Reflection is crucial for professional development in midwifery and provides an opportunity to reflect on gaps in knowledge and skills and implement improvements (Nursing and Midwifery Council (NMC), 2019). Bass et al (2017) developed the holistic reflection model for midwifery students to develop critical reflection and thinking skills. They state that critical thinking and reflection are crucial elements of midwifery. The reflection described in this article uses the holistic reflection model as a framework. This model provides a structured framework to thoroughly explore experiences from various perspectives through the ‘knowing’ section, to promote critical thinking and enable transformative learning (Bass et al, 2017).
Midwives support people to make individualised choices (NMC, 2018). Assisting people to make individualised and informed decisions can be challenging when they are experiencing pain. As Wiech and Tracey (2013) states, pain often evokes feelings of withdrawal, fear and avoidance, thus influencing decisions. The reflection outlined in this article describes a time when care was provided by a third-year student midwife, Eowyn Robinson, for a woman who altered her birth plan when in labour, out of fear. Pseudonyms have been used to protect anonymity, in line with the NMC (2018) code.
Self-awareness
This reflection explores the experience of caring for a woman, ‘Katy’, who had opted for a vaginal breech birth. Once in labour, she no longer felt safe to have a vaginal breech birth and opted for a caesarean section instead. I felt disappointed that Katy no longer felt like she could labour safely with a breech presentation. I wondered whether the varied opinions of the multi-disciplinary team made a difference to how safe she felt. Considering the known benefits of midwifery continuity of carer (NHS England, 2016), I wondered whether continuity of carer may have improved her confidence in her ability, and therefore whether this model of care may have impacted her feelings of fear and subsequently her decision.
I felt compelled to explore this case study to develop knowledge and professional capability of caring for someone choosing to have a vaginal breech birth and in caring for someone who has lost confidence in her ability to birth safely.
Description
My supervisor and I received handover of care for Katy on the delivery suite. She was multiparous, had had two previous vaginal births, and her fetus was in a flexed breech presentation. After extensive research and discussion of the options with her obstetrician, Katy had decided that she wished to have a vaginal breech birth. She spontaneously laboured and decided once in established labour that she wanted to have a caesarean section instead. She expressed that she was worried that her baby would get stuck. After thorough discussions with myself, my supervisor, and the obstetrician, Katy decided to continue with the caesarean section. I felt confused by her change of decision for a vaginal breech birth.
Reflection
The NMC (2018) states that care plans should be made in conjunction with women, and that women should be fully informed to enable them to make individualised decisions. Katy had the opportunity to make her individualised care plan and stated that she had undertaken her own research to help her make an informed decision.
Midwifery continuity of carer promotes a trusting relationship between the birthing person and midwife (NHS England, 2016). Additionally, Turienzo et al (2021) stated that women cared for by midwifery continuity of carer are more likely to feel safe and supported. Furthermore, a trusting midwife–mother relationship enables women to feel safe enough to relax into labour and keep fear at bay (Moberg, 2015).
I wondered whether Katy's decision to change to a caesarean section, and her feeling unable to have a vaginal breech birth, was a result of feeling unsafe from being cared for by people she did not know. Additionally, although the obstetricians were supportive of Katy having a vaginal breech birth, they advised her to have an epidural and use lithotomy for second stage, in case of the need for interventions. Katy wished to be upright for vaginal breech birth and did not want an epidural, therefore I felt that this was not supportive of her choices.
Dahlen and Gutteridge (2015) discussed how fears can be passed on from health providers to women. This led me to question whether the obstetric opinion, and the defensive approach as to how Katy's birth should be managed, impacted Katy's fear. The midwifery team advocated for Katy to be upright and were supportive of her choices; however, I wondered whether the difference in opinion between members of the multidisciplinary team may have impacted her trust in her body.
According to Adeyemo et al (2022), effective collaborative working between obstetricians and midwives improve clinical and psychological outcomes. Darling et al (2021) found that women viewed birth as a risky process, which was influenced by professionals. This perception of birth as a risky process altered decision making in labour (Darling et al, 2021).
Knowing
Empirical
Winter et al (2017) suggested that an upright position for the second stage of labour may facilitate a physiological breech birth and also provide greater maternal satisfaction. However, Winter et al (2017) also suggested that an upright breech birth may cause challenges for the birth facilitator, particularly if they are inexperienced in providing care to women in upright positions. This suggests that obstetricians may have been inexperienced in supporting upright birth. By contrast, midwives are facilitators of physiological birth and therefore have more experience and are more confident in supporting upright birth. This may explain the differences in opinion between members of the multidisciplinary team (Darling et al, 2021).
Technocratic
Building trusting relationships with women is crucial during labour, to enable women to feel safe and supported and for labour to progress (Moberg, 2015). Additionally, according to Turienzo et al (2021), midwifery continuity of carer supports women to feel safe in labour. Although continuity of carer was not available in this situation, it provided an insight into how important it may be for women in labour.
While I have experienced quickly building relationships with women in labour, and have always received positive feedback about this, I recognise that I lack experience in caring for women having vaginal breech birth, which may have altered the state of fear and hindered the ability to reassure Katy (Morris et al, 2021).
Ethical
Morris et al (2021) found in their qualitative review that obstetricians often highlighted the risks of vaginal breech birth and portrayed caesarean section as safe. Although the obstetric team verbally supported Katy's decision for vaginal breech birth, their defensive management preferences instilled doubt in the safety of vaginal breech birth (Morris et al, 2021).
Increasing evidence shows that anaesthetic use increases morbidities for women, and should thus only be used when necessary and when women request anaesthesic analgesia (Darling et al, 2021). Winter et al (2017) advised that a range of analgesia options should be made available to women; however, it should be recognised that an epidural may increase the risk of intervention during a vaginal breech birth. This raises the ethical consideration of advising for the use of anaesthetic against maternal request and against current evidence.
Aesthetics
During the transition into second stage of labour, contractions can often become expulsive. Women may feel a sense of fear and loss of control. Reassuring women during this phase is common practice for midwives (Anderson, 2010). However, Warland et al (2018) found in their retrospective study that women reported having an intuition that something was wrong more frequently prior to having a stillborn baby than women who had a live birth.
When Katy became fearful, differentiating fear stemming from transitioning, to fear from intuition that something did not feel right was challenging. There were no other external signs of transition, such as rhombus of Michaelis, anal gaping and purple line; however, these may have become apparent imminently (Downe and Marshall, 2020).
Socio-political
Katy was being cared for by a traditional model of care. The benefits of midwifery continuity of carer for increasing feelings of trust and safety, in addition to the psychological and clinical benefits for women, are documented in many studies (Sandall et al, 2016). Buckland et al (2010) found in their qualitative study that women being cared for by midwifery continuity of carer experienced increased confidence in their ability to birth without intervention and felt empowered. Although qualitative studies are not regarded as robust evidence, they provide valuable opinions and experiences (Harvey and Land, 2021). Continuity of carer enables midwives to provide individualised care for women (Dove and Muir-Cochrane, 2014). Traditional models of midwifery care are based on the utilitarian approach of providing care that has maximum benefits for maximum people, and is therefore not supportive of holistic individualised care (Afhami et al, 2018).
Evaluation
Following an exploration of the experience from differing perspectives, an analysis was carried out as to how midwifery continuity of carer may have benefitted Katy, and the impact of defensive practice and the challenges of differentiating between transitioning and fear from maternal intuition were critically explored. Morris et al (2021) highlighted the psychological stressors and challenging decision making that is experienced by mothers on learning that their baby is in a breech presentation. This should be considered when providing care to these women.
As highlighted by Moberg (2015), midwifery continuity of carer may have helped Katy feel safe and supported, as Katy only met the team for the first time once in established labour, which may have heightened her sense of fear. Additionally, as previously discussed, a trusting midwife–mother relationship empowers women to feel safe enough to relax into labour (Anderson, 2010). If Katy had experienced continuity of carer, she may have felt safe enough to trust her body. Women cared for by midwifery continuity of carer are more likely to feel empowered and make choices to suit them (Buckland et al, 2010).
Katy would have been more likely to have a physiological vaginal breech birth if cared for by midwifery continuity of carer. Morris et al (2021) conducted a qualitative review and found that women who experienced continuity of carer reported that their midwife was more likely to refer them to obstetricians that were supportive of vaginal breech birth. This may contribute to the high rate of vaginal breech birth in this cohort. Qualitative studies are useful in understanding views and experiences, but cannot be relied on as transferable evidence (Rees, 2011). Additionally, recognition must be given to the recommendations from the Ockenden (2022) report that midwifery continuity of carer could jeopardise safety if staffing is inadequate.
Defensive practice leads to increased interventions, loss of control and disempowerment (Frakes and Gruber, 2020). Fear of litigation is considered a driver in defensive practice (Darling et al, 2021). In their qualitative review, Ries et al (2022) argued that defensive practice is unethical and can lead to unnecessary harm. Midwives and doctors have a professional duty to avoid causing unnecessary harm to people in their care (NMC, 2018; General Medical Council, 2023).
Obstetricians are usually only present when there are deviations from physiological labour, when practices such as lithotomy and epidural are commonplace (Darling et al, 2021). Therefore, they have reduced experience in supporting upright positions, and this may explain why the obstetric team advised the use of lithotomy and epidural in Katy's situation (Darling et al, 2021). However, collaborative working between obstetricians and midwives promotes a physiological approach to birth (Darling et al, 2021), suggesting that if the obstetric and midwifery team had worked collaboratively, this may have supported Katy to have a physiological vaginal breech birth.
The team explored the reasons for Katy changing her mind thoroughly, to ensure she was making an informed decision, and not one biased by pain, as pain can influence decision making (Wiech and Tracey, 2013). The team respected her decision around her care choice, adhering to the NMC (2018) code. Additionally, as discussed by Olza et al (2020), Katy may have been experiencing transition into second stage of labour; the subsequent surge of catecholamines results in elevated levels of noradrenaline and adrenaline, causing increased alertness and activity. As highlighted previously and reported by Warland et al (2018), women who experienced stillbirth are more likely to intuitively feel that something is wrong, long before experiencing stillbirth. However, Warland et al (2018) identified that their study would need further research to provide validity, because the findings may have been impacted by recall negativity bias. Their research was also supported by an earlier study, which had similar findings (Warland et al, 2015). Subsequently, differentiating between physiological fear induced by adrenaline surge during this phase of labour and fear induced by maternal intuition caused professional challenges.
Learning
This exploration of how midwifery continuity of carer can improve people's birth experience and feelings around their birth has increased understanding of how people's experiences can be improved and how women trust their bodies when in a supported environment (Moberg, 2015). Additionally, this exploration provided an understanding of the challenges in differentiating between causes of fear, which is crucial in supporting informed decision making. Pain and fear from physiological transition into second stage could contribute to a change in decision (Wiech and Tracey, 2013; Olza et al, 2020).
Bradfield et al (2019) qualitatively explored midwives' experiences of caring for women through continuity of carer, and reported that midwives felt in tune with women and their needs during labour, indicating that continuity of carer may help midwives to differentiate between fear from transition from intuition. These findings demonstrate the importance of providing midwifery continuity of carer whenever possible (Moberg, 2015).
This reflection has identified the need for care providers to develop confidence in caring for women having a vaginal breech birth, given that fear can be passed from care provider to women, diminishing trust in their bodies (Dahlen and Gutteridge, 2015). Confidence in caring for women having a vaginal breech birth also decreases risk of defensive practice, subsequently reducing the risk of unnecessary intervention (Frakes and Gruber, 2020).
Developing confidence in caring for women having a vaginal breech birth can be achieved through increased exposure to vaginal breech birth (Sloman et al, 2016). However only 3–5% of women have a breech presenting fetus at term, and since the ‘term breech trial’ by Hannah et al (2000), elective caesarean section is usually recommended, despite numerous studies debating the validity of the trial's findings (Sloman et al, 2016). In Sloman et al's (2016) qualitative review, midwives stated that additional training on vaginal breech birth helped to increase their confidence in facilitating a vaginal breech birth. The additional training consisted of videos of real vaginal breech birth.
This reflection has also highlighted the need for collaborative working between midwives and obstetricians, in order to support physiological vaginal breech birth (Darling et al, 2021). Collaborative multidisciplinary working can be improved with team training, suggesting that increased multidisciplinary team training on vaginal breech birth would improve midwives' and obstetricians' confidence in caring for women having a vaginal breech birth (Lavelle et al, 2018).
The A-EQUIP supervision model was developed to contribute to high-quality care (NHS England, 2017). Under this model, professional midwifery advocates support midwives in continuous professional development, develop their clinical capability, build resilience, prepare for revalidation and support with work life balance, reducing burn out (NHS England, 2017). Professional midwifery advocates support midwives to process and reflect on situations and support in learning from incidents. This can help midwives with self-care after stressful situations, enabling them to continue to provide compassionate care (NHS England, 2017). Professional midwifery advocates can be used to support midwives in developing their knowledge and skills in supporting vaginal breech birth, developing the ability to differentiate between fear from transition and fear from intuition and support self care, to enable midwives to provide ongoing compassionate care (NHS England, 2017).
Conclusions
On review of the evidence, midwifery continuity of carer is supportive of women feeling safe in labour and of physiological vaginal breech birth. Additionally, continuity of carer may support midwives to differentiate between fear from intuition and fear from transition. However, midwifery continuity of carer may jeopardise safety when staffing is inadequate, and it must be acknowledged that continuity of carer should only be implemented where staffing allows.
Midwives and obstetricians need to improve collaborative working and increase their confidence in providing care for women having a vaginal breech birth, as fear can be passed from care provider to woman and confidence in practice decreases defensive practices. Additional multidisciplinary vaginal breech birth training with videos of vaginal breech birth may help to achieve collaborative working and improved confidence with vaginal breech birth. This reflection is of providing care as a student midwife; however, the findings are relevant across midwifery practice.