementation across sites. RESULTS Although we initially suggested multidisciplinary teams, actively recruiting Trusts yielded services where VBB care was provided through a dedicated clinic, organized and delivered primarily by a lead midwife who functioned as a specialist. This model achieved 87.5% fidelity with the intervention's goal of ensuring the attendance of OptiBreech-trained professionals. Neonatal outcomes remained stable, with an admission rate of 5.5%. Women reported care from specialist midwives as highly acceptable, but the model is vulnerable without a strategic effort to develop additional proficient team members. CONCLUSIONS Dedicated clinics coordinated by specialist midwives appear to be an acceptable and feasible implementation strategy to test the safety and effectiveness of proficient team care for VBB in a clinical trial. Back-up arrangements should be maintained while additional members of the team develop proficiency.
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Affiliation(s)
- Tisha Dasgupta
- Department of Women & Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Sarah Hunter
- Department of Women & Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
- Independent Lay Members of the Research Team, Peterborough, UK
| | - Sharna Reid
- Department of Women & Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
- Independent Lay Members of the Research Team, London, UK
| | - Jane Sandall
- Department of Women & Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Andrew Shennan
- Department of Women & Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Siân M Davies
- Department of Women & Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Shawn Walker
- Department of Women & Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, Women's and Children's Services, London, UK
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Bresson J, Christie K, Walker S. Not too fast, not too slow: A review of historical trends in vaginal breech time management. Eur J Obstet Gynecol Reprod Biol 2023; 287:216-220. [PMID: 37390754 DOI: 10.1016/j.ejogrb.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 07/02/2023]
Abstract
PROBLEM A lack of consistent professional guidance on when to intervene during emergence (buttocks and anus visible at the introitus to birth of the head) in vaginal breech birth (VBB). BACKGROUND Hypoxia and asphyxia are common complications of VBB, especially due to umbilical cord compression around the time of emergence. AIM To gain insight into VBB time management trends, the evidence behind these practices and how they may have influenced outcomes. METHODS Literature review of obstetric textbooks published between 1960 and 2000 contained in the Wellcome Collection and Royal College of Obstetricians and Gynaecologists Library in London. FINDINGS 90 textbooks were reviewed. Recommendations for 'safe' intervals between birth of the umbilicus and the head ranged from 5 to 20 min. Many sources focused only on the time required to deliver the head, with 'up to 10 min' being the most common interval described. The review found no mention of cord compression causing concern earlier in breech births than once the umbilicus itself is delivered, nor any evidence to support the recommendations. DISCUSSION These findings demonstrate a long-term pattern across the second half of the 20th century, whereby birth attendants were urged not to rush emergence nor delay intervention but were given little clear guidance on optimal timings. CONCLUSION Clear, evidence-based guidance should be provided in breech training materials to avoid unnecessary hypoxic injuries, and this guidance should be rigorously evaluated.
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Affiliation(s)
- Jacana Bresson
- Faculty of Nursing, Midwifery and Palliative Care, King's College London. 57 Waterloo Road, London SE1 8WA, United Kingdom.
| | - Keelie Christie
- School of Healthcare, University of Leicester, University Road, Leicester LE1 7RH, United Kingdom
| | - Shawn Walker
- Department of Women & Children's Health, School of Life Sciences, King's College London. 57 Waterloo Road, London SE1 8WA, United Kingdom
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Walker S, Spillane E, Stringer K, Meadowcroft A, Dasgupta T, Davies SM, Sandall J, Shennan A. The feasibility of team care for women seeking to plan a vaginal breech birth (OptiBreech 1): an observational implementation feasibility study in preparation for a pilot trial. Pilot Feasibility Stud 2023; 9:80. [PMID: 37173798 PMCID: PMC10175899 DOI: 10.1186/s40814-023-01299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/10/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND OptiBreech Care is a care pathway for breech presentation at term, including where chosen, physiological breech birth attended by professionals with advanced training and/or proficiency. We aimed to assess the feasibility of implementing OptiBreech team care prior to proceeding with a planned pilot randomised controlled trial. METHODS Our design was an observational implementation feasibility assessment across England and Wales, January 2021-June 2022. Our objectives were to determine whether Trusts could provide attendants with advanced training (implementation feasibility), who deliver protocol-consistent care (fidelity), within existing resources (costs), while maintaining low neonatal admission rates (safety) and adequate recruitment rates (trial feasibility). Participants included women > 37 weeks pregnant with a breech-presenting foetus, requesting support for a vaginal breech birth following standard counselling, and staff involved in the study. No randomisation occurred in this first stage of feasibility work. RESULTS Thirteen National Health Service sites were recruited. A total of 82 women planned births in the study. Sites with a breech specialist midwife recruited at double the rate of sites without (0.90/month, 95% CI 0.64-1.16 vs 0.40, 95% CI 0.12-0.68). Referrals into the study came from midwives (46%), obstetricians (34%) and women themselves (20%). Vaginal births were attended by staff with OptiBreech training at 87.5% (35/40, 95% CI 0.732-0.958) and by staff who met additional proficiency criteria at 67.5% (27/40, 95% CI 0.509-0.814). Fidelity criteria were more consistently met by staff who also met proficiency criteria. There were four neonatal admissions (4.9%, 4/82), including one serious adverse outcome (1.2%, 1/82). CONCLUSIONS A prospective observational cohort of OptiBreech collaborative care, which could potentially support nested or cluster randomisation, appears feasible in sites willing to establish a dedicated clinic and strategically develop further proficient members of staff, with back-up plans for supporting rapidly progressing births. Randomisation procedures remain to be feasibility tested. It is funded by the NIHR (NIHR300582).
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Affiliation(s)
- Shawn Walker
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK.
- Women's and Children's Services, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Rd, London, SW10 9NH, UK.
| | - Emma Spillane
- Kingston Hospital NHS Foundation Trust, Galsworthy Road, Surrey, Kingston upon Thames, KT2 7QB, UK
| | - Kate Stringer
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH, UK
| | - Amy Meadowcroft
- Northern Care Alliance NHS Foundation Trust, Royal Oldham Hospital, Rochdale Road, Oldham, Greater Manchester, OL1 2JH, UK
| | - Tisha Dasgupta
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK
| | - Siân M Davies
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK
| | - Jane Sandall
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK
| | - Andrew Shennan
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK
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Mattiolo S, Spillane E, Walker S. Physiological breech birth training: An evaluation of clinical practice changes after a one-day training program. Birth 2021; 48:558-565. [PMID: 34160107 DOI: 10.1111/birt.12562] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 05/22/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Stella Mattiolo
- Women's and Children's Health, Epsom and St Helier University Hospitals, Epsom, UK
| | - Emma Spillane
- Kingston Hospital NHS Foundation Trust, Kingston, UK
| | - Shawn Walker
- Women and Children's Health, King's College London, London, UK.,Chelsea and Westminster Hospitals NHS Foundation Trust, London, UK
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Morris S, Geraghty S, Sundin D. Development of a Breech-Specific Integrated Care Pathway for Pregnant Women: Protocol for a Mixed Methods Study. JMIR Res Protoc 2021; 10:e23514. [PMID: 33620329 PMCID: PMC7943339 DOI: 10.2196/23514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/29/2020] [Accepted: 01/19/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The development of an integrated care pathway with multidisciplinary input to standardize and streamline care for pregnant women experiencing breech presentation at 36 or more weeks of gestation poses several challenges because of the divisive and contentious nature of the phenomenon. Although many clinicians are interested in obtaining the skills required to safely support women desiring a vaginal breech birth, the primary trend in most health care facilities is to recommend a cesarean section. OBJECTIVE This paper aims to discuss the mixed methods approach used in a doctoral study conducted to generate new knowledge regarding women's experiences of breech birth in Western Australia and professional recommendations regarding the care of women experiencing breech presentation close to or at term. This study was designed to inform the development of an integrated care pathway for women experiencing a breech presentation. This mixed methods approach situated within the pragmatic paradigm was determined to be the optimal way for incorporating multidisciplinary recommendations with current clinical practice guidelines and consumer feedback. METHODS A mixed methods study utilizing semistructured interviews, an electronic Delphi (e-Delphi) study, and clinical practice guideline appraisal was conducted to generate new data. The interviews were designed to provide insights and understanding of the experiences of women in Western Australia who are diagnosed with a breech presentation. The e-Delphi study explored childbirth professionals' knowledge, opinions, and recommendations for the care of women experiencing breech presentation close to or at term. The clinical practice guideline appraisal will examine the current national and professional breech management and care guidelines. This study has the potential to highlight areas in practice that may need improvement and enable clinicians to better support women through what can be a difficult time. RESULTS Data collection for this study began in November 2018 and concluded in March 2020. Data analysis is currently taking place, and the results will be disseminated through publication when the analysis is complete. CONCLUSIONS The results of this study will guide the development of an integrated care pathway for women experiencing a breech presentation close to or at term, with the hope of moving toward standardized breech care for women in Western Australia. This study protocol has the potential to be used as a research framework for future studies of a similar nature. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/23514.
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Affiliation(s)
- Sara Morris
- King Edward Memorial Hospital, Subiaco, Australia.,Edith Cowan University, Joondalup, Australia
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Walker S, Spillane E. Face-to-pubes rotational maneuver for bilateral nuchal arms in a vaginal breech birth, resolved in an upright maternal position: A case report. Birth 2020; 47:246-252. [PMID: 32128883 DOI: 10.1111/birt.12486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Shawn Walker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,Consultant Breech Specialist Midwife, Women's and Children's Services, St Thomas' Hospital, London, UK
| | - Emma Spillane
- Birth Centre Lead and Breech Specialist Midwife, Maternity Services, St George's University Hospitals NHS Foundation Trust, London, UK
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12
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Reitter A, Halliday A, Walker S. Practical insight into upright breech birth from birth videos: A structured analysis. Birth 2020; 47:211-219. [PMID: 31960492 PMCID: PMC7318698 DOI: 10.1111/birt.12480] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/22/2019] [Accepted: 12/23/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND We aimed to identify common features of upright vaginal breech births with good outcomes to refine a physiological approach to teaching breech birth. METHODS We performed a structured analysis of 42 videos of successful upright breech births (eg, kneeling, hand/knees), facilitated by obstetricians (n = 34) and midwives (n = 8) in nine different countries. Precise timings and relevant clinical details were recorded on an Excel spreadsheet. Each video was analyzed twice by at least two members of the research team. Time-to-event intervals, frequencies of interventions, and descriptive statistics were calculated using SPSS. RESULTS A completely spontaneous (labor mechanisms and maternal effort only) birth occurred in 14/42 (33%) cases. The median time between the birth of the fetal pelvis and the head in all births was 1:52 (IQR 1:05,2:46; min:sec). Lack of spontaneous rotation to a sacro-anterior position by the time the fetus had emerged to the nipple line was strongly associated with fetal arm entrapment. The following maneuvers were used: shoulder press to flex the aftercoming head in midpelvis or outlet (n = 24), sweeping down arm/s (n = 12), buttock lift to assist shoulder press (n = 6), modified Mauriceau (n = 6), rotational maneuvers to release an entrapped arm (n = 6), elevate and rotate fetal head to assist engagement (n = 2), and conversion into supine maternal position (n = 2). CONCLUSIONS Most upright breech births occur within 3 minutes of the birth of the fetal pelvis. Upright breech birth attendants use variations of traditional maneuvers. We introduce a physiological breech algorithm as an initial timekeeping framework for teaching, research, and practice.
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Affiliation(s)
- Anke Reitter
- Obstetric and Prenatal Medicine DepartmentHospital SachsenhausenAcademic Teaching Hospital of the Goethe‐University FrankfurtFrankfurtGermany
| | - Alexandra Halliday
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative CareKing’s College LondonLondonUK
| | - Shawn Walker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative CareKing’s College LondonLondonUK,Women’s and Children’s ServicesSt Thomas’ HospitalLondonUK
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13
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Jenkins E, Markham C, Ryder I, Kettle C. Labial trauma post birth: A delphi study of classification and suturing requirements. Midwifery 2019; 71:49-55. [DOI: 10.1016/j.midw.2019.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/20/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
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14
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Fischbein SJ, Freeze R. Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births. BMC Pregnancy Childbirth 2018; 18:397. [PMID: 30305050 PMCID: PMC6180643 DOI: 10.1186/s12884-018-2033-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 09/27/2018] [Indexed: 01/17/2023] Open
Abstract
Background Research on outcomes of out-of-hospital breech birth is scarce. This study evaluates the outcomes of singleton term breech and cephalic births in a home or birth center setting. Methods This is a retrospective observational cohort study of 60 breech and 109 cephalic planned out-of-hospital term singleton births during a 6 year period with a single obstetrician. Outcomes measured included mode of delivery; birth weights; 1 & 5-min Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; and other maternal and neonatal morbidity. Results 50 breech and 102 cephalic presentations were still in the obstetrician’s care at the onset of labor; of those, 10 breech and 11 cephalic mothers required transport during labor. 76% of breech and 92.2% of cephalic births were planned to occur at home, with the remainder at a freestanding birth center. When compared to the cephalic group, the breech group had a higher rate of antepartum and in-labor transfer of care and cesarean section. Among completed out-of-hospital births, the breech group had a significantly higher rate of 1-min Apgar scores < 7 but no significant difference at 5 min. Rates of vaginal birth for both groups were high, with 84% of breech and 97.1% of cephalic mothers giving birth vaginally in this series. Compared to primiparas, multiparas in both groups had less perineal trauma and higher rates of out-of-hospital birth, vaginal birth, and spontaneous vaginal birth. No breech infant or mother required postpartum hospital transport, while one cephalic infant and one cephalic mother required postpartum transport. Of the babies born out-of-hospital, there was one short-term and one longer-term birth injury among the breech group and one short-term brachial plexus injury in the cephalic group. Conclusions A home or birth center setting leads to high rates of vaginal birth and good maternal outcomes for both breech and cephalic term singleton presentations. Out-of-hospital vaginal breech birth under specific protocol guidelines and with a skilled provider may be a reasonable choice for women wishing to avoid a cesarean section—especially when there is no option of a hospital breech birth. However, this study is underpowered to calculate uncommon adverse neonatal outcomes.
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Affiliation(s)
| | - Rixa Freeze
- Wabash College, 211 Center Hall, Crawfordsville, IN, 47933, USA.
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15
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Walker S, Parker P, Scamell M. Expertise in physiological breech birth: A mixed-methods study. Birth 2018; 45:202-209. [PMID: 29205469 DOI: 10.1111/birt.12326] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 10/21/2017] [Accepted: 10/21/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The safety of vaginal breech birth depends on the expertise of birth attendants, yet the meaning of "expertise" remains unclear and subjectively defined. The objective of this study was to define expertise and the roles experts may play in expanding access to this service. METHODS We performed an integrative analysis of two strands of data concerning expertise in physiological breech birth, including the following: survey data from a Delphi study involving 26 very experienced clinicians (mean experience = 135 breech births) and 2 service user representatives, and interviews from a grounded theory study of 14 clinicians more moderately experienced with physiological methods (5-30 upright breech births). Data were pooled and analyzed using constant comparative methods. RESULTS Expertise is defined by its ongoing function, the generation of comparatively good outcomes, and confidence and competence among colleagues. Although clinical experience is important, expertise is developed and expressed in social clinical roles, which expand as experience grows: clinician, mentor, specialist, and expert. To develop expertise within a service, clinicians who have an interest in breech birth should be supported to perform these roles within specialist teams. CONCLUSIONS Specialist breech teams may facilitate the development of expertise within maternity care settings. Evaluation of expertise based on enablement of women and colleagues, as well as outcomes, will potentially avoid the pitfalls of alienation produced by some forms of specialist authority.
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Affiliation(s)
- Shawn Walker
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Pam Parker
- Department for Learning Enhancement and Development, City, University of London, Northampton Square, London, UK
| | - Mandie Scamell
- Centre for Maternal and Child Health Research, City, University of London, Northampton Square, London, UK
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16
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Walker S, Scamell M, Parker P. Deliberate acquisition of competence in physiological breech birth: A grounded theory study. Women Birth 2017; 31:e170-e177. [PMID: 28969997 DOI: 10.1016/j.wombi.2017.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 07/05/2017] [Accepted: 09/08/2017] [Indexed: 11/24/2022]
Abstract
PROBLEM Research suggests that the skill and experience of the attendant significantly affect the outcomes of vaginal breech births, yet practitioner experience levels are minimal within many contemporary maternity care systems. BACKGROUND Due to minimal experience and cultural resistance, few practitioners offer vaginal breech birth, and many practice guidelines and training programmes recommend delivery techniques requiring supine maternal position. Fewer practitioners have skills to support physiological breech birth, involving active maternal movement and choice of birthing position, including upright postures such as kneeling, standing, squatting, or on a birth stool. How professionals learn complex skills contrary to those taught in their local practice settings is unclear. QUESTION How do professionals develop competence and expertise in physiological breech birth? METHODS Nine midwives and five obstetricians with experience facilitating upright physiological breech births participated in semi-structured interviews. Data were analysed iteratively using constructivist grounded theory methods to develop an empirical theory of physiological breech skill acquisition. RESULTS Among the participants in this research, the deliberate acquisition of competence in physiological breech birth included stages of affinity with physiological birth, critical awareness, intention, identity and responsibility. Expert practitioners operating across local and national boundaries guided less experienced practitioners. DISCUSSION The results depict a specialist learning model which could be formalised in sympathetic training programmes, and evaluated. It may also be relevant to developing competence in other specialist/expert roles and innovative practices. CONCLUSION Deliberate development of local communities of practice may support professionals to acquire elusive breech skills in a sustainable way.
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Affiliation(s)
- Shawn Walker
- City, University of London, Centre for Maternal and Child Health Research, Northampton Square, London EC1 V0HB, UK; King's College London, Florence Nightingale Faculty of Nursing and Midwifery, London SE1 8WA, UK.
| | - Mandie Scamell
- City, University of London, Centre for Maternal and Child Health Research, Northampton Square, London EC1 V0HB, UK
| | - Pam Parker
- City, University of London, Learning Enhancement and Development, Northampton Square, London EC1 V0HB, UK
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Walker S, Breslin E, Scamell M, Parker P. Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth 2017; 44:101-109. [PMID: 28211102 DOI: 10.1111/birt.12280] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 01/12/2017] [Accepted: 01/12/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The safety of vaginal breech birth depends on the skill of the attendant. The objective of this review was to identify, synthesize, and report the findings of evaluated breech birth training strategies. METHODS A systematic search of the following on-line databases: Medline, CINAHL Plus, PsychINFO, EBM Reviews/Cochrane Library, EMBASE, Maternity and Infant Care, and Pubmed, using a structured search strategy. Studies were included in the review if they evaluated the efficacy of a breech birth training program or particular strategies, including obstetric emergency training evaluations that reported differentiated outcomes for breech. Out of 1040 original citings, 303 full-text articles were assessed for eligibility, and 17 methodologically diverse studies met the inclusion criteria. A data collection form was used to extract relevant information. Data were synthesized, using an evaluation levels framework, including reaction, learning (subjective and objective assessment), and behavioral change. RESULTS No evaluations included clinical outcome data. Improvements in self-assessed skill and confidence were not associated with improvements in objective assessments or behavioral change. Inclusion of breech birth as part of an obstetric emergencies training package without support in practice was negatively associated with subsequent attendance at vaginal breech births. CONCLUSIONS As a result of the heterogeneity of the studies available, and the lack of evidence concerning neonatal or maternal outcomes, no conclusive practice recommendations can be made. However, the studies reviewed suggest that vaginal breech birth training may be enhanced by reflection, repetition, and experienced clinical support in practice. Further evaluation studies should prioritize clinical outcome data.
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Affiliation(s)
- Shawn Walker
- Centre for Maternal and Child Health Research, City, University of London, London, UK
| | - Eamonn Breslin
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mandie Scamell
- Centre for Maternal and Child Health Research, City, University of London, London, UK
| | - Pam Parker
- Department for Learning Enhancement and Development, City, University of London, London, UK
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