Category: Research Process

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 Cluster Trial Collaborators

Read why our collaborators would like to help extend the provision of OptiBreech care by participating in a cluster trial.

As we prepare our funding bid to scale up OptiBreech care around the UK and evaluate it in a stepped wedge cluster trial, we have invited NHS sites to formally express an interest in collaboration. We are pleased to share some of our collaborators and the reasons they are joining this trial.

Walsall Healthcare NHS Trust

Lead: Joselle Wright, Head of Midwifery

“We are a smaller DGH with 3700 births, smaller units often do not get the opportunity to participate in these amazing research studies. This would be a great opportunity for our women.”

Maidstone and Tunbridge Wells NHS Trust

Lead: Charlotte Gibson, Consultant Midwife

‘This is an exciting opportunity for us to support women’s health research which will positively impact those who provide care, the service we are able to offer and ultimately optimise health and well-being outcomes for those we care for. All with the added and far-reaching benefit of growing and strengthening our clinical research culture and capabilities within our service, community and beyond. It was from women’s and families lived experiences that led us to embark on setting up a Breech Birth Faculty. Our aim is to build the capabilities and confidence within our workforce to support safe and personalised care for those who have a breech baby at term. Collaborating with the Opti Breech Trial will be fundamental in achieving this aspiration.‘

Shrewsbury and Telford NHS Trust

Lead: Dr Olusegun Ilesanmi, Consultant Obstetrician

‘Research within our Trust is important as this enables us to ensure we provide up to date evidence based safe care, with Women & their babies at the centre. The Opti Breech Study promotes informing Women about their options and to plan their care with them rather than making decisions about them, as well as improving our expertise, knowledge, and staff development. We look forward to giving Women within our care the opportunity to be part of the Opti Breech Study’

NHS Lothian, Royal Infirmary of Edinburgh

Leads: Dr Rosemary Townsend and Dr Andrew Brown, Consultant Obstetricians

Wirral University Teaching Hospital

Lead: Consultant Midwife Angela Kerrigan

Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust

Lead: Consultant Obstetrician Fatima Abuamna

North Tees and Hartlepool NHS Foundation Trust

Lead: Kirty Farrington, Sharon Gowans and Julie Woollaston – Research Midwives

We are really excited to be involved in this research! It is a great opportunity to not only work towards delivering evidence-based care for women but also to develop skills and build confidence within the whole maternity workforce

Clinicians gain confidence to engage with research by becoming involved in peer review

Looking to engage with research, develop your critical appraisal skills and sharpen your own writing? If you have academic research training, consider becoming involved in peer review.

In my role as Researcher in Residence at Imperial College London, I support clinical NMAHPPs (nurses, midwives, allied health professionals, healthcare scientists, pharmacy staff and psychologists) to develop careers in research. As part of this, I have begun recommending midwives with Masters or PhDs as peer reviewers, when I am asked to review an article that I know fits their clinical or methodological areas of interest. I also offer support through this process. This fairly simple activity seems to have really hit a chord with clinical midwives who are looking to become more research-active, so I want to share it with others who are supporting clinicians to engage with research.

How the peer review process works

First, let’s de-mystify how people become involved in peer review activity. When you submit an article for publication, this is all done on-line. As part of this process, you enter your personal details, including (this is important!) your areas of interest and expertise. Even if your article is not accepted for publication, your details are retained on the journal’s database. When an assistant editor does a search for peer reviewers with an interest in, say, ‘breastfeeding,’ if you have listed this as one of your areas of interest/expertise, your details will come up in the search results. They are likely to ask the ‘big names’ first, people who have published a lot in this area. But top academics get many more peer review applications than they can accept. So, eventually, you will get asked to peer review in your area. Of course, if you have published as well, this will happen sooner.

For example, in 2012 I submitted a conference report to the British Journal of Obstetrics and Gynaecology (BJOG) because I thought people should know about the exciting, international changes that were beginning to happen around the way breech births were managed. It was rejected within 24 hours (ouch!). But soon, I started being asked to review articles in this area – probably due to very few other people listing ‘breech presentation’ as their area of interest. BJOG has still never accepted one of my academic articles, but by 2016, I was awarded a certificate as one of their top 50 reviewers! In 2018, I was rated a top 1% reviewer in Clinical Medicine by Publons peer review tracker, part of Web of Science. The insight I have gained into the publication process through peer review has been invaluable.

The other way you may get asked to peer review is because someone who is declining to peer review has nominated you as an alternative. Usually, senior academics will nominate more junior academics. This is what I have been doing for clinical midwives who hold at least a Masters at Imperial, provided I know their areas of interest. Again, if you accept the invitation, your details will be in the system, and you will likely receive future invitations.

You can also write to the editor of a journal you are interested in, with your CV, and offer to do peer review.

Benefits of doing peer review

Once they finish a further degree, clinicians often start to feel detached from the academic research world. Doing peer review is one way to stay engaged and be inspired by others’ work. It helps you develop critical appraisal skills. You observe how successful articles are structured, and why, until it becomes second-nature when you begin to plan your own work. You gain exposure to other methods and methodologies being used to answer research questions in your field. And you begin to see gaps in knowledge or need for further research, which may help you define a project you would like to pursue yourself.

Midwife in training Jacana Bresson

If your professional aims include applying for fellowship or research funding, peer review activity is regarded favourably on your CV. You can automatically upload your peer review confirmation e-mail to the Publons website, just by forwarding it. And you can then simply list your public peer review profile on your CV – here’s my Web of Science profile, including peer review.

Personally, I also enjoy the feeling that I am influencing what gets published and becomes part of our evidence base. For example, I have reviewed innumerable articles which either directly concern midwifery practice or have the potentially to significantly impact it, yet the research team does not include a midwife. I have consistently given the feedback that, in the future, it should; and that this should be acknowledged as a limitation in the discussion. By remaining present in the sphere of peer review, midwives and NMAHPPs can make a genuine difference.

Support with this process

For NMAHPPs working at Imperial, I can help you become involved in peer review for the journals you read. If you would find it helpful, I can support you to complete the review, so that you feel confident returning your critical appraisal. The involvement of another person needs to be declared to the editor, as the peer review process is otherwise confidential, but this is acceptable when less experienced reviewers are receiving support.

Visit my Imperial College London People page to contact me and book time for 1:1 support.

PPI Meeting, Sunday 30 October, 10 am

We would like to hear from you! 

Link to join (Teams)

We are in the process of developing a research proposal for a feasibility study to investigate the implementation of bedside resuscitation for breech babies who require breathing assistance at birth.

Research indicates that providing this immediate care next to mothers/birthing people reduces parental distress and is found to be more favourable by clinicians due to improving communication with parents while they provide care.

The purpose of this group session is to gain insight and feedback regarding our research aims and design from stakeholders to ensure the research is the next piece of the puzzle in improving breech care, designed appropriately, and acceptable to women/birthing people.

We have scheduled this meeting for 90mins to ensure everyone has enough time to discuss the proposal and ask any questions and we will also provide an optional short survey for anyone to provide any additional feedback if they were not able to during the meeting.

The meeting will be held on Sunday 30th October 10am – 11.30am via Microsoft Teams. You can attend the meeting for the full 90mins or attend like a drop in session. 

We look forward to meeting with you and hearing your thoughts.

Link to join

With very best wishes,

The OptiBreech Team

Plain English summary of the research (limit 400 words):

OptiBreech Care is a specialist care pathway for women whose baby is positioned bottom-down (breech) at the end of pregnancy. Our team previously studied how hospitals provide team care when a woman requests a vaginal breech birth to make sure it was possible. In this model, women found it easier to plan their choice of a vaginal breech birth or a pre-labour caesarean birth. Fewer women had emergency caesarean births, and outcomes for babies were at least as good as standard care. OptiBreech teams found one aspect difficult: leaving the umbilical cord attached if the baby needs help to start breathing. Team members told us this is challenging to achieve because they do not have appropriate equipment and training.

About 1:5 babies born after a vaginal breech birth need some help to start breathing, and about 1:10 are transferred to a neonatal intensive care unit after the birth. We feel we can reduce this to 1:5 (the UK national average for all births) if our specialist teams are able to provide help next to the mother. This will result in better long-term outcomes for the baby. Families have better experiences if they are not separated from babies, during resuscitation or after. Women in our OptiBreech studies have reported feeling let down because in most births where the baby appeared to need help, the cord was cut immediately, despite OptiBreech and UK Resuscitation Council guidance.

We aim to learn how to get optimal cord management right for every birth, how much it will cost and how it may improve outcomes for babies if we do this. We will supply one site with bedside trolleys and team training; another site will use trolleys they already have, with additional support; all thirteen remaining sites will continue to try to implement the recommendations with what they already have. We will observe the process for 12 months initially, during which we would expect 205 planned breech births to occur. We will conduct interviews with staff, parents and birth supporters following births where babies have needed support, to understand how this is working, or not.

By studying the process within small teams, who care for a population at higher risk of needing assistance to begin breathing at birth, we will be able to study and share insights that can improve the process for all teams, across the UK population of term births. We will share our results in scientific papers and a toolkit. Our research team includes a service user who has planned an OptiBreech birth, who will help us to involve other service users in shaping the research and to communicate the results of the research to a wide audience.

BICS2022 Conference

The OptiBreech Research and Public Involvement team share their work at the #BICS22 conference.

The OptiBreech Team enjoyed meeting each other in person for the first time at last week’s British Intrapartum Care Society Conference. And we won a prize! We are so grateful to the women who have participated in our research, the Principal Investigators who have made it all happen locally, and our Steering Committee. Here’s what we shared at the conference:

Dr Siddesh Shetty and Dr Shawn Walker

Is it feasible to test OptiBreech Care in a clinical trial?: results of the OptiBreech 1 study – Dr Shawn Walker, Tisha Dasgupta, Siân Davies, Sarah Hunter, Phoebe Roberts, Prof Jane Sandall, Prof Andrew Shennan. We shared the results from our first-stage study, OptiBreech 1. We are currently writing these up in publication format and will share as soon as that is ready. This presentation won the top oral abstract prize at the conference.

The roles and responsibilities of breech specialist midwives in the OptiBreech Care Trial feasibility study: a qualitative inventory – Davies, Dasgupta, Natasha Bale, Alexandra Birch, Walker. Siân Davies shared a poster about the role of Breech Specialist Midwives, as described by midwives and obstetricians participating in OptiBreech 1.

Toolkit for implementing breech clinics and specialist midwives to support planned vaginal breech births – OptiBreech PPI Lead and Service User Representative Phoebe Roberts presented this poster. Read more about it here.

Ritika Roy and Cecelia Gray

Women seek ‘connected autonomy’ when they wish to plan a vaginal breech birth at term: a systematic review and meta-synthesis – Ritika Roy, Cecelia Gray, Charlene Prempeh, Walker. Medical students Roy and Gray presented the results of their 2021 King’s Undergraduate Research Fellowships. The results are ready for publication and will be shared in that format soon!

Not too fast not too slow: the legacy of time management in vaginal breech births – Jacana Bresson, Walker. Midwifery student Bresson presented the results of her review of obstetric texts in the Royal College of Obstetricians and Gynaecologists and Wellcome Trust Libraries, funded by a 2022 King’s Undergraduate Research Fellowship.

Assessing feasibility of economic evaluation alongside a full trial for ‘OptiBreech Care’ with development and testing of a decision model to assess its long-term cost-effectiveness – Dr Siddesh Shetty, Dr Shawn Walker, Prof Julia Fox-Rushby. The Health Economics team used this as an opportunity to gain feedback and peer review on the economic model developed.

Thanks also to the BICS Committee, who organise a wonderful, supportive, multi-disciplinary conference every time!

Student and Masters research placements

Developing research capacity is a high priority for our team. Many of our researchers have come to research as clinicians, students or service users first — with a passion for making things better for women and babies.

We have been lucky enough to have a number of students working with us on summer fellowships or student research placements the last couple of years.

Summer 2021 – King’s Undergraduate Research Fellowship (KURF) holders, medical students Ritika Roy and Cecelia Gray, completed a systematic review and metasynthesis of research about women’s experiences of seeking to plan a vaginal breech birth. They presented a poster on their results at the British Intrapartum Care Society (BICS) conference in September 2022 and plan to submit a paper for publication.

2021/2022 – Masters student Hannah Mullins is collecting data for the Optimal Intervals 2 study at Frimley. Her work will build on Emma Spillane’s original work about optimal intervals for vaginal breech births, testing if the hypotheses are correct across a larger, multi-site sample.

Keelie Christie and Jessica Wood collecting data

Spring 2022 – Leicester University midwifery student Keelie Cristie completed a research elective with the OptiBreech team. She helped set up the Optimal Intervals 2 study at Leicester University Hospital and began data collection. She has also helped process some anonymised interview data.

Summer 2022 – This summer we are lucky enough to have three KURF fellows. Medical student Victoria Taiwo is helping to develop a protocol and instrument to survey the extend of midwives working autonomously to provide various aspects of breech care (scanning, ECV, counselling, attending births) in the UK.

Midwifery student Joanne Kotun is analysing anonymised interview data to contribute to our analysis of facilitators and barriers to implementing team care for physiological breech births. She also worked on setting up the optimal intervals study at Guy’s and St Thomas’ Hospital.

Midwifery student Jacana Bresson has completed a review of textbooks in the Wellcome collection and Royal College of Obstetricians and Gynaecologists library. She reviewed historical guidance provided about the optimal lengths of time to be taken in vaginal breech births, to compare to our emerging optimal intervals evidence. She also present her findings at the BICS conference.

And midwifery student Sophie Rayner was awarded a Wellcome Trust Biomedical Vacation Scholarship. With this time, she completed the data collection on the optimal intervals study at Leicester and worked with Victoria on the protocol to chart breech specialist midwives, clinics and teams in the UK.

Student midwife summer research opportunity

We are pleased to announce an opportunity for 2nd year undergraduate students to apply for a Wellcome Trust Biomedical Vacation Scholarship.

A successful applicant will be paid the London Living Wage for 35 hours per week, for seven weeks, beginning 11 July 2020. The project synopsis is:

Recent research suggests specialist services may improve maternal and neonatal outcomes in breech pregnancies, as well as women’s experiences of care. The aims of this research are to summarise the evidence base for these organisational interventions in a literature review, and to determine the prevalence of clinics, teams and specialist midwives dedicated to the care of women with a breech pregnancy in the United Kingdom. The results will be published as a report and used to establish a network of UK breech practitioners for the purposes of joint learning, collaboration and research. They will also inform the on-going work of the OptiBreech Trial.

Although the scholarship is based at King’s College London, applicants can apply from all over the UK. The work can be done remotely. Preference is given to applicants from non-Russell Group universities, from ethnic groups currently under-represented at King’s, mature students, and other groups whose interest in pursuing research the funders are particularly keen to encourage.

Please visit the Wellcome Trust Biomedical Vacation Scholarship page for more information and instructions on how to apply.

For King’s College London students only:

King’s Undergraduate Research Fund


Students can apply via King’s CareerConnect here.

Application opening date: Monday 28 March 2022

Application closing date: Sunday 24th April 2022, 23:59

The list of all projects from all faculties is available here. 

For more information, students can check the KURF website, FAQs and Programme Regulations. Please note that one student can submit only one application. 

If you have any further questions, please contact kurf@kcl.ac.uk.    

— Shawn

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  

Breech-COS international study launches

Round 1 of the international multi-stakeholder Delphi study, Development of a Core Outcome Set for Effectiveness Studies of Breech Birth at Term (Breech-COS) is now open. We invite the involvement of anyone from the following stakeholder groups, who has experience of care for women having vaginal breech births:

QR code for Breech-COS Round 1
  • obstetrician
  • midwife
  • service users (you or your partner have had a breech-presenting baby within the last 5 years)
  • neonatologist
  • researcher
  • health services manager
  • healthcare commissioner
  • health economist
  • statistician
  • support group representative
  • other relevant roles

You can read more information about the research and participate using the link or the QR code below. You are welcome to share this post or forward to your stakeholder associates.

Participation Link: https://qualtrics.kcl.ac.uk/jfe/form/SV_b4uw2QJxcTC8oZM

This consensus-building activity follows on from our systematic review, including Patient and Public Involvement (PPI) activity, Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS): A systematic review on variations in outcome reporting.

Shawn Walker, on behalf of the OptiBreech team