Obstetric Trainees’ Experience in Vaginal Breech Delivery

How often will midwives and obstetricians experience obstetric emergencies or high-risk deliveries: a national cross-sectional study

OBJECTIVE

To estimate how often midwives, specialty trainees and doctors specialised in obstetrics and gynaecology are attending to specific obstetric emergencies or high-risk deliveries (obstetric events).

DESIGN

A national cross-sectional study.

SETTING

All hospital labour wards in Denmark.

PARTICIPANTS

Midwives (n=1303), specialty trainees (n=179) and doctors specialised in obstetrics and gynaecology (n=343) working in hospital labour wards (n=21) in Denmark in 2018.

METHODS

Categories of obstetric events comprised of Apgar score <7/5 min, eclampsia, emergency caesarean sections, severe postpartum haemorrhage, shoulder dystocia, umbilical cord prolapse, vaginal breech deliveries, vaginal twin deliveries and vacuum extraction. Data on number of healthcare professionals were obtained through the Danish maternity wards, the Danish Health Authority and the Danish Society of Obstetricians and Gynaecologists. We calculated the time interval between attending each obstetric event by dividing the number of events occurred with the number of healthcare professionals.

OUTCOME MEASURES

The time interval between attending a specific obstetric event.

RESULTS

The average time between experiencing obstetric events ranged from days to years. Emergency caesarean sections, which occur relatively frequent, were attended on average every other month by midwives, every 9 days for specialty trainees and every 17 days by specialist doctors. On average, rare events like eclampsia were experienced by midwives only every 42 years, every 6 years by specialty trainees and every 11 years by specialist doctors.

CONCLUSIONS

Some obstetric events occur extremely rarely, hindering the ability to obtain and maintain the clinical skills to manage them through clinical practice alone. By assessing the frequency of a healthcare professionals attending an obstetric emergency, our study contributes to assessing the need for supplementary educational initiatives and interventions to learn and maintain clinical skills.

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.

Factors associated with increased odds of cesarean delivery in ART pregnancies

OBJECTIVE

To quantify the effect of medical and obstetrical factors on the odds of cesarean delivery, comparing assisted reproductive technology (ART)-treated women and women with subfertility not treated with ART versus fertile women.

DESIGN

Retrospective cohort.

SETTING

Not applicable.

PATIENT(S)

Singleton deliveries to primiparous women; with the source of this data being the Massachusetts vital and hospital records linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System data (2004-2010).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Mode of delivery.

RESULT(S)

The 173,130 deliveries included 5,768 ART-treated, 2,657 subfertile (1,627 non-ART medically assisted reproduction [MAR] and 1,030 unassisted infertile), and 164,705 fertile pregnancies and 117,743 vaginal and 55,387 cesarean deliveries. ART-treated women were older, more often white and non-Hispanic, and with more private insurance, previous uterine surgery, gestational diabetes, pregnancy hypertension, bleeding, and placental complications than fertile women. Overall rates of cesarean delivery were 45.7%, 43.3%, and 31.1% for ART-treated, subfertile, and fertile women and 41.7% and 45.9% for MAR and unassisted infertile deliveries. When adjusted for demographics, underlying medical factors, previous uterine surgery, and placental and delivery complications, adjusted odds ratios (ORs) compared with fertile women were 1.27 for ART-treated and 1.15 for subfertile women, with greater odds among unassisted infertile (OR 1.26) but not MAR (OR 1.09) women. The strongest confounders of odds of cesarean delivery were age and previous uterine surgery.

CONCLUSION(S)

ART and unassisted infertility were associated with greater odds of cesarean compared with fertile women. Underlying medical and obstetrical risks had strong confounding effects strongly attenuating the odds for cesarean delivery.

Deliberate acquisition of competence in physiological breech birth: A grounded theory study

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.

Principles of physiological breech birth practice: A Delphi study

OBJECTIVE

to establish a multi-professional consensus on shared principles underlying the practice of physiological breech birth.

DESIGN

three-round Delphi e-survey.

SETTING

multi-national.

PARTICIPANTS

a panel of thirteen obstetricians and thirteen midwives, experienced in facilitating physiological breech births in varied settings, and involving varied maternal birthing positions, and two service user representatives.

METHODS

an initial survey contained open-ended questions. Answers were coded and amalgamated into 60 statements in Round 1 and a further 6 statements in Round 2. Participants considered statements in the following categories: first principles (14), maternal positioning (12), birth environment (18), fetal positions (14), safe progress (8). The panel indicated the extent of their agreement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating 4 or 5 on the Likert scale (agreement or strong agreement).

FINDINGS

the panel indicated consensus on 37 of 66 proposed statements concerning 'Principles of Practice.' Negative data (29/66 statements) are also reported, highlighting areas of divergent opinions. The findings suggest a paradigm shift away from risk management strategies based on prediction and control, and towards facilitation strategies based on relationship and response. Upright positions are a tool and not a rule of physiological breech birth.

CONCLUSION

the parameters of 'normal for breech' require further exploration to support professionals working within a paradigm of complex normality. The principles articulated in this research can be used to design further research exploring the influence of physiological breech practices on neonatal and maternal outcomes, including women's experiences of maternity care.

Management of fetal malpresentation

Fetal malpresentation is an important cause of the high cesarean delivery rate in the United States and around the world. This includes breech, face, brow, and compound presentations as well as transverse lie. Risk factors include multiparity, previously affected pregnancy, polyhydramnios, and fetal and uterine anomalies. Appropriate management can reduce the need for cesarean delivery in some cases. This review discusses management options and focuses specifically on external cephalic version and vaginal breech delivery.

The Changing Scenario of Obstetrics and Gynecology Residency Training

BACKGROUND

Significant changes have been noted in aspects of obstetrics-gynecology (ob-gyn) training over the last decade, which is reflected in Accreditation Council for Graduate Medical Education (ACGME) operative case logs for graduating ob-gyn residents.

OBJECTIVE

We sought to understand the changing trends of ob-gyn residents' experience in obstetric procedures over the past 11 years.

METHODS

We analyzed national ACGME procedure logs for all obstetric procedures recorded by 12 728 ob-gyn residents who graduated between academic years 2002-2003 and 2012-2013.

RESULTS

The average number of cesarean sections per resident increased from 191.8 in 2002-2003 to 233.4 in 2012-2013 (17%; P < .001; 95% CI -47.769 to -35.431), the number of vaginal deliveries declined from 320.8 to 261 (18.6%; P < .001; 95% CI 38.842-56.35), the number of forceps deliveries declined from 23.8 to 8.4 (64.7%; P < .001; 95% CI 14.061-16.739), and the number of vacuum deliveries declined from 23.8 to 17.6 (26%; P < .001; 95% CI 5.043-7.357). Between 2002-2003 and 2007-2008, amniocentesis decreased from 18.5 to 11 (P < .001, 95% CI 6.298-8.702), and multifetal vaginal deliveries increased from 10.8 to 14 (P < .001, 95% CI -3.895 to -2.505). Both were not included in ACGME reporting after 2008.

CONCLUSIONS

Ob-gyn residents' training experience changed substantially over the past decade. ACGME obstetric logs demonstrated decreases in volume of vaginal, forceps, and vacuum deliveries, and increases in cesarean and multifetal deliveries. Change in experience may require use of innovative strategies to help improve residents' basic obstetric skills.

The term breech trial ten years on: primum non nocere?

In 2000, the Term Breech Trial was published, and its authors recommended cesarean section as the safest mode of delivery for breech-presenting babies. Criticisms of the trial were raised at the time, which the authors dismissed. Since then, maternal deaths have been recorded among women undergoing cesarean sections for breech presentations. Accordingly, those initial criticisms deserve to be revisited.

In search of work/life balance: trainee perspectives on part-time obstetrics and gynaecology specialist training

Background

Part-time training (PTT) is accessed by approximately 10% of Australian obstetrics and gynaecology trainees, a small but increasing minority which reflects the growing demand for improved work/life balance amongst the Australian medical workforce. This survey reports the attitudes and experiences of both full-time and part-time trainees to PTT.

Methods

An email-based anonymous survey was sent to all Australian obstetrics and gynaecology trainees in April 2009, collecting demographic and training status data, data on personal experiences of PTT and/or trainees, and attitudes towards PTT.

Results

105 responses were received (20% response rate). These indicated strong support (90%) from both full-time (FT) and part-time (PT) trainees for the availability of PTT. PT trainees were significantly more likely than FT trainees to be female with children. Improved morale was seen as a particular advantage of PTT; decreased continuity of care as a disadvantage.

Conclusions

Although limited by poor response rate, both PT and FT Australian obstetric trainees were supportive of part-time training. Both groups recognised important advantages and disadvantages of this mode of training. Currently, part-time training is accessed primarily by female trainees with family responsibilities, with many more trainees considering part-time training than the number that access it.

Fetal outcome for infants in breech by method of delivery: experiences with a stand-by service system of senior obstetricians and women's choices of mode of delivery

OBJECTIVE

To show that the fetal outcome in vaginal deliveries (VD) of breech presentation in a setting of a senior obstetrician stand-by system is as good as in planned cesarean sections.

PATIENTS AND METHODS

This observational prospective intent-to-treat study (n=211 singleton breech presentation pregnancies of ≥35 weeks of gestation) compared two groups of breech deliveries: planned cesarean sections (PCS, n=126) and intended VD (IVD, n=85) resulting in vaginal deliveries (VD, n=46) as well as secondary cesarean sections (SCS, n=39). Women's informed choice as well as strict pre-selection criteria for vaginally intended breech presentation deliveries was followed.

RESULTS

Fetal outcome of vaginal breech deliveries and of primary as well as SCS (45.9% of IVD) was comparable in terms of cord blood pH, base excess, Apgar score, fetal trauma, and transfer to neonatal intensive care unit.

CONCLUSIONS

Vaginal breech delivery is a safe option in a stand-by system of senior obstetricians with controlled decision-making before labor.

Mode of delivery: toward responsible inclusion of patient preferences

Deciding when and how to incorporate patient preferences regarding mode of delivery is challenging for both obstetric providers and policymakers. An analysis of current guidelines in four clinical scenarios (prior cesarean, twin delivery, breech presentation, and maternal request for cesarean) indicates that some guidelines are highly prescriptive whereas others are more flexible, based on physicians' discretion or (less frequently) patient preferences, without consistency or explicit rationale for when such flexibility is permissible, advisable, or obligatory. Although patient-choice advocates have called for more patient-responsive guidelines, concerns also have been raised, especially in the context of discussions of cesarean delivery on maternal request, about the dangers of unfettered patient-preference-driven clinical decisions. In this article, we outline a framework for the responsible inclusion of patient preferences into decision making regarding approach to delivery. We conclude, using this framework, that more explicit incorporation of patient preferences is called for in the first three scenarios and indicate why expanding access to cesarean delivery on maternal request is more complicated and would require more data and further consideration.