A key element of OptiBreech Care is providing additional skilled and experienced staff at planned vaginal breech births (and unplanned ones too if we can manage it!) in line with the RCOG guidance.
We know this supports safety but traditionally it has been hard to achieve as the numbers of vaginal breech births may be few and far between, meaning limited experience and often limited or brief training. Most hospitals have < 1 hr a year for each of the common obstetric emergencies as part of their mandatory training, maybe less depending on each hospital’s rolling program of multidisciplinary skills and drills. Furthermore, expecting whoever is on and available to care for families having a Breech birth puts significant extra stress and strain on the on-call labour teams, often already pressured with complex scenarios and sadly short-staffed wards.
We often get asked- How to do the on-call elements of the OptiBreech care pathway work? Who will cover it? Everyone is doing enough already?!
Each of our current sites may operationalise its on-call systems slightly differently, however, the core elements are the same.
All sites need to create a Breech team- ideally, this consists of a mix of midwifery and obstetric staff willing to be on call for breech births. Ideally, each member will have had some prior experience of a breech birth (although this is not always possible). All members of the Breech team should have completed a recent OptiBreech study day, online or face to face and have had an opportunity to practice rotational manoeuvres via simulation before providing on call for births. We would expect team members to counsel women appropriately regarding experience and expertise as part of the initial personalised care planning.
We would advise that initially, the On-call Breech teams are smallish. You may start with one or two lead people who are first on call with a wider group of staff that want to gain experience and eventually join a full on-call system.
We have found that this is the most successful way to safely develop confidence and competence amongst the team whilst also building a sustainable service. Often when launching the team in a service that hasn’t previously been supporting vaginal breech births, it can take a while for any to come along. Too large a team means that it is hard for people to gain regular exposure and experience and in the long run it takes longer to develop expertise.
Structure and payment of on-calls
All sites have currently been opting for a voluntary on-call system. At my site, many of the team have other on-call commitments (as manager on call or perhaps homebirth on calls) so they try to combine the calls and to date, no one has minded being voluntary on call. If called into the birth, they are always added to the roster to ensure liability coverage and this has worked wonderfully for the intrapartum teams as they are always grateful to have an additional presence with expertise available to support the team!
We have found this system has been provided at no extra cost to the service and has increased staffing on shifts which would have otherwise been under the template. Two of our core Breech team midwives work full-time in Intrapartum services so they have been available often when needed just by the pure nature of their roles and shift patterns. Whilst it is difficult for clinical midwives to be on the call before a shift, both midwives work full time so are already working a significant number of shifts. If one of the families booked for a vaginal breech comes into labour, the labour ward team always work to release them to support with birth as required. Another of our team works as a specialist midwife Monday to Friday and again has often been available during her working hours to support Breech births when needed or if called out overnight is able to rearrange her day as needed.
You will require one lead practitioner who can coordinate the Breech team and ensure appropriate care and on call coverage. Usually this will be the midwife leading the Breech Clinic but it could be an alternative depending on your context. The lead practitioner will provide details of the on-call service and then arrange with the wider team any dates they can’t cover.
In some sites, Breech teams prefer for women to contact them directly when they are in labour and the on-call team alerts the rest of the service, in other teams, the families will contact the triage service as per usual and then the Breech team will be alerted. Your system will depend on how your team is developed and your current on call working practices.
When women are in labour, other team members are invited to attend for additional experience and support, again this is facilitated voluntarily but we have found no problem with people wanting to be involved.
What if we have no one available or we don’t make it in time?
Sites need to make a realistic effort to try and support this as we know it improves safety outcomes and it is the core process outcome for the Optibreech care package but also women are honestly and realistically counselled. If no one from the team is available ( we know last minute dramas can happen) the care would fall to the rostered labour ward team and if they have limited experience in vaginal breech birth, they would counsel them as per their practice, which would usually be to recommend a cesarean birth.
Results from the feasibility study showed that across all sites a Optibreech team member was present for 87.5% of planned vaginal Breech Births.
We have found vaginal breech births have risen from 2 in 2021 to 10 successful (18 planned) last year with no admissions to special care and we have around 1/2 women a month planning a vaginal Breech birth. As our numbers have increased, we have been able to support more midwives and doctors able to lead the care and meet the full OptiBreech proficiency criteria. We are now considering implementing a more traditional on-call system to cover the whole month.
** A key aspect of care is the OptiBreech team member is addition to the case midwife. This is a pivotal part of the safety mechanism. The OptiBreech team member supports situational awareness, liaison with the wider MDT and ensures prompt action is taken if concerns arise**
Other OptiBreech sites operate similar variations to the above model, partly depending on their Breech birth numbers, initial expertise in the team and also taking into consideration individual contexts and staffing models.
Key aspects required for a Successful Optibreech On-Call Team
- Motivated individuals with a desire and flexibility to work this way
- A lead clinician to coordinate care, on-call availability and liaison with families
- A small group of staff initially to enable ongoing enhancement of competency- this group could be expanded as numbers and confidence grow.
We are currently inviting expressions of interest to join the next phase of the research. There will be funding, clinical training and support to implement this model of care. See here for more information or express your interest: https://optibreech.uk/2023/03/06/optibreech-cluster-trial-call-for-expressions-of-interest/