We are in the process of developing a research proposal for a feasibility study to investigate the implementation of bedside resuscitation for breech babies who require breathing assistance at birth.
Research indicates that providing this immediate care next to mothers/birthing people reduces parental distress and is found to be more favourable by clinicians due to improving communication with parents while they provide care.
The purpose of this group session is to gain insight and feedback regarding our research aims and design from stakeholders to ensure the research is the next piece of the puzzle in improving breech care, designed appropriately, and acceptable to women/birthing people.
We have scheduled this meeting for 90mins to ensure everyone has enough time to discuss the proposal and ask any questions and we will also provide an optional short survey for anyone to provide any additional feedback if they were not able to during the meeting.
The meeting will be held on Sunday 30th October 10am – 11.30am via Microsoft Teams. You can attend the meeting for the full 90mins or attend like a drop in session.
We look forward to meeting with you and hearing your thoughts.
Plain English summary of the research (limit 400 words):
OptiBreech Care is a specialist care pathway for women whose baby is positioned bottom-down (breech) at the end of pregnancy. Our team previously studied how hospitals provide team care when a woman requests a vaginal breech birth to make sure it was possible. In this model, women found it easier to plan their choice of a vaginal breech birth or a pre-labour caesarean birth. Fewer women had emergency caesarean births, and outcomes for babies were at least as good as standard care. OptiBreech teams found one aspect difficult: leaving the umbilical cord attached if the baby needs help to start breathing. Team members told us this is challenging to achieve because they do not have appropriate equipment and training.
About 1:5 babies born after a vaginal breech birth need some help to start breathing, and about 1:10 are transferred to a neonatal intensive care unit after the birth. We feel we can reduce this to 1:5 (the UK national average for all births) if our specialist teams are able to provide help next to the mother. This will result in better long-term outcomes for the baby. Families have better experiences if they are not separated from babies, during resuscitation or after. Women in our OptiBreech studies have reported feeling let down because in most births where the baby appeared to need help, the cord was cut immediately, despite OptiBreech and UK Resuscitation Council guidance.
We aim to learn how to get optimal cord management right for every birth, how much it will cost and how it may improve outcomes for babies if we do this. We will supply one site with bedside trolleys and team training; another site will use trolleys they already have, with additional support; all thirteen remaining sites will continue to try to implement the recommendations with what they already have. We will observe the process for 12 months initially, during which we would expect 205 planned breech births to occur. We will conduct interviews with staff, parents and birth supporters following births where babies have needed support, to understand how this is working, or not.
By studying the process within small teams, who care for a population at higher risk of needing assistance to begin breathing at birth, we will be able to study and share insights that can improve the process for all teams, across the UK population of term births. We will share our results in scientific papers and a toolkit. Our research team includes a service user who has planned an OptiBreech birth, who will help us to involve other service users in shaping the research and to communicate the results of the research to a wide audience.
We often share information, especially with professionals, on the Breech Birth Network FaceBook group. We had a post recently promoting hypnotherapy to turn breech babies.
This was my response:
I have approved this post, but I will not in the future approve posts that make claims that do not present the evidence that supports them. This includes training in complementary therapies such as moxibustion.
We now have a wonderful OptiBreech database, which collects data from the point anyone is referred for care related to breech presentation at the end of pregnancy and has a breech presentation confirmed by ultrasound – this can be as early as 32 weeks. It also collects information on how often these babies turn without intervention, and the different types of therapies and advice women receive.
A randomised controlled trial is the best way to test claims for the success of a therapy like hypnotherapy to encourage breech babies to turn head-down. Second-best is a prospective observational study of women who choose and receive hypnotherapy. Because we collect information on women who do not choose and receive hypnotherapy, we still have a point of comparison that would enable us to tell if hypnosis increases turning compared to none.
If any of you providing or teaching complementary therapies would like to collaborate on a trial, please do e-mail me at Shawn.Walker@kcl.ac.uk. We have a team of people who can help design a study and apply for funding. If hypnotherapy is effective, it should be offered to all women within the NHS and included within the OptiBreech care pathway. If not, professionals should not be suggesting it to women.
If you are promoting a therapy, please provide links to the evidence that supports it, to enable women to consider the evidence available before spending money at a time when they are vulnerable. Without evidence, future posts will not be approved.
As you can see from the image below, based on previous research, a certain percentage of babies will turn on their own, without intervention. We know the number that turn is higher when we attempt a manual turning (external cephalic version or ECV). But we also know not everyone wants an ECV, and many women report trying alternative or complementary therapies to encourage their babies to turn. As these are popular and acceptable to large numbers of women, it would be best for us to have high-quality evidence about which therapies are effective at helping more babies to turn.
The OptiBreech Research and Public Involvement team share their work at the #BICS22 conference.
The OptiBreech Team enjoyed meeting each other in person for the first time at last week’s British Intrapartum Care Society Conference. And we won a prize! We are so grateful to the women who have participated in our research, the Principal Investigators who have made it all happen locally, and our Steering Committee. Here’s what we shared at the conference:
Is it feasible to test OptiBreech Care in a clinical trial?: results of the OptiBreech 1 study – Dr Shawn Walker, Tisha Dasgupta, Siân Davies, Sarah Hunter, Phoebe Roberts, Prof Jane Sandall, Prof Andrew Shennan. We shared the results from our first-stage study, OptiBreech 1. We are currently writing these up in publication format and will share as soon as that is ready. This presentation won the top oral abstract prize at the conference.
The roles and responsibilities of breech specialist midwives in the OptiBreech Care Trial feasibility study: a qualitative inventory – Davies, Dasgupta, Natasha Bale, Alexandra Birch, Walker. Siân Davies shared a poster about the role of Breech Specialist Midwives, as described by midwives and obstetricians participating in OptiBreech 1.
Toolkit for implementing breech clinics and specialist midwives to support planned vaginal breech births – OptiBreech PPI Lead and Service User Representative Phoebe Roberts presented this poster. Read more about it here.
Women seek ‘connected autonomy’ when they wish to plan a vaginal breech birth at term: a systematic review and meta-synthesis – Ritika Roy, Cecelia Gray, Charlene Prempeh, Walker. Medical students Roy and Gray presented the results of their 2021 King’s Undergraduate Research Fellowships. The results are ready for publication and will be shared in that format soon!
Not too fast not too slow: the legacy of time management in vaginal breech births – Jacana Bresson, Walker. Midwifery student Bresson presented the results of her review of obstetric texts in the Royal College of Obstetricians and Gynaecologists and Wellcome Trust Libraries, funded by a 2022 King’s Undergraduate Research Fellowship.
Assessing feasibility of economic evaluation alongside a full trial for ‘OptiBreech Care’ with development and testing of a decision model to assess its long-term cost-effectiveness – Dr Siddesh Shetty, Dr Shawn Walker, Prof Julia Fox-Rushby. The Health Economics team used this as an opportunity to gain feedback and peer review on the economic model developed.
Thanks also to the BICS Committee, who organise a wonderful, supportive, multi-disciplinary conference every time!
We will launch our toolkit describing ‘how to build and OptiBreech service from the ground up’ at the British Intrapartum Care Society Conference 2022 in just over a week. When the conference goes live on 29 September, the toolkit will go live.
The toolkit brings together clinical and social science evidence in favour of delivering care for breech pregnancy and childbirth through a dedicated clinic and intrapartum care team, co-ordinated by a breech specialist midwife, working in collaboration with a breech lead obstetrician.
The majority of team roles includes tasks that are already performed by someone in your organisation. They key is to task-shift, so that all breech-relevant service leadership tasks are performed by the specialist(s). This increases their expertise, and their work increases skill and competence across your team.
This model addresses two known problems: individualised care and safety. Women want individualised care in line with national guidance, but the way services are usually delivered within the NHS makes this difficult. Clinics and specialists standardise practice, reducing biases in the direction of both caesarean section and vaginal birth. Women enjoy easier access to both planned vaginal breech birth and planned elective caesarean section. Specialists also drive up the safety and quality of care by helping research inform practice as quickly as possible and facilitating cultural change. They enable vaginal breech births to occur in a planned an organised manner, creating learning opportunities that make unplanned births safer.
The toolkit has been developed by: Shawn Walker (OptiBreech Chief Investigator), Phoebe Roberts (OptiBreech Patient and Public Involvement Lead for this project) and Harriet Boulding from the King’s Policy Institute.
The toolkit will be available HERE for download and includes:
What is the problem?
How does the OptiBreech approach offer a solution?
What is physiological breech birth?
What does OptiBreech ‘proficiency’ mean?
What is the evidence for this model of service delivery?
What you need to build a breech service
A dedicated breech clinic
A Breech Lead Obstetrician
A Breech Specialist Midwife (Band 7 or 8)
Breech specialist midwives
Roles and activities of a breech specialist midwife
Where does the money come from?
Personal characteristics and circumstances required
Compensation and support
Involvement in research and quality improvement
Training other team members
What training involves
Why is this way of training most effective clinically?
Why is this way of training most cost-effective?
Who does a breech clinic rotation
What about people who cannot be on-call?
Maximising economic efficiency
Role of the on-call obstetric team
External Cephalic Version (ECV) and other breech turning modalities
What about continuity for planned CS?
Approaches that do not appear to be effective
Appendix: Proficiency Achievement Record
This toolkit is funded by an ESRC Impact Acceleration Award, from the King’s College London Social Science Impact Fund. Shawn Walker is funded by a National Institute of Health Research (NIHR300582) Advanced Fellowship.
Help us get it right, Wednesday 19th January 2022, 12:00-13:00. Are we accurately reflecting your views on breech specialist midwives and clinics?
We would like to invite women, birthing people and their families who have experienced a breech pregnancy at term to attend an online focus group discussion on Wednesday 19th January 2022, 12:00-13:00 to be conducted via Microsoft Teams. Anyone with an interest and experience of breech pregnancy can participate.
The purpose of this meeting will be to get your perspective on the work we have been doing so far.
We have been working on analysing data from qualitative interviews held with OptiBreech 1 participants. To date, we have interviewed 15 women purposefully sampled to reflect various OptiBreech sites, mode of births, and outcomes. Our main objective was to understand what makes the OptiBreech intervention acceptable (or not) to women.
The key themes that we have found are:
Access to skilled breech care: Vaginal breech birth as a viable and safe option is still unknown to many, and lack of specialists reduced equity of access. Women who were referred to a specialist at one of the OptiBreech sites or were already receiving care at a study site found it easy to access and participate in their care. Women who had to transfer care from another hospital or find an OptiBreech site themselves had a difficult time doing so, often requiring increased effort, multiple trips, time off work etc.
Balanced information: Women really appreciated being provided balanced information on the safety and risks of vaginal breech birth vs. caesarean section including possible complications and how to manage them. This enabled them to make autonomous informed decisions and increased self-efficacy and confidence, not only in themselves but also in the breech specialist midwife. Conversely, when women had to do this research themselves because they were not getting cohesive information from the healthcare professionals, this was seen as a burden and sometimes women were made to feel pressure to choose caesarean section as the ‘safe’ choice.
Shared responsibility: Women often felt emotional burden including feelings of stress, judgement, and guilt because of the choices they had made to have a vaginal breech birth, both from family and friends, as well as other healthcare professionals. Speaking with and being cared for by the OptiBreech specialist midwife helped ease this emotional burden and gave the women confidence in their choices.
Team dynamics: We found that women had placed an enormous amount of trust and confidence in the breech specialist midwife which extended to the rest of the team, attributed to previous experience, skills and knowledge. Although women did not know all the members of the team, the trust and confidence was extended to them because of shared responsibility and training requirements needed by all OptiBreech team members.
We need your input on our findings and invite your opinions on whether these findings are relevant to you, if we have interpreted them correctly, or if we have missed any important factors in what makes OptiBreech an acceptable intervention. At the meeting we will present a short summary of our findings so far, and then have an open discussion to hear any thoughts, opinions, or questions you may have.
The meeting will be held on Wednesday 19th January 2022, 12:00-13:00 via Microsoft Teams.
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…
We invite participation in an on-line PPI (patient and public involvement) meeting to be held on the 10th of December.
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 Thursday 10th December 10.30-11.30am 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 following issues:
A core outcome set is a minimum set of outcomes that should be collected in every study about a topic, in this case vaginal breech birth at term. Making these consistent means that we can better compare and combine studies, and ensure research meets the needs of those who use it.
To develop a core outcomes set, we have conducted a systematic review of the available literature relevant to this project (brief summary below). However, we need your input to determine if these outcomes are important to the people who will use the results of research to make decisions, and how important each is. Does this meet all your informational needs or are there outcomes that have not been identified, which you think is important to record?
Do you think it is important to include salutogenically focused outcomes that emphasize positive well-being of the mother and newborn such as maternal satisfaction, relationship with baby etc.? If so, which factors would you like to see and how important do you think these are?
The next stage will be to ask both professionals and service users to rate the importance of the outcomes to be included in the core outcome set. But before we do this, we want to insure all of the outcomes important to you are included.
You are welcome to share your feedback directly during the focus group meeting or by emailing Tisha Dasgupta (email@example.com), the OptiBreech Research Assistant, at any point. If you are unable to make it and would like to contribute, or have further feedback after the session, please also contact Tisha.
While we do not require written consent for your participation in the meeting, it is important to let you know that the session will be recorded. We intend to take the feedback you provide into consideration while designing the next stage of this project: a multinational Delphi study. No identifiable information will be used such as direct quotes or anecdotes, and we will only report summary data.
Thank you very much for your consideration. Please could you send your RSVP to firstname.lastname@example.org by Monday, 7th December to confirm your attendance at the session? She will be in touch thereafter to provide you access to the online meeting.
We’d also love to hear your views on the information presented on the OptiBreech website!
Overall summary of the Systematic Review
A systematic review of all relevant literature was conducted to identify outcomes, definitions and measurements previously reported in effectiveness studies of breech births at term. 108 studies were identified comprising of systematic reviews, randomised controlled trials and comparative observational studies, with full-text available in English. Below are the most common outcome measures, with a percentage of how many studies reported them. These are the top 10 most frequently reported measures in each category grouped by neonatal, maternal, features of labour, and long-term maternal outcomes respectively.
% studies reported
APGAR score at 5 minutes
Perinatal or neonatal mortality
Admission to neonatal intensive care unit (NICU)
Neonatal birth trauma/morbidity
Brachial plexus injury / peripheral nerve injury
Low umbilical artery pH
Hematoma (cephalic or subdural)
Post-partum haemorrhage (PPH)
PPH requiring blood transfusion
Other serious maternal morbidity/other complications
Each time I teach the Breech Birth Network Physiological Breech Birth Study Day, I explain the feasibility study and trial I am hoping to do and invite feedback from those attending. Below are examples of feedback from around the UK:
Hayward’s Heath, December 2019 — Princess Royal Hospital
Some surprising feedback in a recent meeting with the Lead Obstetrician and Director of Midwifery in one of the South London teaching hospitals who are not currently planning to participate in the randomisation element of the feasibility study. This hospital is further along implementing a breech clinic and some on-call element to support physiological breech births. Because of this, they feel it might be unethical to randomise women to ‘standard care,’ as outlined in the Description of Intervention. They will still be participating in the implementation evaluation aspect of the feasibility study. I and the Steering Group will be considering this and feedback from other Trusts when deciding if the final design should be modified in a larger study.
In addition to face-to-face activities, when developing this proposal I circulated an invitation to participate in PPI via my professional blog (breechbirth.org.uk) and social media. Twenty-one women and three people who work with pregnant women (midwife, doula, osteopath) expressed an interest. Some of these women attended the face-to-face meeting at St Thomas’ Hospital in April 2019, organised by the South London Maternity Voices Partnership. I met with two women individually in East Anglia, and seven women responded to a survey (via SurveyMonkey) asking about their views on the plain English summary of my proposal. This post reports the responses of these seven women to this summary and how this has influenced the form of the final proposal.
All comments are reported and all women were asked for permission to share these responses anonymously.
All seven women (100%) indicated that, “I or my partner have had a breech baby within the last 5 years,” within the UK. Comments included:
I had an undiagnosed breech vaginal delivery in 2015, in spite of having had numerous palpations/sweeps in the weeks leading up to the birth.
I experienced my own undiagnosed breech birth (vaginal delivery) in December 2015. Happy to provide in depth detail of my birth story; it is also published in my own work on this.
My breech baby was undiagnosed as breech, so I have no experience of what it feels like to contemplate the choice between natural breech birth or cesaerean. I am however part of various breech networks on social media and take part in many discussions about this. I had my breech baby at home, and unassisted, with no complications.
“I gave birth at home to my frank breech baby. I wasn’t supported by most of the health professionals I met and when it came to the birth it didn’t feel safe to go to our hospital where they were very short staffed and my labour progressed too quickly for me to get there! I trusted my body knew what to do and our baby was born safely with my just my husband watching! Paramedics arrived and our doula as our baby was born. The midwifes weren’t available for another 4 hours! It was a huge shame as they missed the opportunity to experience my calm, pain free, extremely well researched breech birth.”
Impact on proposal: ‘Undiagnosed breech birth’ means the breech presentation is diagnosed for the first time when the woman is in active labour, rather than during her antenatal care. Occurrences of undiagnosed breech births seem a significant component of ‘breech experience’ among women in the UK. My original proposal focused solely on management of breech presentations that are diagnosed antenatally, but I realised this is not enough. Also, the last randomised controlled trial of term breech births (Hannah et al 2000) included breech presentations diagnosed for the first time in labour. Although recruitment during labour is particularly challenging, PPI feedback indicates meeting this challenge is important.
These results were similar to those received in the face-to-face and staff PPI activities.
I think women will want to take part to ensure that breech pregnancies and births are better dealt with. Natural births of breech babies should be supported more, so this study will help.
I feel women would participate especially if they have had choice taken away from them. Enabling informed choice and joint decision making is crucial for all woman no matter what presentation.
Yes but only if they are reassured prior to birth that they will not be forced into a certain birthing choice because they signed up for the trial. I think constant reminders would be helpful to them that they still have choice throughout otherwise this could be a potential barrier to recruitment.
I felt very pressured during my pregnancy by doctors, and really struggled to make choices. (Whether to homebirth or not). I feel that any woman in this situation or who has had previous experience of hospital would be very glad to take part in something that could change the way women are treated and spoken to in hospitals. I personally would be willing to take part in any research that improved the way pregnant women are treated.
If the question is meaning the breech births that have already happened then it is likely the women will want to take part to help other women. If it is for women about to give birth to breech babies then it depends on how confident, trusting and educated her team of midwives and consultants are of breech vaginal delivery.
Influence on research design: At least some women find decision-making around mode of childbirth with a breech baby difficult, and that at least some women have felt pressured and have experienced a lack of respectful care. Ensuring this research does not result in harm of this type is important to me. This influenced the design in the direction of a pragmatic RCT. In the original proposal, I had planned to conduct an efficacy study, which requires strict adherence to group allocation. However, through engagement with women I came to feel this would not be ethical, nor would it provide the type of ‘real world’ decision-making information women wanted. Recruitment would also have been more difficult.
It will give women a better understanding of their options and what they consist of. It will help women come to the right decision that best suits them.
Empowering women to trust in their body’s natural ability will always be a positive thing
Yes, any additional information to what is already known will always serve to be helpful to women and allow them to make more informed choices.
I think there is very little information available on breech birth, and the stuff that is isn’t “readily” available unless you go looking for it and do your own research. I think newer studies and studies with more data are definitely needed and would provide women with up to date research and the information they need to make informed decisions.
Any extra research would definitely be helpful, the way the world is now it seems most people like statistics and there’s so much health and safety surrounding breech births in many hospitals/countries. Women are then too nervous by the lack of skill so they opt for a c-section.
This is fantastic! I gave birth to my breech baby in November 2017! It was the most incredible experience of my life where I truly tuned into my body. I did huge amounts of research during pregnancy and continue to do so now. Birth is incredible but breech birth is fascinating and it’s become my passion. I would love to be involved with this as much as possible!
Influence: I have created a mailing list to keep all respondents informed of the progress of this research and aware of any opportunities to contribute further, with clear information about how to remove themselves from the list and have any personal data deleted.
Below are some additional comments from women who did not participate in the survey, but expressed interest in PPI participation in general. Although I have anonymised responses, aside from one link the person wanted to share, they came from all over the UK. Women seeking support for a current pregnancy were referred to an independent breech midwife not involved with this research, with their permission.
I just came across this. I’m don’t work in the medical profession but my baby was a breech baby. I requested a vaginal delivery which was very negatively received by my hospital. I very much wanted to attempt it, which I did (in the understanding that if it became too dangerous I would agree to a c-section) However I have found out from a report that the second stage of my delivery was very poorly managed and sadly my baby died just after he was born. I was very much made to feel Like it was my fault for the birth choice I made. I truly wish there had been more open discussion about how my hospital felt about it and why they were so reluctant to support me. Breech birth should be talked about and openly discussed more. Great that it’s finally happening.
I experienced primi breech vaginal birth under Dr X in X Hospital, X city in 2014. I had a doula and I’ve trained to be a doula since. Breech birth in hospital can and should happen, and happen safely. I’m interested in being involved if I can be of use.
During my last pregnancy we found out baby was footling breech at about 36 weeks during a growth scan. Previous to this all midwives and doctors has told me he was head down. I had an ecv and went on to have a successful vaginal birth at 41 +3
I had a breech baby by (reluctant) c-section 3 years ago. There was a general lack of experience in vaginal breech birth in my area.
My daughter (born November 2016) was undiagnosed breech. My waters broke and instead of waiting for the normal 24hrs, the obstetrician recommended an induction as the midwife had picked up a small drop in her heart rate. It was the obstetrician’s opinion that the drop was probably due to position but still no one noticed she was breech. The diagnosis came when I was 5cm dilated and a midwife felt the my daughter’s bum during a VE. I wasn’t given much of an option then and whisked into an emergency c-section.
I’m pregnant again and though still early (28 weeks) baby is currently breech too. I’m trying to explore all my options and to be prepared for different scenarios this time round, but am finding that a lot of the research I come across is inconclusive. If there’s anything I can do to help, I’d be very happy to contribute.
Im currently pregnant with extended breech baby. my second pregnancy. no risks.
I would like to consider the natural birth. Doctors recommend CS but I don’t feel I got all the information to make informed decision.
I heard confusing message like we have no experience which is concerning and no statistics but more list of things which can go wrong.
I would like to find out pros and cons so I can make informed choice.
I would appreciate if you can get in touch with me.
I am 38.5 weeks pregnant.
I’ve stumbled on your website by chance. I had a breech baby in October 2016 at X Hospital. We didn’t discover breech until 41 weeks and at that point I was immediately coerced into agreeing to a c-section which was performed less than 12 hours later. I found the experience highly traumatic and ended up with anxious episodes (flashbacks/obsessive thoughts/nightmares etc etc) which required counselling.
I would love to be able to help with your research in the hope that future women do not have to experience what I did.
I’d like to register my interest. I had a breech pregnancy in 2014 which resulted in a Caesarean section.
I’d love to help in anyway possible. I’m currently a final year Midwifery Student with a passion for VBB and the topic is also my dissertation topic.
Definitely interested in helping in any way with the research!
I used this site and many others in order to make a decision about my recent birth. My baby was extended breech for most of the pregnancy and after reading as much as I possibly could about why a possible vaginal delivery was possible I declined the elective section and waited for natural labour to happen.
Supported by my NHS midwives, I went into labour and made the plan to labour naturally in hospital for a set amount of time and opt for no intervention and an emergency c if things didn’t progress. After an amazing 22 hour labour, a few hours fully dilated with faint declining contractions and no desire to push and no descending baby, I opted for (a calm and requested by myself) “emergency” c and was so happy to have been given the opportunity to give natural birth a good go, and know when to call it a day and not force it.
I wanted to share my story but am really happy to be involved in any research. I was only able to make a decision about my birth as I asked CONSTANT questions and read every single possible thing I could about breech birth. More information definitely needed so women can also make this decision for themselves and like me, EVEN thought I had an emergency c, come out the other end ELATED with their experience as they know they made all the right decisions based on information and not scare stories or sweeping statements.
Thanks for listening 🙂
I am currently 40 weeks pregnant with a breech baby hoping for a natural delivery and I would like to be involved in this project.
I had a very happy breech birth experience in February this year at X Hospital in Wales, X. I was due to have a c-section but went into labour early and then opted for vaginal birth, with encouragement from team of medical staff. Incredible midwives guided me through whole process. I feel so pleased and privileged to have such a positive birth story.
I had an undiagnosed breech vaginal birth 15th March 2015. My daughter had no complications and neither did I. She was born at 40+1. I would be happy to take part in any studies that I may be able to help with.
I saw on the X Facebook page that you are conducting studies on Breech babies.
Unfortunately I’m not available on 29th April but would be happy to help in any other way I can.
My daughter now 13months was a breech baby and I desperately wanted a vaginal birth so had to ECVs to try and turn her. They were both unsuccessful. I refused a planned c-section hoping to deliver vaginally but after 18hours of labour which didn’t progress very well I eventually had a c-section out of fear of endangering her life.
I wish there had been more support to enable a vaginal delivery. I felt that most staff didn’t feel confident enough to support and allow a breech vaginal delivery.
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.
… 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.