Category: Policy

Moving forward: the current status of OptiBreech Collaborative Care

Dear Shawn
Trust all is well at your end
Shawn as we are not doing optibreech trial do we need to change anything at our end especially with regards to legality etc.
some queries which have cropped up here
What is the frequency of training?
Is this MDT training?
Who runs the training?
Optibreech trained staff – numbers and skill mix?
What is the compliance for completion of vaginal breech birth training offered?
Is there a lead for the Optibreech trial – may be helpful to meet with them?
Also otherwise any legal changes etc ….

The OptiBreech pilot trial and feasibility study ended on 31 January 2024. The team made four applications for further funding, but unfortunately funding for a substantive trial was not gained. Without further funding, we will not know the effects of full implementation of the OptiBreech Collaborative Care pathway as the standard care pathway for breech care in the UK.

The evidence from the pilot work indicates better outcomes than any prospective study previously done, especially in the UK. This may change with greater numbers, but without further research, we will never know. Our early economic modelling suggests that the care pathway is likely to be cost effective. Again, without a substantive trial, we will never know.

Many of the sites that participated in the pilot and feasibility work have continued to offer the OptiBreech Collaborative Care pathway to women pregnant with a breech-presenting baby late in pregnancy. When they have had less than ideal outcomes, as is inevitable, those offering this model of care have come under increased pressure to justify offering a service that has not been demonstrated in a full RCT to improve outcomes, compared to standard care.

This is therefore a good time to explain exactly what OptiBreech Collaborative Care is, how it differs from standard care, and if the lack of RCT-level evidence should be a barrier to offering this model of care to women.

What is OptiBreech Collaborative Care?

First of all, OptiBreech Collaborative Care is a care bundle, or care pathway, rather than something entirely new and different from ‘standard care.’ The model organises the elements of care women need to make an informed choice about their planned mode of birth for a breech baby, and to optimise the chances that the outcomes will be good if a woman chooses to plan a vaginal breech birth.

The ways the pathway differs from standard care are outlined below.

A dedicated clinic, co-ordinated by a breech specialist midwife, in collaboration with an obstetric lead for breech

UK national guidelines state that women should be supported to make an informed choice about their planned mode of birth for a breech-presenting baby at term. All of the available qualitative evidence indicates that currently in the UK, the majority of women who might wish to plan a vaginal breech birth do not feel that choice is accessible to them and/or they do not feel supported when they make that request.

Qualitative evidence from both women and clinicians contributing to OptiBreech feasibility work confirmed the lack of accessibility of this care option, which national guidelines state that women should be offered. The OptiBreech pilot trial was stopped early because at an interim analysis, there was ALREADY a statistically significant difference in the number of women planning a vaginal breech births under OptiBreech Care compared to standard care, in which none planned a VBB.

Therefore, there is already RCT evidence that the availability of this option, which national guidelines say women should have access to, is improved by providing an OptiBreech clinic within this model. Given that the available economic modelling suggests supporting the option of a safe-as-possible VBB, and the only available RCT demonstrates a significant difference within even pilot-level data in the availability/acceptitibility of this choice, there does not appear to be a pressing need to justify providing care within a dedicated clinic.

Clear definitions of competent, proficient and specialised in vaginal breech birth

What women who wish to plan a VBB say they need from a breech birth service is to know that it is very likely that someone with skill and experience will attend their birth. This is a completely reasonable request, given that the RCOG guideline states that, “with skilled and experienced attendants, planned VBB is likely to be nearly as safe as planned cephalic birth.”

I have been writing about the problematic ambiguity in this statement since it was published. My PhD was dedicated to defining ‘skill and experience’ and how one acquires these within contemporary maternity care. And OptiBreech was/is about finding out how ‘near’ is ‘near.’

Having definitions of proficiency helps enable women to make an informed decision about the support they can expect to receive around the time of birth. This is a discussion that should occur prior to, and during, every birth. If on the day of labour, the only staff available have minimal training, experience and confidence, the birthing person should be informed transparently and supported in their decision to carry on or divert to an early labour caesarean birth.

During the OptiBreech pilot and feasibility work, we provided teams with a proficiency portfolio document to record their experience level, for their own protection and learning, and to accurately inform women. But it was never a requirement. Every clinician has a responsibility to maintain their own records, as it always has been. If Advanced Practice becomes regulated, this is a model for how this might look for breech practitioners at the moment.

All women should have and should be informed that having their birth attended by a skilled and experienced practitioner does not guarantee a good outcome. But it is the only thing ever associated with the improved likelihood of a good outcome.

A plan for getting the right people in the right place at the right time … and a plan for when this is not possible

The most common way that women are discouraged from planning a VBB when they would otherwise like to consider it, is they are told that the staff at this hospital do not have enough experience / a dedicated team / a specialist. And that is the end of the discussion.

There is not a single hospital on the planet where every member of staff feels completely comfortable and competent to support a vaginal breech birth. None. If you try to tell me yours does, I will tell you to go back, speak with each obstetrician privately, and ask them to tell you how they really feel. People always feel pressure to conform, either conform to discouraging the option of VBB so nobody has to do it, or conform to the illusion that anyone can do it.

The reality is, INDIVIDUAL PEOPLE have skills and experience, INSTITUTIONS have people. No institution has a uniform level of skill and experience throughout its maternity staff to support a VBB at the highest level. In institutions that support VBB regularly, INDIVIDUAL PEOPLE may have a high level of skills and additional synergistic experience working with other members of their team, which again improves the safety of VBB.

The only way to increase the chances that someone with skill and experience will be at the birth is to make a plan for it. OptiBreech teams have never had a minimum required number of trained or proficient members. If there are fewer trained practitioners, the chances that one will be able to attend may be lower. If there are more, they may be more likely to ensure an experienced attendants.

But I cannot emphasise enough that many women are grateful if JUST ONE midwife or obstetrician is willing to work flexibly to attend their birth if they can. Requiring staff to have a minimum level of experience in order to ‘allow’ women to plan a vaginal breech birth is not ethical.

What is the frequency of training?

Guidance for what clinicians should do to acquire competence and maintain proficiency is available in previous consensus-based research. In our feasibility work, staff were required to have completed the OptiBreech training, which had previously been evaluated in NHS settings. And they were required to inform women of their experience levels. And the outcomes were very good.

Requiring a further frequency of training in order to ‘allow’ a woman to attempt a vaginal breech birth introduces an obstacle to informed decision-making without any evidence that it will improve outcomes.

Is this MDT training?

The evidence of how we evaluated the training package and with what professionals is readily available. All training, and the research, were multi-disciplinary. National guidance is that Trust internal mandatory training should be multi-disciplinary, and to our knowledge, this is what current OptiBreech sites are doing.


Who runs the training?

In the OptiBreech feasibility study, training was provided by Breech Birth Network, CIC, as this was the only physiological breech birth training that had previously been evaluated in NHS settings. Since the end of the study, sites run their own internal mandatory training and pay to send their staff to the evaluated, full-day study day when they feel it helpful to train new team members. Many breech specialists lead breech training within their own settings, for both midwives and doctors.


Optibreech trained staff – numbers and skill mix?

I am not sure what this question is aimed at. This answer varies for each Trust and for each woman. It varied for each Trust in our pilot and feasibility work.

Again, requiring a certain number of trained staff before women are ‘allowed’ to plan a vaginal breech birth will restrict both women’s informed choices and the ability of any Trust to begin to develop a team. In most sites, building a team began with one person willing to be on-call, until others developed experience and confidence. This strategy resulting in better than standard outcomes.


What is the compliance for completion of vaginal breech birth training offered?

Again, what is this question aimed at? Who is requiring compliance, to what standard, and due to what evidence?

If a clinician says they have completed an evaluated study day in physiological breech birth and they have not, that would be a violation of professional standards. Prior to OptiBreech, there were no proficiency standards, and we have added guidance.

But – to repeat – requiring additional compliance standards will create a barrier to women accessing care from clinicians willing to support their informed choice. With no evidence that requiring some form of ‘compliance’ will improve outcomes.

The only available evidence (from the OptiBreech feasibility and pilot studies) indicates that providing guideline standards and an evaluated physiological breech birth training day for core staff, who then disseminate it to others through mandatory training and skills drills, so far results in an adverse outcome rate that was 1/10th that in the Term Breech Trial (0.5% vs 5.0%).


Is there a lead for the Optibreech trial – may be helpful to meet with them?

Dr Shawn Walker (that’s me) is the lead for the OptiBreech pilot and feasibility trial, which ended on 31 January 2025.

Wellcome Trust Biomedical Vacation Scholarships, Summer 2024

Deadline for applications: 2 April 2024!

We have a project advertised with this summer research fellowship opportunity. Please share with your student midwifery networks ASAP.

OptiBreech project on page 27!

– Shawn

Why use more retrospective data and modelling to support universal third trimester scanning when prospective data suggests the implementation of specialist vaginal breech birth teams is equally likely to impact outcomes?

Investing in staff and their skill development will achieve the same, if not better, results and should be the priority.

This a response to a recently published report in PLOS Medicine suggesting that implementation of universal third trimester ultrasound scanning in pregnancy improves outcomes for babies and mothers.

The following contributors have approved this expression of concern:

Researchers and Clinicians:

  • Shawn Walker, Researcher in Residence and Honorary Consultant Midwife, Imperial College Healthcare NHS Trust
  • Emma Spillane, Deputy Director of Midwifery and OptiBreech Lead, Kingston Hospital NHS Trust, London
  • Sabrina Das, Consultant Obstetrician and OptiBreech Lead, Imperial College Healthcare NHS Trust
  • Philippa Corson, Consultant Obstetrician and Breech Clinic Lead, Royal London Hospital, Barts Health NHS Trust
  • Susan Bewley, Emeritus Professor of Obstetrics & Women’s Health, King’s College London

OptiBreech Patient and Public Involvement Leads:

UK researchers have an ethical obligation to involve service user groups in design and interpretation of research studies
  • Siân Davies
  • Nimisha Johnstone

Norfolk and Norwich University Hospital Maternity Voices Partnership Service User Representatives:

  • Lisa Brophy
  • Marion Frey-Alqurashi
  • Rachel Graveling
  • Siobhan Ridley
  • Evelyn Shadlock

Knights et al1 confidently demonstrate that routine third trimester, including point-of-care ultrasound (POCUS) performed by midwives, can significantly reduce undiagnosed breech presentation in labour. This is welcome, as women find diagnosis of breech presentation in labour traumatic, regardless of the outcome.2 Although the considerable psychological impacts were not discussed, all should support the plan to increase safety, choice and personalised care through better antenatal detection of breech presentation.

However, the authors then assert that, “Short-term adverse perinatal outcomes, including [neonatal unit] admission and low Apgar scores, were significantly lower for the pregnancies with diagnosed breech presentation at term following a policy for screening by either routine third trimester scan or POCUS.”  This was despite no evidence given that any neonatal outcome achieved a statistically significant improvement. Indeed, hypoxic ischemic encephalopathy (HIE) increased from 0.3% to 0.4% in the St Georges University Hospital (SGH) cohort. The authors then ran Bayesian log-binomial regression models mostly using data from a previous evaluation of the same intervention on a different population (Salim et al),3 falsely concluding that there was a high probability the intervention would reduce adverse outcome rates.

Oxford’s implementation data

The publicly available data for the Salim et al study (S1 Data. Study data set)3 indicate that eight cases of serious neonatal morbidity (HIE and/or death) occurred:

Case numberPresentation at birthGestation at birthMode of birthScan after 35 weeks?Seen in breech clinic?Before or after universal USSPreventable with universal scanning?
23475*Breech39+0VBYesYesBeforeNo
19027Breech37+2VBNoNoBeforePotentially
20535Breech38+1EMCYesYesBeforeNo
22414Breech40+0VBNoNoBeforePotentially
22548Breech38+3EMCYesYesBeforeNo
4343Cephalic (after ECV)42+2VCYesYes (+ECV)BeforeNo
16054*Breech37+0VBYesYesBeforeNo
19867Cephalic (after ECV)42+2VentouseYesYes (+ECV)AfterNo
Key: * = death, ECV = external cephalic version, VB = vaginal breech birth, EMC = emergency caesarean birth, VC = vaginal cephalic birth

In six (75%) Oxford cases, the breech presentation was identified antenally. In 1/2 (50%) undiagnosed cases, a presentation scan would not have prevented the breech labour, which occurred at 37+2 weeks gestation. In both cases of death, the breech had been diagnosed clinically and the women had been seen in breech clinic. In two additional diagnosed cases, the breech service worked exactly as it was intended; two successful ECVs were performed. Nonetheless, HIE occurred following these cephalic births.

The total potential benefit in Oxford was a reduction of two cases of HIE and two less NICU admissions with Apgar <7 at 5 minutes without HIE, i.e. 44 versus 40 neonatal composite adverse outcomes in 1052 third trimester breech presentations, at a cost of 7,673 additional scans and 65 additional ECV procedures. 

Norwich charity funding

Knights et al1 do not explain that Norfolk and Norwich University Hospital (NNUH) spent £100,000 of NNUH Hospitals Charity funding4 on handheld ultrasound scanners. The results in their cohort (Table 4) indicate two fewer neonatal admissions and one less case of Apgar score <7 at 5 minutes after implementation. Neither of these would have been considered a serious adverse outcome in the Term Breech Trial5 nor PREMODA study.6 Thus, there is no causative evidence of improvement, nor is this strategy is likely to prove cost-effective for implementation at scale.

St Georges’ specialist service

Knights et al failed to even look for confounding factors, let alone control for them – a serious source of bias in retrospective studies (see item 7 in the STROBE checklist, ‘Variables’).7 Yet, during their study time frame, and known to the authorship team, SGH also participated in a prospective multi-centre evaluation of physiological breech birth training, the results of which were already published in 2021.8 Both Knights and Mattiolo report a similar number of vaginal breech births, 64 (49 before and 15 after) and 90 (37 before and 53 after) respectively. Mattiolo et al also report outcomes for actual vaginal breech births. Among births where there was no attendant who had completed the enhanced training present, the severe neonatal composite adverse outcome rate was 5/69 (7.2%). Among births attended by someone who had completed the enhanced training, in the same settings, it was 0/21 (0%).

Between 2017-2020, overlapping with the implementation of the scanning programme, a specialist clinic and intrapartum care service for women requesting a vaginal breech birth were implemented at SGH.9  After 100 doctors and midwives had received a whole day’s training, the internal guideline was updated to include a physiological breech management algorithm.10 This was incorporated into monthly mandatory training to all staff, introducing substantial changes to vaginal breech birth practice. All obstetric trainees received half-day training. New joiners received the whole-day training repeated 6-monthly. By 2019, the rate of planned VBB had increased from 1.3% to 12.3% of all births in breech presentation.11 Internal audit of this service demonstrated substantial reduction in the emergency caesarean birth rate, from 42.9% to 24.8% of all births in breech presentation.11

The specialist service at SGH was discontinued when the breech specialist midwife (Spillane) relocated in 2020 and was not replaced. Nevertheless, the potential confounding effects need to be considered. When services invest in staff skill development, those effects extend beyond each individual birth.12

Oxford’s breech team

from the Oxford University Hospitals NHS Foundation Trust website, https://www.ouh.nhs.uk/maternity/antenatal/care/specialist/

A specialist intrapartum service was also implemented at Oxford during the Salim et al. study,13 with the ‘dedicated on-call team’ for vaginal breech births publicly advertised on the hospital website.14 This is a significant difference in practice compared to most NHS units (except OptiBreech sites). Among the breech presentations >37 weeks with labour, planned vaginal breech births increased from 7.4% (12/162) to 17.6% (21/98) after the introduction of universal scanning. The provision of this team also appeared to improve the safety of the actual vaginal breech births that occurred.

 Admission to NNUApgar <7 at 5HIEPerinatal mortality
Planned VBB2/16 (12.5%)0/16 (0%)0/16 (0%)0/16 (0%)
Unplanned VBB7/42 (16.7%)3/42 (7.1%)5/38 (13.2%)2/42 (4.8%)
Secondary analysis of publicly available data from Salim et al

The differences between planned and unplanned VBB are comparable to Mattiolo et al.8 Could the authors use these data in Bayesian log-binomial regression models to demonstrate the beneficial effect of implementing breech birth teams? We cannot assume that similar results would occur in settings that do not offer a similar service. 

Summary

The opportunity to access a third trimester presentation scan remains important, especially for women planning an out-of-hospital birth. But women find it psychologically distressing and dehumanising to be unable to access skilled support for a vaginal breech birth, both antenatally and in labour.15–17 Unless an evidence-based plan for improving this support is in place, matters will never change. When we prospectively evaluated the implementation of breech teams,15 one in five participants transferred from their original booking hospital to access supportive care for a vaginal breech birth.18 Some of these women came from SGH (since this VBB service is no longer available) and NNUH (approximately three hours car drive from the nearest OptiBreech site). Further unanticipated risks are introduced for women whose babies are diagnosed as breech but who cannot access their preferred mode of birth locally. More inequalities are created among women for whom the required travel and self-advocacy is impossible.

Determining which interventions improve clinical and cost-effectiveness outcomes for term breech pregnancies requires properly powered, prospectively registered, randomised controlled trials with publicly available, pre-specified protocols and anonymised data sets. It is extraordinary that £100,000 of charitable money was spent on equipment alone, outside the context of carefully planned research, and without service user involvement in priority setting. This has merely resulted in a poor-quality publication and plenty of mass media soundbites.4,19,20 Currently, many NHS sites lack the funding for trained staff to offer all needed care options (ECV, VBB and ELCB) that are currently recommended in RCOG21 and NICE guidelines.22,23 Investing in staff and their skill development will achieve the same, if not better, results and should be the priority.

References

  1. Knights S, Prasad S, Kalafat E, et al. Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study. PLoS Med. 2023;20(4):e1004192. doi:10.1371/journal.pmed.1004192
  2. Lightfoot K. Women’s Experiences of Undiagnosed Breech Birth and the Effects on Future Childbirth Decisions and Expectations. DHealthPsych. University of the West of England; 2018. http://eprints.uwe.ac.uk/33278
  3. Salim I, Staines-Urias E, Mathewlynn S, Drukker L, Vatish M, Impey L. The impact of a routine late third trimester growth scan on the incidence, diagnosis, and management of breech presentation in Oxfordshire, UK: A cohort study. Myers JE, ed. PLoS Med. 2021;18(1):e1003503. doi:10.1371/journal.pmed.1003503
  4. Norfolk and Norwich University Hospitals NHS Foundation Trust. Extra pregnancy scan significantly reduces the number of breech births, new research shows. Website. Published 2023. Accessed April 16, 2023. https://www.nnuh.nhs.uk/news/extra-pregnancy-scan-significantly-reduces-the-number-of-breech-births-new-research-shows/
  5. 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. 2000;356(9239):1375-1383. doi:10.1016/S0140-6736(00)02840-3
  6. Goffinet F, Carayol M, Foidart JM, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol. 2006;194(4):1002-1011. doi:10.1016/j.ajog.2005.10.817
  7. Vandenbroucke JP, Von Elm E, Altman DG, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med. 2007;4(10):1628-1654. doi:10.1371/JOURNAL.PMED.0040297
  8. Mattiolo S, Spillane E, Walker S. Physiological breech birth training: An evaluation of clinical practice changes after a one‐day training program. Birth. 2021;48(4):558-565. doi:10.1111/birt.12562
  9. Spillane E, Walker S. Case study supporting continuity of care models for breech presentation at or near term. Pract Midwife. Published online 2019:36-37.
  10. Spillane E, Winstanley C, Swer M. Breech. St George’s Hospital Practice Guideline; 2019.
  11. Spillane E. St George’s Breech Clinic – Results. In: Physiological Breech Birth Training [Online]. Breech Birth Network; 2020. Accessed April 18, 2023. https://vimeo.com/486516151
  12. Walker S, Parker P, Scamell M. Expertise in physiological breech birth: A mixed-methods study. Birth. 2018;45(2):202-209. doi:10.1111/birt.12326
  13. Ord C. John Radcliffe midwife, Anita Hedditch, shortlisted for national award | Oxford Mail. Oxford Mail. https://www.oxfordmail.co.uk/news/17420964.john-radcliffe-midwife-anita-hedditch-shortlisted-national-award/. Published February 9, 2019. Accessed April 16, 2023.
  14. Oxford University Hospitals. Specialist antenatal clinics – Maternity. Website. Published 2023. Accessed April 16, 2023. https://www.ouh.nhs.uk/maternity/antenatal/care/specialist/
  15. 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
  16. Morris SE, Sundin D, Geraghty S. Women’s experiences of breech birth decision making: An integrated review. Eur J Midwifery. 2022;6(January):1-14. doi:10.18332/EJM/143875
  17. Petrovska K, Watts NP, Catling C, Bisits A, Homer CS. ‘Stress, anger, fear and injustice’: An international qualitative survey of women’s experiences planning a vaginal breech birth. Midwifery. 2017;44(0):41-47. doi:10.1016/j.midw.2016.11.005
  18. Walker S, Spillane E, Stringer K, et al. The feasibility of team care for women seeking to plan a vaginal breech birth (OptiBreech 1) – an observational implementation feasibility study in preparation for a pilot trial. BMC Pilot & Feasibility Studies. 2023;In Press.
  19. Hall R. Third scan could greatly reduce UK breech birth numbers. The Guardian. Published April 7, 2023. Accessed May 1, 2023. https://www.theguardian.com/society/2023/apr/06/third-scan-reduce-uk-breech-birth-numbers-study-suggests
  20. Pickles K. Third scan could cut breech births by 70%. The Daily Mail. Published April 7, 2023. Accessed May 1, 2023. https://www.mailplus.co.uk/edition/health/270217/third-scan-could-cut-breech-births-by-70?collection=16684
  21. Impey L, Murphy D, Griffiths M, Penna L, on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. BJOG. 2017;124(7):e151-e177. doi:10.1111/1471-0528.14465
  22. NICE. Intrapartum care for women with existing medical conditions or obstetric complications and their babies. Evidence review for breech presenting in labour. NICE guideline [NG121]. NICE. Published 2019. https://www.nice.org.uk/guidance/ng121/resources/intrapartum-care-for-women-with-existing-medical-conditions-or-obstetric-complications-and-their-babies-pdf-66141653845957
  23. NICE. Antenatal Care.; 2022. Accessed November 29, 2022. https://www.nice.org.uk/guidance/ng201

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

Breech Clinics and Specialist Midwives Toolkit

Download the Toolkit here.

Birmingham Women’s Report of their new breech specialist service, October 2022

Original blog:

We will launch our toolkit describing ‘how to build and OptiBreech service from the ground up’ at the British Intrapartum Care Society Conference 2022 in just over a week. When the conference goes live on 29 September, the toolkit will go live.

Image: Kate Stringer

The toolkit brings together clinical and social science evidence in favour of delivering care for breech pregnancy and childbirth through a dedicated clinic and intrapartum care team, co-ordinated by a breech specialist midwife, working in collaboration with a breech lead obstetrician.

The majority of team roles includes tasks that are already performed by someone in your organisation. They key is to task-shift, so that all breech-relevant service leadership tasks are performed by the specialist(s). This increases their expertise, and their work increases skill and competence across your team.

This model addresses two known problems: individualised care and safety. Women want individualised care in line with national guidance, but the way services are usually delivered within the NHS makes this difficult. Clinics and specialists standardise practice, reducing biases in the direction of both caesarean section and vaginal birth. Women enjoy easier access to both planned vaginal breech birth and planned elective caesarean section. Specialists also drive up the safety and quality of care by helping research inform practice as quickly as possible and facilitating cultural change. They enable vaginal breech births to occur in a planned an organised manner, creating learning opportunities that make unplanned births safer.

The toolkit has been developed by: Shawn Walker (OptiBreech Chief Investigator), Phoebe Roberts (OptiBreech Patient and Public Involvement Lead for this project) and Harriet Boulding from the King’s Policy Institute.

The toolkit will be available HERE for download and includes:

Background information

  • What is the problem?
  • How does the OptiBreech approach offer a solution?
  • What is physiological breech birth?
  • What does OptiBreech ‘proficiency’ mean?
  • What is the evidence for this model of service delivery?

What you need to build a breech service

  • A dedicated breech clinic
  • A Breech Lead Obstetrician
  • A Breech Specialist Midwife (Band 7 or 8)

Breech specialist midwives

  • Roles and activities of a breech specialist midwife
  • Where does the money come from?
  • Personal characteristics and circumstances required
  • Compensation and support
  • Involvement in research and quality improvement

Training other team members

  • What training involves
  • Why is this way of training most effective clinically?
  • Why is this way of training most cost-effective?
  • Who does a breech clinic rotation
  • What about people who cannot be on-call?
  • Maximising economic efficiency

Other considerations

  • Role of the on-call obstetric team
  • External Cephalic Version (ECV) and other breech turning modalities
  • What about continuity for planned CS?

Approaches that do not appear to be effective

References

Appendix: Proficiency Achievement Record

This toolkit is funded by an ESRC Impact Acceleration Award, from the King’s College London Social Science Impact Fund. Shawn Walker is funded by a National Institute of Health Research (NIHR300582) Advanced Fellowship.