Preferences and perspectives on vaginal breech delivery in Ghana.

OBJECTIVE: To evaluate obstetrician/gynecologist and midwife perspectives and experiences with vaginal breech deliveries in Ghana. METHODS: Respondents completed a survey on their experiences, training, comfort levels, and decision making about vaginal breech deliveries. Comparisons were made across obstetricians/gynecologists and midwives. Multiple logistic regression explored predictors of comfort performing vaginal breech deliveries. RESULTS: Respondents comprised 93 (36.5%) obstetricians/gynecologists and 162 (63.5%) midwives. Most believed that some breech fetuses should be delivered vaginally, with higher agreement from obstetricians/gynecologists than from midwives (n = 86, 97.7% versus n = 207, 80.8%, P = 0.001). Midwives were more likely to strongly agree that training was adequate for obstetricians/gynecologists (n = 65, 55.6% versus n = 8, 9.8%, P < 0.001) and midwives (n = 60, 49.6% versus n = 6, 7.4%, P < 0.001). Most (n = 192, 94%) respondents wanted more experience and/or training. Despite most providers performing only one ot five breech vaginal deliveries yearly, 77.4% (n = 199) were comfortable performing them and 79.5% (n = 202) were comfortable supervising them. Significant predictors of comfort performing vaginal breech delivery were perceived adequacy of training (odds ratio 8.74, 95% CI 3.39-22.52) and belief that vaginal breech deliveries should be performed (odds ratio 4.28, 95% CI 1.33-13.72). CONCLUSION: Respondents were more likely to feel comfortable performing breech vaginal deliveries if they felt that their training was adequate. Vaginal breech deliveries can only be offered as safe alternatives to cesarean delivery if training and experience are maintained in low-resource settings.

Attitudes towards breech management among a team of maternity clinicians in Australia undertaking breech training.

BACKGROUND: Australian women seeking a vaginal breech birth report limited access to this option due to resistance from clinicians and strict medical criteria. Limited evidence exists to determine the attitudes, knowledge, experience and perceived confidence of Australian maternity clinicians towards the management of a breech presentation at term. AIM: The aim of this study is to identify experience, knowledge and attitudes of birth suite clinicians' before and after training, toward term breech presentation and management practices. METHODS: A mixed methods research design was used that included a survey tool. A survey of 29 midwives and 11 medical professionals who attended an educational course in breech management ("BABE - Becoming a Breech Expert") was undertaken pre and post BABE training. RESULTS: While participants were experienced in providing maternity services, the results indicated most were inexperienced in facilitating a vaginal breech birth. Prior to training, most participants believed vaginal breech birth had a higher risk of neonatal morbidity and mortality compared to caesarean birth. The prospect of a woman choosing a breech birth outside of medical recommendations made many participants "nervous". Despite this, support to ensure there was informed decision-making and respect for a woman's choice was high. Following training, clinician knowledge of assessment of risks for breech birth and intention to discuss breech management options with women increased. CONCLUSIONS: Participation in breech management training is beneficial to increasing clinician knowledge and assessment of risk and confidence towards discussing vaginal breech birth management, respect for women's choice and informed decision-making.

What if something goes wrong? A grounded theory study of parents' decision-making processes around mode of breech birth at term gestation.

OBJECTIVE: To explore factors that influence parents' decision-making for mode of breech birth at term gestation. DESIGN: A grounded theory study conducted using a constructivist approach. Semi-structured telephone interviews were recorded and transcribed verbatim and analysed using the software NVivo for Mac version 11.4.0. SETTING: England, UK. PARTICIPANTS: Twelve parents with breech presentation confirmed by ultrasound at ≥36+0 weeks gestation were recruited from several UK social media forums. FINDINGS: Two core themes impacting on a parent's decision-making process for term breech birth were identified. Firstly, a framework of potential influences including partner and relationship, family and friends, health professionals, own birth culture, self, shared experiences and the time available for decision-making. Secondly, mortality salience, or parental focus on risk of potential injury or death associated with birth, was found to be central to every participant's narrative. KEY CONCLUSIONS: This study highlights the individuality and wider framework of parent's decision-making influences for term breech birth, and demonstrates to care providers the conflicted emotions that may be experienced. The findings of this study may guide midwives and other professionals in providing person-centered, non-judgmental, balanced and evidence-based mode of term breech birth counselling. IMPLICATIONS FOR PRACTICE: Health professionals should adopt a parentcentred approach to counselling for mode of term breech birth, considering parents' wider influences in their decision-making and the fear of injury or death surrounding both vaginal breech birth and caesarean section. They can also facilitate parents to understand the influences that might be guiding their own decision-making.

'Stress, anger, fear and injustice': An international qualitative survey of women's experiences planning a vaginal breech birth.

OBJECTIVE: the outcomes of the Term Breech Trial had a profound impact on women's options for breech birth, with caesarean section now seen as the default method for managing breech birth by many clinicians. Despite this, the demand for planned vaginal breech birth from women does exist. This study aimed to examine the experiences of women who sought a vaginal breech birth to increase understanding as to how to care for women seeking this birth option. DESIGN: an electronic survey was distributed to women online via social media. The survey consisted of qualitative and quantitative questions, with the qualitative data being the focus of this paper. Open ended questions sought information on the ways in which woman sourced a clinician skilled in vaginal breech birth and the level of support and quality of information provided from clinicians regarding vaginal breech birth. Thematic analysis was used to analyse and code the qualitative data into major themes. FINDINGS: in total, 204 women from over seven countries responded to the survey. Written responses to the open ended questions were categorised into seven themes: Seeking the chance to try for a VBB; Encountering coercion and fear; Putting the birth before the baby?; Dealing with emotional wounds; Searching for information and support; Traveling across boundaries; Overcoming obstacles in the system. KEY CONCLUSIONS: for women seeking vaginal breech birth, limited system and clinical support can impede access to balanced information and options for care. Recognition of existing evidence on the safety of vaginal breech birth, as well as the presence of clinical guidelines that support it, may assist in promoting vaginal breech birth as a legitimate option that should be available to women.

This baby is not for turning: Women's experiences of attempted external cephalic version.

BACKGROUND: Existing studies regarding women's experiences surrounding an External Cephalic Version (ECV) report on women who have a persistent breech post ECV and give birth by caesarean section, or on women who had successful ECVs and plan for a vaginal birth. There is a paucity of understanding about the experience of women who attempt an ECV then plan a vaginal breech birth when their baby remains breech. The aim of this study was to examine women's experience of an ECV which resulted in a persistent breech presentation. METHODS: A qualitative descriptive exploratory design was undertaken. In-depth semi-structured interviews were conducted and analysed thematically. RESULTS: Twenty two (n = 22) women who attempted an ECV and subsequently planned a vaginal breech birth participated. Twelve women had a vaginal breech birth (55 %) and 10 (45 %) gave birth by caesarean section. In relation to the ECV, there were five main themes identified: 'seeking an alternative', 'needing information', 'recounting the ECV experience', 'reacting to the unsuccessful ECV' and, 'reflecting on the value of an ECV'. CONCLUSIONS: ECV should form part of a range of options provided to women, rather than a default procedure for management of the term breech. For motivated women who fit the safe criteria for vaginal breech birth, not being subjected to a painful experience (ECV) may be optimal. Women should be supported to access services that support vaginal breech birth if this is their choice, and continuity of care should be standard practice.

Supporting Women Planning a Vaginal Breech Birth: An International Survey.

OBJECTIVE: The aim of this study was to explore the experiences of women who planned a vaginal breech birth. METHOD: An online survey was developed consisting of questions regarding women's experiences surrounding planned vaginal breech birth. The survey was distributed between April 2014 and January 2015 to closed membership Facebook groups that had a consumer focus on vaginal breech birth. RESULTS: In total, 204 unique responses to the survey were obtained from women who had sought the option of a vaginal breech birth in a previous pregnancy. Most women (80.8%) stated that they were happy with the birth choices they made, and a significant proportion (89.4%) would attempt a vaginal breech birth in subsequent pregnancies. Less than half of women were formally referred to a clinician skilled in vaginal breech birth when their baby was diagnosed breech (41.8%), while the remainder sourced a clinician themselves. Half of the women felt supported by their care provider (56.7%) and less than half (42.3%) felt supported by family and friends. CONCLUSION: The women who responded to this international survey sought the option of a vaginal breech birth, were subsequently happy with this decision, and would attempt a vaginal breech birth in their next pregnancy. Access to vaginal breech birth is important for some women; however, this choice may be challenging to achieve. Consistent information and support from clinicians is important to assist decision-making.

Midwives' views, experiences and feelings of confidence surrounding vaginal breech birth: A qualitative study.

OBJECTIVE: to explore midwives' views, experiences and feelings of confidence surrounding vaginal breech birth (VBB). DESIGN: a qualitative study was conducted with 12 participants using three focus group discussions. Data were transcribed verbatim and thematic analysis was used to analyse the data. SETTING: UK midwives were recruited from different geographical areas who worked in community areas, hospital areas and as independent practitioners. FINDINGS: three themes were identified. Firstly, midwives viewed VBB in dimensions of normality, perceiving it to be an unusual norm on one hand while also acknowledging potential problems. Secondly, midwives expressed varied feelings of preparedness; the majority feeling inexperienced and under-prepared with VBB, yet more confident when supported by other colleagues. Lastly, midwives described restrictions on women's choice of VBB; perceiving other practitioners as limiting women's choices through coercion, yet providing a balanced choice themselves. CONCLUSIONS: there should be an opportunity for midwives to be mentored by a more experienced practitioner in VBB. Practice areas should develop a guideline for VBB which acknowledges the role of the midwife in facilitating normal breech birth. Balanced written and verbal information on VBB may further assist decision making for women considering a VBB. Education in VBB should focus on learning what is normal for VBB and must emphasise the importance of teamwork and understanding roles within multidisciplinary teams.

Women's experiences of planning a vaginal breech birth in Australia.

BACKGROUND: In many countries, planned vaginal breech birth (VBB) is a rare event. After the Term Breech Trial in 2000, VBB reduced and caesarean section for breech presentation increased. Despite this, women still request VBB. The objective of this study was to explore the experiences and decision-making processes of women who had sought a VBB. METHODS: A qualitative study using descriptive exploratory design was undertaken. Twenty-two (n = 22) women who planned a VBB, regardless of eventual mode of birth were recruited. The women had given birth at one of two maternity hospitals in Australia that supported VBB. In-depth, semi-structured interviews using an interview guide were conducted. Interviews were analysed thematically. RESULTS: Twenty two women were interviewed; three quarters were primiparous (n = 16; 73%). Nine (41%) were already attending a hospital that supported VBB with the remaining women moving hospitals. All women actively sought a vaginal breech birth because the baby remained breech after an external cephalic version - 12 had a vaginal birth (55%) and 10 (45%) a caesarean section after labour commenced. There were four main themes: Reacting to a loss of choice and control, Wanting information that was trustworthy, Fighting the system and seeking support for VBB and The importance of 'having a go' at VBB. CONCLUSIONS: Women seeking a VBB value clear, consistent and relevant information in deciding about mode of birth. Women desire autonomy to choose vaginal breech birth and to be supported in their choice with high quality care.

Fetal behavioral dynamics in cephalic versus breech presentations.

Differences in fetal neurodevelopment can have important implications on future perceptual and learning capabilities. The aim of this study was to assess autonomic nervous system and complexity dynamics in fetal heart rate (FHR) tracings from 27 singleton fetuses in cephalic or breech presentations, matched for gestational age (37(+3) -40(+4) weeks), weight, gender and outcome. Breeches exhibited significantly higher mean FHR and LF/(MF + HF) ratio, as well as lower entropy, denoting increased sympatho-vagal balance and decreased complexity, consistent with the occurrence of more active fetal behavioral states. These findings suggest that there are neurodevelopment differences between fetuses in cephalic and breech presentation.

Maternal experiences of vaginal breech delivery.

BACKGROUND: The optimal mode of breech birth remains controversial. In Finland, a trial of vaginal delivery is possible if strict selection criteria are met. As clinical practice in managing vaginal breech birth differs from that in normal delivery, the birth experience may also be different. This cohort study compares the childbirth experience between term breech and vertex deliveries. METHODS: Intended vaginal term breech births from 2008 to October 2012 were included, and for every breech delivery, a vertex control was selected. The proportions of deliveries ending in a cesarean section and of mothers who had given birth vaginally before were equal in both groups. Three hundred eight mothers were sent the childbirth experience questionnaire and 170 returned it. RESULTS: The birth experience does not differ between breech and vertex births, except for aspects with respect to the choice of birthing position. Indications of an even more positive experience were observed in the breech group, with the exception of the choice of analgesia, but these were not statistically significant. Primiparity, emergency cesarean section, infant birth trauma and prolonged hospital stay were identified as risk factors for a negative birth experience. CONCLUSION: The birth experience of vaginal breech birth seems to be at least as positive as the vaginal vertex birth experience.

Fear for external cephalic version and depression: predictors of successful external cephalic version for breech presentation at term?

BACKGROUND: Objective was to determine whether fear for external cephalic version (ECV) and depression are associated with the success rate of ECV in women with a breech presentation at term. METHODS: Prospective study conducted in the Catharina Hospital Eindhoven between October 2007 and May 2012. Participants fulfilled The Edinburgh Depression Scale (EDS) questionnaire and expressed their degree of fear on a visual analogue scale from one to ten before ECV. Obstetric factors were evaluated as well. Primary outcome was the relation between psychological factors (fear for ECV and depression EDS scores) and ECV success rate. Secondary outcome was a possible relation between fear for ECV and increased abdominal muscle tension. RESULTS: The overall success rate was 55% and was significantly lower (p < 0.001) in nulliparous women (44.3%) compared with parous women (78.0%). Fear for ECV and depression EDS-scores were not related with ECV success rate. Parity, placental location, BMI and engagement of the fetal breech were obstetric factors associated with ECV outcome. There was no relation between fear for ECV and abdominal muscle tone. CONCLUSION: Fear for ECV and depression were not related with ECV success rate in this study. Engagement of the fetal breech was the most important factor associated with a successful ECV. TRIAL REGISTRATION EBIS: The Eindhoven Breech Intervention Study, NCT00516555.