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

Proposal Development: What do staff think?

In developing this proposal, I sought feedback from clinical leaders in the participating Trusts, as well as my research support team and personal international network of breech clinicians.

In May 2019, a Physiological Breech Birth study day was held at St Thomas’ Hospital in London. This included presentation of the feasibility study design, with an invitation to provide feedback via the Poll Everywhere app.

A total of 77 people attended the day. Information on their backgrounds is below.

All attendees received a Description of Intervention and an explanation of the feasibility study design by the Chief Investigator. We asked health care professionals and trainees how many women they felt would be willing to participants. Their responses ranged from 0-8, with a mean of 4.3. This was slightly lower than predicted by PPI work with women.


Reassuringly, after learning about physiological breech birth and the proposed feasibility study, professional opinions about the potential of the intervention appeared largely positive. But this was a self-selecting audience who chose to attend the study day and may not reflect the opinions of the wider maternity care team. And not everyone who attended the day was able to stay until the end to complete the survey.

Physiological Breech Birth care depends on a portion of health care professionals being willing to work flexibly in order to ensure experienced support at breech births. Feedback indicated that, although this was not something every practitioner was willing to do, a sufficient number to create a breech team was likely to be achievable.

Read more about health care professionals’ responses to the feasibility study design:

Written by Shawn Walker, 6 June 2019

PPI: proposal development phase

While I was developing this proposal, I sought input from service users in several ways:

Ensuring good information

The importance of complete and understandable information about the feasibility trial and about the option of vaginal breech birth was echoed across feedback from all sources. This has been highlighted as the main ethical issue in the Detailed Research Plan.

As the protocol develops, I will engage carefully with those who have indicated an interest in remaining involved in the feasibility study to ensure information meets women’s needs. My colleague Emma Spillane, breech midwife at St George’s Hospital in London, has been developing an information leaflet about options for breech a term. This includes infographics, which women with autism and information processing challenges have fed back is very helpful. I will build on this for the feasibility study.

We will also look carefully at the number of women who are not able to participate in the trial because of informational barriers, such as the inability to understand written English. This will help to understand what translation services, into what languages, we may need to make use of in a full trial to enable equity of participation and access.

Lay reviewers from the RDS London Fast Track Service expressed concern about the legal situation should an adverse outcome occur with a vaginal breech birth. Women in both arms of the trial will be able to choose their preferred mode of birth. The difference is: women under physiological breech birth care will be offered assurance that, if they choose to plan a vaginal breech birth, the team will do everything possible to ensure they are attended by someone who is trained, skilled and experienced in physiological breech birth. In many NHS Trusts, the availability of such support is uncertain, as it depends on who is on shift in the labour ward on any given day/night. Women will be counselled as per the RCOG guideline and local guidelines regardless of their group allocation. They will be informed that we are doing this trial because the available evidence indicates that the physiological breech birth approach may improve access to and outcomes of vaginal breech births, but that we are not certain – hence the need for the research.

Will women participate in this research?

Designing a trial that would produce useful information for women, using methods that were acceptable to women participating in the research, was an important priority to me. The Term Breech Trial46experienced recruitment difficulties, which may have influenced the results.35 Early feedback moved the trial design in a more pragmatic direction, to a design that enables women to have the final say in whether they have an ECV and how they give birth to their breech baby. Another benefit of this design is that it will enable us to study how this new model of care influences women’s perception of the choices available to them.

When we asked those who attended the MVP meeting how many women out of 10 they thought would agree to participate, the range of answers was 5-8, with an average of 6.66. To increase enrolment, MVP members recommended a second recruitment opportunity immediately prior to any scheduled ECVs. This will give women time to think about it, and research midwives ability to identify potential candidates who may not have been offered the opportunity to participate immediately following their scan. This has been incorporated into the trial protocol.

One concern was that all women who participate would want specialist care, and would be disappointed if randomised to standard care. Although making specialist care unavailable outside of the trial is necessary for this design to succeed, and there was general agreement and understanding about this, some women felt it was unfair. For this reason, when a decision is made about whether to proceed to a full trial, we will consider whether randomisation at the individual level has worked. We will compare this to feedback from Trusts who indicate a willingness to participate in a full trial. Following the completion of the feasibility study, we will consider whether the current design will work. If not, and if enough Trusts are keen to participate, another design may be more appropriate, such as a stepped wedge cluster randomised controlled trial. In this type of research, individual Trusts would be randomised to implement physiological breech birth care at different times, rather than individual women.

What about the women who have had negative experiences of breech birth? Or those who are happy with standard care?

Women who respond to a call for involvement in development of a breech birth trial are more likely to have had either positive experiences of breech birth or negative experiences finding a lack of experienced support, for either planned or unplanned breech births.

Thank you to Maureen Treadwell of the Birth Trauma Association for helping me ensure this proposal is informed by the experiences of women who have felt traumatised by not being able to plan a vaginal breech birth, as well as those who have felt traumatised after planning a breech birth that did not go to plan. Women who have had negative experiences of breech birth may be more reluctant to engage in discussions about a breech trial, for very good reasons. Service user advocates like Maureen, who listen carefully to the stories of many women across the UK, help these voices to be heard as we strive to Do No Harm.

Maureen and the BTA highlighted that the goal of any further breech research should be to increase the quality of information and the availability of choice for women carrying a breech baby at term, rather than as part of a strategy that to reduce the CS rate.

This resonated with feedback from the RDS London Fast Track Review Service, through which four public representatives provided a review of two versions of the Plain English Summary. Again, the views of the general public about breech birth research are likely to be different to those held by women who have experienced a term breech pregnancy themselves. One RDS reviewer expressed concern that if physiological breech birth were deemed ‘safe,’ women would feel pressured to choose a vaginal birth rather than a CS, and this would undermine the priority of ensuring women are well supported regardless of their choice of mode of birth.

Thank you

… to everyone who took the time to respond to my research proposal, to members of South London MVP for giving me permission to share their feedback and to Alison Bish for co-ordinating responses from RDS London. I am extremely grateful and confident the design is better for everyone’s involvement.

If you would like to view the tool I used for the Maternity Voices Partnership Meeting, you can download it here.