Re-engaging with vaginal breech birth: A philosophical discussion

The post term breech trial terrain

Fourteen years ago, the TBT (Hannah et al, 2000) was published in the Lancet, with its conclusions providing persuasive confirmation that vaginal breech birth was high risk, having adverse effects for both mother and fetus. The trial transformed breech birth practices across the world with startling immediacy (Lawson, 2012) the trial itself being stopped earlier than originally planned because ‘the lives of mothers and babies were at risk’ (Hannah et al, 2000: 219). Since then vaginal breech birth has been a topic of heightened debate within the community and has decreased in practice partly due to caesarean section becoming progressively safer and more widely used, and partly because of the indications of the TBT. The TBT has been widely criticised and the original findings have been disputed by a number of participants who were present at the Breech Birth Conference (Glezerman, 2006; Bisits, 2012) along with the original authors, who subsequently found in their 2-year follow up that there were no differences in outcome deriving from mode of delivery (Whyte et al, 2004) for either the mother or the baby. However, because it continues to inform current practice on an international level, it is important for midwives to fully understand the flaws of the TBT.

The inclusion criteria for the TBT was seemingly straight forward including singleton breech presentation (frank or complete) at 37 weeks gestation, randomly selected into either a planned caesarean section or a planned vaginal breech delivery group. Exclusions were an estimated fetal weight of over 4 kg, fetopelvic disproportion, or any fetal or maternal complication, such as placenta praevia or fetal anomaly, which might impede a vaginal delivery. However, published results included an accepted 3.5 hour second stage, and women with an obstetric history including caesarean section deemed suitable for the vaginal delivery group; inclusions which many practitioners would assume unsuitable in practice today. Units were to provide ‘usual’ standards of care, although this varied dramatically with some units being unable to provide oxygen via a mask within 10 minutes of delivery or endotrachial tubes within 30 minutes, which for most professionals would not be an acceptable standard of care in any maternity setting. Added to this, several sets of multiple pregnancies were included, and women were recruited to the trial once in active labour (Glezerman, 2006) raising issues of informed consent. For 122 of 558 planned breech deliveries, there were no licensed obstetricians present, rendering a higher adverse risk for perinatal outcomes in those groups. Vaginal deliveries were to be carried out by ‘experienced’ professionals, although, as critics (Glezerman, 2006; Fahy, 2011; Lawson, 2012) assert, there is strong evidence to suggest that some clinicians participating in the TBT were inexperienced in safe breech delivery, their level of expertise being self-determined. These issues question general adherence to the inclusion criteria and therefore generalising the findings of the TBT becomes problematic. Nevertheless, the TBT still warrants attention, continuing to have a profound effect on present practice and is often presented to women carrying breech babies as a decision-making tool, favouring caesarean section over vaginal birth, shaping midwifery practice and creating implications for mothers facing breech as a complication of pregnancy.

Hannah et al's (2000) work concluded caesarean section, compared to vaginal breech birth, to be the preferred and safest option for a breech baby. This stance is still championed by bodies such as the National Institute for Health and Clinical Excellence (NICE, 2004) who state that caesarean section is indicated for singleton breech presentation as it ‘reduces perinatal mortality and neonatal morbidity’ (NICE, 2011: 57). This stance brought about huge debate at the conference, the subsequent sequelae of the TBT resulting in a deskilled workforce of midwives lacking confidence and experience in vaginal breech birth, and deskilling women in their role as natural experts in the field of spontaneous breech birth, arising from a lack of willing health care supporters. This asks whether it is time for NICE to re-evaluate their stance in light of emerging evidence. More recent studies such the PREMODA group (PREsentation et MODe d'Acouchment: presentation and mode of delivery) (Goffinet et al, 2006) presented by Sophie Alexander at the Breech Birth Conference, used a similar criteria as the TBT but a stricter selection criteria and management style, (82% pelvemetry, and 100% fetal heart monitoring), with startlingly different outcomes. PREMODA's observational prospective study in more than 8000 women, amongst others (Alarab et al, 2004; Vistad et al, 2013), concluded that vaginal breech birth in a unit where this is common practice remains a safe and viable option as long as certain controlled criteria are met (Goffinet et al, 2006; Toivonen et al, 2012). Because assisted breech birth has been tested in the TBT against caesarean section, the findings do not apply to what many women are seeking; the experience of spontaneous vaginal birth. It is worth considering whether women, told they can try to achieve a normal breech birth, know these differences or are indeed equipped with the comprehensive decision-making information to consider the implications behind the ‘choices’ offered. Spontaneous breech birth as a valid, achievable option, has transformed in the most part to that of breech delivery—a highly managed event within the terrain of obstetric emergency, removing it from the sphere of midwifery practice. Withdrawing breech birth from skilled midwives has left women with few options and birth choices. So why is it, that an outdated study continues to erode essential midwifery skills, and how can practitioners turn the tide and regain their confidence?

Many issues continuing to challenge contemporary midwifery practice are crystallised within the breech context. These include informed consent or coercion, women deemed too high-risk for certain models of care, the demise of individualised woman-focused care provided by known individuals, and the escalating fear cascade perpetuated by current cultural ideologies surrounding birth. Presently, midwives and midwifery students have little room for learning, observing and participating in vaginal breech birth, creating challenges for changing the dearth of breech practice into a terrain of further facilitation and training. If midwives must advocate for women's choices in a situation where there is a lack of appropriately skilled practitioners, then they need to be part of the solution, otherwise midwives become unavoidably complicit in the continued erosion of their role as a provider of normality in breech contexts. The need for midwives to reclaim and review vaginal breech birth is worthy of attention, raising issues about wider midwifery practices highlighted by the Breech Birth Conference, 2012. The largest concern for prospective parents and indeed midwives is what ratio of risk and benefit is present with maternal choice to birth a breech baby vaginally.

Whose risk are we talking about?

Birth is unknown, yet midwives must prepare for each birth eventuality spending their careers relying on midwifery competencies and training to deal with each arising situation. The ability to constantly assess and reassess on an individual and ongoing basis is carried out in every aspect of midwifery practice. Midwives deal with the variety of potential risk while maintaining their focus on the ‘normal’. Risk however, is always a comparison of two possibilities; both carry a certain degree of risk, not no risk at all. It is too easy to become risk-focused given the increased understanding of the minutia of factors for risk potential, as research methods become more sophisticated (Klein et al, 2007). The 1 in 1000 dictates the professional focus. Understandably, midwives want women to be prepared, but the 999 pregnancies with normal outcomes become forgotten, with midwives needing to ensure that women are informed of all of the possible negative sequelae (Guttier et al, 2011). Birth expectations are personal and individual; therefore, conflicts in risk perception may arise with each woman and midwife having a different perception because of previous experiences of birth and what may constitute an acceptable risk.

The risks of vaginal breech birth must be weighed against the potential benefits for both mother and baby. It is widely understood that breech-presenting babies have a higher incidence of perinatal morbidities than cephalic presentations regardless of mode of delivery. Cord compression and prolapse (Shuttler, 2013), head entrapment (0.5% at term) (Cheng and Hannah, 1993), and respiratory difficulties with an increased incidence of resuscitation are major fetal risks and midwifery concerns, although Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) (2000) attributes many breech hypoxic incidents to poor practitioner recognition and inaction. Caesarean section, however, poses a wide array of maternal morbidities including post-partum haemorrhage leading to hysterectomy, and a longer hospital stay (NICE, 2011); as well as significant consequences for future pregnancies such as placenta accreta and percreta, uterine rupture, and repeat caesarean section (NICE, 2004; Scott, 2010). Therefore, it is vital that mothers consider all implications for themselves and their babies (Chapman, 2013). There is also a marked difference between elective and in-labour caesarean section; and between breech delivery and spontaneous breech birth (Shuttler, 2013).

Residing in a high-risk category, the discussions of options include external cephalic version (ECV) and mode of delivery, in which vaginal breech birth may be offered but often only if women are particularly insistent. Exploration of these decisions is often left until 36–38 weeks gestation, leaving women to face a potentially fearful and unknown birth scenario (Guttier et al, 2011), with a very small window of opportunity for planning. Practitioners may need to consider the normal professional practice and balance the risk ratio for each individual woman. The best way to reduce risk as the research states (Goffinet et al, 2006) would be to equip maternity units with experienced practitioners in vaginal breech birth, seeing as the experience of facilitator continues to be a key factor in outcomes. Building trust between clinicians to change practice is slow, but as evidence-based practitioners, change must occur. To not do this heightens other risk factors, particularly women's psychological wellbeing, which rarely arises in the ‘risk’ discussion (Guttier et al, 2011; The Birth Trauma Association, 2014).

Because of these complexities, breech presentation poses difficulties and risk for midwives with little or no breech experience. Ethically, referral to obstetric colleagues must take place as per the Code (Nursing and Midwifery Council (NMC), 2008) if certain practices fall out of our sphere of knowledge, yet some women still want a midwifery-led birth experience regardless of presentation. Many midwives are keen to facilitate women to achieve the birth that they want and secondarily gain more experience themselves in more complex scenarios. In the post TBT climate how achievable is this? If wanting to birth vaginally, women are often positioned to decline recommended caesarean, having to refuse treatment, creating an uncomfortable and challenging situation during pregnancy in relation to their midwives. Concerns were voiced at the Breech Birth Conference (2012) regarding the risk of increased caesarean rates to the childbearing population, and the long-term implications of using a caesarean-section ‘elective for all’ approach to breech. It has a profound economic impact on an already stretched health service, every additional 1% rise in caesarean rate costs the NHS an additional £5 million per year (NHSIII, 2014), as well as heightening the risks of serious complications and future pregnancy choice. It could be argued that professionals are putting themselves at risk, because in order to re-learn lost practices, their lack of experience potentially increases adverse outcomes. However, it is not good enough that women are demanding a service, because, as discussed on the ‘impact for choice’ panel at the Breech Birth Conference, if the service is not available it cannot be offered and leaves women with no choice.

Normal, abnormal or neither?

Ordinarily the discussion of breech and normality refers to where it is placed within the normal/abnormal framework associated with the risk agenda. The Royal College of Midwives (RCM) Campaign for Normality suggests that breech presentation is ‘normal, just not typical’ (RCM, 2005) and warns not to consider it as an abnormality. However, ‘normal’ does not ordinarily warrant immediate referral to obstetric colleagues, yet midwives are guided to do just this, a step that would not be necessary in any other ‘normal’ scenario. We cannot therefore, apply the usual terminology of normality to a situation which has become progressively more pathologised.

This professional disparity of where breech resides in the normal/abnormal debate does not aid the pursuit of normal midwifery facilitation or women's choice. There is a conflict between the ‘variation of normal’ school of thinking and the understanding that more complex reasons are associated with presentation. It may be better to acknowledge breech as liminally placed between normal and abnormal birth, highlighting the juncture of professional indecision regarding breech and normality. Professional agreement could aid clarification but would be dependent on current available evidence. How much experience warrants enough to gain agreement? Arguably this stance would also be different for midwives and obstetricians, with their prospective differences in perspectives and role. This also has the potential to be divisive rather than finding a collaborative solution between a wider multidisciplinary team. Currently, this professional indecision places women as either high risk without necessarily being so, or infers to women that their pregnancy (and baby) is not normal, leaving women feeling that there is something inherently ‘wrong’, and possibly risky about pursuing their wishes for vaginal birth.

How elective is elective?

Choices offered to women experiencing breech pregnancies are often dependent on some point in a notional future in which their baby might change its position. If breech persists then current UK recommendation is to proceed to elective caesarean section (NICE, 2011: 11). For something to be truly ‘elective’ it must be either permitting or involving a choice. Kotaska (2011) suggests that the stance taken of not offering care, often the case in vaginal breech birth, amounts to the same as refusing care, especially if professionals do not actively support and refer women on to units who offer vaginal breech birth.

Maternal autonomy should be at the very centre of our discussion, and fully informed choice means being in receipt of all of the information and compassionately supported to make the right individual decision. In reality this means transparent discussion of joint obstetric and midwifery consultation, levels of practitioner expertise on offer, differences between breech delivery and birth, and implications of vaginal birth and caesarean section for postnatal recovery and future pregnancies. This discussion may need revisiting on several occasions to clarify and reassure women, and should be performed in an adequate time frame for decision-making. The problem with early discussion is that by term only 3–4% of women will still be carrying breech and so many discussions can seem preemptive. Currently, several countries who have maintained proficient levels of practice (Goffinet et al, 2006) and offer vaginal breech birth services suggest that facilitating breech birth in this setting is straightforward because the ethos generates professional support and up-skilling with practitioners being actively encouraged. Waites (2003) reported women's feelings on being diagnosed breech included shock, sadness and a sense of disappointment about something they had not anticipated. Guttier et al, (2011) suggest that it is not fetal presentation itself which becomes a stressor but instead the importance women place of mode of birth. NICE guidance on caesarean section states ‘a pregnant woman is entitled to decline the offer of treatment such as caesarean section’ (NICE, 2011:10) and that ‘refusal of treatment’ needs to be one of the woman's ‘options’ (NICE, 2011: 10), but what then is her alternative? For women to trust in care providers who state that they do not posses the desired level of expertise is inappropriate. So where does the responsibility of choice lie? To support women's choice the ultimate responsibility lies with women. Can midwives be truly supportive of women's choice when it goes against what is nationally recommended and lies beyond the midwife's skill, herself unable to offer the desired care at her clients place of birth. Phenomenological research suggests women want this choice (Founds, 2007; Guttier et al, 2011) with care provided by a known person, or at least familiarity with their carer at the point of birth. Without midwifery understanding and support women's may feel isolated and ill equipped to decide, leading to coercive behaviour of professionals. Midwives should present women with current evidence, but because much is based on elective caesarean section versus obstetric delivery how appropriate is this as a starting point for discussion?

The way forward

At best midwives are ‘with woman’ regardless of personal feelings, advocating and supporting women's values and decision-making. Midwives are keepers of normality (Kirkham, 2010) and breech normality needs defining both for the midwives, working continuously towards maintaining levels of normality in the face of rising interventionist practices; and for women who risk losing their positions as the experts of their own birth experiences. Speakers at the Breech Birth Conference (2012) suggested that in order to resurrect vaginal breech birth into the mainstream and not merely pockets of specialist interest, collaboration is necessary at the onset of the breech discovery. The message being advocated was that trust is vital to ensure between women and midwives, midwives and obstetric staff, enabling supportive mentorship and ongoing learning from current research. This could aid midwives return to being competent in vaginal breech facilitation but can only happen if the institutional setting is conducive.

Dahlen suggests normal birth is ‘on the endangered list’ (2010: 156). Perhaps the demise of vaginal breech birth can be used as a warning, a lesson in what could affect midwifery practice if there is a continued move away from intimate, relationship-based midwifery care. If practice continues to operate within institutionalised and increasingly larger obstetric-led units, the criteria for midwifery-lead becomes restricted, with many women in the ever-expanding high-risk category.

The potential to create more harm than good by health professionals becomes at risk when fantasies, belief systems and dreams which women hold around the birth of their children become a cite for interference. A shrinking percentage of women experience their pregnancies, birth and postnatal periods with no intervention, and practitioners have an increasingly feto-centric approach, overshadowing other important aspects of entering motherhood. Thanks to the championing of midwives such as Jane Evans (2012) and Mary Cronk (2011), practise of vaginal breech birth has developed enabling women's birth empowerment and there is much to be learnt from their experience and expertise in this woman-centred approach. Pockets of breech support across the country are growing and this has the potential to become commonplace, but the issue remains of how to bridge the gap between current practice and training and opportunity. The international consensus at the Breech Birth Conference (2012) was that breech needed further engagement within health services and individual units; determining that vaginal breech birth is safe, providing certain criteria are met. Increased confidence by training more practitioners is essential as RCOG states, ‘it is important that both clinicians and hospitals are prepared for vaginal breech delivery’, suggesting that ‘women should be informed that there is no evidence that the long-term health of babies with breech presentation is influenced by how the baby is born’ (RCOG, 2006: 2–4). If women are carefully assessed and found to meet selection criteria then planned vaginal breech birth is a reasonable option (RCOG, 2006; Society of Obstetricians and Gynaecologists of Canada, 2009). The RCM's Campaign for Normality (2005) suggests ways of normalising breech which can be consolidated by simulation in the absence of opportunity. A key part of midwives' role and the duty of care (NMC, 2008) could extend to each other as colleagues as well as the women in our care. Until midwives are supporting each other in the area of vaginal breech birth, we will continue to heighten risk because of our diminishing skill, being party to our own decreasing sphere of practice. In the UK, this could be an area of development for the Supervisor of Midwives role inputting support of the RCM's suggestions in the ‘acquisition of skilful techniques’ (2005) with a goal of higher attendance of study days and conferences like the international effort in Washington. If we choose to follow the Campaign for Normality (RCM, 2005) guidance and use ‘judicial clinical judgement’, utilising a solid understanding of normal breech physiology, and attempt to see breech through the frame of normality rather than emergency only, perhaps breech could return to the realm of 3 midwifery care. Until midwives actively support J women in their choice to have a normal vaginal ^ breech birth, we will not have the skill-set to 2 provide them the opportunity.