I’ve recently joined the maternity staff at Westmead Hospital as the new Clinical Midwifery Consultant. I remember at interview discussing the role as being integral to achieving the objectives of Maternity – Towards normal birth in NSW (TNB) (NSW Health, 2010). We discussed how collaboration between midwives and doctors was essential, and that for a balanced approach there was a need for midwifery input into clinics for women with breech presentation, those considering the next birth after caesarean section(s) and women with diabetes in pregnancy.
Westmead has already successfully implemented case load midwifery so I knew I would be actively involved in working towards some of the other TNB key objectives. I was therefore delighted that setting up a breech clinic would be one of my first tasks in my new role. To give some perspective on how big a step forwards this is, I'd like to briefly discuss some recent history relating to breech birth.
The Term Breech Trial (TBT) (Hannah et al., 2000) totally changed breech birth for women. It compared planned vaginal breech and elective caesarean section when the fetus was a breech presentation. Results from the TBT showed little difference in perinatal mortality rates but a significant increase in morbidity rates for newborns born vaginally. The TBT led to an abrupt increase in caesarean sections (CS) for women with breech presentations: almost overnight women were given no choice in their mode of birth. It also resulted in a rapid decrease in the number of clinicians, both midwives and obstetricians, who were skilled in assisting women to have a vaginal breech birth.
The TBT has since been widely criticised for its selection criteria and intrapartum management: the inequity of skill level in maternity units grouped together: and the use of short-term morbidity as a surrogate marker for long-term neurological impairment [SDGC,
2009). Fahy (2011) argued that recommendations from the TBT did not apply to spontaneous breech births attended by skilled practitioners. She cited the use of the lithotomy position for birth being standard and the TBT didn't evaluate upright positions during birth.
A two-year follow up of the TBT actually showed a greater number of babies with neurodevelopmental delay in the planned CS group - 3.1 % as opposed to 2.8% in those born vaginally (Whyte et al., 2003). Of the 18 vaginally born breech infants with serious neonatal morbidity who were followed, 17 were neurologically normal at two years of age and one died of a condition not related to mode of birth (SOGC, 2009).
Although CS was considered the safest mode of delivery for the breech baby, it still posed a risk for the mother. Verhoeven et al. (2005) examined the outcomes of 8500 elective caesareans performed in the Netherlands over four years following the TBT. This study found that while 19 perinatal deaths may have been prevented, four maternal deaths occurred that could have been avoided.
Lawson (2011) poignantly highlighted this in his discussion of a Coroner's report into the death of an Australian woman in 2007. The Coroner's report attributed the cause to postpartum haemorrhage. There was a brief reference in the report that the CS was an emergency carried out at full dilatation for breech presentation; it did not mention that the woman had a previous history of two spontaneous vaginal births without complication. Lawson (2011) suggested the report conveyed the impression that the cause of death was solely due to the effects of uterine atony and that those complications around breech CS are underappreciated and under-reported.
The PREMODA study (Goffinet et al., 2006) showed that careful selection for vaginal breech birth resulted in no difference in outcome for either group. Hartnack et al. (2011) looked at the consequences of the TBT on Denmark's CS rate for breech presentation which increased from 79.6% to 94.2% but without the anticipated reduction in rates of perinatal mortality and morbidity. The re-examination of the TBT demonstrates that CS is no longer the only birth option for women with breech presentation.
Westmead is fully embracing the philosophy of TNB (NSW Health, 2010) and is working towards attaining its key objectives. We needed a breech service in the West. Andrew
Pesce, one of our consultant obstetricians, had already held up his hand to do it and I came on board because many women in "high risk" clinics miss out on midwifery input.
I was willing to go on call and caseload the women wanting vaginal breech births so they received some continuity of care, even if it was only for a few weeks. The women are referred to us at 36-37 weeks gestation and we expect 2-3 referrals a week from the Women's Health Clinic, caseload midwifery program and from the Women's Health Ward (WHW). I tend to visit the WHW on a daily basis to see if there are any suitable candidates for our service. We haven't had any out-of-area referrals yet, but will accept them.
Our clinic is on a Wednesday morning and Andrew and I usually see the women together, but if Andrew is unavailable I will see the women by myself. We also offer external cephalic version (ECV) hopefully on the same day, but if not, within 2 days of attending the breech clinic. Scheduling the procedure is easier as I'm there to attend to pre- and post-ECV
cardiotocographs (CTG) and can coordinate the appointment to coincide with Andrew's availability.
Our service has had a positive impact on the Day Assessment Unit which would previously have had to provide staff to cover for the procedure. It's helpful if the women have had a recent ultrasound scan (US) To fulfil the criteria for ECV we need the US to show the estimated fetal weight (EFW), amniotic fluid index (AFI), placental location and any anomalies that would exclude them from the procedure. They're counselled verbally and also receive written information regarding ECV.
Some women already know what they want to do: others need some time to consider their options. It is often an extremely stressful time for the women and their partners and we're able to offer them calm reassurance and consistent information.
My attendance while the CTG is in progress offers the opportunity to find out what childbirth education, if any, the women have undertaken and whether they have an idea of how they want to approach the birthing process. If the ECV is unsuccessful, the women are referred for CT pelvimetry. Andrew has arranged bulk billing with a facility close by as we're unable to offer this at Westmead. This is contrary to standard practice (RCOG, 2006; SOGC, 2009) but 82% of the women attempting vaginal birth in the PREMODA study had radiologic pelvimetry. Andrew feels the women and their partners have more confidence to plan vaginal birth if they have the reassurance of this information.
They're then seen with their pelvimetry results the next week and their options are discussed. If the woman opts for a CS, they return to their usual clinic and a
CS is booked for them. Those women wanting to have a vaginal birth will be seen in the breech clinic until their baby is born. Again, we can discuss the options for labour. We talk about active birth and pain relief in labour, basically fine-tuning the details. In consultation with the woman, a birth plan is documented in her medical records and a copy goes to the birth unit. The plan details individual requirements and any complications that may exist. We discuss with the women, when they need to call the birth unit to come in and stress they need to inform the staff they're having a planned vaginal breech birth.
The clinic continues to be a work in progress and we're in the process of updating policies and procedures for ECV and breech birth. We're also developing an education package for obstetricians and midwives. It will have a theoretical component, teaching sessions using mannikins and supervision at the births.
I feel we're able to give the women we see some control and choice about the mode of birth that they didn't have previously. They're also given some continuity as both Andrew and I see them at each visit and we're both on call for when they go into labour. Each appointment is 30 minutes long so the women and their partners have the opportunity to discuss and express any concerns and I think one of the most important aspects is the provision of consistent information.
We have encountered some difficulties. As more women attend the clinics, it's become clear that we need written information for the women. The leaflets we have don't present the information in the way we would like and need updating. We have to create our own and get them translated. The demographic in our area means we see many women where English isn't their first language and there's often a need for an interpreter. These women often don't attend childbirth classes.
Ranjit's story is shared with her permission. Ranjit was the first woman having a vaginal breech and was an Indian primigravida [a woman experiencing her first pregnancy] who hadn't had any childbirth education. As a profession, I think we tend to label women from some ethnic groups and stereotype them with a certain set of behaviours in labour. Fortunately, I had time during the visits to give her a crash course on what to expect during labour and some coping strategies. I've been meeting with the Parent Education CMC to see if we can provide some classes that especially meet the needs of women planning a vaginal breech birth.
Ranjit presented in the latent phase of labour and was one cm dilated. We were able to provide her and her husband with information and encouraged them to go home and rest. When Ranjit returned to the birth unit she was in established labour and already eight cms dilated!
Another hurdle is that women with a breech presentation are perceived as high risk. There was a bit of a battle with the anaesthetic team: they wanted her to be nil by mouth after her first admission. Fortunately, she went home and the problem sorted itself out. There has to be communication and collaboration regarding the care of the women between all those involved and ideally before they present in labour!
The TBT has made us fear vaginal breech birth. When over 400 midwives and doctors were asked their biggest fear, the response was the death of a baby (Dahlen, 2010). I read recently an article by Hannah Dahlen (2011) where she explored the way risk in childbirth is perceived and asked why we focus on when things go wrong, rather than the majority of the time when all goes well.
Dahlen (2011) talked about 'fearsome risk' being a term given to risks that have high consequences and low probabilities and how these risks result in 'probability neglect'. This is where the preventative action undertaken in response to the risk involves giving up too much to avoid the risk. As a result, we encounter 'action bias', an overreaction even when the risk is low, due to the high levels of associated emotion.
I think that this could apply to the fears around breech birth. It could be argued that the TST resulted in 'action bias' with the recommendation of CS for all breech births. The risk of perinatal mortality with vaginal breech birth is relatively low, 2:1000 (RCDG. 2006). Alternatively, we know CS also carries risk.
Re-examination of the evidence around breech birth has given us a more balanced approach toward options for the women we see in the clinic. It has been a positive demonstration of what can be achieved in a short space of time when midwives and doctors come together in collaboration. Our service is still in its infancy but is already making an impact on the women's birth experiences.
This photograph and the story of Ranjit and Rai have been used with their consent; our first parents to opt for [vaginal] breech birth. They say a picture paints a thousand words.
- Dahlen, H. (2010). Undone by fear? Deluded by trust? Midwifery. 26(2). 156-162.
- Dahlen, H. (2011). Perspectives on risk or risk in perspective? Essentially MIDIRS, 2(7). 17-21.
- Fahy. K (2011). Is breech birth really unsafe? Treatment validity in the Term Breech Trial. Essentially MIDIRS. 2(10). 17-21.
- Goffinet, F., Carayol, M., Foidart, J. M., Alexander; S., Uzan, S., Subtil. D. ... & PREMDDA Study Group. (2006). Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol. 194(4). 194(4), 1002-1011.
- Hannah, M. E, Hannah, W J., Hewson, S. A., Hodnett;, EO., Saigal, S., Willan, A. R. for the Term Breech Trial Collaborative Group. (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: A randomised multicentre trial. Lancet, 356, 1375-1383.
- Hartnack Tharin. J. E, Rasmussen, S., & Krebs, L. (2011). Consequences of the Term Breech Trial in Denmark. Acta Obstetrica et Gynecologica Scandanavica. 90(7), 767-771.
- Lawson. G. (2011). Report of a breech cesarean section matemal death. Birth. 38(2). 159-161.
- NSW Health. (2010). Maternity - Towards Normal Birth in NSW. Policy Directive PD2010_045. North Sydney: NSW Dept of Health. Retrieved from: http://www.health.nsw.govau/policies/pd/2010/pdf/ PD2010_045.pdf
- Royal College of Obstetricians and Gynaecologists (RCOG). (2006). The management of breech presentation. Greentop guideline no. 20b. London: RCOG;. Retrieved from: http://www.rcog.org.uk.../GT2ObManagemen_ofBreechPresentation.pdf
- Society of Obstetricians and Gynaecologists of Canada (SOGC). (2009). Vaginal delivery of breech presentation. SOGC clinical practice guideline no. 226. J ObsTet Gynaecol Can., 31(6). 557-566. Retrieved from: http://www.sogc.org.../gui226CPG0906.pdf
- Verhoeven, A. T , de Leeuw, J. P., & Bruinse, H. W (2005). Breech presentation at term: Elective caesarean section is the wrong choice as a standard treatment because of too high risks for the mother and her future children. Ned Tijdschr Geneeskd. 149(40), 2207-2210.
- Whyte, H., Hannah, M., & Saigal. S. (2003). Term Breech Trial Collaborative Group: Outcomes of children at 2 years of age in the Term Breech Trial. Am J Obstet Gynecol, 189, S57.
This article was first published in Midwifery Matters, March 2012. Reproduced with permission.