Avni Batish and Kate Stringer, photo by George Haroun
On May 8th, we will be holding an online meeting to establish a consensus on short-term outcomes in our Breech-COS study. We invite anyone with an interest to attend.
Looking back on 2023, we at Breech Birth Network would like to celebrate another year of collaborative work to make vaginal breech birth safer — for those who choose this mode of birth, and those who have no choice.
Within the past year, our instructors have delivered our fully evaluated training day to fourteen healthcare services in the UK, covering Scotland, Wales and England. This has provided hands-on instruction to over 700 clinicians. We have also delivered training abroad in several different countries. Our online course has reached over 1500 subscriptions globally.
We also delivered the course for the first time as a joint event with the Royal College of Obstetricians and Gynaecologists. This first event was over-subscribed, drawing 105 participants from across the UK and abroad.
OptiBreech Leads have also used our resources to deliver internal training to staff at sites participating in that research.
We also want to celebrate midwife Rosemary Umolu, who has assisted us by co-ordinating trainers for our study days over the past year. She did all this while completing her Masters in midwifery exploring what human factors affect the management of breech delivery. Congratulations Rosemary!
Rosemary’s project was inspired by her experience as a student midwife with a breech delivery that took just under 20 minutes to resolve. The event ended with Rosemary performing a maneuverer called a shoulder press to free the baby’s head. Although both mother and baby were clinically well at time of discharge, the incident inspired Rosemary to conduct a Scoping Review exploring what human factors affect our decision-making skills during critical events. What was once seen as another mode of delivery is now viewed by many clinicians as a medical emergency that needs to be managed. The scoping review found human factors such as communication, fear, confidence and expertise all play a significant role in the management of vaginal breech births. However, simulation training and dedicated breech teams may help improve confidence in midwives and obstetricians and their ability to manage physiological breech births successfully. In doing so, we encourage women to birth more autonomously and confidently, trusting in their body and being fully informed about their choices.
As a community interest company, all of our profits are channeled back into activities that support our aims. We have supported several new instructors to gain experience delivering the training by paying their expenses and a small daily rate for their time to teach alongside our most experienced instructors. We have paid for student midwife research assistants working on the OptiBreech project, enabling that work to progress and those midwives to develop capacity for a clinical academic career. We have supported breech researchers to attend conferences to present their work. And we have paid open access fees so that breech research can reach all of those who need it the most.
But we’ve also been in transition. We’re an incredibly small team, and a few changes in administrative support has been a challenge. At the end of the year, we finally appointed a permanent operations manager, Rebecca Rivers, who will be settling into the role in the coming months. Welcome Rebecca!
We’ve also been aware for some time that the online training platform we are using is clunky and not meeting learners’ needs for ease of access, community and discussion. Sorry about this. If anyone knows an educational technologist with a passion for disseminating breech research and practice, please direct them our way!
But finally, we have recently transitioned to a new online learning platform, which we are very excited about! This platform will operate through a browser and an app, making access easy. And it will provide much more opportunity for discussion and community-building, to enable our breech providers to learn from each other. To ease this transition, we’ve automatically enrolled anyone who has ever purchased our online course in the new space for one year.
Looking forward to 2024, we can already see it is going to be a busy one! We have six study days booked across the UK for the first three months of the year and expect this to continue. Demand is growing as clinicians learn how our systematic approach can help them to keep breech births safe, especially for novice attendants who may only be exposed through training before needing to manage an unexpected situation.
The Vaginal Breech Birth study day at the RCOG will run again this year on 9 May 2024. Trainees are able to get half of the course fees reimbursed through their training budgets.
Our new online platform also makes it easier to share our online training with universities who train midwives and doctors. We trialed this in 2023, and in 2024 we will be launching a package just for students, which they can access via their universities. Watch this space!
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 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:
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.
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%).
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.
This will be of particular interest to obstetric specialty trainees, many of whom will be able to use study leave and have course fees paid (50%) through educational budgets because the course is hosted by the RCOG.
We look forward to supporting more obstetricians, midwives and paramedics to feel confident in their ability to support vaginal breech births, and to provide appropriate hands-on assistance when indicated.
This Monday, we held a training day at St. Mary’s Hospital in Paddington, London, to support the Imperial OptiBreech Team, led by Consultant Obstetrician Sabrina Das.
OptiBreech Just Giving Page
We will be donating 10% of any revenue obtained from this and all future study days to the OptiBreech Just Giving page, which is raising money to provide sites with extra support so that team members can continue to be on-call for women planning a vaginal breech birth.
We would be incredibly grateful if you would join us in this support by donating if you can and sharing the link with your social networks.
Below is some recent research to demonstrate how we are helping to make breech services better and safer for all families:
First OptiBreech results poster! Walker, S., Dasgupta, T., Hunter, S., Reid, S., Shennan, A., Sandall, J., Davies, S., 2022. Preparing for the OptiBreech Trial: a mixed methods implementation and feasibility study. BJOG An Int. J. Obstet. Gynaecol. 129, 70. https://epostersonline.com/rcog2022/node/4909
Spillane E, Walker S, McCourt C, 2022. Optimal time intervals for vaginal breech births: a case-control study. NIHR Open Res. 2, 45.https://doi.org/10.3310/nihropenres.13297.1
Walker S, Dasgupta T, Halliday A, Reitter A, 2021. Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS): A systematic review on variations in outcome reporting. Eur. J. Obstet. Gynecol. Reprod. Biol. 263, 117–126. https://doi.org/10.1016/j.ejogrb.2021.06.021
Happy new year, breech advocates! We’ve got nearly 10 hours of evidence-packed, video-rich, detail-loving breech birth training content waiting for you.
Our fully updated 2022 course is now on-line. To help you reach your new year’s resolution of developing some beautiful breech skills, the course will be available at a discounted price of £50 for the first two weeks of January. No code needed; access is for one year.
Image by Katherine Gilmartin
Along with a new course, our Vimeo library has a NEW PASSWORD. This is available from the “Resources for Teaching and Implementation” section of any course you are enrolled in, along with our amazing Dropbox of guidelines and training resources. Registered users have permission to use the content for non-profit teaching purposes — because learning together is the safest, most effective way to do it.
All of our online courses also come with free access to our Online Webinars. These are one-hour discussions on topics that have arisen during the course of our practice or others’, where we share learning and reflection with each other.
If you have previously completed any of our on-line courses, you are eligible to register for the Refresher course for only £10/year. This is exactly the same as the main course, but for a nominal cost to help us keep our platforms online. You can review the course, or just complete the assessment to obtain a new certificate for your portfolio.
Image by Katherine Gilmartin
Anyone organising or attending one of our face-to-face courses will be given free access to the on-line course for one year. Due to the on-going pandemic and need for social distancing, we rarely have external places to offer as we did pre-2020, but you can still host a study day for yourself and your colleagues.
If your site is participating in the OptiBreech Trial, your free online training package has already been updated.
What if I have attended an in-person course in the past? Access to the Refresher Course is only available to those who have purchased and completed one of our on-line courses, beginning in 2021. All of our previous courses have been advertised with one year’s access to our Vimeo Library. Content is updated regularly, so our recent courses are significantly expanded, based on current research, compared to those of previous years. If you have completed the main course, the system will automatically consider you eligible to take the Refresher. If you use our videos for teaching within your institution, we encourage you to ask your employer to reimburse your training so you can continue to maintain access.
Opportunities
Finally, some opportunities to become more involved in Breech Birth Network. We would really like some help with the following, and if you are willing to make a regular commitment and develop the skills necessary, we can also pay you! Emma and I developed the skills to do all this because that is what was necessary, and we know others can too.
Ideally, we would like to involve people who are supporting breech births professionally in some way, so that the learning that occurs in these roles also spills over into developing your own practice. That’s what makes it worthwhile for us. And obvs, we expect that you would have completed our training to know what you are getting into and that your approach to breech birth aligns with ours.
Online Webinatrix. We do our online webinar series ad hoc at the moment, but we’d like it to happen regularly.
Video Master. We have a large Vimeo library, but in order to make the most of it, it needs to be organised — edited, tagged, consent forms stored securely, etc.
Online education Diva. In addition to developing new content based upon new evidence or learning from practice in our communities, we have a need to develop translated versions of our courses to make them more accessible to a wider audience. We use Articulate 360 and WordPress, and although we don’t expect you to come in with those skills, we need someone who is willing to develop them to get the job done.
Accounting Guru. This doesn’t necessarily need to be a birth professional. We use Xero, and our amazing admin assistant Charlie has been doing this for us for a few years, but now needs to hand over due to other exciting things happening in her life.
If you are interested in any of these roles and prepared to make a commitment to helping our small, not-for-profit enterprise grow, please get in touch using the form below.
Breech Birth Network are pleased to announce the publication of an evaluation of our physiological breech birth training, conducted in eight NHS hospitals across England and Northern Ireland. Click on the image below to read the full evaluation.
Highlights
Multi-disciplinary training, involving NHS midwives and obstetricians
Only training to have demonstrated an increase, rather than a decrease, in vaginal breech births following delivery of the training package, although this was not statistically significant
Use of upright positions at birth increased significantly
Pilot data: no adverse outcomes among births attended by someone who had completed the training, compared to a background rate of 7%
Pilot data: perineal outcomes similar to cephalic births
Congratulations to midwife Stella Mattiolo, who collected and analysed this data as part of her Masters in Research.
The team at Sygehus Sønderjylland, the University Hospital of Southern Denmark, has created a wonderful new series of training videos for upright breech birth. We are thrilled to be able to share them with you!
The creation of the videos was led by obstetrician Kamilla Gerhard-Nielsen, who also led the implementation of the upright breech concept in the hospital and its introduction in Denmark.
They also host a FaceBook page. Image: Obstetricians Katrin Loeser and Kamilla Gerhard-Nielsen
Providing advanced training to a core breech clinical teaching team is potentially more efficient and effective than training the entire maternity care team using traditional methods. The theory is strong, but rigorous research needs to be done.
Traditional training, looks something like this: Participants take time away from clinical commitments to attend a dedicated training session, ranging in length from a few hours to a whole day or more.
Challenges for this approach in the context of breech birth
1. It’s expensive
While preparing the research proposal for the #termbreech2020 Physiological Breech Trial, I worked closely with NHS Research & Development Finance specialists. Using the Agenda for Change pay scales, we calculated that providing 1 day of physiological breech birth training to 5 obstetricians and 5 senior midwives will cost the service £2,442 just to release them from clinical work. Multiplying this to cover the whole staff will obviously increase the cost exponentially. And then there is the cost of paying the trainers.
This is why most training programmes, like PROMPT, use a ‘train the trainers’ approach. It is a more efficient and effective way to disseminate training throughout an organisation. [PROMPT is a great multi-professional training package, but unfortunately, they excluded outcomes for breech births from their evaluation (Draycott et al 2006). So this training has not yet been evaluated for vaginal breech birth.]
2. The effects of training wear off before most people will have a chance to use it
Our systematic review of the effectiveness of breech training strategies showed that breech training can improve objectively assessed skill and knowledge, but that these effects wear off quickly, sometimes within 6 weeks, sometimes within 72 hours. A bigger concern was that, in some cases, confidence increased but objectively assessed skill did not. Training alone is likely not sufficient to improve breech skills, but for those who have some clinical experience, it may extend current understanding.
If you train a staff of 40 (or more) in a service that has only 1 breech birth per month, most of them will not have a chance to consolidate their learning in clinical practice. And if you do not have a plan for ensuring that someone who has attended enhanced training will attend the vaginal breech births that do occur, the enhanced training will not contribute to improvement in outcomes.
3. Clinical support in practice appears to make the biggest behavioural change
A surprising finding from our systematic review was that attendance at an obstetric emergencies-type training course was inversely associated with attendance at vaginal breech births, unless a system was in placed to provide clinical support in practice. This means that clinicians attended fewer vaginal breech births after taking breech training as part of an obstetric emergencies package. Although no quantitative evaluation was done, the studies that reported increase in breech births attended all had a model for ensuring experienced support in practice.
Conclusion
Implementing a breech clinical teaching team is a way of ‘training everyone.’ The model just differs from traditional ‘training day’ methods, which have not proven effective on their own in sustaining safe vaginal breech services.
Paying a few people who want to support breech births to be on-call occasionally and to cascade training is likely less expensive than providing enhanced training to the entire maternity care team, or even the entire senior team. But we need to implement the model and evaluate it in a systematic way in order to determine cost effectiveness. This is why experienced health economists are central to the #termbreech2020 Physiological Breech Trial and helped develop the design.
According to the evidence, breech clinical teaching team is also likely to result in greater availability of the option of vaginal breech birth for women who want them. This was a central concern of the women who participated in #termbreech2020 Physiological Breech Trial public engagement work.
But! Isn’t experienced senior clinical support what consultant obstetricians do? … Good question. We’ll discuss that next …
The team at Sygehus Sønderjylland, the University Hospital of Southern Denmark, has created a wonderful 
