INTRODUCTION: We have established a Vaginal Breech Initiative (VBI) to increase access to, and training in, the process of vaginal breech delivery. The VBI is a collaborative care team composed of physicians and nurse-midwives that leads care of participating women. Components of the VBI are: thorough antenatal screening, strict inclusion and exclusion criteria, rigorous informed consent, established delivery guidelines, and frequent simulation training. METHODS: This is a retrospective analysis of the VBI from 8/2011 to 11/2017. Inclusion criteria were: gestational age 34-42 weeks, singleton pregnancy, estimated fetal weight 2000-3800g, frank or complete breech, flexed head, adequate clinical pelvimetry, head and abdominal circumference within normal range and concordant, spontaneous labor and presence of a Vaginal Breech Team member. The primary outcome was incidence of vaginal breech delivery. Maternal and neonatal outcomes were examined secondarily. RESULTS: In total, 47 patients underwent a vaginal breech trial of labor, of which 72.3% had a successful vaginal breech delivery (n=34/47). Piper forceps were utilized in 11.8% of deliveries (n=4/34). The incidence of postpartum hemorrhage was 2.1% (n=1/47). There was one 3rd degree laceration (2.1%; n=1/47). Neonatal outcomes included an 8.5% incidence of neonatal intensive care unit admission (n=4/47) and a 2.1% frequency of head entrapment (n=1/47). CONCLUSION: The majority of patients undergoing breech vaginal delivery through our VBI had a successful vaginal breech delivery. Perinatal morbidity outcomes were rare. Through careful patient selection, counseling, and collaboration, breech vaginal deliveries performed in the context of a VBI are feasible in an academic medical center.
INTRODUCTION: Collaborative guidelines were instituted at our academic practice to streamline the existing process of consultation, collaboration, and transfer of care between obstetricians and midwives. We aim to investigate attitudes of providers toward the collaborative model, and how the implementation of an institutional guidelines document influences perceived provider satisfaction, oversight of collaboration, and delivery of patient care. METHODS: A qualitative survey of the faculty was administered using an electronic data capture system. RESULTS: Thirty-three faculty members were sent surveys, 76% were completed (n = 25, 16 obstetricians, 9 midwives). All respondents perceived collaborative practice improves patient outcomes. Formal guidelines were reported as necessary to direct collaborative practice by 44%, while another 44% reported them to be unnecessary. Respondents either agreed or strongly agreed (100%) that a collaborative model improves vaginal delivery rate, and patient satisfaction. While one respondent was neutral, and another disagreed that a collaborative practice improves provider satisfaction with care, the remaining 91% agreed or strongly agreed that it does. Finally, while 70% of respondents disagreed that collaborative practice increases provider perceived stress associated with patient care, 24% were neutral, 8% agreed, and 4% strongly agreed. CONCLUSION: The majority of respondents agree that a collaborative model benefits patients and providers, but equally agree and disagree with formal guidelines to direct collaboration. Subsequent analysis will explore the relationship between responses and the role of the respondent. Additional research investigating such guidelines will be beneficial in understanding collaborative models, and will assist practices interested in implementing similar models.
INTRODUCTION: At the George Washington University, we have established a Vaginal Breech Initiative (VBI) to increase access to, and training in, vaginal breech delivery as a component of a cesarean prevention strategy. The VBI is a collaborative team consisting of physicians and nurse midwives using strict antepartum and intrapartum guidelines to facilitate safe and successful vaginal breech delivery. The purpose of this study was to examine adherence to our protocol. METHODS: We performed a retrospective chart review of all women undergoing a breech trial of labor between 8/2011 and 6/2019. Our primary outcome measure was adherence to protocol. Women were considered adherent if they had an EFW 2500–3800 g, gestational age of 34–42 weeks, singleton pregnancy, frank or complete breech, and had appropriate breech counseling. Our secondary outcome was successful breech vaginal delivery and adverse maternal/fetal outcomes. RESULTS: Of all women undergoing a breech trial of labor (n=63), 47 adhered to our protocol (74.6%). Of those, 37/47 (78.7%) had a successful breech delivery. Of the patients who underwent a breech trial out-of-protocol (n=16), 12/16 (75%) had a successful breech delivery (P=.74). Overall, we had an 77.8% vaginal breech success rate. When in-protocol women were compared with those out-of-protocol, there were no statistically significant adverse maternal/fetal outcomes. CONCLUSION: While we adhered to our established protocol in 74.6% of women undergoing a breech trial of labor, we found this did not correlate to successful breech delivery. We will continue to examine our protocol and identify which components are most highly correlated with vaginal breech success and safety.
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