Northern breech conference: Breech birth - making choice a reality

26-27 September 2014, Sheffield

By Sophie Whitecross

AIMS Journal, 2015, Vol 27 No 1

Sophie is a midwifery lecturer at Swansea University, and also practices as a midwife in Swansea.

A few months ago, whilst I was struggling to think of basic antenatal scenarios for teaching first year midwifery students, a colleague diagnosed me with 'obstetric thrush' and advised me to 'recolonise my midwifery flora'. After almost four years working primarily in a hospital labour ward it seemed that my brain had been saturated by thoughts of obstetric intervention. This troubled me, as I definitely view birth as a normal physiological process. I have a strong woman centered philosophy, with a staunch view of the importance of informed choice.

Luckily, I was already planning to attend the North of England Breech Conference in Sheffield the following weekend. It may initially appear that a conference about breech birth, defined in midwifery education as a 'malpresentation'¹ and taught widely as an obstetric emergency,² would seem a strange place to get back in touch with midwifery. However, I did exactly that.

Organised by the Sheffield Citywide 1-1 team, a small team of incredible midwives, with the support of their Head of midwifery Dotty Watkins, and consultant obstetrician Julia Bodle (who I suspect was a midwife in a former life) the conference was, in a word, inspirational. The midwives in the 1-1 team, Helen, Sarah and Nicola, with obstetrician Julia Bodle, offer a 24-hour on call service, for women who are planning a vaginal breech birth at term. This service ensures that women are supported by birth attendants who are skilled in vaginal breech birth, a key contributory factor in ensuring a safe outcome for mother and baby.³

Jane Evans and Frank Louwen, speakers at the Northern breech conference

Perhaps the clearest message from the conference was the importance of this multidisciplinary working. Poor multi-professional team working and lack of communication have long been highlighted as contributory factors to substandard care in the past.⁴ There were numbers of excellent examples of how midwives and doctors have been working in partnership with excellent outcomes.

The conference included inspiring keynote speakers, presenting and also facilitating hands on teaching sessions. We also heard directly from families who had been cared for by the Sheffield 1-1 team. It was very powerful to have women and their partners speak directly about their experiences of informed decision-making (before being referred to the Sheffield team, one woman's consultant obstetrician opened his diary and asked her on what date she would like her caesarean section). Hearing these families speak so openly and honestly about their experiences made the whole conference 'real' – women want and deserve choice, and should be the key decision makers in plans for birth.

Informed choice is not only a basic human right but has also been a government commitment in relation to maternity services for many years.^5,6 In 2014, over twenty years since Changing Childbirth was first published, lack of informed choice for women with term, breech presenting babies is surely completely unacceptable. As Benna Waites, a clinical psychologist, so eloquently explained, it is a physician's obligation not to eliminate risk but to help people weigh risk, benefit and potential harm, informed by the best scientific evidence.⁷

The so-called scientific evidence informing care for breech presenting babies has a lot to answer for. The Term Breech Trial⁸ meant that almost overnight women were strongly encouraged to 'choose' caesarean section as the safest thing for their baby. The flaws of the Term Breech Trial have long since been highlighted⁹ and two prospective trials have since demonstrated that vaginal breech birth at term, in the right circumstances, is a safe option.^10,11

The conference was not about promoting vaginal breech birth, but sharing evidence and teaching the skills to give midwives and obstetricians the confidence to support women who do choose vaginal breech birth.

Hearing experienced independent midwife Jane Evans speak so calmly and confidently about facilitating breech birth highlighted the importance of the midwifery profession maintaining the knowledge and skills required to support women who make this choice. Professor Frank Louwen, from Frankfurt, Germany, has been supporting women to birth breech babies in upright positions for the last seven years. His skills and knowledge were awe-inspiring, but equally importantly, the way he and 'his midwives' worked in partnership, with each other, and with women was evident throughout his presentation.

The Royal College of Obstetricians and Gynaecologists (RCOG) has said since 2006 that women should have the choice of a breech 'delivery' – but this often meant the woman lying down and having an epidural and forceps. It is currently considering evidence on the benefits of women giving birth to healthy, term breech babies in upright positions and its new guidance on breech birth should be out soon. As well as the Sheffield conference, you might like to see this comprehensive write up of two other breech conferences which provides some of the thinking and research behind this potential sea change in practice breechmidwife.wordpress.com/2014/10/19/rcog-andoxford- breech-conferences-october-2014/

The message is clear. Midwives and doctors need to work together, to provide safe, multi-disciplinary care for women with breech presenting babies. We cannot make caesarean section, through our own skills deficit, the only viable option for women. Women need unbiased information and support from those involved in their care. This is the only way to keep safe vaginal breech birth alive, develop and maintain our skills, and make choice a reality again. Sheffield, I salute you.

References

1. Henderson C, MacDonald S (eds.) (2004) Mayes' midwifery: a textbook for Midwives. 13th edition. Elsevier. London.
2. Barnfield S, Crofts J, Draycott T, Laxton, C, Winter C, (eds.) (2012) PROMPT Course Manual, 2nd edition. Cambridge University Press. Cambridge.
3. Maternal and Child Health Consortium (2000) Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) 7th annual report. Maternal and Child Health Consortium. London.
4. Lewis, G (ed) (2007) The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer – 2003-2005. The Seventh report on Confidential Enquiries into Maternal Deaths in the United Kingdom. CEMACH. London.
5. Department of Health (1993) Changing Childbirth: report of the Expert Maternity Group (Cumberlege report). HMSO. London.
6. Department of Health (2007) Maternity matters: choice, access and continuity of care in a safe service. HMSO. London. See: webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidan ce/DH_073312 (accessed 17 October 2014).
7. Waites B (2003) Breech birth. Free Association Books. London.
8. Hannah ME, Hannah WJ, Hewson SA et al (2000) Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Lancet, 356 (9239): 1375-1383.
9. Glezerman M (2006) Five years to the Term Breech trial: the rise and fall of a randomized controlled trial. Am Jour Obs Gynae, 194 (1): 20-25.
10. Goffinet F, Carayol M, Foidart JM et al (2006) PROMODA study group. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am Jour Obs Gyn, 194 (4): 1002-1011.
11. Maier B, Georgoulopoulos A, Zajc M et al (2011) Fetal outcome for infants in breech by method of delivery: experiences with a stand-by service system of senior obstetricians and women's choices of mode of delivery. Journal of Perinatal Medicine 39 (4): 385-90.