Experienced midwives maintain primary care during planned breech births
The Montfort Hospital in Ottawa recently recognized midwives’ full scope of practice when it determined that it is no longer mandatory for midwives to transfer care to obstetricians for clients planning vaginal births for breech babies.
The hospital’s revised protocol states that it is only necessary for midwives to consult during the second stage of labour for complications or for C-sections. At that time, the midwife and the obstetrician on call will determine whether care needs to be transferred. Midwives who have experience delivering breech babies vaginally will maintain primary care
of their clients. The revised protocol is in accordance with the College of Midwives of Ontario’s Indications for Mandatory Discussion, Consultation and Transfer of Care and the Society of Obstetricians and Gynaecologists of Canada’s guidelines.
“The Montfort Hospital completely supports midwives working within their full scope of practice, as midwives are regulated by their own College,” says Ann Salvador, the administrative director of the Family Birthing Centre at the hospital. “The College of Midwives of Ontario standards recommend a consultation in labour, not a transfer. Midwifery clients appreciate having their primary care provider retain care.”
Twenty-one midwives have privileges at the hospital. Salvador says the midwives are fully integrated members of the healthcare team.
“Midwives are key participants, and have an active voice on every relevant maternal-newborn committee,” she says.
Teresa Bandrowska, head midwife of the hospital’s division of midwifery, says that while midwives and their clients drove the process to change the protocols, having colleagues who
respect their skills and support the model of midwifery care were also important factors.
“We have a really collegial, open relationship with colleagues and administration and they’re very informed-choice friendly,” says Bandrowska.
During the fiscal year 2012-13 there were 3096 births at the Montfort. Midwives attended 302 of those - about 10 per cent.
The change in policy is supported by updated research analysis regarding breech birth. When the Term Breech Trial (TBT) (Hannah et al. Lancet. 2000 Oct 21;356(9239):1375-83) was
published in 2000, hospital practices worldwide changed rapidly to respond to the conclusions that C-sections were safest for breech babies.
In The inappropriate use of randomized trials to evaluate complex phenomena: a case study of vaginal breech delivery (BMJ 2004), Canadian physician and researcher Andrew Kotaska states that the TBT “rapidly dictated a new standard of care for the management of breech deliveries around the world.”
But in the years since the publication of the TBT, a number of studies have critiqued its findings. Kotaska noted that “this trial failed to adequately appreciate both the complex nature of vaginal breech delivery and the complex mix of operator variables necessary for its safe conduct.
“Delivering a breech presentation vaginally is a skill: guided by science, its safety relies on the experience of practitioners and caution,” Kotaska writes.
New perspectives on the TBT have led to a rethinking of the need for mandatory C-sections for breech babies and an acknowledgement that maternity care providers with skill and experience in vaginal breech deliveries should be able to offer their clients this option, as is now the case for experienced midwives at the Montfort.