Shawn Walker

Effectiveness of vaginal breech birth training strategies: An integrative review of the literature.

BACKGROUND The safety of vaginal breech birth depends on the skill of the attendant. The objective of this review was to identify, synthesize, and report the findings of evaluated breech birth training strategies. METHODS A systematic search of the following on-line databases: Medline, CINAHL Plus, PsychINFO, EBM Reviews/Cochrane Library, EMBASE, Maternity and Infant Care, and Pubmed, using a structured search strategy. Studies were included in the review if they evaluated the efficacy of a breech birth training program or particular strategies, including obstetric emergency training evaluations that reported differentiated outcomes for breech. Out of 1040 original citings, 303 full-text articles were assessed for eligibility, and 17 methodologically diverse studies met the inclusion criteria. A data collection form was used to extract relevant information. Data were synthesized, using an evaluation levels framework, including reaction, learning (subjective and objective assessment), and behavioral change. RESULTS No evaluations included clinical outcome data. Improvements in self-assessed skill and confidence were not associated with improvements in objective assessments or behavioral change. Inclusion of breech birth as part of an obstetric emergencies training package without support in practice was negatively associated with subsequent attendance at vaginal breech births. CONCLUSIONS As a result of the heterogeneity of the studies available, and the lack of evidence concerning neonatal or maternal outcomes, no conclusive practice recommendations can be made. However, the studies reviewed suggest that vaginal breech birth training may be enhanced by reflection, repetition, and experienced clinical support in practice. Further evaluation studies should prioritize clinical outcome data.

Standards for midwife practitioners of external cephalic version: A Delphi study

INTRODUCTION expansion of advanced and specialist midwifery practitioner roles across professional boundaries requires an evidence-based framework to evaluate achievement and maintenance of competency. In order to develop the role of Breech Specialist Midwife to include the autonomous performance of external cephalic version within one hospital, guidance was required on standards of training and skill development, particularly in the use of ultrasound. METHODS a three-round Delphi survey was used to determine consensus among an expert panel, including highly experienced obstetric and midwife practitioners, as well as sonographers. The first round used mostly open-ended questions to gather data, from which statements were formed and returned to the panel for evaluation in subsequent rounds. FINDINGS standards for achieving and maintaining competence to perform ECV, and in the use of basic third trimester ultrasound as part of this practice, should be the same for midwives and doctors. The maintenance of proficiency requires regular practice. CONCLUSIONS midwives can appropriately expand their sphere of practice to include ECV and basic third trimester ultrasound, according to internal guidelines, following the completion of a competency-based training programme roughly equivalent to those used to guide obstetric training. Ideally, ECV services should be offered in organised clinics where individual practitioners in either profession are able to perform approximately 30 or more ECVs per year in order to maintain an appropriate level of skill.

Deliberate acquisition of competence in physiological breech birth: A grounded theory study

PROBLEM Research suggests that the skill and experience of the attendant significantly affect the outcomes of vaginal breech births, yet practitioner experience levels are minimal within many contemporary maternity care systems. BACKGROUND Due to minimal experience and cultural resistance, few practitioners offer vaginal breech birth, and many practice guidelines and training programmes recommend delivery techniques requiring supine maternal position. Fewer practitioners have skills to support physiological breech birth, involving active maternal movement and choice of birthing position, including upright postures such as kneeling, standing, squatting, or on a birth stool. How professionals learn complex skills contrary to those taught in their local practice settings is unclear. QUESTION How do professionals develop competence and expertise in physiological breech birth? METHODS Nine midwives and five obstetricians with experience facilitating upright physiological breech births participated in semi-structured interviews. Data were analysed iteratively using constructivist grounded theory methods to develop an empirical theory of physiological breech skill acquisition. RESULTS Among the participants in this research, the deliberate acquisition of competence in physiological breech birth included stages of affinity with physiological birth, critical awareness, intention, identity and responsibility. Expert practitioners operating across local and national boundaries guided less experienced practitioners. DISCUSSION The results depict a specialist learning model which could be formalised in sympathetic training programmes, and evaluated. It may also be relevant to developing competence in other specialist/expert roles and innovative practices. CONCLUSION Deliberate development of local communities of practice may support professionals to acquire elusive breech skills in a sustainable way.

Effectiveness of Vaginal Breech Birth Training Strategies: An Integrative Review of the Literature

Citing this paper Please note that where the full-text provided on Kings Research Portal is the Author Accepted Manuscript or Post-Print version this may differ from the final Published version. If citing, it is advised that you check and use the publishers definitive version for pagination, volume/issue, and date of publication details. And where the final published version is provided on the Research Portal, if citing you are again advised to check the publishers website for any subsequent corrections.

Understanding the roots of health inequalities requires new methods

It is easy to teach health-care professionals and students to follow a guideline, tricky to teach them to become aware of unconscious biases and assumptions that may influence how they follow that guideline. Substandard care may be easily recognised in retrospect, but understanding how and why it continues to happen, to some populations more than others, is key to reducing such disparities. Hypertensive disorders of pregnancy affect women of immigrant populations more often and with worse outcomes than native residents of industrialised countries. Yet a recent systematic review indicated that few studies have compared social and cultural differences affecting women speaking up about signs and symptoms of pre-eclampsia, or the responses of their health professionals (Carter et al., BMC Pregnancy and Childbirth 2017, 17: 63). Epidemiological studies have uncovered differences in outcomes, but they cannot unveil the mechanisms behind these differences – the how and why of health inequalities. Complex questions require different methods. The research of Sauvegrain et al. takes a sophisticated step into this gap. The team analysed the complex care trajectories of women treated for hypertension or pre-eclampsia in France, in order to explore whether differences in response and treatment may explain differences in outcomes between white women born in France of French parents and immigrants from sub-Saharan Africa. Rigorous qualitative analysis of women’s care narratives was correlated with health-care records, confirming care differentials, particularly in acting on early signs and symptoms of hypertension and pre-eclampsia. By comparing prenatal care trajectories, and focusing their study specifically on experiences of hypertension and/ or pre-eclampsia, Sauvegrain et al. were able to identify differences in the patterns of care experienced by the groups they were comparing. They were also able to create testable hypotheses from the empirical data. These findings resonate with an earlier study by Jonkers et al. (Reproductive Health Matters 2011, 19:144– 153), which also used interviews and case notes to explore ethnicityrelated factors contributing to substandard care, this time in the Netherlands. Jonkers et al. found that first-generation immigrants experienced significant communication problems when interacting with health services despite a high level of education and hardly any language barrier. Sauvegrain et al. found disparities in communication despite the fact that the majority of the African immigrant participants came from high socioeconomic backgrounds in their home countries, and spoke excellent French. The barriers appear to be something that language alone cannot overcome. The results of Sauvegrain et al. suggest that it would be worthwhile to conduct quantitative studies to determine whether differential care patterns contribute to the higher incidence and severity of hypertensive disorders of pregnancy among immigrant women. It would also be worthwhile to replicate their methods to explore other aspects of maternity care, and the complex mechanisms that may contribute to health disparities despite the best intentions of the professionals involved.

Low overall mortality and morbidity for breech babies in the Netherlands

Sir We are concerned about the way Vlemmix et al. (1) represented the results of their study about the impact of increased rates of elective cesarean sections (ELCS) for breech presentation on neonatal outcomes. The authors identified a steady low rate of neonatal mortality associated with vaginal breech deliveries (VBD) in the Netherlands in 1999–2007 (1.6/1000 overall or 1.3/ 1000 for planned VBD) despite a large increase in the number of ELCS performed. This research adds to the growing body of retrospective data indicating significantly less risk of neonatal mortality for VBD than suggested by the term breech trial (TBT) (approximately 1:100) (2). The risk of neonatal mortality for planned VBD in this study is comparable to the risk of planning a vaginal birth after cesarean (VBAC) rather than an ELCS, an acceptable option that women are encouraged to consider in most European countries (3). Taken in context, the results therefore support the view that it would be reasonable for a larger proportion of women to attempt a VBD in their current pregnancy, rather than plan a VBAC in their next, particularly for first time mothers. Outcomes for babies may be further improved by the one thing the authors did not suggest: better training and approaches to the management of VBD. The authors call for the proportion of women who plan a VBD in the Netherlands (40%) to be reduced and for the Dutch national guidelines to be revised to exclude the fact that the 2-year outcomes in the TBT were no better for the ELCS group than for the planned VBD group (4). Given that women are concerned about the long-term effects for their children more than any other factor (5), this information should only be replaced by better, more contemporary research on 2-year and long-term outcomes. This study’s methodology does not justify its predictions about lives saved. It overestimates the risks of planned VBD because the category in this study absorbs risk from: