The heightened focus on risk affects maternity care providers' attitudes towards vaginal breech birth (Berhan and Haileamlak, 2016), and this professional apprehension may have the potential to limit the vital support, advocacy and empowerment of women's choices. In relation to current and future midwifery practice, these professional attitudes, coupled with tertiary and clinical organisational teaching methods, may be highly influential. Simulation is a particular teaching tool with a long history in obstetric and midwifery education (McKenna et al, 2011), and which continues to play a significant role in training in contemporary educational institutions and clinical environments. Education, and the enabling of sharing of knowledge, is often a major deciding factor in certain skills being imparted to the next generation of clinicians. This raises the question as to whether midwifery students are being adequately prepared to apply vaginal breech birth skills to clinical practice or not, and ultimately if planned vaginal breech birth is facing extinction.
The historical perspective
Simulation has a long history in midwifery and obstetric education, with models and props being faithful tools used by educators for centuries. A lack of diagnostic technologies and interventions in the past required birth attendants to be skilled and prepared for breech presentations, so models, purposely designed for both demonstration and interaction with learners, were used for obstetric training for both doctors and midwives (Owen, 2012). The limited literacy and formal education possessed by midwives, who often assisted medical accoucheurs (a historical term for an obstetrician), was recognised by Giovanni Antonio Galli in the 1700s, and so, to address this gap in theoretical knowledge, he constructed a birth simulator complete with a glass uterus and fetal mannequin, and assessed pupils on their ability to successfully birth the fetus while blindfolded (Owen, 2012).
Eighteenth century French royal midwife Madame du Coudray used materials including leather, bones and fabric, to create life-sized models known as ‘obstetric machines’ for the purpose of training midwives in the knowledge and skills required to manage deviations from the normal mechanisms of birth (Yuill, 2017). Madame du Coudray also documented the importance of providing accoucheurs with regular opportunities to practice and refresh skills required for complex birth scenarios, and later editions of du Coudray's models were even able to release fluids to mimic amniotic fluid and blood.
In 1742, William Smellie, who has been credited with designing some of the most intricate simulation models, advertised courses in the art of midwifery, using practical simulation to cover multiple potential presentations and complexities. He received criticism for using replica fetuses made from materials including wood and rubber, rather than using fetal cadavers as was common practice at the time, and these natural mannequins continued to be used into the twentieth century (Owen and McDonald, 2013). In 1755, a former student and assistant of Smellie, Colin Mackenzie, opened a school of midwifery in London, where one of Mackenzie's students, William Hey, noted that observing others' mistakes during simulations was beneficial to his own learning experience (Owen, 2016). In 1767, surgeon John Leake discussed the advantage of simulation to one's education and development of safe clinical practice. He suggested that practitioners' initial introduction to invasive technical skills is more appropriate on artificial bodies rather than ‘on real subjects, to the manifest danger of the patient and the ruin of their own reputation’ (Owen, 2016: 106). This suggests that individuals required repeat opportunities to hone their skills before being considered proficient to practise on real-life women.
The acquisition of obstetric simulators by training institutions continued to rise throughout the nineteenth and twentieth centuries, gradually improving in fidelity (Ennen and Satin, 2010), and some surviving examples are displayed in museums in Europe and Australia. One particular exhibit is a leather fetus complete with digits and skull suture lines and housed inside a torso. This was used to teach birth attendants how to determine fetal presentation and practice manoeuvres such as those applied to vaginal breech birth (Owen and McDonald, 2013).
Midwifery student training today
Simulation training has become a standard feature of contemporary midwifery training and education programmes. From du Coudray's humble yet pioneering obstetric machines, 21st century technology now provides clinicians with high-fidelity equipment that can be programmed to respond to real time interventions (Yuill, 2017). In busy maternity hospitals, increasing numbers of midwifery and medical students in clinical environments are all vying for experiences to gain skills in normal and complex cases. Additionally, clinical placement shortages further reduce students' chances of witnessing and/or participating in more complex situations alongside experienced clinical staff (McKenna et al, 2011). Midwifery education relies on simulation training in order to provide students with opportunities to develop relevant practical skills, including the management of both undiagnosed breech presentation and planned vaginal breech birth, and may aid in relieving some of the potential tensions associated with these student-saturated environments (Bogossian et al, 2012). While it has been suggested that simulation training may be a solution to the declining numbers of clinicians retaining proficiency in vaginal breech birth, simulation limits support and supervision available to students. Concern has been expressed about relying on simulation training alone, which may not provide adequate levels of competence to sufficiently prepare students to safely transfer skills to clinical practice (Hunter, 2014). This therefore increases the importance of protecting and increasing skill mixes to improve learning opportunities for students.
Another important role of simulation in midwifery education is to provide opportunities for hands-on, experiential learning, which enables students to develop and refine practical skills that can be translated to safe clinical practice (Yuill, 2017). This pedagogical approach is based upon scenarios that can be replicated, where mistakes can be made in a supportive and controlled environment. Performance can then be improved upon without causing harm or compromising the safety of actual women and babies, allowing individuals and teams to attain greater confidence and competence in these skills before their application to real-life clinical situations (Lendahls and Oscarsson, 2017). Simulation activities also allow students to gain familiarity in identifying and using specialised equipment, which is useful when emergencies arise in the clinical setting and timely interventions are critical. Simulation therefore provides opportunities for students to learn, practise and demonstrate knowledge and skills—including specific management and specialised manoeuvres pertaining to vaginal breech birth—and may also be beneficial in reducing students' anxieties associated with limited exposure to this while on clinical placement (Vermeulen et al, 2017).
As an educational strategy, simulation can also assist students in developing their ability to link theory to practice, which can be further enhanced by providing opportunities for reflection and critical thinking (Lendahls and Oscarsson, 2017). The provision of interactive scenarios that require teamwork also helps to improve team coordination, delegation of roles and communication (Shepherd et al, 2014). Reflection is a crucial element of improving practice and confidence, and debriefing following drills also allows educators and participants to assess the efficacy of their actions, by identifying what went well and the areas for improvement.
In the context of the midwifery philosophy of being ‘with woman’, technology has its limitations, and the human interaction and intimate nature of maternity care may be lost when attempting to replicate clinical situations in non-clinical settings (Sanders and Steele, 2014). Some argue, therefore, that some vital aspects of midwifery care cannot, and perhaps should not, be replaced by simulation, as it cannot adequately substitute the educational value of real-life clinical experiences (Yuill, 2017). However, as tertiary teaching methods continue to move away from face-to-face classroom settings into increasingly isolating external self-directed formats, simulation can provide valuable activities accommodating for different learning styles and promote interaction with peers, which is essential to working within multidisciplinary teams (Bogossian et al, 2012). It has also been found that, compared to more experienced staff, some students are hesitatant to engage with simulation training when other participants are strangers, or feel intimidated by their perceived limited abilities in interprofessional drills (Vermeulen et al, 2017).
‘Simulation has a long history in midwifery and obstetric education, with models and props being faithful tools used by educators for centuries. A lack of diagnostic technologies and interventions in the past required birth attendants to be skilled and prepared for breech presentations, so models were used for obstetric training for both doctors and midwives’
Practice trends and a professional culture preoccupied with risk
Breech presentation occurs in approximately 3-5% of singleton pregnancies at term. The results of the Term Breech Trial (Hannah et al, 2000) had a profound impact on changes to clinical guidelines on the management of breech presentations globally, as it concluded that planned caesarean section was the safest method of birth for breech presentations and gave reasons to recommend this as a universal approach to management (Sanders and Steele, 2014). Despite the subsequent recognition of the study's flaws and unsubstantiated evidence, many clinicians still consider planned caesarean section best practice, and it continues to be the routine—and sometimes only—recommendation presented to women (Petrovska et al, 2017).
Professional dilemmas arise in regards to respecting and advocating for women's autonomy when standard care is declined and their preferences are beyond individual clinicians' skillsets (Jenkinson et al, 2015). Since the Term Breech Trial, global rates of caesarean section have increased significantly, although research evidence such as that presented in the PREMODA study (Carayol et al, 2004), which was considered to be the ‘antidote’ to the Term Breech Trial, supports vaginal breech birth as a safe birth option for women who have otherwise uncomplicated pregnancies and can be referred to midwives and obstetricians who possess the appropriate expertise (Hunter, 2014). Research also suggests strong correlations between the level of clinical skill and experience held by maternity care providers and outcomes of vaginal breech birth (Walker et al, 2017). If there were greater accessibility to care, facilitated by competent and experienced practitioners, more women would opt for vaginal breech birth. In fact, data supplied by a Finnish hospital showed that one in every three women with breech presentation met prescribed eligibility and were willing to consider vaginal breech birth (Toivonen et al, 2014).
Routine caesarean section for breech presentations becomes problematic in that the scope for sharing of knowledge, clinical expertise and skills in the management of vaginal breech birth is reduced, limiting opportunities for future generations of clinicians to gain proficiency in these skills through observation and hands-on involvement (Antomarchi et al, 2014). Unless intentional efforts are made to accommodate women wanting vaginal breech birth, opportunities for senior clinicians to mentor and supervise junior staff will become increasingly rare (Sanders and Steele, 2014). Consequently, the skill mixes within organisational staffing and professions will continue to be depleted, and may be lost altogether (Sloman et al, 2016). Clinical staff with expertise in vaginal breech birth are therefore invaluable to the environments in which they work and to other staff members (including the few students who have an opportunity to experience vaginal breech birth in practice) (Walker et al, 2017). Vaginal breech birth will continue to be the preferred mode of birth for some women, therefore, staff proficient in these skills are also invaluable as leaders that can champion vaginal breech birth in the paradigm of complex normality.
Literature on students' preparedness for vaginal breech birth
Literature specific to midwifery students' theoretical and practical preparations for breech birth is limited. Most available literature focuses on simulation as an educational tool for midwifery students (Norris, 2008; Stone et al, 2017), and endorses it as a way to develop deeper understanding of theory and critical thinking, facilitate hands-on opportunities to learn and refine practical skills. One study concluded that simulation was a valuable tool, particularly for training midwifery students in responding to high-risk, low-frequency clinical situations that may not be seen during their midwifery education (Bogossian et al, 2012). Students' participation in experiential learning opportunities not only increases familiarity with the necessary techniques, but also enhances other skills, such as effective communication and teamwork. Other studies have suggested, however, that exploring qualified midwives' feelings and confidence in managing vaginal breech birth observed that some felt that their pre-registration training had been inadequate, as gaining competency through simulation does not necessarily deem clinicians to be safe and competent in real cases (Sloman et al, 2016). While simulation may be helpful in preparing midwifery students for clinical situations, there is no evidence to suggest it can replace the value of real experience gained within the clinical setting entirely (Cooper et al, 2012).
Conclusion
The clinical skills, knowledge and expertise required to manage vaginal breech birth safely are in danger of becoming extinct in high-resource countries. An active approach to preserve these skills also serves to protect women's choices for birth. Changes in attitudes and practice regarding vaginal breech birth need to occur to ensure these clinical skills are not lost and can continue to be passed on to future generations. High numbers of medical and midwifery students, and limited skill mixes among qualified staff may prevent students from being adequately prepared for vaginal breech birth. Simulation training therefore promotes links between theory and practice, and provides midwifery students with opportunities to learn and practise technical manoeuvres. Ideas on the importance of training and preparedness from centuries earlier still ring true and are reflected by the development of high fidelity simulators today. There are gaps in research as to whether midwifery students feel adequately prepared and what contributes to this. Interviewing students or recent graduates who have experienced vaginal breech birth in the clinical setting to assess the standard of theoretical knowledge and practical skills training they had before the event may provide a valuable contribution to the body of knowledge.