Category: Engagement

OptiBreech cluster trial: Call for expressions of interest

Expressions of interest are invited for sites to collaborate on an HTA funding bid for a stepped wedge cluster trial of OptiBreech care.

We are aiming to submit a funding proposal in August 2023 and if successful, plan to begin work on the trial in summer 2024. We hope to include sites from Scotland, Wales, Northern Ireland and England, with a preference for sites outside of London that benefit from participation in research less frequently.

Summary:

Research Team:

  • Shawn Walker, Consultant Midwife and OptiBreech Chief Investigator, Shawn.Walker@imperial.ac.uk   
  • Andrew Copas, Professor of Clinical Trials in Global Health, UCL
  • Kate Walker, Clinical Professor of Obstetrics, University of Nottingham
  • Debra Bick, Professor of Clinical Trials in Maternal Health, Warwick Clinical Trials Unit
  • Emma Spillane, Deputy Director of Midwifery, Kingston Hospital
  • Kate Stringer, Consultant Midwife and Implementation Lead, Surrey and Sussex Hospitals
  • Siân Davies, Perinatal Psychologist and PPIE Lead
  • Nimisha Johnstone, PPI co-investigator

 What is OptiBreech collaborative care?

OptiBreech care is a new care pathway for delivering standard care to women and birthing people pregnant with a breech-presenting baby at term. This population is defined as: breech presentation at birth, or at any scan from 35+0 weeks or where a successful external cephalic version (ECV) has been performed.

The service is provided through a dedicated clinic, co-ordinated by a breech specialist midwife, working collaboratively with a breech lead obstetrician. All management options are offered – external cephalic version, vaginal breech birth and elective caesarean birth. ECV attempts are provided by clinic staff in a same-day service where required. Intrapartum care for vaginal breech births follows the OptiBreech physiological breech birth guideline, developed by the OptiBreech Collaborative. The breech lead midwife and obstetrician lead on training throughout the service, including mandatory updates and simulations. The specialist midwife also co-ordinates a continuity of care service, so that whenever possible planned breech births are attended by a member of the team with full OptiBreech training and experience managing complications. Members of the team are also part of an extended OptiBreech community of practice, which provides regular practice updates and opportunities for reflection as they develop competence and expertise.

How does this differ from standard care?

This is a new way of organising care and training for breech presentation at term. Current standard care is characterised by a lack of standardisation and adherence to national guidelines from the RCOG(1) and NICE(2). OptiBreech care promotes standardisation for optimal outcomes. The vaginal breech birth training that is provided is the same training offered on the RCOG Labour Ward Management course, RCOG Vaginal Breech Birth study days and Royal Society of Medicine Maternity and Newborn Forum, which led by clinical members of the research team.

Why do we think a cluster trial is appropriate now?

  1. There is strong evidence current standard care pathways do not provide consistent access to all options national guidelines recommend,(3,4) nor do they provide adequate training opportunities for younger obstetricians and midwives.
  2. OptiBreech collaborative care is a pathway developed with significant input from service users and clinicians. It is highly acceptable to women and birthing people, regardless of their care choices or ultimate mode of birth.(5)
  3. Feasibility work has included two NHS training evaluations,(6,7) an observational implementation evaluation and a pilot trial. All three have demonstrated better outcomes compared to standard care for vaginal breech births. For example, the neonatal serious adverse outcome rate for women planning a vaginal birth has been less than 1%, compared to 5% in the Term Breech Trial,(8) and 7% for actual vaginal births in standard care births included in our training evaluation.(7)
  4. The pilot trial demonstrated that women have access to all three guideline-recommended options within the OptiBreech care pathway, but not within standard care (see below).(9)

Pilot trial results: More women planned a VBB when randomised to OptiBreech Care (23.5% vs 0, p = .003, 95% CI =.093,.378). Women randomised to OptiBreech care had: lower rates of cephalic presentation at birth (38.2% vs 54.5%), higher rates of vaginal birth (32.4% vs 24.2%), lower rates of in-labour caesarean birth (20.6% vs 36.4%), lower rates of neonatal intensive care (5.9% vs 9.1%), and lower rates of severe neonatal morbidity (2.9% vs 9.1%). Within the entire cohort, breech presentation on admission to labour/birth (n=44), compared to cephalic presentation (n=38), was associated with: lower levels of neonatal admission (2.3% versus 10.5%), lower levels of severe neonatal morbidity (2.3% vs 7.9%), fewer maternal admissions to HDU (4.5% vs 7.9%) and less severe maternal morbidity (13.6% vs 21.1%). Outcomes for non-British and non-white women were also better than participants from white British backgrounds, which reassures us this service is accessible to minoritised participants. Randomisation was stopped in June 2022 on the advice of the steering committee, at 68 women randomised rather than the planned 104. It was clear 1:1 randomisation would not enable us to compare outcomes for VBB because women were not choosing to plan a VBB within standard care.

We know that the model enables access to a guideline-recommended care option (VBB), but we do not know how this will affect outcomes. A definitive trial that is powered on serious adverse neonatal outcomes is urgently needed and could lead to the implementation of OptiBreech collaborative care across the NHS.

What outcomes do we expect to improve with OptiBreech care?

Based on the results of our feasibility work and the available literature, we think that the rate of serious adverse neonatal outcomes (including death, HIE, admission to the neonatal unit >4 days) is about 4.5% for the entire cohort of term breech babies within standard care, as defined above. We think we can reduce this by about 40%, to 2.7%. This is the primary outcome we are seeking to improve.

We also think that OptiBreech care will be more cost-effective and reduce the rate of emergency caesarean birth.

How do we think OptiBreech care will do this?

We expect up to 1-2 women per month at each centre to plan a vaginal breech birth, with no increase in adverse outcomes for these babies. (Note: This is an estimate of what might happen when services are delivered in this way, but there is no target VBB recruitment rate. Women’s choices remain the same.) Your site will implement the new care pathway for women booked at your service but will not be promoted as an OptiBreech referral site.

Based on available evidence and our feasibility work, we expect a reduction of 0.9% of serious neonatal outcomes will come from increasing skill levels throughout the service, learning from these planned events, and improving mandatory skills training to bring it in line with the most current evidence. We think this will help prevent adverse outcomes in unanticipated vaginal breech births.

In multiple audits and our pilot trial, we have also observed that within this model of care more women choose an elective caesarean birth, and the emergency caesarean birth rate declines. This will result in 0.9% additional improvement in neonatal, maternal and economic outcomes.

How will we evaluate this?

We will evaluate this in a stepped wedge cluster trial, including twenty sites over three years. If your site is chosen to participate, you will implement the care pathway at a point during the three years determined through randomisation. Our research team will analyse outcomes for women receiving care at the sites prior to and after randomisation.

What support would participating sites receive?

If you are one of twenty sites chosen for this trial, your hospital will receive unlimited free physiological breech training. This training is currently provided through the RCOG at a cost of over £360/person. We will train any members of your team you would like to receive full training. We will also train your skills trainers to deliver updates through standard mandatory training activities and periodic simulations.

At this point, we hope to be able to fund one day per week of a Band 7 breech specialist midwife developmental post. This person will be a current Band 6 ready to step up to greater leadership within the service. They would need to be in post for between one to three years, with associated funding between £12,126 and £36,379, depending on your site’s starting point in the trial. They would be supported by senior members of your team to develop into a specialist. Your breech specialist midwife will also collect the data for the study, and the time for this will also be funded through the CRN; this is likely to be approximately 0.1 WTE, depending on the size of your service. This is a desirable post for the right person, which we anticipate will contribute to staff satisfaction and retention, in addition to developing your breech service.

We would provide you with a comprehensive job description, guideline and training resources, operational during the time your site is ‘live’ on the trial. This guideline has been developed by the OptiBreech Collaborative, clinicians who have led the first stages of feasibility work for this trial.

We would provide you with support during the implementation period from an experienced member of our team who has successfully implemented the service we are testing. And we would provide support through our community of practice activities for all members of your team who wish to participate. These include regular practice updates, case reviews and opportunities for reflective supervision with clinicians experienced in supporting physiological breech births. As many new sites will have limited recent experience supporting planned vaginal breech births, this will be re-introduced in a controlled and supported way.

Why else should you consider participating?

If this trial has a positive result, the OptiBreech collaborative care pathway will likely become the standard of care, and you will have already implemented it. If the trial does not demonstrate an improvement in outcomes, your team would still have acquired significant experience in the management of vaginal breech births, which may still bring beneficial skills and knowledge into your service.

Where can I read more about the research supporting OptiBreech care?

The OptiBreech Project Site

Breech Clinics and Specialist Midwives Implementation Toolkit

How can we express an interest in participating?

Please complete this form with your name and contact information. We will contact you with more information about requirements for site selection.

References

1.            Impey L, Murphy D, Griffiths M, Penna L, on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. BJOG [Internet]. 2017 Jun;124(7):e151–77. Available from: http://doi.wiley.com/10.1111/1471-0528.14465

2.            NICE. Antenatal care [Internet]. Clinical Guideline NG201. 2022 [cited 2022 Nov 29]. Available from: https://www.nice.org.uk/guidance/ng201

3.            Morris SE, Sundin D, Geraghty S. Women’s experiences of breech birth decision making: An integrated review. Eur J Midwifery [Internet]. 2022 Jan 25 [cited 2022 Feb 9];6(January):1–14. Available from: http://www.europeanjournalofmidwifery.eu/Women-s-experiences-of-breech-birth-decision-making-An-integrated-review,143875,0,2.html

4.            Roy R, Gray C, Prempeh-Bonsu CA, Walker S. What are women’s experiences of seeking to plan a vaginal breech birth? A systematic review and qualitative meta-synthesis [version 1; peer review: awaiting peer review]. NIHR Open Research 2023 3:4 [Internet]. 2023 Jan 20 [cited 2023 Jan 21];3:4. Available from: https://openresearch.nihr.ac.uk/articles/3-4

5.            Dasgupta T, Hunter S, Reid S, Sandall J, Shennan A, Davies SM, et al. Breech specialist midwives and clinics in the OptiBreech Trial feasibility study: An implementation process evaluation. Birth [Internet]. 2022 Oct 26 [cited 2022 Oct 27];00:1–10. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/birt.12685

6.            Walker S, Reading C, Siverwood-Cope O, Cochrane V. Physiological breech birth: Evaluation of a training programme for birth professionals. Pract Midwife. 2017;20(2):25–8. 

7.            Mattiolo S, Spillane E, Walker S. Physiological breech birth training: An evaluation of clinical practice changes after a one‐day training program. Birth [Internet]. 2021 Dec 23;48(4):558–65. Available from: https://onlinelibrary.wiley.com/doi/10.1111/birt.12562

8.            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. The Lancet [Internet]. 2000/10/29. 2000 Oct 21;356(9239):1375–83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11052579

9.            Walker S, Spillane E, Stringer K, Trepte L, Davies SM, Bresson J, et al. OptiBreech collaborative care versus standard care for women with a breech-presenting fetus at term: a pilot parallel group randomised trial to evaluate the feasibility of a substantive trial nested within a cohort. In peer review. 2023; 

Stakeholder Engagement

Funding for the Breech Specialist Midwife post at Band 7

The activities performed in a breech clinic are not new. ECV, VBB and caesarean birth are all guideline-recommended choices and RCOG-recommended auditable services. Offering them through a dedicated clinic with a small teams with a high level of skill and experience is new. The change management required to shift these tasks into a dedicated clinic, develop the skills to run the clinic and manage the service so that staff who need training are able to rotate through the clinic – this is the ‘new’ thing that requires extra organisational time and incentives. But once in place, it helps all of the basic services run more efficiently, at a higher standard.

Few opportunities for progression – Discussions with midwifery managers and staff outside of the southeast of England indicated there are few opportunities for midwives to progress in their careers to a senior midwife post. For this reason, we will require the appointment to be at least a beginning Band 7. We want the post and the project to offer greater opportunities to health boards and hospitals that benefit from participation in research less frequently.

Not enough research staff – The breech specialist midwife will be seconded to the research team for at least 10% FTE (half a day a week). The funding will this will come from the Clinical Research Network (CRN) pots that fund all research midwives and nurses. Collecting service data also contributes to the breech specialist’s growing expertise. By the end of the project, they will have additional transferrable skills to remain active in clinical research, either through further work as a research midwife or by pursuing a clinical academic role. It also offers the specialist increased flexibility in their working patterns. Sometimes, a clinic day is not full of breech-presenting babies; data can be collected. Sometimes, there is a late diagnosis of breech presentation requiring urgent counselling; or a birth occurs overnight before a research shift; data collection can easily be rescheduled.

Will anyone be willing to take on the role? Managers worried that the post would require someone to take on a lot of responsibility and that their staff are often very junior due to staffing shortages. They often expressed worry that they might not find someone willing to take up the post. However, often in the same conversation, someone was simultaneously offering to fill the post or identifying someone who would be very keen to ‘own’ the project locally. Our experience is also that experienced junior staff often ‘grow’ in this position, as it gives them an opportunity to expand their skills and autonomy with support. However, due to this worry, we will work with sites who express an interest to ensure they have identified someone who is willing and able to take up the position in advance of confirming them as a collaborator on the funding bid.

Does this role or being a part of a team of breech midwives interest you? Fill in our survey to let us know!

Will we have enough numbers?

Most obstetric staff who expressed an interest were very keen to participate but worries that they were not seeing sufficient numbers of women planning a vaginal breech birth to make it worthwhile.

There is no VBB target. We have reassured sites that this study is NOT about promoting vaginal breech birth, and there is no minimum target of VBB numbers to achieve. If no one plans a VBB, and one-month follow-up surveys indicate that they felt well-informed and supported, with all choices available, there is no problem! If on the other hand, follow-up surveys indicated women are meeting resistance when they attempt to plan a VBB, we would work with sites to address this.

“There are many barriers within our service.” Multiple obstetricians who were otherwise keen to support women’s choice to plan a VBB described the same barriers within their service:

  1. Not all women eligible were referred for an ECV attempt. Many were just encouraged to plan a caesarean section. (This aligns with available systematic review evidence, our interview data and our PPI feedback.)
  2. When women chose to plan a VBB after a failed ECV, they often wanted to return to talk about it a bit more. But they returned to their named consultant’s clinic and were discouraged, so many abandoned their hope to plan a VBB. (This aligns with available systematic review evidence, our interview data and our PPI feedback.)
  3. Some women felt confident to plan a VBB with appropriate counselling, but when they arrived in labour, it was very clear that the clinical team on duty were not supportive. Often, they would find any excuse to recommend an emergency caesarean early in labour, eg. suspecting a ‘footling breech’ at 2 cm when previous scans have indicated an engaged pelvis. The few women who continued to plan a VBB often ended up feeling very let-down and disappointed with the service. (This aligns with available systematic review evidence, our interview data and our PPI feedback.)

Because of this, obstetric staff often felt frustrated that, although they wanted to participate, it might not be possible in their setting.

This is the problem in almost ALL settings. You are not alone! The standard care pathway is not working in most settings for precisely these reasons. That is why our proposed intervention is a care pathway intervention. Even if we have improved the safety of VBB, if there is no way for women to benefit from this, and no way for staff to learn from it, nothing will change. This is the problem our ‘intervention’ (a dedicated clinic and service, co-ordinated by a breech specialist midwife) is designed to improve. Once you ensure that women receive consistent counselling and continuity of care, you can begin to benefit from improved training and cultural change.

Inviting your views: OptiBreech ECV or no-ECV trial

A summary of the OptiBreech team’s PPI work with women and other stakeholders about our proposed ECV/no-ECV trial.

If you would like to offer feedback privately, you can contact our PPI Lead, Siân Davies. Siân has lived experience of breech pregnancy, is a perinatal psychologist by training, and has additional training in trauma-informed care. Our PPIE team also includes Nimisha Johnstone.

We held two online engagement events in March 2023. These were attended by four women with lived experience of breech pregnancy and planning a vaginal breech birth and two midwives. Additional feedback was obtained via social media channels and a survey. This was how we advertised them:

Monday, 6 March, 2-3.30 pm — via Zoom

Tuesday, 14 March, 6-7.30 pm — via Zoom

Events are open to women and birthing people and maternity care providers throughout the UK.

Below is a description of one of the studies we would like to do. We invite anyone to comment on the study design and description (online survey; will remain open until early May 2023), particularly families that have had a breech-presenting baby within the past 5 years in the UK. We can answer any questions you have during the engagement meetings, or you can contact us via e-mail using the form below.

OptiBreech ECV or no-ECV trial

ECV with midwives Shawn and Lucia Pederiva (shared with permission)

Approximately 1:25 babies is breech at the end of pregnancy, positioned head-up instead of head-down in the womb. Current standard care is to offer women an attempt at turning the baby to head-down, through pressure on the abdomen (external cephalic version, ECV). However, this procedure is only successful 50% of the time and some women prefer not to try it.

OptiBreech care is delivered through a dedicated clinic, co-ordinated by a breech specialist midwife collaboratively with a breech lead obstetrician. It includes care during labour for women and birthing people who plan a vaginal breech birth (VBB). In our first study of OptiBreech care, women who planned a VBB without a prior attempt at ECV (no-ECV) had higher rates of vaginal birth. In our small trial, women receiving OptiBreech care had higher rates of vaginal birth and better outcomes compared to women receiving standard care, including all modes of birth.

In surveys one month after birth, 61% (27/44) of OptiBreech participants said they would not attempt an ECV in a future pregnancy. OptiBreech clinicians are also uncertain whether trying to turn the baby provides additional benefits, including more vaginal birth and less overall healthcare costs, compared to no-ECV within OptiBreech services.

The thoughts of 44 women following breech pregnancies on ECV if they had another breech baby. Note: This is a current snapshot of our responses and may change. Also, more women in this sample had unsuccessful ECVs, which will influence views.

The aim of this research is to determine if attempting to turn breech babies head-down (ECV) offers additional benefits, compared to OptiBreech care with no-ECV.

The design is a randomised controlled trial. Participants will be women over 36 weeks of pregnancy who wish to plan a vaginal birth regardless of whether their baby remains in a breech position. Those who choose to participate will be allocated by chance (randomised) to one of two options.

The ‘standard care’ group (the control) will have an ECV attempt. If unsuccessful, the person will plan a VBB with OptiBreech care. The experimental group will be no-ECV; these will plan a VBB with OptiBreech care. We will compare these two groups to determine whether the vaginal birth rate differs between them and whether care for one group costs more than care for the other.

Our stakeholders, OptiBreech clinicians, participants and Patient and Public Involvement group members, have highlighted the need for this research. While some women may continue to prefer an ECV attempt, others would prefer not to have one if additional benefits are not clear. This could potentially save healthcare resources or alternatively reassure us that ECV is still important in OptiBreech contexts.

This research is aimed at influencing national guidance. We will work with the Royal College of Obstetricians and Gynaecologists to ensure this happens. We will also share our results with participants and the public through publications and our engagement website, optibreech.uk.

Dr Shawn Walker, OptiBreech Chief Investigator

Stakeholder feedback and questions

From our first engagement event: What happens if someone gets randomised into ECV and they didn’t want this and decides not to go ahead with the plan?

Ideally, we would like people to decide if they will be happy to have an ECV and/or a planned vaginal breech birth before agreeing to participate. However, we respect everyone’s autonomy and ability to withdraw from research interventions. We would continue to include the person’s results (with consent) and would take account of the change of plan in the statistical analysis. The reality of breech care is people often do change their minds, both about ECV and about VBB.

Could woman opt in for ECV or no ECV themselves?

Yes, but not if they are participating in the trial. Randomisation reduces bias by removing the element of choice from both women and clinicians. So participants would need to decide if they are happy to give up that choice, and accept ECV or no-ECV according to the way they are randomised.

If women decide NOT to participate in randomisation but still wish to plan a vaginal breech birth, they will be invited to participate in the observational cohort arm of the study. This option may or may not be available to women booked externally to participating centres, depending on whether OptiBreech care is considered the standard of care or an experimental treatment (on-study only) within that hospital. It may also depend on the team’s capacity.

From our first engagement event: If someone has had a previous caesarean birth but they would like this birth to be vaginal, could having an ECV cause issues because of the previous birth mode i.e. ruptured membranes etc?

Having an ECV after one caesarean appears to be safe, and the current RCOG guidelines recommend this is offered. Regardless of previous mode of birth, approximately 1:200 women (0.5%) require an emergency caesarean birth immediately following the procedure, due to complications. Having an external cephalic version prior to 36 weeks may increase the rate of preterm birth.

From our first engagement event (midwife stakeholder): Computer randomisation does reduce clinical bias, however would the clinical midwife involved in the study increase bias by them recruiting participants?

Yes! This bias could go either way. Sometimes people are not recruited because, for example, the clinician does not feel it would be appropriate to offer them one option or another. Sometimes there is confusion about inclusion criteria so that women at moderate risk (eg. one previous caesarean birth) are not offered the opportunity to participate. To counter-act this potential source of bias, we will create posters for recruiting sites to display in areas where women receive antenatal care, providing them with a neutral point of contact, such as a research midwife. We will also share information on this website about how women can self-refer onto the study. This will enable as many women to access the research as possible and limit the bias from clinician selection.

From our online survey: How do people get consented to the randomisation?

Great question! The health care professional who informed the person about the research would offer further written information and the opportunity to ask questions. Then we would ask for consent, usually online, directly onto our database via the participant’s personal e-mail, which is also used for follow-up surveys. Alternatively, consent can be taken via written signature on the same consent form, on paper. An example of the participant information sheets and consent forms we currently use can be found on our Information for Women and Birthing People page.

In some settings, OptiBreech team care has become the standard of care. In others, it is still considered an experimental care pathway within the service, with the service funded by clinical research network funds. In the latter case, OptiBreech care would only be available through participation in the research.

From our online survey: I’d want more information about what OptiBreech is, but appreciate this may confound the research.

We want participants in this research to have a very clear idea about what OptiBreech Care is. We explain it in our participant information sheets, which are similar to those we would use in this research. These can be found on our Information for Women and Birthing People page.

Questions about breech birth at home

From our online survey:

What about those who wish to birth at home?

I suspect the research will take place in hospital, but that hasn’t been made clear.

Supporting women in any location.

Any data on VBB home birth.

Our OptiBreech Guideline recommends birth in hospital, within an obstetric unit. However, this is not required. We neither require women to give birth in hospital nor require local OptiBreech teams to attend births outside of the hospital. As with most standard breech criteria, our approach is to observe rather than to control. Women on our study have chosen to give birth in the full range of settings available to all other women, although sometimes the ability to do this is affected by local staffing constraints. It is too early to offer information about how place of birth influences results for OptiBreech care.

The OptiBreech position on home breech birth is fully explained in this video blog.

From our online survey: Does this include footling breech presentation? As all basic literature I have found suggests c section always offered with these.

You are absolutely correct that this has been the traditional approach. But our approach is to base all of our guidelines on evidence.

Our view of the literature is that ‘footling’ presentation is poorly and inconsistently defined, making it difficult to draw conclusions about risk. Increased risks pre-term (before 37 weeks) are clear, but the available literature indicates that non-extended (non-frank / both legs straight beside the body) presentations may actually have BETTER outcomes at term. We therefore do not recommend a caesarean birth unless the feet are presenting and the baby’s pelvis is not engaged, eg. positioned above the inlet to the maternal pelvis. We call this position, ‘standing.’

When baby’s legs are flexed (bent), we counsel women about the increased risk of a cord dropping down in labour, which would require a caesarean birth if it happened. And we explain the clinical uncertainty, eg. we do not know for certain whether there is increased risk or not.

Instead, we collect data about what position baby’s legs are in during antenatal scans and what position the legs are in at birth, and of course what the ultimate outcome is. In that sense, yes, footling breech presentation is included, and not excluded, from this research.

Questions and feedback from Amy Weatherup, administrator of the Breech Birth UK Facebook Group.

Answers from Shawn in blue.

Some questions about your study design:

How will you record babies that turn by themselves without an attempted ECV or after a failed ECV?

In the OptiBreech database, we record: 1. Initial plan after first counselling – ECV/VBB/CB; Result of all ECVs planned – not done (and reason)/successful/unsuccessful

Will you allow a 2nd ECV after a failed ECV?

Yes, all women who request an ECV are offered a 2nd attempt (for those women randomised to the ECV arm only).

What will your approach be to other turning methods eg spinning babies, moxibustion, Webster’s technique?

In the OptiBreech database, we record: 1. Counselling, advice, information and other items (eg. moxa sticks) women have been given antenatally; 2. What women report having used in pregnancy in a follow-up survey 1 month after birth

One of our OptiBreech team members is currently analysing this data for her Masters. We think this would make an excellent PhD for a midwife (trial of one or more complementary methods). https://optibreech.uk/2022/10/19/researching-how-to-encourage-breech-babies-to-turn/

Will women have to agree not to try them or will they be allowed or even encouraged? In either case the data on what else they try will need to be collected.

Currently, the OptiBreech care pathway does not include specific advice on complementary therapies. We are collecting observational data on their use only. We will neither be requiring women not to try complementary therapies nor encouraging them to do so.

Hope that helps! Keep up the good work!!!

Thank you!

OptiBreech is helping so many women that are coming through our group – I hope you can find a way to make it more widely adopted once the research is completed (but I realise the NHS is slow…)

We are working on that too! Watch this space …

Responses to the online survey

Who participated?

Other: I experienced undetected footling breech presentation and delivered vaginally at home prior to midwife arrival due to rapid labour. Just over 2 months ago.

Q1 – What do you like about this study?

I felt like my only option was elective c-section so this would have been great to support a vaginal breech birth for me
I am interested to know if not attempting an ECV would lead to better outcome. And how good are the outcomes for mum and baby in BVV.
Having options to birth vaginally rather than being told you must have a c section. That there will be specialists in breech aginal delivery
That it could support trusts to support VBB
The encouragement of the use of natural breech birth
The results can influence that women should not be forced into an ECV automatically. Autonomy is so important
Each study arm has an emphasis on vaginal birth; the study will collect good data on the outcomes of VBB attempts in general and this will allow more birthing people to consider a VBB, with or without ECV.
It could provide some insight to the reality of the benefit of ECV rather than a perceived benefit. Any additional information on breech birth will help empower women with their birth choices.
I like that methods other than ecv are being looked at.
Its taking a good look at optimum care for women with a breech presentation,  acknowledging that they may want a vaginal birth and this is a perfectly reasonable option.
It is lookind xarefully at the impact of ECV. It is supporting vaginal breech birth
I like that women would be allowed to make an informed choice without being pressurised into what they don’t want, considering there are no further risk factors involved
It looks at the clinical benefits and outcomes of a procedure which is often just assumed, or denied without a real discussion
Providing more data on the benefits of an ECV to allow people to make informed choices
I like the idea that in one group the baby decides- if it stays breech it can be born breech. I like that both groups will get to birth vaginally

Q2 – Did anything concern or worry you?

No
No.
No
No
no
Not really
No
Not currently.
No. But I know some women worry about ECV. I had one (which didn’t work) so I’m not bothered.
What about thoae who wish to birth at home?
No
No
No
No, I think this is well thought out research

Q3 – Was there anything you needed more information about, or felt was unclear in the summary?

Note: Where participants expressed questions, we answered these above.
No
No
No
yes
No
Very clear
Does this include footling breech presentation? As all basic literature I have found suggests c section always offered with these.
How do people get consented to the randomisation
I’d want more information about what OptiBreech is, but appreciate this may confound the research.  I suspect the research will take place in hospital, but that hasn’t been made clear.
No
No
No
No, it was all clear

Q4. If we asked 10 women or birthing people who prefer a vaginal birth if they would like to participate in this study, how many of these 10 women do you think will agree to participate?

  • Minimum: 4
  • Maximum: 10
  • Mean: 8
  • Standard deviation: 1.9

Q5. If you were pregnant with a breech baby, would you participate in this study?

Q6 – Why do you feel this study will be acceptable, or not?

Yes
I think it’s acceptable, it’s an interesting topic
Acceptable because it gives women choices with their bodies and births which reduces trauma surrounding a lack of control to try birth vaginally
Na
yes
Anything that gives women autonomy is so important, as they have to deal with the consequences of it. You shouldn’t be made to feel that is the only option
Dedicated care for breech presentation to optimise the chances of a successful vaginal birth in both arms.
It may be tricky because VBB can be taboo, and offering ECV is a standard of care. Some women may feel they are not giving themselves the best chance if they don’t attempt an ECV
Some women won’t want to risk having an ECV.
If birthing people have strong feeling ref ECV they may withdraw if allocated to the ‘wrong’ group.
It allows women making informed choice whilst considering research data and risk factors
This is a really vulnerable time in a pregnancy. Women often have ideas about how they are going to give birth, they are often told for weeks/months don’t worry baby has lots of time to turn and then suddenly it’s all systems go for a c section. It should be talked about more throughout with real tangibility of success rates and impacts
Support of the OptiBreech team will mean candidates are more likely to support a randomised study as they will feel well cared for by experts
I’m both groups there is clearly good care and support from a breech team

Q7 – Is there anything else you would like us to prioritise for OptiBreech research?

I would like to learn more about the outcomes of the VBB when attempted with help of an experienced team.
The collection of evidence to support VBB and VBac
Could woman opt in for ECV or no ECV themselves?
Any data on VBB home birth.
Supporting women in any location.
Getting all hospitals to offer real choice to pregnant women

We also asked for permission to include the quotes provided in our report. Thank you to all those who have helped us to shape this research and our on-going projects.

Upcoming OptiBreech public involvement & engagement meetings

You are invited to help us design and deliver the next stages of OptiBreech research, March 6 and March 14.

You are invited to help us design and deliver the next stages of OptiBreech research. We have scheduled two meetings on the following dates in March:

Monday, 6 March, 2-3.30 pm — via Zoom

Tuesday, 14 March, 6-7.30 pm — via Zoom

Events are open to women and birthing people and maternity care providers throughout the UK.

OptiBreech participants and breech clinic leaders have identified the need to answer the following two questions:

How do the outcomes of head-first birth after an external cephalic version (ECV) compare to vaginal breech birth with OptiBreech care?

  • Will having an attempt at ECV improve outcomes for mothers and/or babies compared to just having a vaginal breech birth?

Is it safe to offer induction of labour for women and birthing people when their babies are breech, if an earlier birth would be safer or the person chooses to be induced after 39 weeks?

  • Current RCOG guidance indicates induction is not commonly recommended in the UK, but some women have told us they would like to have this option. Careful induction of labour is available in other European settings that support vaginal breech birth.

We would particularly like to hear from families who have been affected by breech presentation at the end of pregnancy within the past five years. We will seek your views on how we should design this research and how we should share information with people to ensure they understand the potential risks and benefits of participating.

Shawn

Read:

OptiBreech position on home breech birth

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.

Further Reading

Dasgupta, T, Hunter, S, Reid, S, et al. Breech specialist midwives and clinics in the OptiBreech Trial feasibility study: An implementation process evaluation. Birth. 2022; 00: 1- 10. doi: 10.1111/birt.12685

Mattiolo, S., Spillane, E., & Walker, S. (2021). Physiological breech birth training: An evaluation of clinical practice changes after a one‐day training program. Birth, birt.12562.

Symon A, Winter C, Donnan PT, Kirkham M. Examining autonomy’s boundaries: A follow-up review of perinatal mortality cases in UK Independent midwifery. Birth: Issues in Perinatal Care. 2010;37(4):280-287.

Bovbjerg, M.L., Cheyney, M., Brown, J., Cox, K.J., Leeman, L., 2017. Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States. Birth 44, 209–221.

Bastian H, Keirse MJ, Lancaster PA. Perinatal death associated with planned home birth in Australia: population based study. BMJ. 1998;317(7155):384-388.

Schafer, R., Phillippi, J.C., Mulvaney, S., Dietrich, M.S., Kennedy, H.P., 2022. Experience of decision-making for home breech birth in the United States: A mixed methods study. PhD Thesis: Vanderbilt University.

Fischbein, S.J., Freeze, R., 2018. Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births. BMC Pregnancy Childbirth 18, 397.

Transcript

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. 

February 2023

Dr Shawn Walker

PPI Meeting, Sunday 30 October, 10 am

We would like to hear from you! 

Link to join (Teams)

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.

Link to join

With very best wishes,

The OptiBreech Team

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.

Researching how to encourage breech babies to turn

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.

Shawn

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.

Image: Westgren, M., Edvall, H., Nordström, L., Svalenius, E., Ranstam, J., 1985. Spontaneous cephalic version of breech presentation in the last trimester. Br. J. Obstet. Gynaecol. 92, 19–22. https://doi.org/10.1111/j.1471-0528.1985.tb01043.x
video from Nesta, UK

For more information on Randomised Controlled Trials, see this simple explanation from Nesta in the UK.

What do you think?

We would love to hear from women about whether you think it would be a good idea to test hypnotherapy for turning breech babies at the end of pregnancy.

  • Why or why not?
  • Would you be willing to help us design a test to see if it works?
  • Are there other therapies you would like to see tested?

Thanks as always for your feedback. You can comment on this post or e-mail our team using the form below.

We are also keen to hear from professionals who would like to work with us to deliver research in this area.

BICS2022 Conference

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:

Dr Siddesh Shetty and Dr Shawn Walker

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.

Ritika Roy and Cecelia Gray

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!

The role of the on-call obstetric team in OptiBreech care during births

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:

Perinatologist Brad Bootstaylor
  • 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?

Consultant Obstetrician Sabrina Das, Queen Charlotte’s and Chelsea

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?

Obstetricians Katrin Loeser and Kamilla Gerhard-Nielsen, Aabenraa, Denmark

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?

Obstetrician Zoltán Kovács, Budapest, Hungary

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.

Leonie van Rheenan-Flach, OLVG, Amsterdam

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:

Why don’t women want obstetricians to be involved?

Consultant Obstetricians Niamh McCabe and Janitha Costa, and Breech Specialist Midwife Jacqui Simpson, Belfast 2017

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.

– Shawn

Specialist midwives and clinics – inviting your views

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:

  1. 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. 
  1. 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. 
  1. 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.
  1. 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.  

Join on your computer or mobile app  

Click here to join the meeting  

Saturday at 2pm: Consultation on Draft NICE Antenatal Care Guideline — Breech Birth Network

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…

Saturday at 2pm: Consultation on Draft NICE Antenatal Care Guideline — Breech Birth Network