Practical insight into upright breech birth from birth videos: A structured analysis

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.

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

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.

Breech specialist midwives and clinics in the OptiBreech Trial feasibility study: An implementation process evaluation

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.

Not too fast, not too slow: A review of historical trends in vaginal breech time management

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.

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

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).

Training for breech deliveries with the mother in an upright position: An innovative adaptation of a simulation model

BACKGROUND

Delivery of a breech baby with the mother in an upright position or on all fours has gained a renewed interest. In these positions, the obstetrician or midwife needs to learn new landmarks and maneuvers. A realistic simulation model would be a valuable adjunct for breech on all fours teaching programs.

MATERIAL AND METHODS

This article describes the simulation model and training program we have developed to train an interprofessional team to assist breech births when the mother is on all fours. A questionnaire was used to evaluate the realism of the adapted mannequin and the impact of training on the confidence level of the participants.

RESULTS

On a Likert scale of 1 to 5, 92% of participants agreed or strongly agreed that the adapted mannequin used was realistic for training obstetric maneuvers for complicated breech births. After training, their confidence level supporting a breech birth in an upright position rose from an average of 2.5 to 5.7 on a scale of 1 to 10.

CONCLUSION

Learning the skills for breech deliveries on all fours is made possible by targeted training with this adapted simulation model.

Optimal time intervals for vaginal breech births: a case-control study

Background

Breech births are associated with a high rate of hypoxic injury, in part due to cord occlusion during emergence. Maximum time intervals and guidelines oriented toward earlier intervention have been proposed in a Physiological Breech Birth Algorithm. We wished to further test and refine the Algorithm for use in a clinical trial.

Methods

We conducted a retrospective case-control study in a London teaching hospital, including 15 cases and 30 controls, during the period of April 2012 to April 2020. Our sample size was powered to test the hypothesis that exceeding recommended time limits is associated with neonatal admission or death. Data collected from intrapartum care records was analysed using SPSS v26 statistical software. Variables were intervals between the stages of labour and various stages of emergence (presenting part, buttocks, pelvis, arms, head). The chi-square test and odds ratios were used to determine association between exposure to the variables of interest and composite outcome. Multiple logistic regression was used to test the predictive value of delays defined as non-adherence the Algorithm.

Results

Logistic regression modelling using the Algorithm time frames had an 86.8% accuracy, a sensitivity of 66.7% and a specificity of 92.3% for predicting the primary outcome. Delays between umbilicus and head >3 minutes (OR: 9.508 [95% CI: 1.390-65.046] p=0.022) and from buttocks on the perineum to head >7 minutes (OR: 6.682 [95% CI: 0.940-41.990] p=0.058) showed the most effect. Lengths of time until the first intervention were consistently longer among the cases. Delay in intervention was more common among cases than head or arm entrapment.

Conclusion

Emergence taking longer than the limits recommended in the Physiological Breech Birth algorithm may be predictive of adverse outcomes. Some of this delay is potentially avoidable. Improved recognition of the boundaries of normality in vaginal breech births may help improve outcomes.

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.

[Demelin's maneuver for arm entrapment during vaginal breech delivery]

OBJECTIVES

To evaluate Demelin's maneuver for arm entrapment's dystocia during vaginal breech deliveries after failure of the usual Lovset maneuver.

METHODS

We led a retrospective cohort study in two French maternities. Between January 2013 and June 2020, we included all vaginal breech deliveries of live newborns after 32 weeks of gestation requiring Demelin's maneuver for persistent arm entrapment despite the Lovset maneuver. The primary endpoint was the Demelin's maneuver success without the existence of a neonatal trauma related to the maneuver.

RESULTS

Among 1611 vaginal breech deliveries, 29 with Demelin's maneuver for an arm entrapment were enrolled (prevalence 0,02%). No failure of this maneuver was found. There was 10 nulliparous (34.5%). Mean gestational age was 38±2.4 weeks of gestation. The success of Demelin's maneuver without trauma related to it was estimated at 82.8%. No serious neonatal trauma was noticed. Five fractures (17.2%), one humeral and four clavicular, without sequelae were diagnosed. Mean weight of newborns was 2945.5 grams and the median arterial pH was 7.17. The median 5-minutes-Apgar score was 10. Maternal morbidity was low: one case (3.4%) of obstetric anal sphincter injuries (type III).

CONCLUSION

Demelin's maneuver seems to be an effective and safe method to treat an arm entrapment's dystocia during vaginal breech delivery after failure of the Lovset's maneuver.

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.

Practical insight into upright breech birth from birth videos: A structured analysis

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.