National and international guidelines support maternal choice for mode of childbirth for breech presentation at term. [1][2][3][4] Studies of women's preferences indicate that a significant minority would like the opportunity to attempt a vaginal breech birth (VBB). 5,6 However, in the United Kingdom (UK), although breech presentation at term occurs in 3%-4% of pregnancies, 1 VBBs comprise only 0.3% of all births. 7 This limits opportunities for professionals to acquire breech

Background A physiological breech birth is one in which the woman is encouraged to remain active throughout her labor and able to assume the position of her choice for the birth. Use of this strategy within the United Kingdom National Health Service has led to the use of innovative maneuvers to relieve obstruction when women give birth in upright positions, for example, kneeling or standing. This includes use of the face‐to‐pubes rotational maneuver to relieve extended nuchal arm(s). In this paper, we report a case where the face‐to‐pubes rotational maneuver was used to relieve bilateral nuchal arm entrapment in a breech birth. Methods Single‐case study. We aimed to generate an in‐depth understanding of how this maneuver works and how professionals decide to use it by exploring its use in a real‐life context. Results The face‐to‐pubes rotational maneuver appears to be an effective method of relieving nuchal arm entrapment when used by experienced hands. In cases of bilateral nuchal arm entrapment, elevation to a higher station may be necessary to dis‐impact the arms above the pelvic inlet before the fetus can be rotated. After face‐to‐pubes rotation and release of arms, the head should be realigned in an occiput anterior position for delivery. Conclusion The face‐to‐pubes rotational maneuver can be taught for resolution of nuchal arms in an upright position. Parents should be informed of the availability or not of a specialist midwife trained in physiological breech birth, as this may be important to their decision‐making.

Background OptiBreech Care is a care pathway for breech presentation at term, including where chosen, physiological breech birth attended by professionals with advanced training and/or proficiency. We aimed to assess the feasibility of implementing OptiBreech team care to test it in trial-within-a-cohort study. Methods Our design was a mixed methods trial feasibility assessment across England and Wales, January 2021 – June 2022. Our objectives were to determine whether Trusts could provide attendants with advanced training (implementation feasibility), who deliver protocol-consistent care (fidelity), in a way acceptable to women and staff (acceptability), within existing resources (costs), while maintaining low neonatal admission rates (safety) and adequate recruitment rates (trial feasibility). Participants were women > 37 weeks pregnant with a breech-presenting fetus, requesting support for a vaginal breech birth following standard counselling, and the staff involved in the study. No randomisation occurred in this first stage of feasibility work. Results Thirteen National Health Service sites recruited. A total of 82 women planned births on the study, and 21 staff were interviewed. Sites with a breech specialist midwife and/or dedicated clinic recruited 1 woman/month, while sites without recruited an average of 2 women every 3 months. Referrals into the study came from midwives (46%), obstetricians (34%) and women themselves (20%). Vaginal births were attended by staff with OptiBreech training at 87.5% (35/40) and by staff who met stricter proficiency criteria at 67.5% (27/40). Fidelity criteria were met more consistently by staff who met proficiency criteria. There were four neonatal admissions (4.9%, 4/82), including one serious adverse outcome (1.2%, 1/82); these outcomes compare well with previous breech research. Women found the model of care highly acceptable compared to standard care, and staff providing care generally found the OptiBreech model acceptable. However, staffing shortages throughout the pandemic and persistent negative views of vaginal breech birth outside the teams created challenges. Conclusions A large prospective observational cohort of OptiBreech Care, which could potentially support nested or cluster randomisation, appears feasible in sites willing to establish a dedicated clinic and develop further proficient members of staff strategically, with back-up plans for supporting rapidly progressing births. Randomisation procedures remain to be feasibility-tested. Funded by the NIHR (300582).

Background: Breech births are associated with a high rate of hypoxic injury, in part due to cord occlusion during emergence. Maximum time intervals and guidelines oriented toward earlier intervention have been proposed in a Physiological Breech Birth Algorithm. We wished to further test and refine the Algorithm for use in a clinical trial. Methods: We conducted a retrospective case-control study in a London teaching hospital, including 15 cases and 30 controls, during the period of April 2012 to April 2020. Our sample size was powered to test the hypothesis that exceeding recommended time limits is associated with neonatal admission or death. Data collected from intrapartum care records was analysed using SPSS v26 statistical software. Variables were intervals between the stages of labour and various stages of emergence (presenting part, buttocks, pelvis, arms, head). The chi-square test and odds ratios were used to determine association between exposure to the variables of interest and composite outcome.  Multiple logistic regression was used to test the predictive value of delays defined as non-adherence the Algorithm. Results: Logistic regression modelling using the Algorithm time frames had an 86.8% accuracy, a sensitivity of 66.7% and a specificity of 92.3% for predicting the primary outcome. Delays between umbilicus and head >3 minutes (OR: 9.508 [95% CI: 1.390-65.046] p=0.022) and from buttocks on the perineum to head >7 minutes (OR: 6.682 [95% CI: 0.940-41.990] p=0.058) showed the most effect. Lengths of time until the first intervention were consistently longer among the cases. Delay in intervention was more common among cases than head or arm entrapment. Conclusion: Emergence taking longer than the limits recommended in the Physiological Breech Birth algorithm may be predictive of adverse outcomes. Some of this delay is potentially avoidable. Improved recognition of the boundaries of normality in vaginal breech births may help improve outcomes.

Emma Spillane believes midwives and obstetricians need to acquire more skills and knowledge on breech birth—here's why