I was recently teaching a physiological breech birth training day for Breech Birth Network, CIC where I met a wonderful doula with a vast amount of knowledge on physiological birth and supporting mothers. Following the training day, she contacted me and asked if I would consider writing a book on why breech birth matters and put me in contact with the editors of the ‘Why Matters’ book series. This has got me thinking: why does breech birth matter? Why do I continue to ensure parents have choice in their mode of birth and teach practitioners to facilitate such births? Does it all really matter? The answer is yes, I believe it does.
I recently completed a questionnaire for a delphi research study on breech birth and one comment which really struck me was by a midwife who said she has come to the conclusion, during her time practicing, that there are two paradigms with regard to breech birth. The first is those who persist in their mission to dissuade parents from a vaginal breech birth and inform others that it is dangerous. The second is those who continue to support mothers' choice, teach breech skills and use the evidence to show others that breech birth is a suitable option. I sit in the second paradigm, to improve safety through teaching breech skills, supporting others to do so and support mothers who wish to have a vaginal breech birth.
My journey in supporting such births is through my own birth experience with my second pregnancy. I had a twin pregnancy and one of my babies was in a breech presentation. While I was not a midwife at the time, and appreciate I was not that knowledgeable in birth and adverse outcomes associated with my situation, I was well-read. I knew what I wanted; to be supported to have a physiological birth without unnecessary monitoring and intervention. From as early as my 16-week antenatal appointment, I was told by my consultant I would be required to have a caesarean section (c-section). This advice and recommendation continued throughout my entire pregnancy and prevented me from being able to look forward to the birth ahead. Instead, I continually worried about having a c-section against my wishes. In the end, I did have a vaginal birth, although not a physiological one, but I was proud of myself for remaining steadfast in my decisions. The days and weeks following the birth, I could not stop thinking about how difficult it was for me to have the birth I so wished for. I wanted to ensure other mothers did not have to go through the continual battle throughout pregnancy to have the birth they desired and be supported in their choices. And so, I embarked on my journey to become a midwife.
‘I knew what I wanted; to be supported to have a physiological birth without unnecessary monitoring and intervention’
I support breech birth because I am motivated by two factors which guided my own decision making: 1) the evidence and 2) choice. For many years, I do not feel we have been practicing evidence-based midwifery for breech presentation at term. There have been many publications over the past few years which have supported vaginal breech birth as a suitable option for mothers. A large observational prospective study by Goffinet et al (2006) started to get practitioners thinking about the safety of vaginal breech birth and, in particular, challenged the results of the Term Breech Trial (Hannah et al, 2000).
Sadly, I believe because of fear, it was never regarded or implemented in a way in which the Term Breech Trial was. Following on from this study, Louwen et al (2017), Berhan and Haileamlak (2015), and the Royal College of Obstetricians and Gynaecologists (RCOG) (Impey et al, 2017) all suggest vaginal breech birth is a suitable mode of birth for many mothers. Despite this evidence, vaginal breech birth is still not the recommended mode of birth in most obstetric units, mainly because of fear and an unskilled workforce.
Due to the way in which the Term Breech Trial (Hannah et al, 2000) changed practice, clinicians have lost their skill in facilitating such births. We are in what I like to call a ‘danger period’, where the evidence supports the practice but we do not have the skill to support it and therefore, in many cases, mothers opt to have a vaginal breech birth with the knowledge they may or may not have an experienced practitioner in attendance.
To enable us to overcome this gap in safety, Walker et al (2017) suggests the development of breech teams. This is where a team of practitioners are mentored and supported by a breech specialist to attend breech births. By doing this, a small team of midwives and doctors can increase their skill level relatively quickly while having the support of the breech specialist and improving safety by attending vaginal breech births themselves. The aim of the team is for them to be able to provide that specialist support to wider members of the midwifery and obstetric workforce, supporting them to facilitate such births and thus increasing the skills of others. Research has shown that the only evidence-based intervention to improve the safety of vaginal breech birth is having an experienced practitioner in attendance (Hannah et al, 2000). Developing and maintaining skill can be difficult given the low number of breech births occurring in units. However, other ways to upskill is through teaching the skills to embed knowledge and learning.
‘Aim of the team is for them to be able to provide that specialist support to wider members of the midwifery and obstetric workforce’
In units where vaginal breech birth is supported, such as where I currently work, the number of vaginal breech births should be sufficient to support the training of other practitioners. I currently support, on average, one mother a fortnight to have a vaginal breech birth in a relatively new service. Therefore, you would expect as the service grows the increase in opportunities for learning will increase with a higher number of vaginal breech births.
Re-learning the skill of vaginal breech birth is also important in relation to public health. The rising rates of c-section in the UK have a long-term impact on both mother and child. In 2018–2019, NHS Digital (2019) data showed c-section in the UK to be at a record high of 30%. Many planned c-sections, particularly for first-time mothers, are for breech presentation. Caughey et al (2017) suggest 17% of first-time c-sections are for breech presentation. If we learn how to facilitate such births safely, then not only do mothers have true choice in mode of birth but we can improve the long-term health of both mother and baby.
While c-section has been shown to be the safest mode of birth for the immediate outcomes to neonates, 0.5 per 1 000 births compared to 2 per 1 000 births for vaginal birth, the evidence has shown no difference in long-term outcomes for those babies born by planned c-section or those born vaginally (Impey et al, 2017). Sandall et al (2018) explored the short- and long-term effects of c-section on maternal and child health. They found that c-section was not only associated with maternal morbidities, such as uterine rupture for future births but also effected future pregnancies increasing the chance of placenta accreta/percreta, ectopic pregnancies, stillbirth and preterm birth (Sandall et al, 2018). For the neonate, it has been found that c-section is associated with hormonal, physical and bacterial changes which can all alter the physiology of the neonate (Sandall et al, 2018). It is also well-documented that neonates born by c-section have a greater chance of developing asthma, allergies and atopy (Sandall et al, 2018).
‘If we do not have the skills to facilitate such births, we take choice away from the mother’
Ultimately however, I believe vaginal breech birth is important because if we do not have the skills to facilitate such births, we take choice away from the mother. Additionally, by not supporting a mother's choice to have vaginal breech birth facilitated in a safe environment by an experienced practitioner, we force mothers to give birth supported by those who are inexperienced in less safe environments which increases the chance of adverse outcomes to babies. There will always be mothers who wish to have the option of a vaginal birth with a breech presentation, therefore we have a responsibility as a profession to ensure there are practitioners skilled in the facilitation of such births. Organisations should support those willing to gain these skills, initially through training and then through facilitation, ultimately supporting mothers. BJM