Women's perception of choice and support in making decisions regarding management of breech presentation

02 July 2021
Volume 29 · Issue 7

Abstract

Background

Professional guidelines recommend midwives and obstetricians actively involve women in making decisions about their care. To date, breech research has focused mainly on assessing the effectiveness of different management options.

Aim

This research explores women's experience of breech presentation and their perception of choice and support in making decisions with regards to breech management.

Methods

This study uses a phenomenological research design. Semi-structured interviews took place in hospital or women's homes. A total of six postnatal women who were diagnosed with breech presentation after 36 weeks' gestation took part in the study. Data was analysed using Colaizzi's method.

Findings

A total of 84 significant statements were clustered into four main emerging themes. These include women's feelings, their healthcare expectations, their preferences and their values.

Results

Breech discussions mostly occurred between obstetricians and women. These primarily focused on external cephalic version, Elective Lower Segment Caesarean Section and Breech Vaginal Birth. These options did not always become choices available to women.

Breech presentation refers to the position of a fetus in the uterus where the buttocks or feet present first, as opposed to a cephalic presentation where fetal vertex constitutes the presenting part (Waites, 2003), with an incidence of 3%–4% of all term pregnancies (Impey et al, 2017a; 2017b).

Although vaginal breech delivery has traditionally been considered a common approach in the management of labour, the findings from the Term Breech Trial (TBT) (Hannah et al, 2000) suggested a reduction of neonatal mortality and morbidity amongst service users undergoing Elective Lower Segment Caesarean Section (EL-LSCS). Since its publication, the TBT has been subject to professional criticism (Whyte et al, 2004; Glezerman, 2006; Kotaska, 2007; Lawson, 2012), due to its limitations and biases (see Table 1). Maternal and fetal complications that may derive from undergoing EL-LSCS should not be underestimated either (see Table 2). Irrespective of this, the TBT was pioneer in leading a change in practice that would see a rise in the number of EL-LSCS for breech-presenting women at term and a decline in vaginal breech birth offer.


Table 1. Limitations of the Term Breech Trial
  • Unsound safety allegations in the breech vaginal birth group
  • Biased extrapolation of short-term outcomes towards long-term ones
  • Limited internal and external validity
  • Violation of inclusion criteria
  • Variation in the standard of care between participating centres
  • Lack of professionals' expertise in attending breech deliveries
  • Others
Source: Whyte et al, 2004; Glezerman, 2006; Kotaska, 2007; Lawson, 2012

Table 2. Maternal and fetal complications of lower segment caesarean section
Maternal complications Fetal complications
  • Bladder injury
  • Abdominal pain
  • Wound and/or intrauterine infection
  • Postpartum haemorrhage
  • Blood transfusion
  • Deep vein thrombosis and pulmonary embolism
  • Complications related to repeat caesarean section, including placenta praevia and morbidly adherent placenta
  • Risk of uterine rupture in subsequent pregnancies
  • Hysterectomy
  • Maternal death
  • Temporary breathing difficulties, which can lead to respiratory distress syndrome
  • Admission to the Neonatal Intensive Care Unit
  • Surgical laceration/cut
  • Long term complications, including: asthma and obesity
  • Increased future risk of stillbirth in subsequent pregnancies
Source: National Institute for Health and Care Excellence, 2021

In the UK, the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (Impey at al, 2017a; 2017b) advocate women should be offered a full spectrum of choices when making decisions regarding management of breech presentation at term. These should include access and/or information regarding Complementary and Alternative Medicine (ie moxibustion), External Cephalic Version (ECV), EL-LSCS and Breech Vaginal Birth (BVB). Offering maternal choice and personalisation is a key recommendation in the National Maternity Review and a fundamental component of the NHS Long Term Plan (NHS England, 2016; 2019). The extent to which full choice offer is accomplished in current clinical practice for breech-presenting women, nonetheless, can be questioned. Additionally, the literature relating to women's experiences and their perceptions following breech diagnosis is limited.

This research explores women's perception of choice and support from healthcare professionals, more specifically from midwives and obstetricians, in making decisions regarding breech management following diagnosis at or near term.

Literature review

In order to explore women's perception of choice and support in the management of breech presentation, it is important to gain an understanding of their knowledge and preferences on the subject. This has previously been studied by Raynes-Greenow (2004), who undertook a cross-sectional survey including 174 antenatal pregnancy women with a mean gestational age of 29.9 weeks. The author concluded that 87% of women received information about breech management from books, family and/or friends, as opposed to healthcare professionals. Only 39% of women would consider an ECV as an option, with 72% of women stating they would have wanted to make this decision together with their midwife or doctor. The findings suggest some women were keen but unable to access professional opinion in order to make a decision. Similar surveys demonstrate that, where a full explanation about ECV is provided, the proportion of women who would be keen to undergo ECV increases (Leung et al, 2000; Say et al, 2013). Predictors of successful ECV and vaginal birth should be used in the information giving process (Salzer et al, 2015; Isakov et al, 2019). These include BMI<30, multiparae, polyhydramnios, posterior placenta. This highlights the impact supplying women with information has in making ECV more accepting. Similar studies have, however, achieved contrasting findings. A survey of two cohort studies of Israeli pregnant women experiencing a breech presentation, showed that women were less likely to undergo ECV (from 54% down to 24%) and more likely to want to opt for a EL-LSCS (from 65%–97%) when provided with information about their options (Yogev, 2002).

The quality of information is also vital to identify women's perception of support in order to make true informed decisions. A study into pregnant women's attitudes and perception of support in making a decision regarding breech management concluded that one-third of respondents were not fully aware of their options and, consequently, underwent an elective caesarean section, mainly for safety reasons (Caukwell et al, 2002). Although obstetricians have been found to influence women's decisions regarding breech management (Vyshali et al, 2012), midwives play a crucial role in ensuring clients are fully informed of their choices. The extent to which this is achieved could be argued. Stapleton's (2002) qualitative study identified that midwives were making very little effort to explore and accommodate women's individual information needs. Breech-presenting women who are considering a vaginal breech birth have reported they value clear, consistent and relevant information regarding move of birth; while expecting autonomy and support in making care choices (Homer et al, 2015).

Women's and healthcare provider's experiences of breech presentation was also studied by Founds (2007), who identified women relied on their obstetricians and/or midwives to diagnose and provide information regarding breech management. The interaction between women and healthcare professionals facilitated the construction of meaning regarding breech presentation, thus highlighting their influence in women's experiences.

Women's experiences were further investigated by Guittier et al (2011). From feelings of hope that spontaneous cephalic version would take place, to disappointment when ECV was attempted but unsuccessful and finally uncertainly and doubt in finalising decisions regarding mode of birth; women embarked on a journey of emotions that also highlighted how women perceived the information provided by obstetricians was biased in favour of caesarean section. Consequently, the authors encouraged institutions to promote environments for women to raise their concerns and express their feelings on the topics of caesarean section and breech birth. This could partially be achieved by undertaking further research on the topic of breech presentation. Recent studies (Rattray et al, 2020) have explored the attitudes of midwives and obstetricians, highlighting how training increases knowledge and confidence in vaginal breech birth management, and respecting informed decision-making and choice.

Research methods

Methodological issues and research approach

Qualitative research can be defined as the ‘objective process used in examining subjective human experiences using non-statistical methods of analysis’ (Langford, 2011) through the collection of narrative and subjective human experiences (Polit and Beck, 2014). The purpose of this study is exploratory, so that the subject can be better understood, without intending to generalise research findings (Gray et al, 2016). Although qualitative research may historically have been perceived as being less popular in health sciences, it continues to grow reputation as a unique tool in the study of human experiences, visualised from an individual's point of view (Langford, 2011; Grove et al, 2013).

Research design

Phenomenology is a non-experimental research design that aims to explore and search understanding for people's lived experiences, while integrating the physical, social, psychological, spiritual and emotional needs of human beings. Descriptive phenomenology aims to purely define human experience while bracketing, intuiting, analysing and describing (Polit and Beck, 2014; Neubauer et al, 2019).

Setting and population

The study was conducted within the maternity settings of a district general NHS hospital that attends 5 000 births per annum. The Trust delivers care to a low-to-middle social class, multicultural population. Research participants were recruited postnatally. The inclusion criteria is reflected in Table 3.


Table 3. Study inclusion criteria
  • Service users during the postnatal period, where birth had happened in the last six months prior to the interview date and where breech diagnosis was made prior to delivery, at a gestational age of more than 36 weeks
  • Primiparae and multiparae users
  • Singleton pregnancy
  • English-speaking service users from any cultural background
  • Service users between 18−40 years of age

Sample

A purposive, convenience sampling was used. The author of this study aimed for transferability and not external validity of the results. A total of 24 service users over an eight-month time period met the inclusion criteria. A letter containing a patient information sheet, a consent form and an addressed, pre-paid envelope was sent to potential research participants. A total of nine women responded; two of the respondents did not consent and one client was excluded. A total of six clients consented to taking part in the study. Sociodemographic and obstetric characteristics are presented in Table 4.


Table 4. Sociodemographic and obstetric characteristics
Number of participants (n=6)
Ethnic origin British 4
Asian 2
Marital status Married 5
Separated 1
Parity Primiparae 5
Multiparae 1
Timing of breech diagnosis Antenatally, prior to planning birth choices 3
Antenatally, after planning birth choices 2
Intrapartum 1
Gestation at breech diagnosis Prior to 37 weeks' gestation 1
After 37 weeks' gestation 5
Mode of delivery Vaginal birth 0
Elective caesarean section 2
Emergency caesarean section 4

Data collection

The author of this study used face-to-face, semi-structured interviews. A schedule was used, allowing flexibility and freedom for the participants to highlight what was important to them (Bluff, 2006). An interview grid was designed, based on that of Guittier et al (2011), due to the similarities between both studies. The interview grid used is presented in Table 5. A pilot study of four women was used to ensure the validity of the interview grid and to ask for feedback. Interviews were undertaken by the author. The mean length of the interview was 20 minutes. Flexibility was given for interviews to take place in a hospital setting or at the client's home. Research participants were made aware of their right to withdraw from the study at any point. Four service users were interviewed at home and two in hospital. The Trust's lone worker policy and National Research Ethics Services (NRES) guidance were followed. Interviews were recorded and notes were taken to inform of non-verbal cues (Bluff, 2006). The author acknowledges potential research biases, including the ‘Hawthorne effect’ by which participant's performance may change as a result of them being observed (Chan et al, 2013).


Table 5. Interview grid
The research process will be explained. Consent form to be signed and kept as form of evidence. Interviewee will be informed of her right to withdraw at any time, if desired
  • How did you feel when you learnt that your baby was in breech presentation?
  • What methods were proposed to you for turning your baby?
  • What information did you receive about the childbirth options available, once your baby was found to be presenting breech (caesarean section and vaginal breech, if mentioned)?
  • With whom did you discuss the options available for turning your baby and the choice of method for childbirth?
  • Did you feel you had a choice in selecting a method to turn your baby, if desired?
  • Did you feel you had a choice with regards to mode of delivery, both caesarean section and vaginal breech?
  • Did you feel supported by healthcare professionals in making a decision regarding options available for turning your baby and mode of delivery?
  • How would you describe your experience, overall?
  • What do you value the most regarding your overall care received?
  • What aspects of your care could have been improved on?

Data analysis

Transcription took place, considering interviewees' tone of voice and sighs. A total of 10 minutes of tape recording needed 60–75 minutes of transcription. Each transcript was typed on A4 paper and individually sent to the participants to verify the content. An academic supervisor reviewed the transcripts, adding reliability to the process. The author made efforts to ensure ‘bracketing’ (Chan et al, 2013; Neubauer et al, 2019). Self-awareness, insightfulness, willingness to be wrong, openness and being transparent facilitated this process. Consistency between interviewees' views enhanced credibility. Confirmability was achieved by providing a detailed explanation of how conclusions were reached. Prompt data and content analysis guided data collection on subsequent interviewees (Robinson, 2006; Nelms, 2014). Categories were established. Interviewees confirmed the findings related to their own breech experience.

Ethical issues and access

Ethical approval was sought via the Integrated Research Application System, following the NRES' guidance. Informed consent from research participants was obtained. Confidentiality was maintained, using attributed data to identify the different interview transcripts. Manual files and interview recordings were securely kept by the author via password protection, encrypted data and locked drawer. The principles of beneficence and non-maleficence where considered. The potential benefit of this study included a better understanding of the subject to assist midwives and obstetricians in evaluating practice and identifying areas of service development. Considering that analysing birth experiences may be a sensitive issue for some (Waites, 2003), a referral pathway to perinatal mental health services was readily available but not required. The author ensured their dual role as a midwife and researcher did not overlap by undertaking research activities outside clinical duties and contracted hours.

Results

Description, analysis and synthesis of interview findings. Data analysis was undertaken using Colaizzi's (1978) framework. The author thoroughly read the interview transcripts a number of times, understanding, highlighting and taking into account meaningful comments and non-verbal cues. 84 significant statements were pinpointed and meaning formulated, prior to producing 15 themes, to finally produce four concluding, emerging themes. An example of how emerging themes were formed is included in Table 6. Additionally, examples of women's quotes are presented in Table 7.


Table 6. Example of how emerging themes were formed using Colaizzi's (1978) phenomenological method
1. Transcript and audio
2. Meanings
  • ‘I found out (that baby was breech) in the end’
  • ‘It was a bit scared because I'd never heard (of) it (breech) … It was horrible… I didn't even know what to do and what to feel…’
  • ‘I was a bit frustrated. I wouldn't have had to have been induced had I been scanned when I came in (for induction of labour)’
  • ‘I was heavily dilated … my thoughts were like … “why is this being picked up now? Why was this not recognised before?” I was just in shock as to why it wasn't picked up before’
  • ‘(We felt) slightly disappointed (when they found baby was breech) but we didn't really have much time to worry about it; we were already in labour and it was a bit too late’
  • ‘I learnt (that baby was breech) at 28 weeks. At that stage, you don't feel there is a problem … you know that the greatest chance is that baby will burn … I guess (I was) fairly optimistic but aware that if there is anything I can do to make sure that she (baby) turns, then I am going to try to do it’
  • ‘Through the hospital, nothing was proposed (to turn baby) and it (breech presentation) was ignored the whole way through’
  • ‘I was really shocked. I only found out the day before his due date that he was breech’
  • ‘I originally planned a home birth because I wanted as little intervention as possible … that (diagnosis of breech presentation) means it's going to be a caesarean, just what I had been desperately trying to avoid’
  • ‘I was very anxious and surprised. I was convinced everything was fine and everyone had told me everything was fine’
3. Meaning formulation
  • Breech diagnosis creates uncertainty and fearsome feelings
  • Women experience disappointment and shock when breech presentation is not diagnosed antenatally (in advance)
  • When early breech diagnosis is made and women are informed, they feel optimistic and aim to try ways to turn baby
  • Late breech diagnosis makes women feel frustrated, shocked, anxious and surprised. It can lead to women having to undergo unnecessary procedures (ie induction of labour)
4. Themes Theme cluster
  • Breech diagnosis engenders feelings of uncertainty, fear, disappointment and shock
  • In the event of late breech diagnosis, women feel frustrated, shocked, anxious, surprised, disappointed, urgency
Emergent theme
  • Women's feelings: the impact of breech diagnosis
5. Compiling a description
6. Foundation
7. Validation

Table 7. Examples of participants' quotations for the four emerging themes
1. Women's feelings: the impact of breech diagnosis
  • ‘I was a bit scared because I never heard (of) it (breech presentation) … It was horrible… I didn't even know what to do and what to feel’
  • ‘I was already experiencing contractions from being induced … I wouldn't have had to be induced had I been scanned when I came in? I was a bit frustrated’
  • ‘(We felt) slightly disappointed (when we found baby was breech)’
  • ‘I originally planned a home birth because I wanted as little intervention as possible … I was really shocked. I only found out he was breech the day before his due date’
  • ‘Why was this not recognised before? Part of me still doesn't have closure on the experience’
2. Women's healthcare expectations: breech care
  • ‘In all this (antenatal) period (the community midwife) saw me three or four times’
  • ‘I couldn't get appointments with the midwife … GPs don't have the same experience as the midwife in terms of “feeling” babies and dealing with pregnant ladies … It was a big mistake that it wasn't picked upon beforehand’
  • ‘I do feel like … it was a bit of negligence in terms of the healthcare that I have received from my (GP) surgery … I just felt like another pregnant Asian woman … you know’
  • ‘There wasn't time to kind of go through the (information giving) process’
  • ‘Having an independent midwife … I had her full support if I wanted to go ahead with a (breech) home birth … I tried moxibustion, acupuncture, I went to a chiropractor … I had options’
3. Women's preferences: making breech decisions with guidance
  • ‘In hospital (the care) was very good … but not in (the) GP and community’
  • ‘I couldn't get an appointment with my midwife … they (GP surgery) weren't really bothered’
  • ‘(The doctor) said to me: “we will do the external cephalic version (ECV)”’
  • ‘I discussed things with the surgeon … they said (caesarean section) was the best option’
  • ‘I wasn't really given an option … it was very much: “your baby is in breech position, we will do an emergency caesarean section’’’
  • ‘They offered a vaginal birth or just a caesarean’
  • ‘It was never offered to me to have baby vaginally in the hospital … I was keen to try the ECV … I was 38 weeks when it was finally mentioned by the consultant … I insisted that I would like to try’
4. Women's values: professionalism, trust and safe outcomes
  • ‘I thought the caesarean part was fab … really quick, professional and helpful … The aftercare was beautiful, they were just amazing and it was brilliant … I think that is so important’
  • ‘Staff were brilliant … I can't fault the care I was given’
  • ‘I can't fault (the team) to be honest … they were really good, good service … friendly, no issues at all … The overall efficiency of everybody … after the operation as well … they were really nice’
  • ‘The consultant was very open, informative and supportive … Everybody was so professional, caring… it didn't feel they were just doing their job, it felt like people genuinely cared’
  • ‘The most important thing (was) that my baby was delivered safely in the end and that there was nothing wrong … she was healthy’
  • ‘Going to the operating theatre … we were laughing, they were making me (feel) comfortable’
  • ‘(The best) was 100% the aftercare’

1. Women's feelings

The impact of breech diagnosis

Breech diagnosis was found to evoke a variety of feelings in women. Some of the interviewees experienced a sense of uncertainty, shock, disappointment and frustration after breech diagnosis. These feelings were more powerful in women who had never heard of breech presentation and those whose birth plans were affected by the diagnosis. The timing of breech diagnosis was found to be significant, with five of the interviewees being diagnosed after 37 weeks of gestation. Late breech diagnosis appears to have a negative impact on women's emotional state, triggering doubtful thoughts that lead to unanswered questions. This seemed to be exacerbated by the fact that women were left having to undergo procedures that could have been prevented (ie induction of labour). When early breech diagnosis is made and women feel fully informed, they appear to be more optimistic and aim to try ways to turn the fetus to a cephalic presentation.

2. Women's healthcare expectations

Breech care

Accessibility to maternity services and care provision appeared to play an important part in women's responses to breech diagnosis. Feelings from past events, such as being unable to access antenatal care with a midwife or obstetrician, appeared to evolve. This triggered strong emotions, where some women feel neglected, stereotyped and discriminated. Some of the interviewees highlighted that they expected the NHS to provide specialist breech services, with some of them turning to independent services for support. These included accessing complementary and alternative medicine services (ie moxibustion). Women expected breech presentation to be diagnosed and acted upon promptly, and failure to access antenatal services is perceived to be a contributing factor to late diagnosis. Abdominal palpation is perceived by women to be a core midwifery skill in diagnosing breech.

3. Women's preference: making breech decisions with guidance

Overall, women showed satisfaction with the care and support received from midwives, obstetricians and allied healthcare professionals. Nonetheless, women voiced to be more content with the care they received at the hospital than that of community services, particularly during the antenatal period. With reference to the provision of professional advice, women generally felt they were given sufficient information to make an informed choice. Women reported this information comes mainly from doctors who appear to influence the information-giving process by voicing their preferred management option. The delivery of the breech-presenting fetus under caesarean section appeared to be the preferred mode of birth for obstetricians. A total of three out of the six interviewed women were offered an ECV. Vaginal breech birth was mentioned to a total of four women. Being informed of vaginal breech birth did not necessarily translate to women feeling they had been fully advised, encouraged or offered this as a viable option. Some women felt the information was only provided upon request and that restrictions applied. While some women felt they were able to make a final decision in the management of their breech presentation, others felt they consented to a decision made by an obstetrician. Caesarean section was often recommended due to ‘safety reasons’.

4. Women's values: professionalism, trust and safe outcome

Women highlighted a number of personal traits and professional behaviour in midwives, obstetricians and other healthcare professionals who participated in their care which positively contributed towards their breech experience. These entailed being caring, calm, comforting, feeling safe, prompt-acting, faultless care, professional, being helpful, satisfying, friendly, efficient, and naturally honest. Some women have trust in healthcare professionals and value their opinion and experience as pregnancy experts. When women feel cared for and have a safe outcome, previous negative emotions were diminished. The care received during a caesarean section and imminent postnatal care, being able to access an early discharge and the overall support contributed to this.

Discussion

Three discussion points are identified in response to the research questions:

1. Perception of choice

Women perceive that discussions regarding breech management take place, although it is of concern some perceived breech choices were only available on demand. Caesarean section, ECV and vaginal breech birth were the only management options discussed in the NHS which means at times women need to reach out to private services to find the support they require. This is concerning, since many may not be aware of what services may be available to support them or have the financial resources to access them. Some women feel they had choice, while others perceived they consented to an obstetric decision. Findings from this research correlate with evidence from studies on this subject (Raynes-Greenow et al, 2004; Founds, 2007; Guittier et al, 2011). As anticipated, breech discussions in the NHS appear to take place among obstetricians and women with limited midwifery input. This could be due to organisational culture and midwives' perception of responsibility in providing information. Many of the interviewees in this breech research were subject to late breech diagnosis, which could explain the need for consultant involvement.

2. Perception of support

Women expected maternity services to be easily accessible but they perceived there were barriers to achieving this. There are discrepancies between the support women expect and that they receive which varied amongst primary and secondary settings. Women were generally satisfied with the support received during the birth and postnatal period but expressed dissatisfaction with antenatal care. Understandably, this leaves some women feeling they would have benefited from having more regular antenatal appointments which may have helped with prompt diagnosis. The author of this research initially anticipated there was a need to enhance support and choice offer during the antenatal period which this study proves. Women generally felt midwives should provide support, information and continuity of carer. Improving access to holistic midwifery care and support through the childbirth continuum for all was a priority for all women. These findings directly relate to those of Stapleton et al (2002) and Dartnall et al (2005) and participant's expectations is in line with maternity drivers and national policy (NHS England, 2016; 2019). Women's reports of neglect, stereotyping and discrimination are of major concern, particularly in the light of recent reports highlighting the differences in care outcomes for women from black and ethnic minorities background (Knight et al, 2020). Healthcare services must continue to involve service user feedback in the planning, design and delivery of modern maternity services, including those related to breech management.

3. Breech experience

Breech diagnosis evokes feelings of fear, shock, disappointment and uncertainty. Nonetheless, some women highlight they feel the support they receive antenatally does not meet their expectations which leaves them vulnerable from both a physical and emotional perspective as they have difficulties in accessing help from birth experts. In fact, women feel more optimistic when breech presentation is timely diagnosed and they are given options. These findings are in line with those made by other authors (Bowman, 2001; Waites, 2003; Founds, 2007), although the way in which women manage their emotions following diagnosis is not sufficiently understood. The findings from this research are also paramount in assisting practitioners understand which professional characteristic and aspects of their care women value the most which were not fully explored in similar studies. Thus, women reported that caring, comforting, remaining calm but acting promptly are professional qualities that contributed to them having a more positive birth experience. Not being able to access professional help antenatally was a concern of a number of women.

Recommendations

Continuity of carer models may contribute to improving maternal satisfaction. Midwives have a responsibility in ensuring effective care and communication. NHS providers should consider developing breech services which would contribute to enabling access to specialist, antenatal support for breech presenting women. Additionally, it would help tackle late breech diagnosis and widen management options. Changes to the RCOG (2017b) Management of Breech presentation guidelines promote choice but the extent to which this is achieved practice can be questioned. Further research on the subject may help improve understanding.

Limitations

The author acknowledges the limitations of convenience and purposive sampling, the and Hawthorne effect. Attempts have been made to ensure bracketing. Rigour, transferability, credibility, confirmability and dependability have been at the core of this research's discussions and methodological justification.

Conclusions

Healthcare professionals are required to provide women-centred care but little attention has been paid to women's perception of support and choice to date. The results from this study identified four main themes: women's feelings and the impact of breech diagnosis, women's healthcare expectations, women's opinion and preferences, and women's values in their breech experience. Women perceived breech management discussions consisted of three main choices: undergoing an ECV, caesarean section and vaginal breech. Some women felt they made a choice in managing breech presentation, while others consented to an obstetrician's decision.

Women reported midwives did not appear to be involved in undertaking breech discussions. In addition, they reported satisfaction with the care they received in hospital but felt dissatisfied with their antenatal care, particularly that provided in community settings. While women predominantly feel their care during birth was outstanding, they feel let down by failure to diagnose breech presentation promptly. This ultimately impacts women feeling generally shocked following late diagnosis. The topics barriers in accessing care, the differing satisfaction between primary and secondary care providers, those of communication, the role of the midwife in meeting the psychosocial needs of women and that of late breech diagnosis are of significant importance. Future research exploring the subject of women's perception of support will further contribute to the understanding about this relevant, under-researched subject. This could serve as a pilot for a larger study on the subject.

Key points

  • Healthcare professionals have a responsibility in providing women-centred care
  • Women's feelings can be exacerbated by late breech diagnosis
  • Service users expect obstetricians and midwives to provide information and a variety of choices regarding breech management
  • Midwives and obstetricians should advocate for and ensure service users are aware of all options available to them, following breech diagnosis. These should include management options for turning a breech-presenting fetus, vaginal breech birth and elective lower segment caesarean sections
  • In planning mode of birth, an evidence-based discussion taking into account benefits and disadvantages of all available options should be at the core of the discussions and decision-making process

CPD reflective questions

  • Reflecting on some of the feelings service users experience, how can midwives support communication and continuity following breech diagnosis in advanced gestational age?
  • How can midwives help support multidisciplinary discussions regarding breech management options?
  • Why does the author of the study anticipate continuity of carer may help provide an overall more positive user experience?
  • How can the implementation of a breech clinic bring help service and users and providers?
  • What steps will you follow in designing and implementing a breech clinic?