Dr Shawn Walker, Consultant Midwife and Chief Investigator, explains the OptiBreech position on planned vaginal breech birth at home.
This 13-minute counselling video was created to support our OptiBreech teams when responding to women who request OptiBreech care for a planned vaginal breech birth at home. The care process being tested in our study is care from a team of professionals with physiological breech birth training and/or proficiency (OptiBreech collaborative care). Although our recommended place of birth is within a hospital with immediate access to caesarean birth, obstetric and neonatal support, our protocol does not specify that women must give birth in hospital in order to access this care or participate in the research.
Hello. My name is Shawn Walker. I’m a Consultant Midwife, the Clinical Lead and the Chief Investigator of the OptiBreech Trial.
We’ve had several women ask for support from their OptiBreech team to plan a home birth. I wanted to talk through this a bit so that any woman thinking of participating in our study understands our position on breech home birth and can make a fully informed decision.
First, I want to be absolutely clear: Our recommended place of birth is within a hospital with access to caesarean birth if needed and the support of the complete multi-disciplinary team, including obstetric and neonatal colleagues. This is because the potential risks of a vaginal breech birth are different from cephalic birth, no matter what the setting. Studies in multiple settings have demonstrated that, when breech births become complicated at home, a severe adverse outcome is more likely to result. Sometimes, these risks can occur unexpectedly. An example of this is a cord prolapse, where the umbilical cord slips down between the baby’s legs and becomes compressed before the baby is ready to come out. This can lead to oxygen deprivation if not resolved quickly. If we are in the hospital, we can get you to this help quickly, most of the time. If we are in your home, there may be significant delay.
Ambulance services are also under considerable pressure, so response times may not be ideal if an unexpected event occurs. The availability and response time of an ambulance and the potential transfer time to the nearest maternity unit also need to be considered.
Another thing that impacts an OptiBreech team’s ability to offer care at home is current midwifery and obstetric staff shortages. In some teams, there are still only a few people with significant experience, due to decades of skill erosion. If these people are already working on site in a hospital, it may not be possible for them to leave to attend your birth. Current maternity service staffing levels mean it is increasingly difficult to ensure we keep every birth as safe as possible, and sometimes compromises need to be made. We may need to share responsibility with you for making sure the right person is at the right place at the right time to attend your birth.
A plan for a breech home birth also requires additional co-ordination and planning, and there are additional research procedures on top of this for OptiBreech. It will also require additional time for what we call ‘mediation’ – that is, the senior midwife planning your care will need to communicate and explain the plan to colleagues. This involves reassuring and justifying to colleagues that this has been a fully informed choice. This shouldn’t be incredibly time consuming, but unfortunately it often is. We ask you to please be as patient as possible with your teams, who are often spending time on-call for breech births above and beyond their very demanding core roles. We are all doing the best we can.
It’s also important to understand that if an experienced OptiBreech team member attends your birth, this does not guarantee a perfect outcome. We feel, and our ever-increasing data indicates, that the presence of someone who has completed OptiBreech training is likely to help reduce the risk of a vaginal breech birth. Some of our OptiBreech sites home birth teams have used the occasion of someone planning a breech home birth to upskill the entire team with physiological breech birth training. We feel this is a great approach, and one likely to benefit potential surprise breech home births in the future. Where attendance of a fully proficient specialist is not possible or less likely, we feel preparing the staff who are likely to attend the birth with additional hands-on training is the next best option.
But reduced risk is not the same as no risk. We also feel that where births become very complicated, the presence of someone who has previously resolved complications successfully can help improve the outcome. These people are still rare within the UK, and again – it does not guarantee that unexpected complications will not occur, at home or in a hospital.
Our OptiBreech team members have become involved in delivering this care because they genuinely enjoy using the skills they have spent time developing to support physiological breech birth, when a woman prefers this. We understand that giving birth to a breech baby at home is likely to have the same benefits as planning a head-first home birth, such as a quicker labour, reduced need for pain relief drugs and less risk of intervention. We completely understand why someone would want to be in a setting where they feel comfortable and secure, and not interrupt their labour to travel to hospital. There are many reasons a woman may prefer to give birth at home, and ultimately it is your decision.
It is precisely because we understand these benefits that we are all working so hard to make a safe space within a hospital setting, where you can nest in and give birth the way you prefer, with the support of the full multi-disciplinary team available if you need it, but not necessarily in your birth space. Evidence indicates that some women choose to give birth at home because they feel they will not be supported to plan a physiological breech birth with minimal disturbance in a hospital-based setting, and this is wrong.We all have a duty to address the alienation some people feel that prevents them from accessing care that would benefit them. Consistently achieving better outcomes for the vaginal breech births helps us to create space for more women to attempt a physiological breech birth with minimal interference, when they want that. But this requires trust from everyone involved.
Change and compromise and new ways of working are always challenging. Our teams sometimes find it challenging to provide the service we would ideally like to provide. But the more we can work together and trust each other, the safer we genuinely believe your birth will be. If you do plan a breech birth at home, we have advised our OptiBreech teams that where possible, we consider the ethical thing to do is to provide the most experienced or support available – with the same caveat that experienced support may not always be available. We also want you to be included in our study. We collect information on place of births, and if there is an increased risk, analysing the data is the only way we can determine what this is.
When a breech home birth is planned, we feel the safest approach is to have a low threshold for transfer into hospital if all is not progressing straightforwardly. Indications include but are not limited to, meconium-stained liquor at any point during the first stage of labour, a rising fetal heart rate, active pushing of over an hour, and any other variations from normal. Our recommendation is that you accept the standard monitoring that is offered so that your midwife can identify if any of these indications are present, as early as possible, so that a safe and un-rushed transfer can be arranged. These signs are baby’s way of telling us that they are struggling. We know that a small number (about 3%) of babies are in a breech position because there is an underlying problem or a vulnerability, rather than just chance or baby finds this seat more comfortable. Subtle problems can’t always be identified on a scan, and sometimes the vulnerability is only apparent once labour starts.
Please be reassured that all our teams, and all home birth teams, are invested in maximising your chances of achieving the birth you want. If transfer or caesarean birth is advised, it is because something has indicated that there may be increased risk. Safety is our priority. But we may have different or conflicting mental models of ‘safety’ – please do share your priorities with those planning your care.
As always, we refer to the absolute risk figures in the Royal College of Obstetricians and Gynaecologists guideline. When a head-first birth is planned, the risk of the worst possible outcome – baby dying – is about 1:1000. This is because, to a certain extent, it is impossible to completely eliminate all risk in childbirth. When a breech birth is planned, the risk of baby dying is about 2:1000. This is still a low number, and by far the most likely outcome, no matter what you plan to do or where you decide to give birth, is that you and your baby will be completely well. We have to look at thousands of births to see these differences. But when we do look at the numbers, this is what we see. There are very few reports of breech births at home, but where they exist, they indicate increased risk compared to head-first births. Of course, it is absolutely your right to accept these potential risks and give birth where you choose.
I hope you have found this helpful. I acknowledge that talking about risks is difficult at a time when you want to be developing confidence in your body and ability to birth your baby. As health care professionals, we are also navigating our own risk that supporting any woman to choose a breech home birth will be considered encouraging risky behaviour. We know that respecting people’s intelligence and ability to make informed decisions about their own body, no matter how popular these decision are, is not the same as encouraging risky behaviour. But we do need to make sure that you understand that providing you with the most experienced support we are able to provide for a home birth does not completely mitigate, or eliminate, the risks involved.
So our position is clear: We created the OptiBreech collaborative care pathway because we want you to have a safe space within a hospital setting to have a physiological breech birth without unnecessary interference, if you want that. We feel hospital is the safest place for a planned vaginal breech birth. I personally wanted to be clear about this so that, when you meet with your care providers, they know you have this information and can concentrate on your birth plan. If you have concerns about any care you are receiving related to the OptiBreech service, I invite you to be in contact with me personally. This ensures that learning from your feedback can influence care improvements across the study.
In summary, we respect your bodily autonomy and right to choose your place of birth. And we acknowledge the difficulty all services are experiencing during this current maternity care staffing crisis. I hope that this video has helped you to understand the position that we need to take on this, and that you and your care providers can work together with trust and mutual respect, understanding that we’re all just trying to do the best we can at the moment – all of us.
Ceclia Gray and Ritika Roy (joint first authors) lead a systematic review and qualitative meta-synthesis of women’s experiences of seeking to plan a vaginal breech birth. Gray and Roy are King’s College London medical students who were funded to undertake this work by King’s Undergraduate Research Fellowships.
Women seeking to plan a VBB feel vulnerable and wish to connect with capable and confident healthcare providers. To meet their needs, services should be designed so that they can connect with clinicians who are willing and able to support their autonomy. Services should also seek to limit their exposure to disrespectful and judgemental interactions with healthcare providers.
Gray and Roy were joined by service user co-researcher Charlene Akyiaa Prempeh-Bonsu, who planned a vaginal breech birth in the NHS herself within the past five years. Prempeh-Bonsu contributed to data analysis with support and reflective discussions. She helped to ensure the work reflected the needs and interests of the population being described.
What has your experience been? Have you planned (or tried to plan) a vaginal breech birth within the UK NHS? We invite you to leave a comment below. Please let us know if you gave birth within an OptiBreech site, or not.
We are in the process of developing a research proposal for a feasibility study to investigate the implementation of bedside resuscitation for breech babies who require breathing assistance at birth.
Research indicates that providing this immediate care next to mothers/birthing people reduces parental distress and is found to be more favourable by clinicians due to improving communication with parents while they provide care.
The purpose of this group session is to gain insight and feedback regarding our research aims and design from stakeholders to ensure the research is the next piece of the puzzle in improving breech care, designed appropriately, and acceptable to women/birthing people.
We have scheduled this meeting for 90mins to ensure everyone has enough time to discuss the proposal and ask any questions and we will also provide an optional short survey for anyone to provide any additional feedback if they were not able to during the meeting.
The meeting will be held on Sunday 30th October 10am – 11.30am via Microsoft Teams. You can attend the meeting for the full 90mins or attend like a drop in session.
We look forward to meeting with you and hearing your thoughts.
Plain English summary of the research (limit 400 words):
OptiBreech Care is a specialist care pathway for women whose baby is positioned bottom-down (breech) at the end of pregnancy. Our team previously studied how hospitals provide team care when a woman requests a vaginal breech birth to make sure it was possible. In this model, women found it easier to plan their choice of a vaginal breech birth or a pre-labour caesarean birth. Fewer women had emergency caesarean births, and outcomes for babies were at least as good as standard care. OptiBreech teams found one aspect difficult: leaving the umbilical cord attached if the baby needs help to start breathing. Team members told us this is challenging to achieve because they do not have appropriate equipment and training.
About 1:5 babies born after a vaginal breech birth need some help to start breathing, and about 1:10 are transferred to a neonatal intensive care unit after the birth. We feel we can reduce this to 1:5 (the UK national average for all births) if our specialist teams are able to provide help next to the mother. This will result in better long-term outcomes for the baby. Families have better experiences if they are not separated from babies, during resuscitation or after. Women in our OptiBreech studies have reported feeling let down because in most births where the baby appeared to need help, the cord was cut immediately, despite OptiBreech and UK Resuscitation Council guidance.
We aim to learn how to get optimal cord management right for every birth, how much it will cost and how it may improve outcomes for babies if we do this. We will supply one site with bedside trolleys and team training; another site will use trolleys they already have, with additional support; all thirteen remaining sites will continue to try to implement the recommendations with what they already have. We will observe the process for 12 months initially, during which we would expect 205 planned breech births to occur. We will conduct interviews with staff, parents and birth supporters following births where babies have needed support, to understand how this is working, or not.
By studying the process within small teams, who care for a population at higher risk of needing assistance to begin breathing at birth, we will be able to study and share insights that can improve the process for all teams, across the UK population of term births. We will share our results in scientific papers and a toolkit. Our research team includes a service user who has planned an OptiBreech birth, who will help us to involve other service users in shaping the research and to communicate the results of the research to a wide audience.
We often share information, especially with professionals, on the Breech Birth Network FaceBook group. We had a post recently promoting hypnotherapy to turn breech babies.
This was my response:
I have approved this post, but I will not in the future approve posts that make claims that do not present the evidence that supports them. This includes training in complementary therapies such as moxibustion.
We now have a wonderful OptiBreech database, which collects data from the point anyone is referred for care related to breech presentation at the end of pregnancy and has a breech presentation confirmed by ultrasound – this can be as early as 32 weeks. It also collects information on how often these babies turn without intervention, and the different types of therapies and advice women receive.
A randomised controlled trial is the best way to test claims for the success of a therapy like hypnotherapy to encourage breech babies to turn head-down. Second-best is a prospective observational study of women who choose and receive hypnotherapy. Because we collect information on women who do not choose and receive hypnotherapy, we still have a point of comparison that would enable us to tell if hypnosis increases turning compared to none.
If any of you providing or teaching complementary therapies would like to collaborate on a trial, please do e-mail me at Shawn.Walker@kcl.ac.uk. We have a team of people who can help design a study and apply for funding. If hypnotherapy is effective, it should be offered to all women within the NHS and included within the OptiBreech care pathway. If not, professionals should not be suggesting it to women.
If you are promoting a therapy, please provide links to the evidence that supports it, to enable women to consider the evidence available before spending money at a time when they are vulnerable. Without evidence, future posts will not be approved.
As you can see from the image below, based on previous research, a certain percentage of babies will turn on their own, without intervention. We know the number that turn is higher when we attempt a manual turning (external cephalic version or ECV). But we also know not everyone wants an ECV, and many women report trying alternative or complementary therapies to encourage their babies to turn. As these are popular and acceptable to large numbers of women, it would be best for us to have high-quality evidence about which therapies are effective at helping more babies to turn.
The OptiBreech Research and Public Involvement team share their work at the #BICS22 conference.
The OptiBreech Team enjoyed meeting each other in person for the first time at last week’s British Intrapartum Care Society Conference. And we won a prize! We are so grateful to the women who have participated in our research, the Principal Investigators who have made it all happen locally, and our Steering Committee. Here’s what we shared at the conference:
Is it feasible to test OptiBreech Care in a clinical trial?: results of the OptiBreech 1 study – Dr Shawn Walker, Tisha Dasgupta, Siân Davies, Sarah Hunter, Phoebe Roberts, Prof Jane Sandall, Prof Andrew Shennan. We shared the results from our first-stage study, OptiBreech 1. We are currently writing these up in publication format and will share as soon as that is ready. This presentation won the top oral abstract prize at the conference.
The roles and responsibilities of breech specialist midwives in the OptiBreech Care Trial feasibility study: a qualitative inventory – Davies, Dasgupta, Natasha Bale, Alexandra Birch, Walker. Siân Davies shared a poster about the role of Breech Specialist Midwives, as described by midwives and obstetricians participating in OptiBreech 1.
Toolkit for implementing breech clinics and specialist midwives to support planned vaginal breech births – OptiBreech PPI Lead and Service User Representative Phoebe Roberts presented this poster. Read more about it here.
Women seek ‘connected autonomy’ when they wish to plan a vaginal breech birth at term: a systematic review and meta-synthesis – Ritika Roy, Cecelia Gray, Charlene Prempeh, Walker. Medical students Roy and Gray presented the results of their 2021 King’s Undergraduate Research Fellowships. The results are ready for publication and will be shared in that format soon!
Not too fast not too slow: the legacy of time management in vaginal breech births – Jacana Bresson, Walker. Midwifery student Bresson presented the results of her review of obstetric texts in the Royal College of Obstetricians and Gynaecologists and Wellcome Trust Libraries, funded by a 2022 King’s Undergraduate Research Fellowship.
Assessing feasibility of economic evaluation alongside a full trial for ‘OptiBreech Care’ with development and testing of a decision model to assess its long-term cost-effectiveness – Dr Siddesh Shetty, Dr Shawn Walker, Prof Julia Fox-Rushby. The Health Economics team used this as an opportunity to gain feedback and peer review on the economic model developed.
Thanks also to the BICS Committee, who organise a wonderful, supportive, multi-disciplinary conference every time!
Developing research capacity is a high priority for our team. Many of our researchers have come to research as clinicians, students or service users first — with a passion for making things better for women and babies.
We have been lucky enough to have a number of students working with us on summer fellowships or student research placements the last couple of years.
Summer 2021 – King’s Undergraduate Research Fellowship (KURF) holders, medical students Ritika Roy and Cecelia Gray, completed a systematic review and metasynthesis of research about women’s experiences of seeking to plan a vaginal breech birth. They presented a poster on their results at the British Intrapartum Care Society (BICS) conference in September 2022 and plan to submit a paper for publication.
2021/2022 – Masters student Hannah Mullins is collecting data for the Optimal Intervals 2 study at Frimley. Her work will build on Emma Spillane’s original work about optimal intervals for vaginal breech births, testing if the hypotheses are correct across a larger, multi-site sample.
Spring 2022 – Leicester University midwifery student Keelie Cristie completed a research elective with the OptiBreech team. She helped set up the Optimal Intervals 2 study at Leicester University Hospital and began data collection. She has also helped process some anonymised interview data.
Summer 2022 – This summer we are lucky enough to have three KURF fellows. Medical student Victoria Taiwo is helping to develop a protocol and instrument to survey the extend of midwives working autonomously to provide various aspects of breech care (scanning, ECV, counselling, attending births) in the UK.
Midwifery student Joanne Kotun is analysing anonymised interview data to contribute to our analysis of facilitators and barriers to implementing team care for physiological breech births. She also worked on setting up the optimal intervals study at Guy’s and St Thomas’ Hospital.
Midwifery student Jacana Bresson has completed a review of textbooks in the Wellcome collection and Royal College of Obstetricians and Gynaecologists library. She reviewed historical guidance provided about the optimal lengths of time to be taken in vaginal breech births, to compare to our emerging optimal intervals evidence. She also present her findings at the BICS conference.
And midwifery student Sophie Rayner was awarded a Wellcome Trust Biomedical Vacation Scholarship. With this time, she completed the data collection on the optimal intervals study at Leicester and worked with Victoria on the protocol to chart breech specialist midwives, clinics and teams in the UK.
We will launch our toolkit describing ‘how to build and OptiBreech service from the ground up’ at the British Intrapartum Care Society Conference 2022 in just over a week. When the conference goes live on 29 September, the toolkit will go live.
The toolkit brings together clinical and social science evidence in favour of delivering care for breech pregnancy and childbirth through a dedicated clinic and intrapartum care team, co-ordinated by a breech specialist midwife, working in collaboration with a breech lead obstetrician.
The majority of team roles includes tasks that are already performed by someone in your organisation. They key is to task-shift, so that all breech-relevant service leadership tasks are performed by the specialist(s). This increases their expertise, and their work increases skill and competence across your team.
This model addresses two known problems: individualised care and safety. Women want individualised care in line with national guidance, but the way services are usually delivered within the NHS makes this difficult. Clinics and specialists standardise practice, reducing biases in the direction of both caesarean section and vaginal birth. Women enjoy easier access to both planned vaginal breech birth and planned elective caesarean section. Specialists also drive up the safety and quality of care by helping research inform practice as quickly as possible and facilitating cultural change. They enable vaginal breech births to occur in a planned an organised manner, creating learning opportunities that make unplanned births safer.
The toolkit has been developed by: Shawn Walker (OptiBreech Chief Investigator), Phoebe Roberts (OptiBreech Patient and Public Involvement Lead for this project) and Harriet Boulding from the King’s Policy Institute.
The toolkit will be available HERE for download and includes:
What is the problem?
How does the OptiBreech approach offer a solution?
What is physiological breech birth?
What does OptiBreech ‘proficiency’ mean?
What is the evidence for this model of service delivery?
What you need to build a breech service
A dedicated breech clinic
A Breech Lead Obstetrician
A Breech Specialist Midwife (Band 7 or 8)
Breech specialist midwives
Roles and activities of a breech specialist midwife
Where does the money come from?
Personal characteristics and circumstances required
Compensation and support
Involvement in research and quality improvement
Training other team members
What training involves
Why is this way of training most effective clinically?
Why is this way of training most cost-effective?
Who does a breech clinic rotation
What about people who cannot be on-call?
Maximising economic efficiency
Role of the on-call obstetric team
External Cephalic Version (ECV) and other breech turning modalities
What about continuity for planned CS?
Approaches that do not appear to be effective
Appendix: Proficiency Achievement Record
This toolkit is funded by an ESRC Impact Acceleration Award, from the King’s College London Social Science Impact Fund. Shawn Walker is funded by a National Institute of Health Research (NIHR300582) Advanced Fellowship.
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.