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

Abstract

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.

Introduction

It is estimated that 3–5% of women have a breech presentation at term gestation (Hofmeyr et al., 2015a, Hofmeyr et al., 2015b). The publication of the Term Breech Trial (TBT) (Hannah et al., 2000), sparked a global decline in vaginal breech birth as clinicians implemented its recommendation that women with a breech presentation be delivered by caesarean section (Steen and Kingdon, 2008). However, a two year follow-up of the TBT showed that the perinatal protective effect of planned caesarean did not reduce the risk of death or developmental delay at two years of age (Whyte et al., 2004). Further evidence emerged which exposed methodological flaws of the TBT (Keirse, 2002, Roosmalen and Rosendaal, 2002, Glezerman, 2006) alongside support for vaginal breech birth (VBB) for healthy women who experience an uncomplicated pregnancy (Goffinet et al., 2006, Borbolla Foster et al., 2014, Berhan and Haileamlak, 2015, Mattila et al., 2015).

Following the diagnosis of breech presentation, women are often referred for external cephalic version (ECV) as this increases the likelihood of a vaginal birth and reduce the need for a caesarean section (Hofmeyr et al., 2015b). Despite the recommendation that women have the option for an ECV, VBB inevitably occurs in practice; either when a woman presents undiagnosed in labour, too late for a caesarean, or through maternal choice (Hemelaar et al., 2015). Furthermore, UK guidelines do not recommend routine caesarean for pre-term breech or breech presentation of the second twin (Royal College of Obstetricians and Gynaecologist (RCOG), 2006). In the UK, the Nursing and Midwifery Council (NMC) recommends that midwives should be competent in assisting women having a vaginal breech birth (NMC, 2009). The presence of an experienced clinician at childbirth is shown to reduce the risk of adverse perinatal outcomes for VBB (Su et al., 2003, Goffinet et al., 2006). However, with the declining incidence, there is a high level of concern regarding the safety of VBB due to the loss of practitioner's skills (Cronk, 1998, Kotaska, 2007) despite the implementation of simulation training (Hunter, 2014).

There is little known about midwives’ views, experiences and feelings of confidence surrounding VBB, other than opinions and anecdotes (Cronk, 1998, Evans, 2012, Walker, 2012). A review of the literature revealed one qualitative study conducted in Jamaica (Founds, 2007), showing that providers interpreted breech as abnormal and associated it with underlying pathology (and hence, worse outcomes). However, the study was conducted in rural Jamaica with limited resources and it did not solely focus on midwives and therefore is unlikely to reflect the experiences of midwives in the UK. Consequently, this study aimed to explore midwives views, experiences and feelings of confidence surrounding VBB in the UK, in order to improve clinical practice and education in relation to VBB.