Vaginal Breech Birth Research Articles

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

Objectivethe 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. Designan 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. Findingsin 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 conclusionsfor 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.

How do social discourses of risk impact on women’s choices for vaginal breech birth? A qualitative study of women’s experiences

In this article, we aim to explore the impact of social discourses of risk around childbirth on the decisions made for birth by women who planned to have a breech baby late in pregnancy. This article uses data from a qualitative descriptive study in New South Wales, Australia in 2013. In the study, we talked to 22 women about their decision-making process for planned a vaginal breech birth and the impact of social discourses of risk on this decision. In total, 12 of these women had a vaginal birth and the other 10 had a Caesarean section. In this article, we note that the mothers talked about their option for birth in a social setting in which the dominant discourse focused on the riskiness of breech birth and the vulnerability of female bodies that required medical surveillance, supervision and intervention to ensure a safe birth. Thus, for these mothers their pregnancy was seen through the societal lens of risk and medicalisation, with surgical intervention through a Caesarean section seen by society as the optimum choice. Women could resist this dominant discourse but such resistance required both justification and action, for example, the women who wanted a vaginal birth often had to resist the pressure from their families to have a Caesarean section. We identified four related strands in women’s talk about resisting the dominate discourse: acknowledgment that they would be considered irrational for wanting a vaginal birth; having confidence in and believing that their body could give birth vaginally; convincing significant others that a vaginal birth was possible and desirable and looking for sources of support, for example, from new online social networks.

The fact and the fiction: A prospective study of internet forum discussions on vaginal breech birth

Women with a breech baby late in pregnancy may use the internet to gather information to assist in decision-making for birth. The aim of this study was to examine how women use English language internet discussion forums to find out information about vaginal breech birth and to increase understanding of how vaginal breech birth is perceived among women. A descriptive qualitative study of internet discussion forums was undertaken. Google alerts were created with the search terms "breech birth" and "breech". Alerts were collected for a one-year period (January 2013-December 2013). The content of forum discussions was analysed using thematic analysis. A total of 50 forum discussions containing 382 comments were collected. Themes that arose from the data were: Testing the waters-which way should I go?; Losing hope for the chance of a normal birth; Seeking support for options-who will listen to me?; Considering vaginal breech birth-a risky choice?; Staying on the 'safe side'-caesarean section as a guarantee; Exploring the positive potential for vaginal breech birth. Women search online for information about vaginal breech birth in an attempt to come to a place in their decision-making where they feel comfortable with their birth plan. This study highlights the need for clinicians to provide comprehensive, unbiased information on the risks and benefits of all options for breech birth to facilitate informed decision-making for the woman. This will contribute to improving the woman's confidence in distinguishing between "the fact and the fiction" of breech birth discussions online.

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

BackgroundExisting 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.MethodsA qualitative descriptive exploratory design was undertaken. In-depth semi-structured interviews were conducted and analysed thematically.ResultsTwenty 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’.ConclusionsECV 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.

The aim of this study was to explore the experiences of women who planned a vaginal breech birth. 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. 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. 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

Objectiveto explore midwives’ views, experiences and feelings of confidence surrounding vaginal breech birth (VBB). Designa 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. SettingUK midwives were recruited from different geographical areas who worked in community areas, hospital areas and as independent practitioners. Findingsthree 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. Conclusionsthere 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.

Outcomes of breech birth by mode of delivery: a population linkage study.

Trial evidence supports a policy of caesarean section for singleton breech presentations at term, but vaginal breech birth is considered a safe option for selected women. To provide recent Australian data on outcomes associated with intended mode of delivery for term breech singletons in women who meet conservative eligibility criteria for vaginal breech birth. Birth and hospital records from 2009 to 2012 in New South Wales were used to identify women with nonanomalous pregnancies who would be considered eligible for vaginal breech birth. Intended mode of delivery was inferred from labour onset and management. Of 10 133 women with term breech singleton pregnancies, 5197 (51.3%) were classified as eligible for vaginal breech delivery. Of these, 6.8% intended vaginal breech birth, 76.4% planned caesarean section and intention could not be determined for 16.8%. Women intending vaginal delivery had higher rates of neonatal morbidity (6.0% vs 2.1%), neonatal birth trauma (7.4% vs 0.9%), Apgar <4 at one minute (10.5% vs 1.1%), Apgar <7 at five minutes (4.3% vs 0.5%) and neonatal intensive care unit/special care nursery admissions (16.2% vs 6.6%) than those planning caesarean section. Increased perinatal risks remained after adjustment for maternal characteristics. Severe maternal morbidity (1.4% vs 0.7%) and post-partum readmission (4.6% vs 4.0%) were higher in the intended vaginal compared to planned caesarean births, but these differences were not statistically significant. In a population of women classified as being eligible for vaginal breech birth, intended vaginal delivery was associated with higher rates of neonatal morbidity than planned caesarean section.

Standards for maternity care professionals attending planned upright breech births: A Delphi study

Objectiveto establish a consensus of opinion on standards of competence for professionals attending upright breech births. Designa three-round Delphi e-survey. Settingmultinational. Participantsa panel of 13 obstetricians, 13 midwives and two user representatives. Clinicians had attended >20 upright breech births, or >10 upright among >40 total breech births. Mean level of experience=135 breech births, median=100 breech births. Methodsan initial survey contained open-ended questions. Answers were coded and amalgamated to form 164 statements in the second round and 9 further statements in the third round. Panellists were asked to evaluate their agreement with each statement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating agreement or strong agreement with the statement. Findingsthe panel returned a consensus-level agreement on 63 statements under the theme, ‘Standards of Competence.’ Panellists supported teaching breech as a ‘normal’ skill rather than an emergency, including optimal mechanisms and breech-specific progress measures, upright variations of classical manoeuvres, the initiation of resuscitation with the umbilical cord intact, birth videos as learning tools, and the development of breech teams to support the wider team in all maternity care settings. Conclusionsalthough every health professional should maintain basic competence to assist unanticipated breech births, establishing enhanced training and standards for those who support planned breech births may help protect users and providers of maternity services, while introducing greater choice and flexibility for women seeking the option of vaginal breech birth.

Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field

Backgroundfew women are given the option of a vaginal breech birth in Australia, unless the clinicians feel confident and have the skills to facilitate this mode of birth. Few studies describe how clinicians provide care during the decision-making phase for women who choose a vaginal breech birth. The aim of this study was to explore how experienced clinicians facilitated decisions about external cephalic version and mode of birth for women who have a breech presentation. Methodsa descriptive exploratory design was undertaken with nine experienced clinicians (obstetricians and midwives) from two tertiary hospitals in Australia. Data were collected through face to face interviews and analysed thematically. Findingsfive obstetricians and four midwives participated in this study. All were experienced in caring for women having a vaginal breech birth and were currently involved in providing such a service. The themes that arose from the data were: Pitching the discussion, Discussing safety and risk, Being calm and Providing continuity of care. Conclusionscaring for women who seek a vaginal breech birth includes careful selection of appropriate women, full discussions outlining the risks involved, and undertaking care with a calm manner, ensuring continuity of care. Health services considering establishing a vaginal breech service should consider that these elements are included in the establishment and implementation processes.

Barriers and facilitators for vaginal breech births in Australia: Clinician's experiences.

Since the Term Breech Trial in 2000, few Australian clinicians have been able to maintain their skills to facilitate vaginal breech births. The overwhelming majority of women with a breech presentation have been given one birth option, that is, caesarean section. The aim of this study was to explore clinician's experiences of caring for women when facilitating a vaginal breech birth. A descriptive exploratory design was undertaken. Nine clinicians (obstetricians and midwives) from two tertiary hospitals in Australia who regularly facilitate vaginal breech birth were interviewed. The interviews were analysed thematically. Participants were five obstetricians and four midwives. There were two overarching themes that arose from the data: Facilitation of and Barriers to vaginal breech birth. A number of sub-themes are described in the paper. In order to facilitate vaginal breech birth and ensure it is given as an option to women, it is necessary to educate, upskill and support colleagues to increase their confidence and abilities, carefully counsel and select suitable women, and approach the option in a calm, collaborative way.

Informed Consent to Breech Birth in New Zealand

The authors note significant room for improvement in facilitating informed consent in the management of breech presentation. New Zealand maternity care providers, including midwives, general practitioners and specialist obstetricians, have legal duties to provide full and unbiased information about risks and benefits of all relevant treatment options. In the case of breech presentation, such options include the interventions of external cephalic version or planned caesarean section, as well as the option to decline intervention and proceed with a planned vaginal breech birth. Information should be presented in a balanced and accessible way and not limited to the provider's personal preferences. Women have legal rights to make an informed choice, to give or refuse consent, to a second opinion and to co-operation among providers. The right of competent persons to refuse medical treatment, including the right to refuse caesarean section, is well established. Clinical policies therefore should include appropriate and non-coercive care for women who choose to birth their breech-presenting baby vaginally, compliance with such policies should be the norm, and consideration should be given to any institutional reforms or educational priorities needed to achieve this.

Vaginal breech births: the debate continues

British Journal of Midwifery • August 2015 • Vol 23, No 8 It is not unusual for me to receive a press release or two a day about a new midwifery study with a headline meant to catch my attention. Most of the time I skim read them for importance and file them away to be read more thoroughly at a later date. However, at the end of last month, my inbox pinged with news of new study published in BJOG about the risks of planned vaginal breech birth compared with planned caesarean section for breech presentation (Berhan and Haileamlak, 2015). The title of the press release—‘Caesarean birth “safest” for breech delivery, but the absolute risks of vaginal delivery remain small’—sparked my attention. At a time when the UK’s caesarean section rate is already too high, at 24.6% (Macfarlane et al, 2015; World Health Organization, 2015), will this study help to contribute to the rising numbers of caesarean sections and undo some of the work done to encourage normal births? The methods of breech birth have been hotly debated for many decades. Hannah et al’s (2000) Term Breech Trial (TBT) transformed breech practice, concluding that a planned caesarean section is better than a planned vaginal birth for a term fetus in the breech presentation: swaying the balance towards an increasingly ‘safer’ practice of caesarean section and away from vaginal breech births. However, the TBT was not what it seemed. Sanders and Steele (2012) discussed the TBT, highlighting the flaws in the design of the study. The authors themselves found that there were no differences in outcomes from mode of birth in their 2-year follow-up (Whyte et al, 2004). Despite this, the recommended method of breech birth remains via caesarean section. On initial reading, Berhan and Haileamlak’s (2015) study agrees with the TBT (Hannah et al, 2000). The results showed that the relative risk of perinatal mortality and morbidity was between two and five times higher in planned vaginal breech birth compared to planned caesarean section birth. However, the absolute risks were very small. It is so important that information on relative vs absolute risk is portrayed accurately to women. Neither vaginal breech birth, nor caesarean breech birth is riskfree. Therefore, a woman must be made fully aware of the risks and benefits of each, in order for her to make a truly informed decision about her care. Vaginal breech birth requires skilled management and continuing to deliver breech babies via caesarean section means that midwives are becoming deskilled in this area. Therefore, understanding these risks and chosing a vaginal breech birth is moot if midwives are not able to offer this service. If the options aren’t available because midwives don’t have the skills, where is the choice and how are we going to achieve the demedicalisation of birth? BJM

External cephalic version for breech presentation before term.

External cephalic version (ECV) of the breech fetus at term (after 37 weeks) has been shown to be effective in reducing the number of breech presentations and caesarean sections, but the rates of success are relatively low. This review examines studies initiating ECV prior to term (before 37 weeks' gestation). To assess the effectiveness of a policy of beginning ECV before term (before 37 weeks' gestation) for breech presentation on fetal presentation at birth, method of delivery, and the rate of preterm birth, perinatal morbidity, stillbirth or neonatal mortality. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015) and reference lists of retrieved studies. Randomised controlled trials (RCTs) of ECV attempted before term (37 weeks' gestation) or commenced before term, compared with a control group of women (in breech presentation) in which either no ECV attempted or ECV was attempted at term. Cluster-randomised trials were eligible for inclusion but none were identified. Quasi-RCTs or studies using a cross-over design were not eligible for inclusion. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. Studies were assessed for risk of bias and for important outcomes the overall quality of the evidence was assessed using the GRADE approach. Five studies are included (2187 women). It was not possible for the intervention to be blinded, and it is not clear what impact lack of blinding would have on the outcomes reported. For other 'Risk of bias' domains studies were either at low or unclear risk of bias.One study reported on ECV that was undertaken and completed before 37 weeks' gestation compared with no ECV. No difference was found in the rate of non-cephalic presentation at birth (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.64 to 1.69; participants = 102). One study reported on a policy of ECV that was initiated before term (33 weeks) and up until 40 weeks' gestation and which could be repeated up until delivery compared with no ECV. This study showed a decrease in the rate of non-cephalic presentation at birth (RR 0.59, 95% CI 0.45 to 0.77; participants = 179).Three studies reported on ECV started at between 34 to 35 weeks' gestation compared with beginning at 37 to 38 weeks' gestation. Pooled results suggested that early ECV reduced the risk of non-cephalic presentation at birth (RR 0.81, 95% CI 0.74 to 0.90; participants = 1906; studies = three; I² = 0%, evidence graded high quality), failure to achieve vaginal cephalic birth (RR 0.90, 95% CI 0.83 to 0.97; participants = 1888; studies = three; I² = 0%, evidence graded high quality), and vaginal breech delivery (RR 0.44, 95% CI 0.25 to 0.78; participants = 1888; studies = three; I² = 0%, evidence graded high quality). The difference between groups for risk of caesarean was not statistically significant (RR 0.92, 95% CI 0.85 to 1.00; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was evidence that risk of preterm labour was increased with early ECV compared with ECV after 37 weeks (6.6% in the ECV group and 4.3% for controls) (RR 1.51, 95% CI 1.03 to 2.21; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was no clear difference between groups for low infant Apgar score at five minutes or perinatal death (stillbirth plus neonatal mortality up to seven days) (evidence graded as low quality for both outcomes). Compared with no ECV attempt, ECV commenced before term reduces non-cephalic presentation at birth. Compared with ECV at term, beginning ECV at between 34 to 35 weeks may have some benefit in terms of decreasing the rate of non-cephalic presentation, and risk of vaginal breech birth. However, early ECV may increase risk of late preterm birth, and it is important that any future research reports infant morbidity outcomes. Results of the review suggest that there is a need for careful discussion with women about the timing of the ECV procedure so that they can make informed decisions.

Expedited versus conservative approaches for vaginal delivery in breech presentation.

In a vaginal breech birth there may be benefit from rapid delivery of the baby to prevent progressive acidosis. However, this needs to be weighed against the potential trauma of a quick delivery. The objective of this review was to assess the effects of expedited vaginal delivery (breech delivery from umbilicus to delivery of the head within one contraction) on perinatal outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. Randomised trials of expedited vaginal breech delivery compared with delivery not routinely expedited in women undergoing vaginal breech delivery. Two review authors independently assessed the one identified trial for inclusion.If studies are included in future updates, two review authors will assess risk of bias, extract data and check data for accuracy. No studies were included. There is not enough evidence to evaluate the effects of expedited vaginal breech delivery.

La edad materna avanzada como factor de riesgo de morbimortalidad materna y perinatal

OBJETIVOS: Conocer el riesgo para el parto y la morbimortalidad materno perinatal en la gestante añosa. DISEÑO: Estudio clínico retrospectivo de corte transversal. MATERIAL Y MÉTODOS: Gestante de 35 años o mayor atendida en el Hospital San juan de Dios del Callao, entre enero de 1990 y diciembre de 1991. Se compara los resultados del parto y la morbimortalidad materno perinatal con los de la gestante menor de 35 años atendida en el mismo lapso. RESULTADOS: De 10 445 partos, 744 correspondieron a gestantes añosas (7,7%). Hubo significativamente más partos distócicos en las gestantes añosas (19,2% vs 10,6%), incluyendo presentaciones podálica (7,3%), transversa (0,9%) y otras raras (0,6%), habiéndose atendido más partos podálicos por vía vaginal (6,1% vs 2%); la incidencia de cesáreas fue 11%. La cesárea por cesareada anterior fue la causa más frecuente en ambos grupos. La tasa de mortalidad materna fue 397 por 100 000 nv en la gestante mayor y 41 por 100 000 nv en la menor de 35 años, diferencia de significancia estadística. En la madre añosa, la mortalidad perinatal se debió con mayor frecuencia a la asfixia severa (30%), prematuridad (16,6%) y malformaciones congénitas (13,3%), la tasa de mortalidad perinatal en gestantes añosas fue 39,7 por 1 000 nv, y en menores de 35 años 24,8 por 1000 nv, diferencia estadísticamente significativa. La tasa global de mortalidad perinatal fue 27.8 por 1000 nv. CONCLUSIONES: La gestante de 35 años o más tiene riesgo reproductivo alto y requiere de buena orientación preconcepcional, control prenatal con enfoque de riesgo y descarte de malformaciones fetales, parto institucionalizado y monitorización materna y perinatal pre, intra y posparto.

Maternity Care Plans: A retrospective review of a process aiming to support women who decline standard care.

All competent adults have the right to refuse medical treatment. When pregnant women do so, ethical and medico-legal concerns arise and women may face difficulties accessing care. Policies guiding the provision of maternity care in these circumstances are rare and unstudied. One tertiary hospital in Australia has a process for clinicians to plan non-standard maternity care via a Maternity Care Plan (MCP). To review processes and outcomes associated with MCPs from the first three and a half years of the policy's implementation. Retrospective cohort study comprising chart audit, review of demographic data and clinical outcomes, and content analysis of MCPs. MCPs (n=52) were most commonly created when women declined recommended caesareans, preferring vaginal birth after two caesareans (VBAC2, n=23; 44.2%) or vaginal breech birth (n=7, 13.5%) or when women declined continuous intrapartum monitoring for vaginal birth after one caesarean (n=8, 15.4%). Intrapartum care deviated from MCPs in 50% of cases, due to new or worsening clinical indications or changed maternal preferences. Clinical outcomes were reassuring. Most VBAC2 or VBAC>2 (69%) and vaginal breech births (96.3%) were attempted without MCPs, but women with MCPs appeared more likely to birth vaginally (VBAC2 success rate 66.7% with MCP, 17.5% without; vaginal breech birth success rate, 50% with MCP, 32.5% without). MCPs enabled clinicians to provide care outside of hospital policies but were utilised for a narrow range of situations, with significant variation in their application. Further research is needed to understand the experiences of women and clinicians.

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

BackgroundIn 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.MethodsA 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.ResultsTwenty 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.ConclusionsWomen 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.

Risks of vaginal breech delivery at term compared to elective cesarean section – Reply to comment by Page

We thank Mr Page 1 for his interest in our work 2. We agree with many of the points of concern that he addresses, and in fact we have already discussed many of them in our paper. Our study was retrospective and we could not apply an intention-to-treat approach. The trend towards performing elective cesarean section at birth might have been present before the publication of the Hannah trial, but we are not aware of any other clinical trial that has fuelled such a massive change of management, as can be seen in our Figure 1. There are few publications associated with such a tremendous change in clinical practice, which makes it an important turning point. We feel it is our task to evaluate the effect of (changes in) clinical practice on neonatal outcome and to learn from it. Perinatal death occurred less frequently among multiparous than nulliparous women and comparison of the perinatal death rates before and after publication of the term breech trial did not show a significant difference within the multiparous group (Table 1). However, comparison of the mode of delivery (planned vaginal breech birth vs. elective cesarean section) did show a significant risk difference regarding perinatal death in both nulliparous and multiparous women (Table 4). This is the most important outcome of our study. Indeed, no matter what subgroup we studied, CS appeared to be the slightly safer option from the perspective of the child. We disagree that our main conclusion is to perform as many cesarean sections as possible. Our main recommendation to share the data we and others have provided with pregnant women, encourages them to choose external cephalic version and, when the fetus is in breech position prior to delivery, to use shared decision making. We challenge those who advocate vaginal breech delivery to provide data in order to facilitate shared decision making.

‘Normal’ vaginal breech birth: The clinicians’ perspective

Introduction: Since 2000, women have been advised by many clinicians to have an elective caesarean section for persistent fetal breech presentation at term. Recently, in Australia, there has been work undertaken to reverse this widespread practise and support low-risk women to have a vaginal breech birth (VBB). Aim: To explore the experiences of clinicians who support women having a VBB. Method: Purposive sampling was undertaken of clinicians residing in NSW, Australia, who were identified as working in maternity models that facilitated women to have a VBB. In-depth semi-structured interviews were conducted and transcribed. These will be analysed thematically. A qualitative descriptive design was undertaken. Results: Nine clinicians (five obstetricians and four midwives) were involved in caring for women who had a VBB. All worked in hospitals that provided complex tertiary care. The preliminary themes of collaboration, discussing risk, the importance of support partners and changing practise have been identified. Conclusion: The clinicians interviewed for this study strongly believed that women at low obstetric risk should be supported to have a vaginal breech birth, if this was what they wanted. This discussion will be expanded upon after the full analysis of the results has occurred. Issues of collaboration, education and the importance of risk counselling for women are essential.

Improving confidence in first year midwifery students

Introduction: Since 2000, women have been advised by many clinicians to have an elective caesarean section for persistent fetal breech presentation at term. Recently, in Australia, there has been work undertaken to reverse this widespread practise and support low-risk women to have a vaginal breech birth (VBB). Aim: To explore the experiences of clinicians who support women having a VBB. Method: Purposive sampling was undertaken of clinicians residing in NSW, Australia, who were identified as working in maternity models that facilitated women to have a VBB. In-depth semi-structured interviews were conducted and transcribed. These will be analysed thematically. A qualitative descriptive design was undertaken. Results: Nine clinicians (five obstetricians and four midwives) were involved in caring for women who had a VBB. All worked in hospitals that provided complex tertiary care. The preliminary themes of collaboration, discussing risk, the importance of support partners and changing practise have been identified. Conclusion: The clinicians interviewed for this study strongly believed that women at low obstetric risk should be supported to have a vaginal breech birth, if this was what they wanted. This discussion will be expanded upon after the full analysis of the results has occurred. Issues of collaboration, education and the importance of risk counselling for women are essential.