This 13-minute counselling video was created to support our OptiBreech teams when responding to women who request OptiBreech care for a planned vaginal breech birth at home. The care process being tested in our study is care from a team of professionals with physiological breech birth training and/or proficiency (OptiBreech collaborative care). Although our recommended place of birth is within a hospital with immediate access to caesarean birth, obstetric and neonatal support, our protocol does not specify that women must give birth in hospital in order to access this care or participate in the research.
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Hello. My name is Shawn Walker. I’m a Consultant Midwife, the Clinical Lead and the Chief Investigator of the OptiBreech Trial.
We’ve had several women ask for support from their OptiBreech team to plan a home birth. I wanted to talk through this a bit so that any woman thinking of participating in our study understands our position on breech home birth and can make a fully informed decision.
First, I want to be absolutely clear: Our recommended place of birth is within a hospital with access to caesarean birth if needed and the support of the complete multi-disciplinary team, including obstetric and neonatal colleagues. This is because the potential risks of a vaginal breech birth are different from cephalic birth, no matter what the setting. Studies in multiple settings have demonstrated that, when breech births become complicated at home, a severe adverse outcome is more likely to result. Sometimes, these risks can occur unexpectedly. An example of this is a cord prolapse, where the umbilical cord slips down between the baby’s legs and becomes compressed before the baby is ready to come out. This can lead to oxygen deprivation if not resolved quickly. If we are in the hospital, we can get you to this help quickly, most of the time. If we are in your home, there may be significant delay.
Ambulance services are also under considerable pressure, so response times may not be ideal if an unexpected event occurs. The availability and response time of an ambulance and the potential transfer time to the nearest maternity unit also need to be considered.
Another thing that impacts an OptiBreech team’s ability to offer care at home is current midwifery and obstetric staff shortages. In some teams, there are still only a few people with significant experience, due to decades of skill erosion. If these people are already working on site in a hospital, it may not be possible for them to leave to attend your birth. Current maternity service staffing levels mean it is increasingly difficult to ensure we keep every birth as safe as possible, and sometimes compromises need to be made. We may need to share responsibility with you for making sure the right person is at the right place at the right time to attend your birth.
A plan for a breech home birth also requires additional co-ordination and planning, and there are additional research procedures on top of this for OptiBreech. It will also require additional time for what we call ‘mediation’ – that is, the senior midwife planning your care will need to communicate and explain the plan to colleagues. This involves reassuring and justifying to colleagues that this has been a fully informed choice. This shouldn’t be incredibly time consuming, but unfortunately it often is. We ask you to please be as patient as possible with your teams, who are often spending time on-call for breech births above and beyond their very demanding core roles. We are all doing the best we can.
It’s also important to understand that if an experienced OptiBreech team member attends your birth, this does not guarantee a perfect outcome. We feel, and our ever-increasing data indicates, that the presence of someone who has completed OptiBreech training is likely to help reduce the risk of a vaginal breech birth. Some of our OptiBreech sites home birth teams have used the occasion of someone planning a breech home birth to upskill the entire team with physiological breech birth training. We feel this is a great approach, and one likely to benefit potential surprise breech home births in the future. Where attendance of a fully proficient specialist is not possible or less likely, we feel preparing the staff who are likely to attend the birth with additional hands-on training is the next best option.
But reduced risk is not the same as no risk. We also feel that where births become very complicated, the presence of someone who has previously resolved complications successfully can help improve the outcome. These people are still rare within the UK, and again – it does not guarantee that unexpected complications will not occur, at home or in a hospital.
Our OptiBreech team members have become involved in delivering this care because they genuinely enjoy using the skills they have spent time developing to support physiological breech birth, when a woman prefers this. We understand that giving birth to a breech baby at home is likely to have the same benefits as planning a head-first home birth, such as a quicker labour, reduced need for pain relief drugs and less risk of intervention. We completely understand why someone would want to be in a setting where they feel comfortable and secure, and not interrupt their labour to travel to hospital. There are many reasons a woman may prefer to give birth at home, and ultimately it is your decision.
It is precisely because we understand these benefits that we are all working so hard to make a safe space within a hospital setting, where you can nest in and give birth the way you prefer, with the support of the full multi-disciplinary team available if you need it, but not necessarily in your birth space. Evidence indicates that some women choose to give birth at home because they feel they will not be supported to plan a physiological breech birth with minimal disturbance in a hospital-based setting, and this is wrong. We all have a duty to address the alienation some people feel that prevents them from accessing care that would benefit them. Consistently achieving better outcomes for the vaginal breech births helps us to create space for more women to attempt a physiological breech birth with minimal interference, when they want that. But this requires trust from everyone involved.
Change and compromise and new ways of working are always challenging. Our teams sometimes find it challenging to provide the service we would ideally like to provide. But the more we can work together and trust each other, the safer we genuinely believe your birth will be. If you do plan a breech birth at home, we have advised our OptiBreech teams that where possible, we consider the ethical thing to do is to provide the most experienced or support available – with the same caveat that experienced support may not always be available. We also want you to be included in our study. We collect information on place of births, and if there is an increased risk, analysing the data is the only way we can determine what this is.
When a breech home birth is planned, we feel the safest approach is to have a low threshold for transfer into hospital if all is not progressing straightforwardly. Indications include but are not limited to, meconium-stained liquor at any point during the first stage of labour, a rising fetal heart rate, active pushing of over an hour, and any other variations from normal. Our recommendation is that you accept the standard monitoring that is offered so that your midwife can identify if any of these indications are present, as early as possible, so that a safe and un-rushed transfer can be arranged. These signs are baby’s way of telling us that they are struggling. We know that a small number (about 3%) of babies are in a breech position because there is an underlying problem or a vulnerability, rather than just chance or baby finds this seat more comfortable. Subtle problems can’t always be identified on a scan, and sometimes the vulnerability is only apparent once labour starts.
Please be reassured that all our teams, and all home birth teams, are invested in maximising your chances of achieving the birth you want. If transfer or caesarean birth is advised, it is because something has indicated that there may be increased risk. Safety is our priority. But we may have different or conflicting mental models of ‘safety’ – please do share your priorities with those planning your care.
As always, we refer to the absolute risk figures in the Royal College of Obstetricians and Gynaecologists guideline. When a head-first birth is planned, the risk of the worst possible outcome – baby dying – is about 1:1000. This is because, to a certain extent, it is impossible to completely eliminate all risk in childbirth. When a breech birth is planned, the risk of baby dying is about 2:1000. This is still a low number, and by far the most likely outcome, no matter what you plan to do or where you decide to give birth, is that you and your baby will be completely well. We have to look at thousands of births to see these differences. But when we do look at the numbers, this is what we see. There are very few reports of breech births at home, but where they exist, they indicate increased risk compared to head-first births. Of course, it is absolutely your right to accept these potential risks and give birth where you choose.
I hope you have found this helpful. I acknowledge that talking about risks is difficult at a time when you want to be developing confidence in your body and ability to birth your baby. As health care professionals, we are also navigating our own risk that supporting any woman to choose a breech home birth will be considered encouraging risky behaviour. We know that respecting people’s intelligence and ability to make informed decisions about their own body, no matter how popular these decision are, is not the same as encouraging risky behaviour. But we do need to make sure that you understand that providing you with the most experienced support we are able to provide for a home birth does not completely mitigate, or eliminate, the risks involved.
So our position is clear: We created the OptiBreech collaborative care pathway because we want you to have a safe space within a hospital setting to have a physiological breech birth without unnecessary interference, if you want that. We feel hospital is the safest place for a planned vaginal breech birth. I personally wanted to be clear about this so that, when you meet with your care providers, they know you have this information and can concentrate on your birth plan. If you have concerns about any care you are receiving related to the OptiBreech service, I invite you to be in contact with me personally. This ensures that learning from your feedback can influence care improvements across the study.
In summary, we respect your bodily autonomy and right to choose your place of birth. And we acknowledge the difficulty all services are experiencing during this current maternity care staffing crisis. I hope that this video has helped you to understand the position that we need to take on this, and that you and your care providers can work together with trust and mutual respect, understanding that we’re all just trying to do the best we can at the moment – all of us.
Dr Shawn Walker