Shawn talks about some of the challenges of improving the way we deliver care for mothers and their breech babies.
Yesterday was International Day of the Midwife. I saw but didn’t participate in the social media celebrations. Not because I wasn’t feeling it, but because my clinical academic midwife life was full to the brim. 931 more words
Continuous cyclic pushing is a non-invasive tool for expediating breech births with minimal hands-on intervention, or for confirming in a timely manner that further intervention is required to achieve a safe outcome.
Shawn Walker, RM PhD, King’s College London and Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex Hospital
Sabrina Das, MB ChB, MRCOG, Imperial College Healthcare NHS Foundation Trust, Queen Charlottes & Chelsea Hospital
Emma Spillane, RM MSc, Kingston Hospital NHS Foundation Trust
Amy Meadowcroft, RM, Northern Care Alliance NHS Foundation Trust
In the United Kingdom (UK) National Health Service (NHS), we have been working towards a collaborative, multi-disciplinary trial for breech presentation at term. Our complex intervention*, based on physiological breech birth practice tailored for a hospital-based care pathway, is called OptiBreech Care. In the OptiBreech Care Trial (IRAS 303028, ISRCTN 14521381) feasibility study, vaginal breech births are facilitated using physiological breech birth approach. This approach has been developed through prior research and testing of strategies described by others, 1–4 including midwives practising in out-of-hospital settings. As a result, it differs from assisted delivery techniques most hospital-based clinicians are familiar with. This creates a need to clearly articulate each component for effective implementation in practice. The purpose of this article is to articulate the theory and practice of one element of our complex intervention that we consider essential to the method: continuous cyclic pushing. Although different from most clinicians’ habit of ‘waiting for the next contraction,’ continuous cyclic pushing can easily be incorporated into assisted breech delivery practice.
* In clinical trials, an ‘intervention’ is the thing you do differently to try to change the outcome. Complex interventions contain more than one component, and the effect is thought to be the sum of the parts. OptiBreech Care is a care pathway intervention – a new care pathway for women and others whose babies are breech at the end of pregnancy.
Physiological Breech Birth
In a 2012 article, UK midwife Jane Evans described an approach to supporting spontaneous vaginal breech births as ‘physiological breech birth.’5 This approach centres on the normal mechanisms and movements of both mother and baby, in contrast to assisted breech delivery, where the birth attendant routinely manoeuvres the baby. Upright maternal birthing positions, such as kneeling, are frequently used, in contrast to routinely directing women to assume a supine position. Evans described how a normal breech birth exhibits ‘steady progress with each contraction.’5(p20) She also described how mothers move in response to the movements a healthy baby makes, especially the ‘tummy crunch’6(p48) or full body recoil flexion.3 Evans, who practiced for decades as an independent midwife, also observed that such a normal breech birth was ‘now hard to replicate within the UK’s National Health Service (NHS).’
In the OptiBreech Trial, we are trying to do just this: introduce a physiological breech birth approach into NHS practice settings, particularly obstetric units, and evaluate the outcomes. This has several potential advantages, including greater equity of access for more women, immediate access to the multi-disciplinary team (MDT) during birth, and shared learning throughout the MDT, with the potential to influence cultural changes.
But approaches to care (known as ‘complex interventions’ in the context of a trial) do not always work the same way in different settings. For example, physiological birth processes seem to work more efficiently the further one gets from an obstetric unit.7–10 Women who use NHS services have a much wider range of needs, complexities, birth philosophies and preparation levels than women who employ independent midwives. And greater involvement of the MDT means the physiological breech birth approach intersects with, and may conflict with, other cultural norms and practices. This may make it harder to implement some of its components, and potential conflucts may introduce additional risks.
Therefore, when testing a complex intervention in a trial, there is a need to clearly articulate each of the main components.11,12 This helps ensure those implementing the package of care know exactly what they are implementing. It also enables us to evaluate whether each aspect has been implemented as planned. We have observed that, although relatively simple itself, the concept of continuous cyclic pushing conflicts with current embedded cultural norms and assumptions about vaginal breech birth in many settings. An improvement in outcomes is likely to require a change in approach, but change can create uncomfortable feelings as teams deal with uncertainty in attempting a new approach.13,14 We hope to make the process of implementing continuous cyclic pushing, as a tool to support physiological breech birth, easier and safer by articulating the rationale and making visible some of the conflicting assumptions.
Description of the Technique
Continuous cyclic pushing: what it is and when it is used
Consistent with the Royal College of Obstetricians and Gynecologists’ guideline,21 we do not encourage active pushing until the breech is visible on the perineum, although we do not interfere with spontaneous maternal effort. This permits maximum recovery and fetal oxygenation between contractions. Continuous cyclic pushing begins when the birth attendant encourages the woman to push following the birth of the fetal pelvis. ‘Continuous’ refers to its use both during and between contractions until the birth is complete. ‘Cyclic’ refers to alternation between pushing effort and brief pauses for rest and breathing, resuming effort again when the woman is ready, regardless of whether a contraction is present. Following the birth of the pelvis, due to the high likelihood of cord compression, a significant pause between contractions is counter-productive for preserving fetal well-being.
We are aiming to complete the birth within the intervals recommended in the Physiological Breech Birth Algorithm: within 7 minutes of rumping (+3 station), within 3 minutes of the birth of the umbilicus.3,15 Attendants support women through continuous cyclic pushing with language such as: “Well done. Now take a few deep breaths. Your baby is almost here. [brief pause for the deep breaths] And when you are ready, just collect your strength and push again.” In this way, it more closely resembles spontaneous pushing, in which women generally push three to five times per contraction, rather than directed pushing, in which women are instructed to take a deep breath at the beginning of the contraction and then hold it and bear down throughout the contraction.16
Once the fetal pelvis has passed completely through the perineum, there is often a short pause, much like there is with a head. The woman feels a release of pressure and sense of relief. She may stop pushing and take a few deep breaths, over a period of about 20 seconds. In an ideal physiological breech birth, the woman will have received no direction about pushing5 and will be completely tuned into her body, usually in a forward-leaning kneeling position. Following this natural pause, some women will continue to feel pressure and an urge to push, and they will simply collect their breath and do that when they are ready. If this doesn’t happen, the next contraction will occur within about a minute from the end of the previous contraction. Consistent with the available evidence,3,15 this process will be complete in an average (median) of about a minute and a half, and in most cases under three minutes, with no assistance required. The combination of maternal effort, movement and gravity is sufficient.
There are many examples of situations that deviate from the ‘ideal’ physiological breech birth described above. Being in tune with one’s body in labour and being supported to give birth without any directed pushing is very difficult to achieve in the hospital environment. It is routine practice in many hospitals to put women into lithotomy (supine, legs in stirrups) for a vaginal breech birth. Or she may have chosen an epidural, which will affect the Ferguson’s or fetal ejection reflex, even if it is a mobile epidural. Sometimes, there are concerns about the baby arising late in labour, such as the presence of late decelerations or a rising baseline on fetal heart auscultation, where one would not want the birth to take any longer than absolutely necessary. Intervals between contractions can also be longer than optimal, for example if the woman is exhausted in second stage or from the stress of undertaking an unplanned breech vaginal birth. Even well-meaning directions from the birth team can detract from the physiological birth process: “Now relax. Just breathe. And wait for the next contraction.” The woman’s attention is now focused on the attendant’s directions, away from the pressures and promptings of her own body, as she gains mastery over any spontaneous urge she may have, believing this is essential for her baby’s safety.
Many of us supporting physiological breech births within NHS settings have used continuous cyclic pushing in practice when we have observed the situation to be less than ideal for a completely physiological breech birth, for any of these reasons. And we have observed that, where there is no entrapment of arms or head, continuous cyclic pushing effects continuous progress. With the next episode of maternal effort, rotation begins and the legs are born, with the next effort the arms are born, etc. The head usually requires more than one episode of maternal effort, but with less time between. This similar to the ‘little pushes’ a midwife may coach a woman through as the head is being born in a cephalic birth, or the birth of the shoulders between contractions, guidance intended to optimise the perineal outcome. In either type of birth, when there is no entrapment, the process is not strenuous; it is simply effective. Furthermore, it is effective regardless of the woman’s birthing posture, but when upright, prompted maternal movement also assists descent and rotation, eg. ‘give it a wiggle’.
How does continuous cyclic pushing help us to identify complications early?
In contrast, strenuous effort and minimal or no progress is indicative of need for manual assistance. Consider the following scenario: the pelvis is born sacrum transverse as we would expect. Between contractions, the woman has no spontaneous urge to push. With the next contraction, a few centimetres of descent are observed, so that the baby’s knees are now born. No rotation has occurred. This repeats with the next contraction, two minutes later. With quite a bit of encouragement and effort during the contraction, the feet are finally born, about four minutes after the pelvis. The baby has still not rotated. The team await the next contraction, two minutes later. No descent occurs, and it is now very clear that the birth is complicated by a nuchal arm entrapment. Resolution of the entrapment is difficult because the baby has descended deeply into the pelvis with the arm extended, with less room and more resistance when rotational manoeuvres are attempted. The process takes three minutes. And then assistance is needed for the head. It is easy to see how the minutes add up, even when contractions continue to come regularly. And sometimes they do not.
Our observation is that, by encouraging continuous cyclic pushing, we can observe the signs of obstruction earlier, enabling us to intervene more quickly and effectively. In the above scenario, following the brief pause that occurs after the birth of the pelvis, if the woman does not resume movement and effort spontaneously within about 30 seconds, the attendant would gently encourage it (‘wiggle and push’). If pushing were strenuous and progress minimal, especially with no rotation, we would assume this was due to obstruction and deliver the fetal legs. We would again encourage the woman to collect her breath, and to ‘wiggle and push.’ If the next episode of strenuous effort did not result in the birth of the arms, we would assist this with rotational and other manoeuvres. And so on.
Potential conflicts with current practices
Applying cephalic birth ‘habits’ to breech births?
Each of us has seen in practice and in clinical reviews of adverse outcomes a tendency to instruct the woman to breathe and wait for the next contraction after delivery of the pelvis or arms. We consider that professionals may be doing what they would do in a cephalic birth. Following delivery of the head, there is (sometimes) a pause until the next contraction that delivers the body. During this time, reassurance is often given to the woman that she has done well and that with the next contraction she will have her baby.
A similar confusion may present itself when we observe ‘rumping’ to occur. Clinicians may think it normal to observe the presenting part for some time prior to the birth as this is what we may observe in a cephalic birth with no detriment to the fetus. But in a cephalic birth, only the head is in the pelvis. Due to the different mechanisms of a breech birth, once both buttocks remain on the perineum between contractions, the umbilicus is in the pelvis along with both the body and the legs. This increases the likelihood of cord occlusion and progressive acidosis if delay is not recognised and action taken. It is also very difficult to accurately assess the fetal heart rate with external monitoring when the pelvis and body are this deeply engaged.
Historical use of ‘wait for the next contraction’ as a breech-specific strategy
Very few trials have been done comparing different approaches to managing vaginal breech births. But in 1989, Arulkumaran et al published a trial in which they compared two techniques. In Group A (expediated breech delivery), “During one contraction and bearing down efforts, spontaneous expulsion of the buttocks were allowed up to the hip of the fetus so as not to deliver the umbilicus. Then the patient was requested to relax till the onset of the next contraction with the aim of delivering the whole fetus with the subsequent contraction.”17(p48) Group B was similar, but women were allowed to deliver the baby up to the shoulders, and a loop of cord was pulled down. The design of the trial was based on the assumption that fetal oxygenation is considered to be potentially impaired once the umbilicus is delivered, due to umbilical cord compression.18 Women gave birth in supine positions. The trial results were inconclusive. But ‘wait for the next contraction’ was part of a routinely interventive approach to managing a breech birth, contrasting with Evans’ repeated calls for “no directive pushing”5(p18) in physiological breech births.
Power from above is safer than pulling from below
The fundamental purpose of skill and technique with vaginal breech birth is to prevent progressive acidosis as much as possible, while avoiding the potential trauma of a quick or overly-manipulated delivery. To this end, the theme that power from above is safer than pulling from below repeats frequently in literature related to upright breech birth,19 the physiological breech birth approach,2 as well as many guidelines. The current Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline on Management of Breech Presentation at Term explains, “Techniques to maximize power from above include effective maternal effort, hands and knees posture, the Bracht manoeuvre, and oxytocin augmentation.”20(p1201) Again, we need to consider the effects of context with regards to which sources of power from above we can effectively employ.
The Royal College of Obstetricians and Gynaecologists guideline does propose the use of the Bracht manoeuvre as an alternative,21 but this requires the woman to give birth on her back, which, when assisted by physiological breech birth-trained professionals, over three quarters of women do not do.22 To perform the manoeuvre, the attendant raises the legs and trunk of the baby over the mother’s pubic symphysis and abdomen, using an upwards movement without traction to achieve delivery of arms and fetal head. Of the Bracht manoeuvre, Professor Peter Dunn described, “[I]n this method, the obstetrician does little more than gravity would have achieved, had the woman been allowed to deliver in the natural upright position.”23(pF77) As UK midwives and obstetricians are not routinely trained in the safe use of the Bracht manoeuvre, we prefer to simply allow women to deliver in the upright position when they want to. And we supplement this with continuous cyclic pushing if appropriate.
In 2017, Louwen et al19 described 229 successful upright breech births in Frankfurt, where women gave birth in upright maternal birthing positions, usually hands and knees. The team provided a detailed description of their approach. To achieve power from above rather than below, they explained, “We rely on the mother’s contractions, but sometimes proceed to the use of oxytocin, and fundal pressure (the Kristeller manoeuvre)”19(psupp) (indications not given). While Louwen’s team’s work provides a precedent and example for upright breech hospital-based practice, this cannot directly translate to UK-based practice, in which the Kristeller manoeuvre is not routinely used, nor to the context of the OptiBreech Trial, in which most physiological breech births are led by midwives unless recourse to instrumental or surgical delivery is required. While the OptiBreech team members work closely with the MDT, oxytocin is not routinely prescribed for the purposes of increasing frequency and power of contractions around the time of birth. We cannot assume that without the total package of tools, or a replacement, we can achieve the same results.
Continuous cyclic pushing is a core skill taught in the Breech Birth Network’s Physiological Breech Birth training course. This is the only training programme focused on vaginal breech birth that has been evaluated including outcome data for actual breech births.22 Among 21 vaginal breech births attended by professionals who completed the training in 6 NHS hospitals, there were no severe adverse neonatal or maternal outcomes (using the composite definition used in the Term Breech Trial24), compared to a background rate of 7% among other breech births in the same hospitals, attended by professionals who did not complete the training. Additionally, among those 21 births, 11/21 (52%) of women had intact perinea.
We might compare this to available evidence concerning more invasive means of preventing delayed descent in a vaginal breech birth: oxytocin infusion and fundal pressure. Although both of these interventions are considered acceptable in different contexts,19,20 there is evidence that injudicious just could cause harm. Secondary analysis of the Term Breech Trial data indicated that the use of oxytocin augmentation increases risks in vaginal breech births.26 Concerns have also been raised about the risks associated with fundal pressure, especially when excessive force is used, including increased cervical and perineal tears, neonatal injuries and maternal dissatisfaction with care.27,28 While there may still be a place for the use of these interventions by experts, there is a need for high-quality evidence of their benefit before recommending them to the general population of practitioners in guidelines. When upskilling professionals who have had minimal exposure to and experience with vaginal breech birth, we prefer to start with less invasive interventions that are unlikely to cause harm and likely to be more acceptable to women who wish to have active births, in which they feel like a primary agent.
As clinicians regularly attending vaginal breech births in NHS hospitals, we are satisfied that continuous cyclic pushing produces clear effects with none of the risks associated with preventable delay, if the next contraction is slow in arrival, or hands-on interventions applied before we have confirmed they are necessary.
In our approach, we rely heavily on maternal movement (enabled by upright postural positions), maternal effort, fetal effort (full body recoil flexion)2,3 and gravity to optimise the likelihood of an unassisted vaginal breech birth. Where the team considers it beneficial to minimise the time required for the baby to emerge, for any reason, the first intervention is always to encourage maternal movement and effort (‘wiggle and push’). This is recorded and evaluated as a fidelity measure in the OptiBreech Trial. With this approach, we recognise the locus of greatest efficacy lies within the mother-baby unit,2 and this is the first source of power we draw upon when a safe outcome appears to be at risk for any reason.
We therefore consider continuous cyclic pushing is an important tool for expediating the birth with minimal hands-on intervention, or for confirming in a timely manner that further intervention is required to achieve a safe outcome. We cannot yet make any claims that use of continuous cyclic pushing does or will increase the safety of vaginal breech births. But we hope by clearly described the practice itself, its rationale, and its relationship to alternative courses of action used in other settings, others may consider and evaluate its usefulness in their own practice.
1. Walker S, Scamell M, Parker P. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery. 2016;34:7-14. doi:10.1016/j.midw.2016.01.007
2. Walker S, Scamell M, Parker P. Principles of physiological breech birth practice: A Delphi study. Midwifery. 2016;43(0):1-6. doi:10.1016/j.midw.2016.09.003
3. Reitter A, Halliday A, Walker S. Practical insight into upright breech birth from birth videos: A structured analysis. Birth. 2020;47(2):211-219. doi:10.1111/birt.12480
4. Walker SR, Parker PR, Scamell MR, Shawn Walker C, Nightingale F. Expertise in physiological breech birth: A mixed-methods study. Birth. Published online 2017:1-8. doi:10.1111/birt.12326
5. Evans J. Understanding physiological breech birth. Essentially MIDIRS. 2012;3(2):17-21.
7. Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011;343:d7400-d7400. doi:10.1136/bmj.d7400
8. Hastie C, Fahy KM. Optimising psychophysiology in third stage of labour: theory applied to practice. Women Birth. 2009;22(3):89-96. doi:10.1016/j.wombi.2009.02.004
10. Carpenter J, Burns E, Smith L. Factors Associated With Normal Physiologic Birth for Women Who Labor In Water: A Secondary Analysis of A Prospective Observational Study. Journal of Midwifery & Women’s Health. 2022;00:1-8. doi:10.1111/JMWH.13315
11. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. doi:10.1136/bmj.g1687
12. O’Cathain A, Croot L, Duncan E, et al. Guidance on how to develop complex interventions to improve health and healthcare. BMJ Open. 2019;9(8):e029954. doi:10.1136/bmjopen-2019-029954
14. Leslie MS, Erickson-Owens D, Cseh M. The Evolution of Individual Maternity Care Providers to Delayed Cord Clamping: Is It the Evidence? Journal of Midwifery & Women’s Health. 2015;60(5):561-569. doi:10.1111/jmwh.12333
15. Spillane E, Walker S, McCourt C. Optimal Time Intervals for Vaginal Breech Births: A Case-Control Study. Authorea Preprints. Published online September 24, 2021. doi:10.22541/AU.163251114.49455726/V1
16. Lemos A, Amorim MM, Dornelas de Andrade A, de Souza AI, Cabral Filho JE, Correia JB. Pushing/bearing down methods for the second stage of labour. The Cochrane Database of Systematic Reviews. 2017;2017(3). doi:10.1002/14651858.CD009124.PUB3
17. Arulkumaran S, Thavarasah AS, Ingemarsson I, Ratnam SS. An alternative approach to assisted vaginal breech delivery. Asia Oceania J Obstet Gynaecol. 1989;15(1):47-51. Accessed February 2, 2018. http://www.ncbi.nlm.nih.gov/pubmed/2735841
18. Hofmeyr GJ, Kulier R. Expedited versus conservative approaches for vaginal delivery in breech presentation. Cochrane Database of Systematic Reviews. 2012;(6). doi:10.1002/14651858.CD000082.pub2
19. Louwen F, Daviss B, Johnson KC, Reitter A. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans? International Journal of Gynecology & Obstetrics. 2017;136(2):151-161. doi:10.1002/ijgo.12033
20. Kotaska A, Menticoglou S. No. 384-Management of Breech Presentation at Term. Journal of Obstetrics and Gynaecology Canada. 2019;41(8):1193-1205. doi:10.1016/j.jogc.2018.12.018
21. Impey L, Murphy D, Griffiths M, Penna L, on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. BJOG: An International Journal of Obstetrics & Gynaecology. 2017;124(7):e151-e177. doi:10.1111/1471-0528.14465
24. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356(9239):1375-1383. doi:10.1016/s0140-6736(00)02840-3
25. Battersby C, Michaelides S, Upton M, Rennie JM, Jaundice Working Group of the Atain (Avoiding Term Admissions Into Neonatal units) programme, led by the Patient Safety team in NHS Improvement. Term admissions to neonatal units in England: a role for transitional care? A retrospective cohort study. BMJ Open. 2017;7(5):e016050. doi:10.1136/bmjopen-2017-016050
26. Su M, McLeod L, Ross S, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. American Journal of Obstetrics and Gynecology. 2003;189(3):740-745. doi:10.1067/S0002-9378(03)00822-6
27. Hofmeyr GJ, Vogel JP, Cuthbert A, Singata M. Fundal pressure during the second stage of labour. The Cochrane Database of Systematic Reviews. 2017;2017(3). doi:10.1002/14651858.CD006067.PUB3
28. Farrington E, Connolly M, Phung L, et al. The prevalence of uterine fundal pressure during the second stage of labour for women giving birth in health facilities: a systematic review and meta-analysis. Reproductive Health. 2021;18(1):1-17. doi:10.1186/S12978-021-01148-1/TABLES/6
A successful applicant will be paid the London Living Wage for 35 hours per week, for seven weeks, beginning 11 July 2020. The project synopsis is:
Recent research suggests specialist services may improve maternal and neonatal outcomes in breech pregnancies, as well as women’s experiences of care. The aims of this research are to summarise the evidence base for these organisational interventions in a literature review, and to determine the prevalence of clinics, teams and specialist midwives dedicated to the care of women with a breech pregnancy in the United Kingdom. The results will be published as a report and used to establish a network of UK breech practitioners for the purposes of joint learning, collaboration and research. They will also inform the on-going work of the OptiBreech Trial.
Although the scholarship is based at King’s College London, applicants can apply from all over the UK. The work can be done remotely. Preference is given to applicants from non-Russell Group universities, from ethnic groups currently under-represented at King’s, mature students, and other groups whose interest in pursuing research the funders are particularly keen to encourage.
In the OptiBreech Care pathway, women with a breech-presenting baby at the end of pregnancy receive care primarily from a midwife with enhanced training and proficiency (a Breech Specialist Midwife). This begins in a dedicated clinic, where they are offered three options from the start:
vaginal breech birth, supported by the specialist midwife or another member of the OptiBreech team;
an attempt to turn the baby head-down (external cephalic version, ECV), performed by someone who does >20 procedures per year; or
a planned caesarean delivery around 39 weeks.
When women choose to plan a vaginal breech birth, term births are supported by the specialist midwife or OptiBreech team member. Standard labour care is provided by either the caseload midwife or a member of staff on duty. The OptiBreech team is there as an additional layer of support. Their skills and experience enable all staff to learn breech skills with a ‘safety net.’ This minimises the variability in skills and attitudes towards breech birth by making sure we get the right people in the right place at the right time.
But breech care led by a specialist midwife is a significant departure from business as usual in UK maternity care, where care for all vaginal breech births has customarily fallen to the on-call obstetric staff. Understandably, some obstetric colleagues have requested clarification about their role and lines of responsibility. The purpose of this post is to answer some important questions based on the OptiBreech Care Trial protocol.
I do not have experience or training supporting upright breech births. Will I be responsible for managing upright breech births for women on the trial?
Good question — the answer is No. We hope to determine the safety profile of a physiological approach to breech births, which includes upright maternal positioning where the birthing person chooses this. In order to test this, we need to ensure that these births are attended by professionals who have both training and experience in physiological breech birth, the OptiBreech team. The protocol, which has received ethics approval and is insured by clinical trials insurance, specifies that the OptiBreech team member is considered the clinical lead at all OptiBreech births, up until either forceps or caesarean delivery is indicated and care handed over.
What if an OptiBreech team member is not available?
OptiBreech participant information and verbal advice given during breech choices counselling inform women that there is never a 100% guarantee that an OptiBreech team member will be available, due to the unpredictable nature of labour. In the OptiBreech 1 observational study, as of March 2022, we have achieved this >94% of the time. There is a very good chance both women and staff can depend on OptiBreech support.
However, on the occasions that this is not possible, the person would receive ‘standard care’ led by the on-call senior obstetrician on labour ward, just as any other woman who planned a vaginal breech birth outside of the study, or had a breech presentation diagnosed in labour, would receive.
If an OptiBreech member is leading care, am I required to be there?
Vaginal breech births are still at higher risk of an adverse outcome than cephalic births, regardless of the mode of delivery. Safety depends on the team being prepared for this. Although the rate of instrumental delivery is lower than with cephalic birth, forceps may be needed for the after coming head. And when needed, although most caesarean births occur for non-urgent reasons such as obstruction during the first stage of labour, others are more urgent. Therefore, the OptiBreech model is one in which the multi-disciplinary team (MDT) works closely together. The OptiBreech team takes responsibility for physiological breech birth where this remains within clearly specified safety parameters, communicates frequently, escalates promptly and hands over care when the birth requires assistance with forceps or surgery.
The Royal College of Obstetricians and Gynaecologists provides clear guidance about the Roles and responsibilities of the consultant providing acute care in obstetrics and gynaecology. This specifies a list of “Situations in which the consultant must ATTEND unless the most senior doctor present has documented evidence as being signed off as competent. In these situations, the senior doctor and the consultant should decide in advance if the consultant should be INFORMED prior to the senior doctor undertaking the procedure.” (p14) Vaginal breech birth is included in this list.
Our friends at OLVG Amsterdam have created a video to review the procedure for applying forceps to the aftercoming head, for those rare occasions that it may be required. At OptiBreech sites, we have also worked with Practice Development teams to ensure forceps are available during mandatory training exercises so that obstetric staff have an opportunity for simulation practice.
Ideally, unless the birthing person requests differently, we encourage a member of obstetric staff to be quietly present at all births. This makes for a more seamless transition should help be required. And it leads to greater understanding of physiological breech birth across the maternity care team.
What if an adverse outcome occurs on labour ward when I am the consultant on-call. Won’t I be held responsible for it?
The clinician leading care is responsible for what they did or did not do. As this is a clinical trial, there are several additional layers of clinical governance and clinical trials insurance, which enable us to test a new care process with as much safety as possible for all involved. If your assistance is needed, you can be expected that this will be escalated to you in a timely manner. If it is not, the OptiBreech team member is responsible for that.
In a physiological breech birth approach, the OptiBreech team members are obligated to follow clear guidance, which was co-created with the wider OptiBreech Collaborative of midwife and obstetrician clinicians delivering the study across the UK. Key features are:
use of the physiological breech birth algorithm to ensure the birth proceeds spontaneously or is assisted within a timeframe based on previous research — this means, if your assistance with forceps is requested, we expect this to occur well before the baby has become compromised;
regular reflective seminars to support and share learning occurring within the study. Your local PI can tell you how to access these.
Why don’t women want obstetricians to be involved?
They do! They very much do. Essentially, women who plan a vaginal breech birth want the same thing as women who plan a head-first birth. They want to labour in as calm and relaxed a way as possible, knowing that their midwifery team is remaining quietly vigilant. And they want the obstetric team to be there if complications arise.
Our qualitative interviews with women indicate that positive and supportive interactions with an obstetric consultant enhance women’s experience of breech pregnancy and birth. They especially value consultant obstetrician input within a dedicated breech clinic. The interviews indicate that women in the study are receiving detailed, balanced counselling from breech specialist midwives, including detailed information about complications and how these might need to be managed. When their interactions with a knowledgeable and supportive consultant obstetrician are ‘singing from the same hymn sheet,’ women feel confident that the team is aligned and able to assist them if required.
On the other hand, when they encounter any member of staff who expresses judgement of their choice, suggests they do not have a choice or provides imbalanced counselling that exaggerates the risks involved in vaginal birth, women understandably become distrustful, of that individual and of the ability of the team to work cohesively. Many also become distrustful of themselves and request a caesarean delivery they do not really want out of fear and shame. Some also remain at home in labour much longer than would be advised, or refuse to give birth on the obstetric unit. While we support women’s informed choices about place of birth, we feel the safest outcomes for all can be achieved by creating a safe and welcoming space for women to give birth with the support of the entire MDT close at hand.
Personally, I feel incredibly grateful to have enjoyed some truly and supportive collaborative relationships with obstetric colleagues. It has helped me recognise the value of this when it is in place, and the significant risk to safety when it is not.
I have further questions or concerns. How can I share them?
If you are an obstetrician at a site participating in the OptiBreech Trial, we are very keen to hear from you. It is important to the success of the trial that we listen and respond to the views of all stakeholders. But we can only do this if you share them with us.
Members of our research team who are not involved in delivering OptiBreech care conduct interviews with health care professionals at participating sites. The transcripts from these interviews are then anonymised, so no one is able to identify you or where you work. They are then analysed by the research team, who are not involved in delivering OptiBreech care themselves. You can register your willingness to provide feedback in this way by completing the Interest and Proficiency Survey (password:5minutes), ticking only the box for consent to interview. You will then be contacted by the research team, and your views will become part of trial’s overall feasibility assessment.
You can place a comment on this page, which would be part of the public discussion. We have also added a feedback form below, where you can send questions and/or concerns to the research team.
Help us get it right, Wednesday 19th January 2022, 12:00-13:00. Are we accurately reflecting your views on breech specialist midwives and clinics?
We would like to invite women, birthing people and their families who have experienced a breech pregnancy at term to attend an online focus group discussion on Wednesday 19th January 2022, 12:00-13:00 to be conducted via Microsoft Teams. Anyone with an interest and experience of breech pregnancy can participate.
The purpose of this meeting will be to get your perspective on the work we have been doing so far.
We have been working on analysing data from qualitative interviews held with OptiBreech 1 participants. To date, we have interviewed 15 women purposefully sampled to reflect various OptiBreech sites, mode of births, and outcomes. Our main objective was to understand what makes the OptiBreech intervention acceptable (or not) to women.
The key themes that we have found are:
Access to skilled breech care: Vaginal breech birth as a viable and safe option is still unknown to many, and lack of specialists reduced equity of access. Women who were referred to a specialist at one of the OptiBreech sites or were already receiving care at a study site found it easy to access and participate in their care. Women who had to transfer care from another hospital or find an OptiBreech site themselves had a difficult time doing so, often requiring increased effort, multiple trips, time off work etc.
Balanced information: Women really appreciated being provided balanced information on the safety and risks of vaginal breech birth vs. caesarean section including possible complications and how to manage them. This enabled them to make autonomous informed decisions and increased self-efficacy and confidence, not only in themselves but also in the breech specialist midwife. Conversely, when women had to do this research themselves because they were not getting cohesive information from the healthcare professionals, this was seen as a burden and sometimes women were made to feel pressure to choose caesarean section as the ‘safe’ choice.
Shared responsibility: Women often felt emotional burden including feelings of stress, judgement, and guilt because of the choices they had made to have a vaginal breech birth, both from family and friends, as well as other healthcare professionals. Speaking with and being cared for by the OptiBreech specialist midwife helped ease this emotional burden and gave the women confidence in their choices.
Team dynamics: We found that women had placed an enormous amount of trust and confidence in the breech specialist midwife which extended to the rest of the team, attributed to previous experience, skills and knowledge. Although women did not know all the members of the team, the trust and confidence was extended to them because of shared responsibility and training requirements needed by all OptiBreech team members.
We need your input on our findings and invite your opinions on whether these findings are relevant to you, if we have interpreted them correctly, or if we have missed any important factors in what makes OptiBreech an acceptable intervention. At the meeting we will present a short summary of our findings so far, and then have an open discussion to hear any thoughts, opinions, or questions you may have.
The meeting will be held on Wednesday 19th January 2022, 12:00-13:00 via Microsoft Teams.
Round 1 of the international multi-stakeholder Delphi study, Development of a Core Outcome Set for Effectiveness Studies of Breech Birth at Term (Breech-COS) is now open. We invite the involvement of anyone from the following stakeholder groups, who has experience of care for women having vaginal breech births:
service users (you or your partner have had a breech-presenting baby within the last 5 years)
health services manager
support group representative
other relevant roles
You can read more information about the research and participate using the link or the QR code below. You are welcome to share this post or forward to your stakeholder associates.
The local Breech Lead makes a plan for how they will provide care for this birth. Ideally, someone who meets all of the OptiBreech Proficiency Criteria will attend the birth. Where this is not possible, the team will do their best to have someone attend the birth who has completed OptiBreech training.
How will they do that?
In this setting, ensuring experienced support is straightforward. The hospital employs a Consultant Midwife with a special interest in breech birth. She meets all of the Proficiency Criteria, and part of her job role is to attend planned vaginal breech births. While she is not paid for additional time on call, her Head of Midwifery has authorised her to claim time back for any birth she attends outside of her normal working hours.
In order to make the service sustainable, the Consultant Midwife will support the clinical staff caring for the woman to gain experience. Her role is to provide an additional layer of OptiBreech support and safety. Where possible, she will seek to involve another member of the OptiBreech team. This is the group of colleagues who expressed an interest in providing OptiBreech care, through the OptiBreech Interest and Proficiency Survey.
What if the Consultant Midwife can’t make it to the birth?
The expectation is that, where possible, a member of the OptiBreech team will be present for all of second stage at a minimum. For planned breech births, there is usually at least a few hours warning, time enough to sort out who is available to attend. All women are informed that there is not an absolute guarantee, and assisted to think through what might happen if no skilled and experienced practitioner is available.
If the Consultant Midwife can’t make it, she will liaise with her colleagues to determine whether someone else on the OptiBreech team is available. If no other skilled and experienced member of staff who has completed OptiBreech training is available, the woman will be informed of this. She will be counselled by the consultant obstetrician on-call and decide if she would like to proceed with a vaginal breech birth or have a caesarean section, just as she would if she were planning a VBB outside of the study.
If this occurs, and nobody who has completed OptiBreech training is available to attend the birth, this will be recorded on the Case Report Form. The research team will be monitoring this closely so that we can give women an accurate idea of how well they can depend on their birth being attended by someone with OptiBreech training.
There is no ‘penalty’ if a participating site is not able to get someone with the OptiBreech training to the birth. Part of what our feasibility testing will determine is how often this occurs. Women in our PPI group expressed understanding that it may be hard for Trusts to guarantee attendance, especially in the early days, but that they appreciated the willingness to try.
What will happen during the birth?
The OptiBreech team member who attends will lead the birth but liaise closely with the on-call consultant obstetrician, as an additional layer of safety. The team will ensure that the Pro Forma is completed, documenting the care around the time of birth.
What will happen after the birth?
The local Principal Investigator will gather the data from the birth and enter it onto a Case Report Form. This will be securely returned to the research team.
If the woman has consented to a follow-up interview or long-term outcome collection, the research team will be in touch as appropriate.
Your Research & Development Office have given your site the green light! This post will outline your first steps now that you are starting in the OptiBreech 1 Study.
In accordance with the protocol at site set-up, all sites should:
Provide the OptiBreech research team with a copy of your current guideline covering the management of breech presentation at term, including information provided to women.
Provide us with materials used in mandatory training and any specialist site-specific training, or a brief description. For example, we are interested if your mandatory training uses an in-house package or is based on PROMPT or another training programme.
Please answer: When a woman plans a vaginal breech birth, is it routine to put a plan in place to ensure she has experienced support at the birth, e.g. formal or informal on-call system? (Yes/No)
Liaise with your research team to identify how you will deliver the anonymised data required in the protocol, outlined below.
Make the OptiBreech training available to your staff members. The research team will provide further information on how to do this.
The above information outlines the minimum required for sites who are participating in OptiBreech 1. For sites who are also intending to offer OptiBreech support for planned or unplanned breech births, these are the next steps.
Invite your colleagues to express an interest in delivering OptiBreech care by completing the consent form and survey. This is linked from the top of the Information for Professionals page. (password is available from the protocol or research team)
All staff members supporting OptiBreech births need to have completed the OptiBreech Training, also available from the Information for Professionals page. (password is available from the protocol or research team)
On-line participant Information Sheets and Consent Forms are all linked from the Information for Women and Birthing People page. (password is available from the protocol or research team — the research team are happy to run through this process with you whenever you like, so do not hesitate to be in touch)
In this study, the following count as accruals:
recruitment of women who are planning a vaginal breech birth with OptiBreech support;
interviews with health care professionals who have been involved directly or indirectly with care for women recruited to the study.
Because of the importance of developing services slowly and carefully where vaginal breech births have been rare in the past couple of decades, we have enabled sites to access the enhanced training in exchange for anonymised, retrospective data only; however the return of this data will not count as an accrual. There is no minimum recruitment target, though we may seek to interview key staff about their feelings of readiness / willingness to support planned vaginal breech births or to develop a proficient team.
When the breech presentation is diagnosed, staff should determine if there is someone available who has completed the enhanced training and/or meets the proficiency criteria, who can attend and support the birth. You can download a Breech Birth Pro Forma to assist with collecting all of the data we need about the birth.
If someone with OptiBreech training has attended the birth, the woman may be approached after the birth and asked for her consent for her data to be used in the study, as per the standard consent procedures. The person has the right to decline use of their data. The Participant Information Sheet and Consent Form are linked from this page (including a video version of the PIS). The password for the on-line Consent Form (preferred) is available from your local Principal Investigator.
Consent should be sought by someone who attended the birth, and they should also offer a thorough debrief of what happened at the birth at this time.
The longer explanation
In OptiBreech 1, we are collecting prospective observational data on planned vaginal breech births, where women and birthing people consent to our use of this data. This will include rates of vaginal birth and adverse outcomes for babies (death or admission to the neonatal unit) and mothers (PPH, severe perineal tears). We will also be looking at how many women plan a vaginal breech birth, and how many are attended by someone who has attended OptiBreech training and/or maintained proficiency-level experience. This will enable us to calculate whether a large trial will be possible.
Many participating sites are just beginning to re-build a breech birth service after decades of not offering such a service. Where overall experience levels are low, some Trusts are expecting to start out with mainly ‘undiagnosed breech births.’ This refers to a situation where the breech presentation is identified for the first time after the person has been admitted in labour. Approximately 20-30% of breech presentations are diagnosed for the first time in labour, or 5% where universal third trimester scanning has been implemented (Salim et al 2021).
The benefit-risk balance of vaginal birth vs caesarean section is altered when a woman is in labour. The findings of the Term Breech Trial indicated that a caesarean section performed prior to the start of labour significantly reduces risks to the baby compared to a vaginal birth (when the classical methods of delivery used in the TBT are used, Su et al 2003). This effect was less significant in early labour but still clear. However, when the woman was in active labour, defined as 3 cm or more, the benefit was less clear and did not reach statistical significance.
A potential benefit from a CS in labour needs to be balanced against known risks to the woman and future pregnancies. Although most women are very willing to sacrifice themselves for any benefit to their baby, a CS performed near to or in the second stage of labour also significantly increases the risks of early preterm birth and late miscarriage in all future pregnancies (Watson et al 2017).
Although many clinicians will still want to offer women a CS if they feel they have time to counsel appropriately, because of the change in benefit-risk balance in labour, the RCOG guideline currently advises that women near to or in the second stage of labour should not routinely be offered a CS. Women in our PPI group also tell us that being asked to decide on the mode of birth for a breech baby in labour, where there is no immediate threat to fetal well-being, is very stressful and can result in birth trauma, even where outcomes are good (Lightfoot 2018).
The OptiBreech study is designed on the premise that getting someone to a vaginal breech birth who has 1) completed an enhanced, evidence-based training package; and/or 2) has acquired proficiency-level experience, is likely to improve the outcomes of both planned and unplanned breech births. Therefore, we have worked into the protocol a way of enabling women with a breech presentation diagnosed in labour to participate, taking account of the RCOG guidance for obtaining valid consent to participate in perinatal research where consent is time critical (2016, see also Vernon et al 2006).
Women in our PPI group expressed that taking consent for participation in labour was not appropriate. As this is an observational, rather than interventional, stage of the study, and attendance of an OptiBreech-trained professional would be something in addition to, rather than replacing, standard care, they felt it was appropriate that women’s consent be taken retrospectively in the postnatal period. Standard counselling about mode of birth, according to RCOG guidelines, would apply in labour.
Women also identified that many found the experience of undiagnosed breech birth traumatic regardless of the outcome, due to the concern staff expressed when discovering their baby to be breech. However, they were rarely offered an opportunity to process what had happened with staff who were present. PPI participants said they felt women would benefit from careful explanations in the postnatal period. We therefore added the last step. We are grateful for the guidance of our PPI group, so that we can make participation in OptiBreech 1 potentially beneficial for women, rather than a burden.
If you have any comments to make about this process, you are welcome to leave them here or contact the research team.
You are invited to an open discussion about the Draft of the new NICE Antenatal Care Guideline. Breech Birth Network would like to collect the views of families who have experienced a breech presentation at term and care providers on the draft guidance. Josephine and Thiago talk about their experience of Ulysse’s breech birth at…