Current Experience With the Vaginal Breech Initiative at the George Washington University Hospital [1E]

Abstract

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.

State of the breech in 2020: Guidelines support maternal choice, but skills are lost….

“…One potential model is to establish regional centers of excellence that maintain access to trained physicians and midwives, guidelines for appropriate patient selection and labor management, and resources to address uncommon complications including use of Piper Forceps and symphysiotomy for head entrapment. One example at an academic center, the George Washington Hospital, is the Vaginal Breech Initiative . This center had 47 women with trials of labor over 6 years with 34 successful vaginal breech births.…”

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

“…These documents contain clear statements about the need to respect a woman's decision and that information on risks and benefits for all option for birth should be provided. There is also some evidence emerging of specialist multidisciplinary teams to support planned vaginal breech births wherever possible, along with some other services who support formal referral processes and counselling of women prior to decision making for VBB (Borbolla Foster et al 2014;Maier et al 2011;Marko et al 2015;Walker, Scamell & Parker 2016). Increasing the existence of such services may raise the profile of VBB as a valid option and,…”