Keywords
breech presentation, physiological breech birth, breech specialist midwives, OptiBreech, interim analysis, cohort study, multi-trial cohort
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Walker S, Das S, Stringer K et al. How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort [version 2; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2025, 3:61 (https://doi.org/10.3310/nihropenres.13500.2)
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Research Article
Revised
How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort
[version 2; peer review: 1 approved, 2 approved with reservations]
PUBLISHED 14 Nov 2025
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Abstract
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Corresponding author:
Shawn Walker
Competing interests:
SW and ES are co-Directors of Breech Birth Network, Community Interest Company, a not-for-profit social enterprise that delivers VBB training and supports research. They and other members of the OptiBreech Collaborative have received teaching fees and expenses for providing breech training. Profits from these teaching activities are used to fund further research and teaching activities.
Grant information:
This project is funded by the National Institute for Health and Care Research (NIHR) (Grant number: NIHR300582).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2025 Walker S et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Walker S, Das S, Stringer K et al. How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort [version 2; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2025, 3:61 (https://doi.org/10.3310/nihropenres.13500.2)
First published: 23 Nov 2023, 3:61 (https://doi.org/10.3310/nihropenres.13500.1)
Latest published: 14 Nov 2025, 3:61 (https://doi.org/10.3310/nihropenres.13500.2)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Revised Amendments from Version 1
Data have been updated with final data from the OptiBreech cohort database. Minor revisions for clarity have been made, as recommended by reviewers. These include definitions for key terms used in tables. Before each table, key findings are summarised in text. This adds clarity, context and focus to the findings. Three new tables are added. These report infant feeding outcomes, by cohort and planned mode of birth, and outcomes following different types of cord management immediately following birth. In the discussion, a paragraph is added regarding the influence of PPIE work on the analyses that were undertaken and their presentation in the report.
See the authors' detailed response to the review by Jennifer Barrowclough
See the authors' detailed response to the review by Sara Morris
See the authors' detailed response to the review by Robyn Schafer
Introduction
OptiBreech collaborative care is a specialist, multi-disciplinary care pathway for women and birthing people with a breech-presenting fetus at term, developed out of previous research and in collaboration with service users and clinicians1–4.
Approximately 1 in 20 pregnant women have a breech presenting fetus at the end of pregnancy. Babies are at higher risk of poor outcomes, regardless of the mode of birth5. Mothers experience increased rates of surgical delivery and birth trauma. Balancing these risks through person-centred care, centred on the person’s values and life context, is improved when obstetricians and midwives have skill and experience in vaginal breech birth (VBB). Providers cannot offer the choice of a VBB if they do not have the skills to do so safely. Due to the way care is usually delivered in standard services, experience in VBB is difficult to acquire.
Variations in skill and experience are dangerous and expensive. In 2021–22, the National Health Services’ (NHS) financial liabilities for claims of obstetric negligence causing cerebral palsy was £36.8 billion6. Twelve percent of obstetrics claims for cerebral palsy relate to poorly managed VBBs, despite representing only 0.3% of total births7. Our team developed an evidence-based management algorithm that aims to reduce the leading cause of breech birth-related injury: asphyxia8–10.
Current NHS strategies to reduce risk focus on reducing the numbers of VBBs, through external cephalic version (ECV, turning the baby head-down) and/or planned caesarean birth (CB)11. An unintended effect has been a decline in health care professionals’ VBB skills12. This strategy has reduced the VBBs we can anticipate, resulting in a lack of learning opportunities for staff to safely manage those we cannot predict. Due to maternal choice, lack of universal diagnosis by ultrasound scan13, and late-changing fetal positions (unstable lie), VBBs continue to occur, but their rarity makes them vulnerable.
OptiBreech collaborative care is an alternative strategy that differs from UK NHS standard care in the following ways: The service is co-ordinated by a Breech Specialist Midwife1,4 with support from a Breech Lead Obstetrician. Women who prefer to plan a VBB are actively supported, and staff maximise the learning opportunity from each planned VBB. The multidisciplinary team prepares for these births and manages them according to the OptiBreech guideline and algorithm. Professionals with advanced training in physiological breech birth14,15 attend VBBs whenever possible. A small, experienced team provides continuity for women and professionals2; their role is to train and support the wider team. This practice includes the option of upright maternal birthing positions4,16.
Within the OptiBreech collaborative care pathway, women are offered all guideline-recommended options: VBB, ECV, and planned CB. Women find this service beneficial, regardless of their mode of birth1. Due to substantial differences in clinical practices and the way services are delivered, OptiBreech care is expected to result in different safety outcomes from standard care. The current logic model and TIDieR checklist17 for OptiBreech collaborative care have been reported in previous publications1,18. The OptiBreech training package has been described in detail in evaluation publications14,15. The OptiBreech Clinical Practice Guideline is included in the protocol uploaded to the ISRCTN registration19. Much of this information is also available on the project’s engagement website, optibreech.uk.
Patient and Public Involvement and Engagement (PPIE) work aimed to ensure the study’s design, analysis, reporting, and interpretation were influenced by women who have lived experience of planning or attempting to plan a VBB. Previous research indicated this population was least well served within current NHS standard care, and this work aimed to improve their outcomes and experience of care1,20–22, while maintaining choice and good outcomes for all women using the service.
This paper reports all data collected during the OptiBreech feasibility trial, which closed to enrolment on 31 January 2024. The purpose of reporting this analysis is to provide women and clinicians with as much up-to-date information as possible about what they can expect when planning a VBB with OptiBreech care, for those services continuing to operate, and to inform future research. We have chosen this publication venue (NIHR Open Research) to enable transparent reporting and updating as the cohort grows, so that all stakeholders have contemporaneous information on which to base decisions.
Throughout the paper, we focus on sex-specific terminology ‘women’ and ‘mothers’ for clarity, and because all participants self-reported their gender identity as ‘female.’ We also acknowledge that some birthing people do not identify with the sex they were assigned at birth and should receive care that respects their identity.
Methods
Study design
The OptiBreech Multiple Trial Cohort was designed to host multiple trials related to care for breech presentation in the third trimester and birth. This is to enable prospective data collection for a large cohort of women planning a VBB with OptiBreech collaborative care, to assess rare safety outcomes, while answering questions requiring a smaller, randomised sample that could be nested within this cohort.
Patient and Public Involvement
Stakeholder involvement was facilitated through multiple public meetings, held in person and on-line during the research design stage23. Two lay members of the Trial Steering Committee and one member of the research team were service users with lived experience of planning a VBB. Additional service users with lived experience of planning a VBB participated as members of the research team during qualitative work to refine the OptiBreech care pathway intervention1,22 and consensus work to identify and prioritise outcome measures24,25.
PPIE input especially influenced the way we analysed and presented our results. Our PPIE group prioritised knowing how outcomes for VBBs compared with those for planned and actual cephalic births, regarded as the ‘normal’ care pathway. One of the challenges in breech research is the constantly moving parts – fetal presentation can change up to the point of labour and sometimes during; women may initially prefer one plan but change their minds for various reasons other than clinical concerns; and for each planned mode of birth, a portion of women will have a different mode of birth than the one they chose, due to the unpredictable nature of labour and birth.
For this reason, we have performed several subgroup analyses that interrogate the data from different points of view. For each section, we begin with the question that the analysis answers, from the point of view of policy makers and/or service leaders, and from the point of view of women and birthing people making informed decisions about their care options. Service users also advocated for an equity analysis due to growing awareness of increased risk of adverse outcomes among women of minoritised ethnicity and skin colour in the UK26. Demographic information has been reported in line with the latest NICE style guide27.
Inclusion and exclusion criteria
Inclusion criteria for the OptiBreech cohort are:
Live, singleton pregnancy with a breech-presenting fetus confirmed by ultrasound scan;
Over 16 years of age;
Referred for specialist care for breech presentation antenatally from 32 weeks;
Breech presentation from 37 weeks discovered in labour;
Requesting or preferring a vaginal birth; and
Giving informed consent to participate to contribute data to the cohort study.
Exclusion criteria for the cohort are:
Currently included studies
Studies currently included in the OptiBreech database are listed below and summarised in Figure 1: Participant Flow
Figure 1. Participant Flow data to 31 January 2024.
1) The OptiBreech Care Trial: a feasibility study for a pragmatic trial of care for women with a breech-presenting baby at term. Randomised participants (68) were recruited between 10 January 2022 and 09 June 2022. Inclusion and exclusion criteria were more narrowly defined and are reported in detail in the pilot trial report28. Cohort participants were recruited until 31 January 2024 and focused on women who preferred to plan a VBB regardless of whether their baby remained in a breech position. This study was funded by the UK National Institute for Health and Care Research (NIHR, 300582) and sponsored by King’s College London. Ethics approval was obtained from the West London & GTAC Research Ethics Committee (21/LO/0808, 19 November 2021). The pilot trial was prospectively registered with the ISRCTN (14521381, 18 October 2021)19. The full protocol is available on the trial registration page19.
Consent process
Participants were recruited following a referral for counselling and/or care relating to breech presentation in the third trimester. The consent and randomisation process for the OptiBreech Care feasibility pilot has been described elsewhere28. Information sources about the OptiBreech Care pathway, including all Participant Information Sheets and Consent Forms, was available via the OptiBreech engagement website (optibreech.uk) and wherever possible provided to women in advance of their appointment. Participants randomised to or requesting OptiBreech care received collaborative care co-ordinated and led by a specialist midwife. They were informed that this was a new care pathway and that they could request standard obstetric care if they preferred. Each participant provided consent to participate via written or e-consent form. Demographic data on ethnicity and gender was self-reported at the same time. Following the end of the pilot trial, recruitment focused on women requesting OptiBreech care due to a preference for vaginal birth, regardless of whether their baby remained in a breech position.
Participants were able to withdraw consent at any time if they wished. Where consent was withdrawn, this is indicated in the Participant Flow (Figure 1), but no data has been reported.
Procedures
Participants in the ‘standard care’ arm have received care that does not involve access to OptiBreech-trained specialists for antenatal care or birth. Generally, they were offered ECV as a first-line intervention and/or referred to their named obstetric consultant’s antenatal clinic for further counselling regarding mode of birth if ECV failed or was declined. Participants in the OptiBreech care arm were counselled by a member of the OptiBreech team and were offered the option of planning a VBB with OptiBreech support, attempting an ECV, or planning a pre-labour CB from 39 weeks gestation.
Outcomes
This report (v2.0) includes the cohort’s demographics and short-term outcomes, including: mode of birth, safety, infant feeding and fidelity outcomes, measured at discharge from birth care. Below each Table (1–16), a key is included that defines medical terms and abbreviations and provides information on how and when the outcomes included in that table were measured.
Statistical analysis
Descriptive statistics only are reported. The study was not designed or powered to enable any inferential statistics. However, one aim of reporting the descriptive data in this way is to enable the design of future, appropriately powered investigations, based on the descriptive incidence rates.
This report is an analysis of a compete feasibility study data set. We deal with missing data by reporting the current denominator of available data, for each outcome, where this is not equivalent to the total number of cases. During each interim analysis process, the team cleans the data by identifying missing data points and following up with site PIs, to ensure they are available for future cohort analyses.
An interim analysis was initially done by one member of the team (SW or SMD) using SPSS Version 29.0.1.0. Table data were checked against output files by other members of the team (SW, SMD, or JB). To verify the analysis, JK and AH repeated a sub-section of the analysis by randomisation arm / cohort using Stata/MP version 17.0. Analysis of the final data set was completed and checked by the lead author (SW0
Baseline demographics are analysed by cohort (randomisation arm, non-randomised cohort, and overall OptiBreech care cohort).
Presentation on admission, mode of birth and safety outcomes were assessed by: 1) cohort; 2) plan following first counselling (intention to treat); 3) those who planned a VBB at any point versus those who had not and those who had planned a cephalic birth; 4) actual VBBs versus vaginal cephalic births; 5) presentation on admission for labour/birth care; and 6) ethnicity. The group ‘did not plan a VBB at any point’ includes women who planned a caesarean birth and women who planned a cephalic birth, including those whose fetus was discovered to be presenting breech in labour. ‘Planned cephalic births’ included all those whose breech presentations were identified in the third trimester whose baby turned spontaneously or via ECV following recruitment, and those whose fetus was discovered to be presenting breech in labour but had planned a cephalic birth.
These subgroup analyses were chosen because 1) this comparison enables comparison of the non-randomised cohort with the randomised cohorts; 2) PPIE group members valued this analysis to support informed decision-making; 3) these are the comparisons most often used in large observational cohort studies; 4) this comparison was prioritised by PPIE group members; 5) cephalic presentation at birth is evaluated as an outcome in Cochrane Reviews concerning the management of breech presentation at term; and 6) our PPI group was keen to ensure non-white-British and Black or Brown participants could access and were not disadvantaged within this model of care.
Infant feeding outcomes are analysed by cohort (standard care vs OptiBreech care) and whether the women had planned a VBB or cephalic birth.
Fidelity measures are reported for actual VBBs only, analysed according to whether there was a professional present who had completed the OptiBreech training, versus whether there was no OptiBreech trained professional present.
Role of the funding source
SW and this research are funded by a National Institute for Health and Care Research (NIHR) Advanced Fellowship. The NIHR had no role in study design, data collection, data analysis, data interpretation, or writing of the report. Breech Birth Network, a not-for-profit Community Interest Company, provided training for OptiBreech teams, educational resources, and funding for PPIE, and conference presentations.
Results
Results are presented by sub-group analysis category. With each table, we include the key questions the analysis seeks to answer, by stakeholder group. In all instances, it is not yet possible to detect any significant differences between groups, due to the small sample size.
Analysis by randomisation group / cohort
Table 1 Key Questions:
1) How do characteristics of participants differ between ‘standard care’ and ‘OptiBreech care’ groups?
2) Are people from minoritized groups able to access participation in this research?
Table 1. Baseline characteristics, by randomisation group / cohort.
Gestational age at enrolment was similar for women randomised in the pilot trial, but on average two weeks later for women recruited to the observational study. This is influenced by the high number of women in the cohort transferring care from another booking hospital to access participation in this research (25/147, 17.0%). All randomised and most non-randomised (90.5%) participants were recruited prior to the start of labour. Over half of participants were from UK minority (non-white-British) backgrounds, and 26.5% (48/181) were Black or Brown women.
Table 2 Key Questions:
1) Service leaders: How does the model of care influence the vaginal birth rate?
2) Service users: How likely am I to achieve the vaginal birth I want within OptiBreech care?
Table 2. Presentation on admission and mode of birth outcomes, by randomisation arm / cohort.
The highest percentage of vaginal birth were seen among women recruited to the OptiBreech Care observational cohort (71/146, 48.6%), compared to women randomised to either standard care (8/33, 24.2%) or OptiBreech Care (11/34, 32.4%). Women randomised to standard care had a higher percentage of in-labour caesarean birth (12/33, 35.4%), compared to women randomised to OptiBreech Care (7/34, 20.6%) or recruited to the cohort (40/146, 27.4%).
Table 3 Key Questions:
1) Service leaders: How does the model of care influence neonatal outcomes?
2) Service users: How likely am I to be separated from my baby following birth? How likely is my baby to be unwell?
Table 3. Neonatal outcomes, by randomisation arm / cohort.
Neonatal outcomes were similar across all models of care. When women received OptiBreech care, babies were more likely to be admitted to transitional care (21/180, 11.7%), compared to standard care (2/33, 6.1%). When women received OptiBreech care, babies were less likely to be admitted to a neonatal unit (8/180, 3.9%), compared to standard care (2/33, 6.1%).
Table 4 Key Questions:
1) Service leaders: How does the model of care influence maternal outcomes?
2) Service users: How likely am I to be unwell after my birth? What are the outcomes for my perineum likely to be?
Table 4. Maternal outcomes, by randomisation arm / cohort.
Admissions to maternal HDU were similar across groups. Women receiving OptiBreech Care were less likely to experience severe morbidity prior to discharge (randomised: 4/34, 11.8%; non-randomised: 12/144, 8.3%), compared to standard care (5/32, 15.6%). There were no maternal deaths. Women receiving OptiBreech Care had lower rates of intact perineum (126/179, 70.4%), compared to standard care (29/33, 87.9%), reflecting the increased vaginal birth rate.
Analysis by first plan following counselling (entire cohort)
Table 5 Key Questions:
1) Service leaders: How does an ECV service affect the vaginal birth rate?
2) Service users: How likely am I to have the type of birth I choose to plan?
Table 5. Presentation on admission and mode of birth outcomes, by first plan following counselling.
In this study, women who planned a VBB without an initial attempt at ECV had a higher vaginal birth rate (29/58, 50%) than those women who planned an attempt at ECV (55/135, 40.7%, includes successful and unsuccessful attempts). When women planned a pre-labour caesarean birth, 12.5% (2/16) had a VBB despite this plan.
Table 6 Key Questions:
1) Service leaders: How does an ECV service affect neonatal outcomes?
2) Service users: How will my care choices influence outcomes for my baby?
Table 6. Neonatal outcomes, by first plan following counselling (entire cohort).
In this cohort, women who planned a VBB had better neonatal outcomes than women who planned an ECV or had breech presentation diagnosed for the first time in labour. The exception was Apgar score of <7 and 5 minutes, which only occurred among the cohort of women who planned a VBB (2/58, 3.4%).
Table 7 Key Questions:
1) Service leaders: How does an ECV service affect maternal outcomes?
2) Service users: How will my care choices influence my health after birth?
Table 7. Maternal outcomes, by first plan following counselling (entire cohort).
Women who planned a VBB had lower rates of severe maternal morbidity (5/56, 8.9%), compared to women who planned an ECV (14/134, 10.4%) or planned a pre-labour caesarean birth (2/16 (12.5%).
Analysis by planned mode of birth / actual mode of birth / presentation on admission
Table 8 Key Questions:
1) Service leaders: How does achieving cephalic presentation at birth affect vaginal birth rates?
2) Service users: How likely am I to have the type of birth I choose to plan? How will my baby’s position at the time of birth influence this?
Table 8. Mode of birth outcomes, by planned birth / presentation on admission.
In this cohort, women who planned a VBB at any point had fewer overall vaginal births (54/117, 46.2%) than women who planned a cephalic birth (37/61, 60.7%) after the baby turned, spontaneously or by ECV. Women who planned a VBB had fewer in-labour caesarean births (32/117, 27.4%) than women who planned a cephalic birth (20/61, 32.8%). Women who gave birth vaginally to a baby in breech position had fewer instrumental deliveries (3/56, 5.4%) than women who gave birth to a head-down baby (4/34, 11.8%). Women whose baby was in a breech position when admitted for labour or birth had lower rates of vaginal birth (53/153, 39.2%) than women whose baby was in a cephalic position (35/57, 61.4%).
Table 9 Key Questions:
1) Service leaders: How does achieving cephalic presentation at birth affect neonatal outcomes?
2) Service users: How will my care choices influence outcomes for my baby?
Table 9. Neonatal outcomes, by planned birth / presentation on admission.
In this cohort, the babies of women who planned a VBB at any point received any form of neonatal resuscitation (22/117, 18.8%) more often than when women planned a cephalic birth (6/61, 9.8%) after the baby turned, spontaneously or by ECV. The babies of women who planned a VBB had less severe neonatal morbidity (0/117) than women who planned a cephalic birth (2/61, 3.3%). The babies of women who planned a VBB were admitted to transitional care less (11/117, 9.4%) than women who planned a cephalic birth (10/61, 16.1%). These results were similar for babies born vaginally in a breech position, compared to cephalic births, and for babies admitted for labour/birth in a breech position, compared to a cephalic position. Admissions to a neonatal unit were similar across groups, and there were no neonatal deaths.
Table 10 Key Questions:
1) Service leaders: How does achieving cephalic presentation at birth affect maternal outcomes?
2) Service users: How will my care choices influence my health after birth?
Table 10. Maternal outcomes, by planned birth / presentation on admission.
Women who planned a VBB at any point were admitted to a maternal HDU less often (4/117, 3.4%) than women who planned a cephalic birth (4/61, 6.6%), after the baby turned spontaneously or by ECV. Women who planned a VBB at any point experienced less severe morbidity (12/115, 10.3%) than women who planned a cephalic birth (9/61, 14.8%). Women whose babies were in a breech position on admission for labour/birth experienced less severe morbidity (12/150, 8.0%) than women whose babies were in a cephalic position (8/57, 14.0%). Serious maternal morbidity was higher for women who gave birth vaginally to a breech baby (6/56, 10.7%), compared to vaginal birth of a cephalic baby (3/34, 8.8%).
Analysis by ethnicity
Table 11 Key Questions:
1) Service leaders: How do vaginal birth rates compare between ethnic groups in this cohort?
2) Service users: How do vaginal birth rates compare between ethnic groups?
Table 11. Mode of birth outcomes, by ethnicity.
Rates of vaginal birth were similar across ethic groups. Black or Brown participants had VBBs more often (20/55, 36.4%) than white participants (36/158, 22.8%). White women experienced higher rates of caesarean birth at full dilation (white British: 7/101, 6.9%; all white participants: 7/158, 4.4%) than other ethnic groups (non-white British: 1/112, 0.9%; Black or Brown participants: 1/55, 1.8%).
Table 12 Key Questions:
1) Service leaders: How does ethnicity influence neonatal outcomes within an OptiBreech care model?
2) Service users: How will my ethnicity affect outcomes for my baby within an OptiBreech care model?
Table 12. Neonatal outcomes, by ethnicity.
The babies of white women experienced more severe neonatal morbidity (white British: 3/101, 3.0%; all white participants: 2/158, 1.3%) than other ethnic groups (non-white British: 0; Black or Brown participants: 0).
Table 13 Key Questions:
1) Service leaders: How does ethnicity influence maternal outcomes within an OptiBreech care model?
2) Service users: How will my ethnicity affect my health after birth within an OptiBreech care model?
Table 13. Maternal outcomes, by ethnicity.
White women were admitted to a maternal HDU less often (white British: 3/101, 3.0%; all white participants: 7/158, 4.4%) than other ethnic groups (non-white British: 8/112, 7.1%; Black or Brown participants: 4/55, 7.3%). White women experienced lower overall rates of severe maternal morbidity (white British: 9/99, 9.1%; all white participants: 14/156, 9.0%) than other ethnic groups (non-white British: 12/112, 20.8%; Black or Brown participants: 7/54, 13.0%). When women gave birth vaginally, white women experienced higher rates of episiotomy (white British: 14/46, 30.4%; all white participants: 19/63, 30.2%) than other ethnic groups (non-white British: 8/44, 18.2%; Black or Brown participants: 3/27, 11.1%). Minority ethnic groups experienced higher rates of OASI (non-white British: 2/44, 4.5%; Black or Brown participants: 2/27, 7.4%) than white women (white British: 0 all white participants: 0).
Infant feeding outcomes
Table 14 Key Questions:
1) Service leaders: How does provision of OptiBreech collaborative care influence women’s ability to breastfeed when they have chosen this?
2) Service users: How will OptiBreech care influence my ability to feed my baby the way I have chosen?
Table 14. Infant feeding outcomes, by cohort and planned mode of birth.
Breastfeeding outcomes were similar, whether women received standard care, compared OptiBreech care, and whether they planned a VBB at any point, compared to a cephalic birth.
Fidelity outcomes
Table 15 Key Questions:
1) Service leaders: How does the presence of an OptiBreech team member affect adherence to the OptiBreech Algorithm?
2) Service users: How does the presence of an OptiBreech team member affect my ability to give birth in an upright position if I want to? How does the presence of an OptiBreech team member affect the likelihood that my baby’s umbilical cord will remain intact until after s/he has started breathing?
Table 15. Fidelity criteria, by presence of an OptiBreech team member.
Most VBBs in this cohort were attended by a midwife (39/49, 79.6%), compared to an obstetrician (10/49, 20.4%). When births were attended by an OptiBreech team member, the attendant was more likely to have attended >10 VBBs (17/48, 35.4%) or >20 VBBs (21/48, 43.8%), compared to when no OptiBreech trained professional was present (0/6). When an OptiBreech-trained professional was present, women gave birth in an upright position 77.6% (38/49) of the time. When an Opti-Breech-trained professional was present, adherence to the Physiological Breech Birth Algorithm was >90% with regards to timings (<5 minutes pelvis-to-birth; <7 minutes rumping-to-birth). However, for only 61.2% (30/49) of babies did the umbilicus remain intact until after the onset of respirations.
Table 16 Key Questions:
1) Service leaders: How does maintaining the umbilicus intact until after the onset of respirations impact neonatal outcomes?
2) Service users: Will keeping the umbilicus intact until after my baby has started breathing affect whether we need to be separated due to admission to the neonatal unit?
Table 16. Incidence of neonatal admission, analysed by whether the umbilicus remained intact.
When the umbilicus remained intact until after the onset of respirations, in adherence to OptiBreech guidance, compared to when it was immediately clamped and cut: fewer babies had an Apgar under 7 at 5 minutes (0/145 vs 2/64, 3.1%), fewer babies were admitted to transitional care (11/145, 7.6% vs 11/64, 17.2%), and fewer babies were admitted to a neonatal unit (4/145, 2.8% vs 4/64, 6.3%). These differences were more pronounced for the subgroup of neonates who had an Apgar less than 7 at 1 minute.
Discussion
Data from the OptiBreech Care feasibility and pilot trial indicate that providing support for planned VBB within an OptiBreech collaborative care pathway has been as safe as a planned cephalic birth in the same hospitals. While this is the largest data set of planned vaginal breech births published in the UK since 200529, the sample size is still too small to evaluate rare but important outcomes, such as severe neonatal morbidity or mortality. The Royal College of Obstetricians and Gynaecologists (RCOG) guideline estimates that perinatal mortality following planned caesarean birth at 39 weeks is 0.5/1000, following planned cephalic birth is 1/1000, and following planned vaginal breech birth is 2/10005. Evaluating OptiBreech care for this outcome will require thousands of births. Our intention with the multiple trials cohort is to facilitate multiple nested randomised controlled trials to answer important questions about breech care with different endpoints, while accumulating a sufficient sample to evaluate rare outcomes such as perinatal mortality. This will refine the OptiBreech care pathway for maximum efficiency and effectiveness, for all women requiring breech care.
Prior to the start of this cohort, two preliminary studies were done. The first evaluated the OptiBreech training package (‘Physiological Breech Birth’) within NHS settings15. This observed a serious neonatal morbidity rate of 0/21 (same composite, 0%) among births attended by an OptiBreech trained attendant, compared to 5/69 (7.2%) among births where the attendant had NOT attended the training15. This suggests the results of the Term Breech Trial are still relevant to standard care within the UK30.
The second evaluated the feasibility of implementing OptiBreech collaborative team care for planned VBBs18. In this study, among 82 planned VBBs, one serious adverse outcome (same composite, 1.2%) occurred. In the OptiBreech cohort reported in this paper, 117 women have planned a VBB, with no serious adverse neonatal outcomes. We have therefore reported 220 prospective VBBs across three studies, including the present study, with one serious adverse neonatal outcome (0.45%). This is very near to the rate of adverse outcomes observed among low-risk women planning cephalic (head-first) births in the UK-based Birthplace in England study (0.43%)31. Neonatal admission rates across the feasibility studies following planned VBBs have been below 5%, similar to rates for all term births in the UK32.
We feel our results so far are due to strong qualitative work to develop the programme theory for the OptiBreech collaborative care model. Our logic model was developed and refined through: frequent and meaningful PPIE activities; systematic reviews to establish background, questions and women’s experiences8,22,33; Delphi consensus methods, including clinicians and service users, on core competencies and important outcomes4,16,24,25,34; grounded theory methods to describe how clinicians learn breech skills2,3; qualitative interviews with women1 and staff; implementation feasibility work to prepare for a substantive clinical trial1,18; and a pilot randomised trial28.
Detailed observational work also theoretically underpins our practice guidelines, including video analysis and case control studies to define ranges of ‘normal’ in breech births8–10. The OptiBreech Algorithm aims to reduce the leading cause of breech birth-related injury: asphyxia8–10. Our team has raised concerns previously that current guidelines are not optimally safe10,35. Historically, breech practice has not been based on evidence, particularly around the expected time intervals as the breech baby emerges8. This is the fourth paper in which we report that, in most cases with good outcomes, the birth has completed within three to five minutes of the birth of the fetal pelvis9,10,18. We strongly feel this should be regarded as ‘normal for breech.’
Our OptiBreech guideline continues to recommend attendants aim for the birth to be complete within five minutes from the birth of the pelvis, including time for manoeuvres. It is especially important for novices, who are inherently less confident to intervene, to have clear guidelines that alert them when a threshold of increased risk is approaching. Current RCOG5 and PROMPT36 guidelines recommend assisting only after five minutes have passed following birth of the pelvis and emphasise a ‘hands off’ approach. Our guideline promotes using maternal effort and movement (‘wiggle and push’) as a first-line intervention if advancement pauses for 30 seconds or more at any point after the birth of the pelvis. This optimises maternal agency and minimises the need for attendants to manually intervene. We feel waiting five minutes to assist the birth offers no advantages. Rather, it increases the risk of an adverse outcome should the attendant discover after five minutes that the delay is due to arm or head entrapment, which takes further time to resolve.
There are limitations to presenting feasibility data in this way. We cannot assume that the results will continue in the same manner, and a much larger sample size will be needed to determine overall safety. Although local investigators have an obligation to report serious adverse outcomes, currently missing data may reveal in future analyses outcomes that are less positive than they currently appear. These results also do not apply to all planned VBBs. The OptiBreech teams follow a specific care algorithm10 with manoeuvres specific to upright breech birth37, the presence of an OptiBreech team member increases the likelihood that this will be followed2,18, and their presence facilitates shared learning from each birth throughout the team. Outside of this model of care, the absence of one or more of these potential mechanisms may impact outcomes.
This analysis has also helped us to identify areas that require further support for clinical change. Our guideline also recommends that, should the baby be born in poor condition, resuscitation be initiated with the umbilical cord intact16. Current evidence supports leaving the umbilical cord intact until after the onset of respirations38,39, and service users have identified this in PPIE work as an important and under-studied outcome for them25,40. However, these data indicate OptiBreech teams are not optimally achieving this. Understanding why and developing a strategy for addressing this difficult area of implementation will require further research and collaboration with neonatal teams. While most research has focused on premature babies41, for whom this practice provides significant benefit, the difference in neonatal admission rates in our data suggest it may be beneficial for term babies as well.
We remind readers that this is a feasibiity data set. Some data points are missing, and in a small data set, results can change dramatically in a short period. However, at this point, we are encouraged by this very positive set of pilot data, which will grow with each trial funded.
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Walker S, Das S, Stringer K et al. How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort [version 2; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2025, 3:61 (https://doi.org/10.3310/nihropenres.13500.2)
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
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A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
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Version 1
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PUBLISHED 23 Nov 2023
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How to cite this report:
Schafer R. Reviewer Report For: How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort [version 2; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2025, 3:61 (https://doi.org/10.3310/nihropenres.14650.r31049)
The direct URL for this report is:
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-31049
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-31049
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 08 Apr 2024
Approved with Reservations
VIEWS 18
Thank you for the invitation to review this original research article entitled, “How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?” This publication provides an interim analysis of maternal and neonatal outcomes in a prospective
... Continue reading
CITE
HOW TO CITE THIS REPORT
Schafer R. Reviewer Report For: How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort [version 2; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2025, 3:61 (https://doi.org/10.3310/nihropenres.14650.r31049)
The direct URL for this report is:
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-31049
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-31049
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Author Response 14 Nov 2025Shawn Walker, Women and Children's Health, King's College London, London, UK14 Nov 2025Author ResponseThank you for the invitation to review this original research article entitled, “How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?” This publication provides an ... Continue reading
COMMENTS ON THIS REPORT
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Author Response 14 Nov 2025Shawn Walker, Women and Children's Health, King's College London, London, UK14 Nov 2025Author ResponseThank you for the invitation to review this original research article entitled, “How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?” This publication provides an ... Continue reading
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Barrowclough J. Reviewer Report For: How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort [version 2; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2025, 3:61 (https://doi.org/10.3310/nihropenres.14650.r31389)
The direct URL for this report is:
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-31389
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-31389
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 01 Apr 2024
Approved with Reservations
VIEWS 13
Congratulations on conducting the OptiBreech collaborative care study and documenting the comprehensive interim analysis that may lead to improved outcomes for women and their babies following breech presentation. I suggest some minor revisions and points to consider below. The manuscript
... Continue reading
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HOW TO CITE THIS REPORT
Barrowclough J. Reviewer Report For: How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort [version 2; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2025, 3:61 (https://doi.org/10.3310/nihropenres.14650.r31389)
The direct URL for this report is:
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-31389
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-31389
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Author Response 14 Nov 2025Shawn Walker, Women and Children's Health, King's College London, London, UK14 Nov 2025Author ResponseCongratulations on conducting the OptiBreech collaborative care study and documenting the comprehensive interim analysis that may lead to improved outcomes for women and their babies following breech presentation. I suggest ... Continue reading
COMMENTS ON THIS REPORT
-
Author Response 14 Nov 2025Shawn Walker, Women and Children's Health, King's College London, London, UK14 Nov 2025Author ResponseCongratulations on conducting the OptiBreech collaborative care study and documenting the comprehensive interim analysis that may lead to improved outcomes for women and their babies following breech presentation. I suggest ... Continue reading
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How to cite this report:
Morris S. Reviewer Report For: How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort [version 2; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2025, 3:61 (https://doi.org/10.3310/nihropenres.14650.r30827)
The direct URL for this report is:
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-30827
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-30827
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 20 Dec 2023
Approved
VIEWS 12
Thank you for the invitation to review the article titled How safe is it to plan a vaginal breech birth with Optibreech collaborative care?: Analysis of cumulative data within the Optibreech Multiple Trials Cohort.
The title ... Continue reading
The title ... Continue reading
CITE
HOW TO CITE THIS REPORT
Morris S. Reviewer Report For: How safe is it to plan a vaginal breech birth with OptiBreech collaborative care?: analysis of cumulative data within the OptiBreech Multiple Trials Cohort [version 2; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2025, 3:61 (https://doi.org/10.3310/nihropenres.14650.r30827)
The direct URL for this report is:
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-30827
https://openresearch.nihr.ac.uk/articles/3-61/v1#referee-response-30827
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
-
Author Response 14 Nov 2025Shawn Walker, Women and Children's Health, King's College London, London, UK14 Nov 2025Author ResponseThank you for the invitation to review the article titled How safe is it to plan a vaginal breech birth with Optibreech collaborative care?: Analysis of cumulative data within the Optibreech ... Continue reading
COMMENTS ON THIS REPORT
-
Author Response 14 Nov 2025Shawn Walker, Women and Children's Health, King's College London, London, UK14 Nov 2025Author ResponseThank you for the invitation to review the article titled How safe is it to plan a vaginal breech birth with Optibreech collaborative care?: Analysis of cumulative data within the Optibreech ... Continue reading
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