Category Archives: Research

How ‘evidence-based’ is your Algorithm?

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Vaginal breech birth (VBB) is a controversial area of research, in an area of high obstetric litigation. Understandably, people are wary of introducing changes in practice that could expose them, mothers or babies to additional risks. Our research team responds frequently to questions and challenges about our approach, how it aligns with national guidance, and the evidence base.

Recently, a colleague became concerned after reading that the Health Services Investigation Board (HSIB) had presented evidence in Parliament in 2020 about the use of an algorithm to assist a baby’s birth.

The report did not indicate which algorithm was used in this instance, and there are many in circulation. Neither Breech Birth Network nor the OptiBreech Collaborative have ever produced an algorithm for use by maternity triage teams to support breech births at home, nor have we ever promoted the use of our algorithm for this purpose. We have not been informed by any sites in the south-east of England that have been using our algorithm that they have been instructed by the HSIB to stop using it.

How does the OptiBreech Algorithm align with national guidance?

The Physiological Breech Birth Algorithm (OptiBreech Algorithm) is designed to guide clinical decision-making during simulation training, to develop these skills for use in practice. The Vaginal Breech Birth training is approved and delivered via the Royal College of Obstetricians and Gynaecologists (RCOG). The 2023 course was attended by 105 obstetricians and midwives from across the UK, and international visitors.

The description of manoeuvres in our algorithm is fully compliant with RCOG Management of Breech Presentation guidance, which states that, “If the operator has the skills of undertaking the manoeuvres with the mother in a forward position these should be performed without delay.”

In the RCOG guideline, all evidence relating to management of active second stage is based on ‘expert opinion.’ This guidance states that, “[I]ntervention to expediate breech birth is required if there is evidence of poor fetal condition or if there is a delay of more than 5 minutes from delivery of the buttocks to the head, or of more than 3 minutes from the umbilicus to the head.”

How does the OptiBreech Algorithm differ from national guidance?

Our Algorithm and OptiBreech guideline recommend that the birth should be complete within (including time for manoeuvres): 7 minutes from rumping (both buttocks and anus visible on the perineum), 5 minutes from the birth of the pelvis, and/or 3 minutes from the birth of the umbilicus. This is more conservative than the RCOG guideline and, in principle, less likely to contribute to delay in a baby’s birth – unless earlier intervention actually causes complications (see below).

The RCOG guidance was published in 2017 and is intended to be updated every three years. It has not since been updated, but that does not mean that the evidence base has not moved on.

What evidence is the OptiBreech Algorithm based on?

First version

The first version of the Physiological Breech Birth Algorithm was used in Breech Birth Network training in 2017. It was based on video evidence conducted with Dr Anke Reitter. This structured study of video evidence measured median and range interval times for a series of upright breech birth videos. We also recorded the observable mechanisms (position changes) of the breech baby as they journeyed out of the maternal pelvis, and how these related to whether attendants used interventions to facilitate the birth. From this data, we produced an algorithm, including indications that assistance is needed and which interventions were indicated.

Prior to this, training had been based on a combination of instructing attendants to remain “Hands off the breech,” or to perform a set of routine manoeuvres, each of which are only appropriate to supine positions. This was clearly causing confusion and delay.

Refinements

Midwife Emma Spillane then further tested the time intervals with a case-control design and found similar results. While head and arm entrapment only occurred once each, when interventions were used, attendants to ‘case’ births (neonatal admissions or death) waited almost twice as long to intervene as those at ‘control’ births (no neonatal admission).

How has the OptiBreech Algorithm been tested in practice?

Currently, the OptiBreech Algorithm guides vaginal breech birth management within all OptiBreech research, alongside a more detailed OptiBreech Practice Guideline. These materials are reviewed regularly within the OptiBreech Collaborative, based on reviews of their use in practice and our continually evolving evidence base. We follow a Community of Practice approach and host frequent webinars focused on developments in practice.

There are more outcome data associated with use of the OptiBreech Algorithm than any other breech algorithm we can identify. To date, we have evaluated the effects of training and service delivery based on the OptiBreech Algorithm in three prospective studies:

The training evaluation

In our 2016-2019 evaluation, obstetricians and midwives received training in ‘physiological breech birth’ based on the OptiBreech Algorithm. We compared clinical outcomes for births attended by someone who had completed the training with those not attended by someone who had completed the training. We prospectively recorded 0/21 (0%) severe neonatal outcomes when VBBs were attended by someone who had completed the OptiBreech training, compared to 5/69 (7.2%) where no clinicians present had completed the training.

The implementation evaluation

We evaluated how well thirteen National Health Service (NHS) hospitals were able to implement breech intrapartum teams and provide OptiBreech-trained professionals for VBBs, planned or unplanned. This study observed one neonatal SAE among 82 planned (1.2%) and 40 actual VBBs (2.5%). In the birth where the SAE occurred, the woman was positioned in a supine position, had spinal anaesthesia prior to the start of second stage, and Loveset’s and Mauriceau-Smellie-Veit (M-S-V) were used as instructed in the PROMPT flowchart.

Among VBBs, 34/39 (87.2%) were complete within 5 minutes of the birth of the pelvis. One was born very quickly, without an attendant, so the data is missing.

The prospective observational cohort (In Press)

Our prospective observational cohort study collects outcomes for women who receive OptiBreech collaborative care for a planned or unplanned VBB, currently across 10 NHS sites. Management of labour is based on the OptiBreech Algorithm and Practice Guideline. 

In our latest analysis of data received to 8 September 2023, the database records 97 planned and 42 actual VBBs. None of them involved a neonatal SAE. Two babies had an Apgar <7 at 5 minutes (2.1%). We have interval data available for 30 of these births, and 27 of them (90%) were completed within 5 minutes of the birth of the pelvis.

Total prospective VBBs

These studies include a total of 200 prospectively observed* and 103 actual OptiBreech VBBs, with one neonatal SAE. This corresponds to a rate of 0.5% for planned VBB and 1.0% for actual VBBs to date.

(* The training evaluation did not include planned VBBs that ended in caesarean birth. These rates could change as we accumulate further data.)

How does this compare to other vaginal breech birth research?

To measure neonatal severe adverse events (SAEs), we use a composite measure, that is made up of: neonatal mortality (death, neonatal admission to SCBU/NICU for >4 days, Apgar <4 at 5 minutes, HIE Grade 3, Intubation / ventilation >24 hours, parenteral or tube feeding >24 hours, seizures or convulsions > 24 hours, peripheral nerve / brachial plexus injury present at discharge, skull fracture, spinal cord injury). This measure is based on a similar composite used in the Term Breech Trial and PREMODA studies.

In the Term Breech Trial, the neonatal SAE rate for planned VBB was 52/1039 (5.0%) overall and 29/511 (5.7%) in countries with a low overall perinatal mortality rate, such as the UK.

In PREMODA, the neonatal SAE rate for planned VBB was 40/2502 (1.6%).

In the largest study of VBB in the UK this century, Pradhan et al reported a low Apgar (<7 at 5 minutes) rate of 52/882 (5.9%).

Does immediate assistance result in more complications?

Among the 103 actual VBBs we have evaluated, 88.4% were completed within five minutes of the birth of the pelvis, and the neonatal SAE rate was 1%. A rate of 88.4% under 5 minutes is NOT achievable without actively encouraging or assisting the birth. Our guidance is clearly not resulting in an increase in serious complications. In our next analysis, we will look at rates of assistance and minor complications.

Who are the OptiBreech Collaborative? And what is the basis for their claims of expertise?

The OptiBreech Collaborative consists of the Principal Investigators for our research at various sites across the UK, including breech specialist midwives and obstetricians. We all support planned (and unplanned), term, singleton VBBs regularly. Names are acknowledged in our recent publications. The Collaborative is led by Dr Shawn Walker, a consultant midwife and the chief investigator of the OptiBreech studies.

The RCOG guidance states, “Guidance for the case selection and management of vaginal breech birth should be developed in each department by the healthcare professionals who supervise such births.”

You would be hard pressed to identify a lead obstetrician in the UK who has clinically led a team that has supported 200 planned, term, singleton VBBs over the past six years. That is essentially what we have done — during a pandemic, in severely stretched NHS hospitals, without the backup of clear national guidance, and often in the face of extraordinary resistance to our efforts.

We are not even certain the authors of the RCOG guidance, who are eminent, experienced and well-respected obstetricians, are regularly supervising planned, term, singleton VBBs. We certainly know that a majority of consultant obstetricians in the UK are not regularly supervising planned, term, singleton VBBs. If women are to be believed, many professionals are actively discouraging planned VBB by providing only inaccurate and/or biased information.

The RCOG guidance points to ‘an article by Evans’ (not publicly available) to describe the technique and manoeuvres to be used for VBBs in an ‘all fours’ position. We absolutely credit Jane Evans and Mary Cronk with introducing VBB in an ‘all fours’ position to UK practice with the first ever training provided, and their training was our starting point. Mary Cronk (who attended a total of 25 VBBs in her career) introduced the phrase, “Hands off the breech.” This has been widely adopted by the RCOG and other guidelines. But neither Evans nor Cronk has ever shared any outcome data. The OptiBreech effort has transparently reported 200 prospectively observed VBBs.

While we eagerly began with Evans-Cronk methods, our own experience and research has simply taught us that we get better outcomes when we assist the birth sooner rather than later, using our physiology-based, responsive approach rather than a routine set of manoeuvres. That is what we practice, that is what we evaluate, and that is what we teach.

We never expected that we would end up recommending more active intervention and liberal use of episiotomy with any delay on the perineum (after other methods are used). But there is no point in doing research if you do not believe the results and allow it to guide your practice.

What is the evidence for other algorithms currently in use?

We cannot identify a single study that has compared outcomes for VBBs before and after training based on a different breech algorithm with actual clinical outcome data that improved, other than ours.

We have identified one study (Hardy et al 2020), which evaluated training based on the ‘appropriate manoeuvres,’ Lovesets and M-S-V. The pre-training low Apgar rate was 0/56 and post-training it was 7/80 (8.8%, p=0.041). Special care nursery admissions also increased. In our view, these methods should not continue to be taught unless someone can produce any evidence at all that teaching them improves clinical outcomes.

In 2021, we escalated our concerns to the then President of the RCOG and the Chief Executive of the RCM, who have promised us a review of current guidance. We hope, for the sake of breech babies and their parents, that this review begins soon.

We would be happy to be corrected. Please do direct us to any available empirical evidence underpinning other breech training or algorithms currently in use across the UK or elsewhere.

— Shawn

Webinar 30 August 5PM: Testicular complications of vaginal breech birth

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Join the webinar using this Zoom link: https://us02web.zoom.us/j/88170521832?pwd=U1RUSzhPNTJ3elVRSFRuL3c2bGszQT09

David Coggin-Carr is a UK+US dual-certified obstetrician, Maternal-Fetal Medicine subspecialist and early career physician-scientist at the University of Vermont (UVM). He practices full-spectrum MFM in Vermont and upstate New York and additionally serve as Associate Medical Director of the Birthing Center and Associate Director of Quality for Obstetrics at UVM Medical Center. In recent years he has developed a strong interest in physiological breech birth in response to the local community’s desire for greater autonomy around their birth choices amidst a near-total lack of trained/experienced providers in the region. Accordingly, he now regularly provides consultations and intrapartum support for planned vaginal breech birth.

Image: Book of Traceable Heraldic Art

All births have the potential for injury, whether this be facial markings from forceps delivery or lacerations from a caesarean birth. Vaginal breech birth has its own variations. This webinar will explore how vaginal breech birth affects neonatal genitals, both normal variations in appearance from being born bottom-first, to potential injuries.

We will also discuss what research on genital injuries should be done, and how these should be measured and reported in clinical trials. This discussion will inform the on-going Breech-COS (core outcome set) in the OptiBreech research programme.

We will discuss and consider the statements:

There should be no requirement to report genital injury as a separate category in ALL effectiveness studies of breech birth at term, although it may be reported in some. It should not be included in the Breech-COS composite measure of severe morbidity.

or

The incidence of significant genital injury, defined as one that is likely to have long-term, life-altering consequences, should be reported as a separate category in ALL effectiveness studies of breech birth at term. Significant genital injury should be included in the Breech-COS composite measure of severe neonatal morbidity associated with vaginal breech birth.

For all sites that have expressed an interest in our planned stepped wedge trial of OptiBreech collaborative care: please include your name and hospital in the chat, and we will award one site selection point for every site that participates.

References

Kekki, M., Koukkula, T., Salonen, A., Gissler, M., Laivuori, H., Huttunen, T.T., Tihtonen, K., 2022. Birth injury in breech delivery: a nationwide population-based cohort study in Finland. Arch. Gynecol. Obstet. https://doi.org/10.1007/S00404-022-06772-1

Habek, D., 2023. Traumatic testicular avulsion during amniotomy in vaginal breech delivery. Eur. J. Obstet. Gynecol. Reprod. Biol. https://doi.org/10.1016/j.ejogrb.2022.12.003

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? — The OptiBreech Project

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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.

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? — The OptiBreech Project

OptiBreech cluster trial: Call for expressions of interest — The OptiBreech Project

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Expressions of interest are invited for sites to collaborate on an HTA funding bid for a stepped wedge cluster trial of OptiBreech care. We are aiming to submit a funding proposal in August 2023 and if successful, plan to begin work on the trial in summer 2024. We hope to include sites from Scotland, Wales, […] OptiBreech cluster trial: Call for expressions of interest — The OptiBreech Project

Breech-first twins

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Women with breech presentation at term should now be offered the choice of a vaginal or caesarean birth, benefits and risks of both for her individually, and the implications for future pregnancies (RCOG, 2017). Vaginal breech birth and vaginal twin birth are both made safer by the attendance of specialist, skilled practitioners (Su et al, 2003; Barrett et al, 2013). When it comes to the combination of vaginal breech and twin births, there remains a lack of professional consensus on the safety of vaginal birth compared to planned caesarean. This is particularly true of breech presenting twins, where the first twin is breech at term, compared to twins in a vertex-breech order, which has been subject to more research.

RCOG breech guidance (2017) recommends planned caesarean in cases where the first twin is breech, but not in the case of twins where the second twin is breech. This recommendation is influenced by the Hogle et al paper (2003), which found lower Apgar scores at five minutes for breech-first twins born vaginally. However, the paper did not find any other significant negative outcomes for these babies, such as neonatal unit admissions, need for resuscitation or increased mortality. Women considering a vaginal breech birth are now routinely informed that following a vaginal breech birth, babies are more likely to have lower Apgar scores, but that this does not translate into severe illness or long-term health consequences. Therefore, breech lead twins behave similarly to singleton breech babies who are born vaginally, meaning they should also be suitable for vaginal birth depending on maternal choice.

As with many areas of breech, research studies are mostly retrospective and often reporting on small numbers. Nonetheless, evidence dating from 1998-2022 suggests no significant difference in neonatal morbidity or mortality for lead breech twins born vaginally or by caesarean, or any difference in outcomes for breech lead twins compared to cephalic lead twins (Grisaru et al, 2000). In 2020, Korb et al published their secondary analysis of the JUMODA twin study, which concluded that planned vaginal birth with a breech twin first is not associated with higher neonatal mortality or morbidity for either twin. In their systematic review, Steins Bisschop et al (2012) found no difference in neonatal outcomes between vaginal or caesarean birth for breech first or second twin. Several authors stress the value of practitioners and centres having exposure to and skills in facilitating vaginal breech and vaginal twin birth.

Where caesarean is recommended (Nassar et al, 2005; Hogle et al, 2003), these papers appear to generalize the singleton findings of the Term Breach Trial (Hannah et al, 2000), which have since been called into question. Bourtembourg et al (2012) recommend caesarean for nulliparous clients, but this is based on likelihood of vaginal birth, rather than negative impact on mother or baby. The RCOG breech guideline (2017) mentions the risk of interlocking when the first twin is breech, but the only available evidence on this is from Cohen et al in 1965; none of the studies analysed in this review cited interlocking of twins to be a significant labour complication.

The impact on maternal health was not included in many of these studies, but where this was considered, findings suggest either no difference to maternal morbidity (Bats et al, 2006); a greater incidence of postpartum haemorrhage following planned caesarean (Ghesquière, 2022); or an increased incidence of deep vein thrombosis and pulmonary embolism (Sentilhes, 2007) following planned caesarean. These findings should be incorporated into consultations on the benefits and risks of modes of birth.

According to the evidence reviewed, planning a vaginal birth with breech-presenting twins is a reasonable choice and should be approached in a similar way to singleton breech birth. However, the birth must be facilitated in a unit with staff skilled and experienced in vaginal breech and vaginal twin birth.

Are there any additional considerations?

Estimated fetal weight should be considered. Blickstein et al (2000) found benefits from planned caesarean in cases when the breech twin weighed less than 1500g. As is often the case in breech, babies weighing over 3800g were recommended for caesarean section in many studies, which means they are omitted from the current evidence base.

Jacana Bresson

Reflections on International Day of the Midwife, 2022

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Yesterday was International Day of the Midwife. I saw but didn’t participate in the social media celebrations. Not because I wasn’t feeling it, but because my clinical academic midwife life was full to the brim. This included:

This is the dress I made for Professor Jim Thornton’s retirement party, which I couldn’t attend due to another breech birth!
  • Supporting a planned OptiBreech vaginal breech birth through the night and until the birth occurred in the morning;
  • Conducting two interviews for the Wellcome Biomedical Vacation Scholarship at 9.30 and 11.00 — amazing candidates this year!;
  • Receiving the news that the OptiBreech team has been awarded a £15k ESRC Impact Acceleration Grant;
  • Receiving and responding to the news that both my funder and my employer have received complaints that the OptiBreech Project is ‘promoting vaginal breech birth;’
  • Being a keynote speaker in the Virtual International Day of the Midwife 2022 conference at 2 pm;
  • Allowing my little dog to take me for a walk to support my physical and mental health;
  • Taking a massive nap; and
  • Spending a wild evening in on my sofa, knitting a jumper for my son Waldo the Stonemason and listening to a Miss Marple audio book.

If you feel exhausted just reading that list, you’re as human as me!

A team is not a group of people that work together. A team is a group of people that trust each other.

– Simon Sinek, shared by Céline, an attendee at my VIDM presentation

OptiBreech

This feasibility study is undoubtedly the most challenging and most rewarding thing I have ever done in my life. Being a research leader means being a change leader, and change is never easy. The OptiBreech Project is proposing a paradigm change in the way we support vaginal breech birth. This means a change from promoting caesarean section (CS) to supporting each individual women’s choice of mode of birth, in line with NICE Guidance. And it means a change from using unreliable ‘selection criteria,’ which are also inconsistent with the concept of individual choice, to relying on specialist expertise to respond to unfolding and infinitely unique circumstances.

When I sit down to eat some dark chocolate and peanut butter because I’ve worked my butt off today …

Being a breech specialist is not easy. In addition to a lot of time spent on-call, it’s not like working in a low-risk midwifery setting, where you can anticipate 90% of women will have the normal birth that they want. Many women are heart-broken when they find out their baby is breech. We can support them to plan an elective CS, and some women are happy about this, but many are very disappointed, even when they feel this is the best option for them and their baby. For those who want to plan a vaginal birth, but only if the baby is head-down, baby turning (ECV, external cephalic version) is only successful up to 50% of the time. We are still there for women when it does not work.

For those who want to plan a vaginal breech birth, the barriers sometimes seem impossible. It’s not uncommon for women to make an informed decision to plan a physiological breech birth (PBB) and return to clinic in tears because of the way someone has spoken to them, be that another health care professional, a friend or family member, or an unkind stranger on social media with opinions about the wisdom of their choice. The criticism, judgement and stigma can feel very heavy at such a vulnerable time. Our interviews with women on the study indicate they have felt supported to change their minds and plan an elective CS in these circumstances. Of course we can and do facilitate women changing their minds, but we can’t take away the hurt women feel when they wished for more support to make a different choice.

Birthing people who stick with their choice to birth vaginally despite such ubiquitous doubt frequently want reassurance that everything will be okay. Of course, we can never guarantee a perfect outcome. We can only guarantee that we are doing our best to increase the chances we will get professionals with enhanced training and experience to their birth. We believe this will improve outcomes for these births (that is the premise of the research), but we will not know until many OptiBreech births have occurred. And we all have to be prepared for a higher need for intrapartum CS to achieve a safe outcome for breech babies, even when trying for a vaginal birth.

Those of us supporting women who choose physiological breech births face similar criticism and judgement on a regular basis. Sometimes the lack of respect and unkindness feels overwhelming, and it is tempting to succumb to despair. I find it helps to remember that behaviour like this comes from a place of fear, a belief that doing things differently could have disastrous outcomes. Nobody wants this, and nobody wants to be responsible for it. In difficult times, I lean into the support I feel from many wonderful midwifery and obstetric colleagues, who help bring me back to a place of compassionate understanding. Only by opening to understanding each other can we move towards trust and safety — physical, emotional and spiritual safety in each others’ hands.

Listening to my ‘Joy and Love’ playlist helps too. Here’s a mini playlist of my favourite Resistance Revival Chorus songs, for anyone who needs them today.

Continuous cyclic pushing: a non-invasive approach to optimising descent in vaginal breech births — The OptiBreech Project

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Shawn Walker, RM PhD, King’s College London and Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex Hospital Sabrina Das, MB ChB, MRCOG, Imperial College Healthcare NHS Foundation Trust, Queen Charlottes & Chelsea Hospital Emma Spillane, RM MSc, Kingston Hospital NHS Foundation Trust Amy Meadowcroft, RM, Northern Care Alliance NHS Foundation Trust Background In the […]Continuous cyclic pushing: a non-invasive approach to optimising descent in vaginal breech births — The OptiBreech Project

Reflections on the Ockenden Report in the context of breech presentation

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The recent release of the final Ockenden Report has shed light on deeply painful experiences for the women, families and healthcare professionals involved. For those of us who have not been involved, the call to deep reflection can also be a painful experience, but a necessary one.

I have been asked by several people what I feel this means for vaginal breech birth. Will women still want one after this report, where promotion of vaginal breech birth against maternal request for a caesarean section was a contributing factor in some very sad outcomes? Will professionals be even more reluctant to support women who wish to choose a vaginal breech birth, for fear of being accused of zealous pursuit of normal birth at all costs?

My answer is this: I welcome this report because I see it as affirmation of the need for individualised care, the need to listen to women, the need to place their values and needs at the centre of care.

Women who want a caesarean section, regardless of their baby’s presentation, should have easy access to one. I counsel several women with a breech-presenting baby every week about their birth choices, and I encounter many women who appear to be somewhat relieved that their baby is breech. They do not want an attempt at baby turning (external cephalic version, ECV, to a head-down position). They want a caesarean section. And their baby being breech means they will have one without the need to justify their choice. 

I stopped talking women into an attempt at baby turning (ECV) a decade ago because I audited the results of my first breech clinic. By introducing a breech specialist midwife pathway, I doubled the rate of ECV acceptance almost overnight. Women trusted me. For two women, I remember clearly convincing them that ECV was ‘best.’ I even said to one after a successful procedure, “Aren’t you glad you had a go?” One woman had a long, complicated induction that ended with an emergency caesarean section and massive obstetric haemorrhage (bleeding). The other had a failed attempt at suction cup delivery, failed attempt at forceps delivery and a caesarean section. I have also been present when an ECV attempt at 36 weeks led to an emergency caesarean section, in which we found the cord ended up in front of the baby’s head as it was trying to engage. I’m pretty sure none of these women ended up happy that someone convinced them to have an ECV rather than a planned CS. If this has been your experience, or similar, I am so deeply sorry.

But I also meet many women who decide that an attempt at baby turning is the best choice for them. They really want to try for what they see as a ‘normal birth,’ in a birth centre with midwives and access to the birth pool. They are prepared to accept the relatively small risks associated with ECV and vaginal birth — after all, I can remember these women as individuals after a decade of doing breech work — because they feel the potential benefits outweigh the risks. These women deserve to be offered this attempt, with experienced providers who have a consistently good success rate. And if adverse outcomes happen, they deserve NOT to be treated as if they made the wrong decision. None of us has a crystal ball.

It is my responsibility to explain why baby turning is the nationally recommended ‘treatment’ for breech presentation. When I explain this, I explain the potential benefits of and increased likelihood of having a straightforward vaginal birth, particularly in a first pregnancy. I also explain to every woman that, in 2022, by far the most likely outcome no matter what she chooses to do (ECV, VBB, CS) is that she and her baby will be well and safe following the birth. There are small differences in risk between each choice, but ultimately, with skilled support and a plan in place, the outcomes are very good for all choices. She should feel supported to make the choice that ‘feels’ right to her. We professionals should then do our best to make this choice as safe as possible, while continuing to communicate any changes to the risk profile she initially accepted.

I deeply feel that women who want a caesarean section should be able to have one, without judgement or difficulty. I am reassured by our qualitative data in the OptiBreech study, that the breech specialist midwives and breech clinic obstetricians providing counselling are all doing it in a way where women feel they have genuine choices but are not pressured in one direction in another. Participants say this repeatedly and express how much they value this balanced counselling.

I also deeply feel that women who want to attempt a physiological breech birth should have the best possible support for that option. They should also feel their choice is supported without judgement, shame or pressure. Part of enabling women to make this choice involves enabling healthcare professionals to develop skills and work in ways that make ‘a vaginal breech birth with skilled and experienced support’ – which the RCOG guideline tells us should be nearly as safe as a cephalic birth – possible. This is a win-win situation. By supporting the women who WANT to plan a physiological breech birth well, we also increase our skill level to support those rare occasions when there is no choice available due to the rapid progress of an early or unplanned breech labour. When this occurs in the context of rigorously governed research, we can be even more confident that this learning will occur.

Sadly, this is not possible for most women in the UK. Every meeting of our OptiBreech Patient and Public Involvement (PPI) group involves talking through some amount of trauma. Our research team includes women who have sadly lost their babies to poor care and want to preserve the choice with BETTER care and women who have experienced severe complications from caesarean sections they did not want. But almost ALL members of our group, including partners, have expressed trauma from being repeatedly blocked, judged and unable to access skilled, supportive care for a vaginal breech birth. They have read national guidelines that said this should be an option, then found that their local health services had zero commitment to delivering this; they effectively had no choice.

On the other hand, our PPI group has been adamant that they do not want research to demonstrate vaginal breech birth is BEST. They want research to demonstrate what the actual, current risks are for all choices, and to show us how we can help all women make the choice that is right for them.

The vaginal breech birth skill set has remained largely static since the 1970’s, with ‘put the woman in an upright position’ being virtually the only innovation in breech care – until recently. It is as if we have been managing shoulder dystocia with only McRoberts and Gaskin manoeuvres – of course we would expect bad outcomes. (shoulder dystocia = where the baby’s shoulders become stuck in a head-first birth; McRoberts = pulling the woman’s legs back to her abdomen to create space in the pelvis; Gaskin = turning the woman to a hands/knees position)

Yet many professionals trying very hard to do the research we need to improve outcomes for breech babies are also exposed to the trauma of incivility and lack of respect. There is a particular power dynamic that exists between obstetricians and midwives that can make uncooperative behaviour threatening and dangerous – because the best outcomes for planned vaginal breech births are achieved when there are skilled, trusted care providers and a low threshold for using interventions (such as caesarean section) when they are needed. If you are afraid to refer to a person who has previously spoken to you harshly, publicly criticised you or outright refused to have anything to do with a physiological breech birth, this can introduce hesitation where there should be none. Some midwives have also found it difficult to maintain engagement with some women because being called to repeatedly justify women’s choices to colleagues is very emotionally draining, leading to avoidance behaviour. This is neither healthy, nor safe.

Multiple obstetricians who have tried to progress OptiBreech research have also experienced blocking, incivility, and general lack of respect. Discussions have been shut down before they begin. Junior doctors who want to learn the skills find they have no support to do this and remain silent. This has led to communication breakdowns and undermined safety at a time when we all need to be working at our best to learn and improve.

Do I think there is a place for physiological breech birth post-Ockenden? The demand for skilled breech care continues, and we are contacted each week from across the UK by women who are looking for support. In our OptiBreech project, there have been exemplars of healthy communication and excellent teamwork to achieve good outcomes for mothers and babies, and we are focusing on these as the way forward. I am grateful for the warm and respectful interactions I have with many of my colleagues; these sustain us all in our challenging everyday work. Examples of successful co-operation are especially valuable given the extreme pressures staff have been facing with chronic under-staffing and pandemic conditions. And our learning about how to support breech births well is accelerating at light speed as we share our experiences through constant reflection among OptiBreech leads at active sites. We will persist for as long as we can.

Enabling physiological breech birth, and research about how to make it safer, is NOT about promoting natural birth at all costs, nor about promoting natural birth at all. It is about placing the women who use our services at the centre of all we do, bringing our best to meet them where they are at and constantly striving for better. Which is, in my opinion, what the Ockenden Report calls us to do.

This blog is the personal opinion of Dr Shawn Walker and not the NIHR, King’s College London or any NHS institution.

Breech-COS international study

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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

student midwife literature reviews

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My name is …, I’m a third year student midwife at X University and I am about to begin my literature review, I have decided to focus on vaginal breech birth. I haven’t finalised my question yet as I feel I need to read some more research to be able to word it correctly but I’m really interested in vaginal breech birth and practictoner skill. I’m ambitiously hoping my review might encourage the trust I work in to trial a breech birth team. I was wondering if you might be able to point me in the direction of any research regarding practitioner skill or breech birth teams? I understand we need much more research, but in your opinion is there any particular area that is really lacking in research that would support a move towards normalising vaginal breech births? I appreciate this is a very busy time for everyone having to work from home and understand you may not have time to respond to me at the moment but I’m so excited at the idea that don’t want to leave any stone unturned, any advice you have would be very appreciated.  

Hope to hear from you soon!

(Thank you for permission to share this exchange.)

Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre

Hello, 

Thank you for your message and your interest.

I write about this topic constantly https://breechbirth.org.uk/publications/. My PhD thesis contains a section on it, although this is a few years old now. Reference lists to our publications will help get you started. We also include information on building competence in the Breech Birth Network on-line training.

You could do a review on breech teams, breech clinics or midwife involvement in breech care. We need someone to lead some sort of consensus project to produce something like this for breech midwives: https://www.networks.nhs.uk/nhs-networks/diabetes-midwives/documents/NHSDAKC%20Midwives%20Standards.pdf That is a long-term project that will require funding, support and networking with key stakeholders, such as the RCM and RCOG. But it starts with a literature review.

You could do a literature review around midwives’ roles, any literature about competencies already out there, any evidence about the roles that midwives are taking, any evidence about outcomes associated with midwife-attended breech births (there is some in one of the TBT follow-up studies, I think by Su?).

My advice would be, whatever you do, treat it as a first step in becoming an expert in this area yourself. While it is great to try to convince your Trust they can do this, eventually, someone is going to need to actually put themselves on call and attend the births. So while you understandably feel at the beginning of a journey, see yourself as starting and committing to that journey, rather than trying to convince someone else to 😊 It may take years, but the breech revolution is a looooong-term game, requiring all of us to take small steps, with patience, but continuing to move forward, inch by inch. You will be constantly running into a wall. We turn to each other for support, do not give in to despair, and keep going. Eventually, enough of us running into the same wall will knock it down.

Another option is to do a review of outcomes associated with breech clinics and breech teams. This would be very valuable, but it will require a ‘no stone unturned’ approach indeed. This is because content about clinics and teams is usually embedded in articles, rather than listed as a key word. So you would have to do a general search on ‘breech presentation’ after 2000, eliminate obviously irrelevant articles and duplicates, then do searches on the words ‘team’, ‘clinic’ and ‘specialist’ and other related words such as ‘on-call’ and ‘stand-by,’ within the abstract and text of the articles themselves. It’s not as simple as a PICO search on randomised controlled trials, but it would pull together the general trends associated with clinics and teams (for ECV as well as VBB results), demonstrating a need for further research focusing on these as interventions themselves. (Here’s an example to get you started.)

To that end, make sure you are using a Reference Management Software programme. I use Mendeley. If you are going to become a breech specialist yourself, you will need to be very familiar with the literature and have it easy to hand when you want to apply for funding or write up your work. Do that now and begin to build your library of evidence, organised to help you make your arguments. Reference Management Software will also help you search the text.

Be sure to check the reference lists of any articles that qualify and our publications.

And choose a topic that you are interested in going on to do further research about because a literature review is the first step. Aim to write a literature review that you can publish, even in a student midwife journal, but ideally more. You are not doing a ‘student midwife literature review.’ You are doing a literature review. There’s no reason your first go need be any less worthy than any medical or post-graduate student doing a literature review for the first time, many of which get published. Your work and your mind are just as worthy, and when you spend time doing something properly, you have insight others can learn from.

Once you graduate, begin to identify sources of funding for the next stages. Research/breech practice is a great combination because it gives you some flexibility (e.g. not responsible for as many clinics/shifts) and helps move practice forward.

If you’ve done our on-line training, you can begin to become involved in assisting with training through BBN. Continual review and engagement is the best way to continually develop your confidence. We have on-line seminars frequently.

Join the community of practice: Have you found really good breech team / breech clinic references for your literature review? Post them below in the comments to help others get started.

I am very happy to provide specific advice and guidance as an external supervisor for students who are intending to follow through, taking their project to publication. We need more voices contributing to this effort.

Best wishes,

Shawn

Update: I just undertook a mini literature review due to a student reporting how difficult it was to find qualifying papers. First: sympathy. Yes it is. Second: Unfortunately, there is no shortcut for very thorough understanding and overview of a topic in which you would like to gain expertise.

But how exciting! Every time I do this, I learn more, from discovering more qualifying papers to other topics that people have looked into. I could spend all day lost in these papers, connecting one to the other, piecing the jigsaw together. However, I need to get on with other things. First, some more tips:

  1. Frankfurt. This group publish under FRABAT. You could make an argument for this being a dedicated centre, and all of the subsequent publications would qualify for inclusion. The group challenges many strongly-held assumptions about ‘exclusion criteria,’ which may not be as useful in an experienced centre.
  2. Do you speak/read Spanish? Garcia Adanez et al 2013
  3. Do you speak/read French? Marzouk et al 2011