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.
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!
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.
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.
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.
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:
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?
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?
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?
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.
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:
use of the physiological breech birth algorithm to ensure the birth proceeds spontaneously or is assisted within a timeframe based on previous research — this means, if your assistance with forceps is requested, we expect this to occur well before the baby has become compromised;
regular reflective seminars to support and share learning occurring within the study. Your local PI can tell you how to access these.
Why don’t women want obstetricians to be involved?
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.
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.
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:
service users (you or your partner have had a breech-presenting baby within the last 5 years)
health services manager
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.
Your Research & Development Office have given your site the green light! This post will outline your first steps now that you are starting in the OptiBreech 1 Study.
In accordance with the protocol at site set-up, all sites should:
Provide the OptiBreech research team with a copy of your current guideline covering the management of breech presentation at term, including information provided to women.
Provide us with materials used in mandatory training and any specialist site-specific training, or a brief description. For example, we are interested if your mandatory training uses an in-house package or is based on PROMPT or another training programme.
Please answer: When a woman plans a vaginal breech birth, is it routine to put a plan in place to ensure she has experienced support at the birth, e.g. formal or informal on-call system? (Yes/No)
Liaise with your research team to identify how you will deliver the anonymised data required in the protocol, outlined below.
Make the OptiBreech training available to your staff members. The research team will provide further information on how to do this.
The above information outlines the minimum required for sites who are participating in OptiBreech 1. For sites who are also intending to offer OptiBreech support for planned or unplanned breech births, these are the next steps.
Invite your colleagues to express an interest in delivering OptiBreech care by completing the consent form and survey. This is linked from the top of the Information for Professionals page. (password is available from the protocol or research team)
All staff members supporting OptiBreech births need to have completed the OptiBreech Training, also available from the Information for Professionals page. (password is available from the protocol or research team)
On-line participant Information Sheets and Consent Forms are all linked from the Information for Women and Birthing People page. (password is available from the protocol or research team — the research team are happy to run through this process with you whenever you like, so do not hesitate to be in touch)
In this study, the following count as accruals:
recruitment of women who are planning a vaginal breech birth with OptiBreech support;
interviews with health care professionals who have been involved directly or indirectly with care for women recruited to the study.
Because of the importance of developing services slowly and carefully where vaginal breech births have been rare in the past couple of decades, we have enabled sites to access the enhanced training in exchange for anonymised, retrospective data only; however the return of this data will not count as an accrual. There is no minimum recruitment target, though we may seek to interview key staff about their feelings of readiness / willingness to support planned vaginal breech births or to develop a proficient team.