Undiagnosed breech births in the OptiBreech 1 Study

How can women with an undiagnosed breech birth participate in the OptiBreech Study? This post covers the process.

The short answer: How does it work?

Image courtesy of Dr Anke Reitter, Frankfurt
  1. If staff feel it is in the woman’s best interests to call someone to the birth who has completed the OptiBreech training and/or achieved the proficiency criteria, then they should do so.
  2. When the breech presentation is diagnosed, staff should determine if there is someone available who has completed the enhanced training and/or meets the proficiency criteria, who can attend and support the birth. You can download a Breech Birth Pro Forma to assist with collecting all of the data we need about the birth.
  3. If someone with OptiBreech training has attended the birth, the woman may be approached after the birth and asked for her consent for her data to be used in the study, as per the standard consent procedures. The person has the right to decline use of their data. The Participant Information Sheet and Consent Form are linked from this page (including a video version of the PIS). The password for the on-line Consent Form (preferred) is available from your local Principal Investigator.
  4. Consent should be sought by someone who attended the birth, and they should also offer a thorough debrief of what happened at the birth at this time.

The longer explanation

In OptiBreech 1, we are collecting prospective observational data on planned vaginal breech births, where women and birthing people consent to our use of this data. This will include rates of vaginal birth and adverse outcomes for babies (death or admission to the neonatal unit) and mothers (PPH, severe perineal tears). We will also be looking at how many women plan a vaginal breech birth, and how many are attended by someone who has attended OptiBreech training and/or maintained proficiency-level experience. This will enable us to calculate whether a large trial will be possible.

Many participating sites are just beginning to re-build a breech birth service after decades of not offering such a service. Where overall experience levels are low, some Trusts are expecting to start out with mainly ‘undiagnosed breech births.’ This refers to a situation where the breech presentation is identified for the first time after the person has been admitted in labour. Approximately 20-30% of breech presentations are diagnosed for the first time in labour, or 5% where universal third trimester scanning has been implemented (Salim et al 2021).

The benefit-risk balance of vaginal birth vs caesarean section is altered when a woman is in labour. The findings of the Term Breech Trial indicated that a caesarean section performed prior to the start of labour significantly reduces risks to the baby compared to a vaginal birth (when the classical methods of delivery used in the TBT are used, Su et al 2003). This effect was less significant in early labour but still clear. However, when the woman was in active labour, defined as 3 cm or more, the benefit was less clear and did not reach statistical significance.

A potential benefit from a CS in labour needs to be balanced against known risks to the woman and future pregnancies. Although most women are very willing to sacrifice themselves for any benefit to their baby, a CS performed near to or in the second stage of labour also significantly increases the risks of early preterm birth and late miscarriage in all future pregnancies (Watson et al 2017).

Although many clinicians will still want to offer women a CS if they feel they have time to counsel appropriately, because of the change in benefit-risk balance in labour, the RCOG guideline currently advises that women near to or in the second stage of labour should not routinely be offered a CS. Women in our PPI group also tell us that being asked to decide on the mode of birth for a breech baby in labour, where there is no immediate threat to fetal well-being, is very stressful and can result in birth trauma, even where outcomes are good (Lightfoot 2018).

The OptiBreech study is designed on the premise that getting someone to a vaginal breech birth who has 1) completed an enhanced, evidence-based training package; and/or 2) has acquired proficiency-level experience, is likely to improve the outcomes of both planned and unplanned breech births. Therefore, we have worked into the protocol a way of enabling women with a breech presentation diagnosed in labour to participate, taking account of the RCOG guidance for obtaining valid consent to participate in perinatal research where consent is time critical (2016, see also Vernon et al 2006).

Women in our PPI group expressed that taking consent for participation in labour was not appropriate. As this is an observational, rather than interventional, stage of the study, and attendance of an OptiBreech-trained professional would be something in addition to, rather than replacing, standard care, they felt it was appropriate that women’s consent be taken retrospectively in the postnatal period. Standard counselling about mode of birth, according to RCOG guidelines, would apply in labour.

Women also identified that many found the experience of undiagnosed breech birth traumatic regardless of the outcome, due to the concern staff expressed when discovering their baby to be breech. However, they were rarely offered an opportunity to process what had happened with staff who were present. PPI participants said they felt women would benefit from careful explanations in the postnatal period. We therefore added the last step. We are grateful for the guidance of our PPI group, so that we can make participation in OptiBreech 1 potentially beneficial for women, rather than a burden.

If you have any comments to make about this process, you are welcome to leave them here or contact the research team.