«City Research Online Original citation: Walker, S. (2013). Undiagnosed Breech: towards a woman-centred approach. British Journal of Midwifery, 21(5), ...»
Some population-based studies have noted a disproportionately higher incidence of perinatal mortality for babies who were undiagnosed prior to labour, when reporting on adverse outcomes following vaginal breech births (Krebs and Landhoff-Roos, 1999; CESDI 2000). However, these studies do not compare data for undiagnosed breech babies who were delivered by caesarean section, which is important, as these babies have been observed to be at higher risk regardless of mode of delivery (Cockburn et al, 1994).
The association of undiagnosed breech with poor outcomes may be due to lack of antenatal care for some women, which may contribute to missed diagnosis (Krebs and Landhoff-Roos, 1999; Babay et al, 2000; Usta et al, 2003). Results were similarly poor where studies included results for breech babies born outside of hospital settings (Krebs & Landhoff-Roos, 1999; Bako Undiagnosed Breech: towards a woman-centred approach et al, 2000; CESDI 2000). CESDI also reported several cases where women were admitted in early labour, but diagnosis occurred much later, after interventions known to increase risk (such as augmentation of a dysfunctional labour) had already been applied.
The numbers included in these studies are not large enough individually to draw conclusions about rare outcomes such as neonatal death and serious morbidity, and the assessment and management skills that produced these outcomes have arguably been in decline since some of the first studies were published. However, the data do suggest that diagnosis of breech presentation for the first time in labour should not in itself be considered a contraindication for a vaginal birth (RCOG, 2006). In addition to women who have received little or no antenatal care, the other category of women most likely to avoid diagnosis of breech presentation are those women otherwise at very low obstetric risk who have not been subject to increased antenatal monitoring, and therefore most likely to have a straightforward vaginal birth regardless of presentation.
Since the publication of the Term Breech Trial, breech research has focused on external cephalic version (ECV) and the role of appropriate selection criteria in ensuring good clinical outcomes (Verhoeven et al, 2005; Goffinet et al, 2006; Vendittelli et al, 2006). The RCOG breech management guidelines Undiagnosed Breech: towards a woman-centred approach note: “Although much emphasis is placed on adequate case selection prior to labour, assessment of the previously undiagnosed breech in labour by experienced medical staff can also allow safe vaginal delivery” (2006:5), referencing Nwosu (1993). Indeed, this lack of clarity on exactly how much difference antenatal diagnosis makes to outcomes is the reason universal third trimester ultrasounds to increase detection rates have not been recommended (Bricker et al, 2008) Women-centred counselling Women will be looking to their providers to assist them in making a wise decision. Problems arise in the intrapartum counselling process not when women are offered a caesarean section according to national and local guidelines, but when that ‘offer’ is given as ‘advice,’ or appears to be her only viable option.
Practitioners must keep in mind that to offer a caesarean section during active labour suggests to a woman that something is ‘wrong’ with her baby, and that she should now reconsider her decision to birth vaginally. While we must explain why we are offering a caesarean section, we must also be unbiased about putting the situation into perspective, using all of the information available to us, including the significantly increased risks for a Undiagnosed Breech: towards a woman-centred approach mother receiving a caesarean section in active labour, and the lack of conclusive evidence that a caesarean section will improve the outcome for her baby once in active labour. She should be given the benefits of a vaginal birth for herself and her baby, as well as the risks (General Medical Council (GMC), 2008), both immediate and long-term (Whyte et al, 2004), including for future pregnancies (Verhoeven et al, 2005). Mothers should also be informed that the results of the Term Breech Trial do not apply to spontaneous, steadily progressing labours where the management is expected to be ‘materially different’ from that in the trial (Fahy, 2011; Hofmeyr et al, 2011; Evans, 2012). Exactly what ‘materially different’ means is a matter for debate, but certainly includes births where women birth in upright positions, which were not represented in the Term Breech Trial.
Consent for a caesarean section cannot be gained until a woman knows what the alternatives are, including the support she will receive to birth her baby vaginally if that is what she prefers. If a plan for support is not available, or staff are not willing and confident, a vaginal birth is not a viable option, and the woman may feel coerced into having a caesarean section or entering into a conflicted relationship with her providers, which puts everyone at risk. Wide variation has been observed in rates of vaginal breech births, whether breech presentation was diagnosed antenatally or in labour, unrelated to objective selection criteria (Nwosu et al, 1993; Jackson and Tuffnell, 1994; Goffinet et Undiagnosed Breech: towards a woman-centred approach al, 2006). Some have attributed this to a wide variation in consultant preferences and attitudes (Nwosu et al, 1993; Jackson and Tuffnell, 1994;
Dhingra and Raffi, 2010).
The role of the midwife With inconsistency from obstetric colleagues, to whom midwives will refer management once a breech presentation is discovered, how should midwives uphold their professional obligations to be a woman’s advocate? In a Royal College of Midwives (RCM) Student Life e-newsletter, student midwife Naomi Carlisle describes witnessing an undiagnosed breech birth (2012). In her account, the woman, having expressed her preference for a vaginal birth, is advised according to the attending obstetrician’s preferences, including a precautionary epidural and intervention where it was not necessary, while the attending midwife advocated (described as ‘battling’) for evidence-based practice and truly informed consent: ‘It was interesting hearing the doctor explaining all the positives of a CS and all the negatives of a vaginal breech delivery.’ Carlisle reflects on how the woman must have found it ‘extremely confusing to receive conflicting advice,’ but a good outcome - a vaginal delivery in theatre - resulted. The woman was pleased and Carlisle ‘left the shift feeling elated.’ Undiagnosed Breech: towards a woman-centred approach Many midwives will recognise this situation as common. The midwife who felt confident to advocate for the woman to such an extent may be less common, though surely she herself was empowered by the woman’s equally uncommon clarity about her wish for a vaginal birth. One wonders about the outcome of the inevitable case review process, and whether the midwife’s efforts were acknowledged (positively or negatively).
Following the example of other midwives writing about breech (Cronk, 1998;
Fahy, 2011; and Evans, 2012), midwife Penny Cole situates such spontaneous, term births in the ‘continuum of normality,’ in her recent reflective piece following attendance at an unexpected breech birth (Cole, 2012). However, the common practice of transferring care to obstetric colleagues following a diagnosis of breech presentation, coupled with the minimal breech experience of most midwives, may put midwives who do support women to attempt a natural birth, especially in an unplanned situation, in a precarious situation. Indeed, we have the strange conflict between the RCM s Campaign for Normal Birth (2005), which advocates encouraging women to birth in an upright position, and concerns voiced by authors such as Scamell (2010) that facilitating an all-fours birth may put the midwife at professional and legal risk.
Undiagnosed Breech: towards a woman-centred approach Where are women’s voices in this debate? Reflecting on her breech home
birth, midwife Anna Berkley writes:
“The birth of my son (who was an undiagnosed breech) would have been a very different experience in hospital, probably traumatic, for all of the family.... I would have ended up lying on my back... my legs in the lithotomy position with an epidural... - and him delivered by forceps or, more commonly, a ceasarean section and a hospital stay of at least three days. Of course, I could have opted out of these protocols, but this is quite a difficult thing to do while in labour.
It is human nature to want to please our caregivers, and I would have hated to be seen as ‘difficult’ or ‘demanding’” (2006:17).
This suggests that the choices which (at least some) women want are not available in most hospitals. If obstetric colleagues are not comfortable providing support for a physiological breech birth, how should midwives respond, individually and collectively?
Although the modern management of breech is dominated by obstetrics, midwives participate in the construction of definitions of normality, in reference to physiological birth (Walsh 2007), and how this is monitored and measured. Midwives also define when it is appropriate, and for whom, to Undiagnosed Breech: towards a woman-centred approach extend a midwifery sphere of practice (Hartley 1997). Given the continued debate about whether breech presentation is an abnormality or an unusual normal (Cronk, 1998; Scamell, 2010), it may be useful to define a collaborative category, normal for breech.
Perhaps it is also time for professional organisation to clarify an appropriate midwifery approach to care for women with breech-presenting babies, one which acknowledges the need for close collaboration with obstetric colleagues but also recognises the expertise of midwives in facilitating normality, even in obstetrically complex situations. A midwifery guideline for breech birth would include a definition of what constitutes ‘normal’ for breech presentations, appropriate woman-centred counselling, and how midwives who wish to can achieve competency to include the collaborative management of normal breech births in their sphere of practice.
Looking forward: research into women’s experiences and preferences As a diagnosis of breech presentation for the first time in labour affects approximately 1:100 women, maternity services should have a coherent, evidence-based strategy for continuing to provide all options of care. In order to offer truly woman-centred care, midwives need to know what information women need antenatally in order to make a plan in case this situation arises, Undiagnosed Breech: towards a woman-centred approach and how to discuss the possibility. We also need to understand more about the choices women want (or would want) when confronted with an unanticipated diagnosis of breech presentation in labour, and how to deliver appropriate information in a way women experience as mostly supportive and enabling, rather than conflicted or coercive. Finally, we need to continue to explore as collaborating professionals how we can deliver a consistent, woman-centred service when management preferences among lead professionals are inconsistent.
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Carlisle, N (2012) An undiagnosed breech. RCM Student life e-newsletter.
[online] Available at: www.rcm.org.uk/college/yourUndiagnosed Breech: towards a woman-centred approach career/students/student-life-e-newsletter/student-life-october-2012/anundiagnosed-breech/ [Accessed 29 December 2012].
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