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Schafer R, Bovbjerg ML, Cheyney M, Phillippi JC. Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study. PLoS One 2024; 19:e0305587. [PMID: 39037977 PMCID: PMC11262641 DOI: 10.1371/journal.pone.0305587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 06/01/2024] [Indexed: 07/24/2024] Open
Abstract
OBJECTIVE Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling). DESIGN Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats). SETTING Planned community birth (homes and birth centers), United States. SAMPLE Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset. METHODS Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes. MAIN OUTCOME MEASURES Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death. RESULTS One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after congenital anomalies were excluded. CONCLUSIONS All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.
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Affiliation(s)
- Robyn Schafer
- Division of Advanced Nursing Practice, School of Nursing, Rutgers University, Newark, NJ, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States of America
| | - Marit L. Bovbjerg
- Epidemiology Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States of America
| | - Melissa Cheyney
- Department of Anthropology, Oregon State University, Corvallis, OR, United States of America
| | - Julia C. Phillippi
- School of Nursing, Vanderbilt University, Nashville, TN, United States of America
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Walker S, Spillane E, Stringer K, Trepte L, Davies SM, Bresson J, Sandall J, Shennan A. OptiBreech collaborative care versus standard care for women with a breech-presenting fetus at term: A pilot parallel group randomised trial to evaluate the feasibility of a randomised trial nested within a cohort. PLoS One 2023; 18:e0294139. [PMID: 37967120 PMCID: PMC10650999 DOI: 10.1371/journal.pone.0294139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 10/18/2023] [Indexed: 11/17/2023] Open
Abstract
OptiBreech collaborative care is a multi-disciplinary care pathway for breech presentation at term, with continuity from a breech specialist midwife, including where chosen, for vaginal breech birth (VBB). Pilot randomised trial using unblinded 1:1 parallel group allocation to OptiBreech versus standard care, within a cohort. Participants were women with a breech-presenting fetus > 33 weeks, at four sites in England, January-June 2022. A two-stage consent process was used. Participants consented to undergo random selection to be offered a 'new care process', with a choice to accept it, or not. Primary objectives were to identify recruitment, acceptance, and attrition rates. Randomisation procedures and potential primary outcomes for a substantive study were also feasibility-tested. 68 women were randomised between January-June 2022. The consent process was acceptable to participants, but randomisation was unacceptable to women who specifically sought OptiBreech care. Two women withdrew due to concerns about sharing personal information. More women planned a VBB when randomised to OptiBreech Care (23.5% vs 0, p = .002, 95% CI = 9.3%,37.8%). Women randomised to OptiBreech care had: lower rates of cephalic presentation at birth (38.2% vs 54.5%), higher rates of vaginal birth (32.4% vs 24.2%), lower rates of in-labour caesarean birth (20.6% vs 36.4%), lower rates of neonatal intensive care (5.9% vs 9.1%), and lower rates of severe neonatal morbidity (2.9% vs 9.1%). Randomisation was stopped on the advice of the steering committee before the planned sample of 104, as lack of access to VBB within standard care prohibited comparison of outcomes. Demand for VBB is sufficient for a cohort study, but comparison of outcomes by 1:1 randomisation is not feasible. OptiBreech care would be best evaluated using stepped wedge cluster randomisation. Funded by the United Kingdom National Institute for Health and Care Research (NIHR300582). Clinical trial registration: ISRCTN 14521381.
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Affiliation(s)
- Shawn Walker
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
- Women’s and Children’s Services, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Emma Spillane
- Kingston Maternity, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, Surrey, United Kingdom
| | - Kate Stringer
- Women’s Services, Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, United Kingdom
| | - Lauren Trepte
- Women’s and Children’s Services, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Siân M. Davies
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Jacana Bresson
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Jane Sandall
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Andrew Shennan
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
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Savchenko J, Asp M, Blomberg M, Elvander C, Hagman A, Pegelow Halvorsen C, Lindqvist P, Nelander M, Skiöld B, Brismar Wendel S. Key outcomes in childbirth: Development of a perinatal core outcome set for management of labor and delivery at or near term. Acta Obstet Gynecol Scand 2023; 102:728-734. [PMID: 36965044 PMCID: PMC10201975 DOI: 10.1111/aogs.14560] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/07/2023] [Accepted: 03/10/2023] [Indexed: 03/27/2023]
Abstract
INTRODUCTION Consistency and relevance of perinatal outcome measures are necessary basics for obstetric research, audit, and clinical counseling. Still, there is an unwarranted variation in reported perinatal outcomes, which impairs research synthesis, validity, and implementation, as well as clinical benchmarking and longitudinal comparisons. The aim of this study was to develop a short-term perinatal (fetal and neonatal) Core Outcome Set to be used in research and quality assurance of management of labor and delivery at or near term. MATERIAL AND METHODS The methods were guided by the Core Outcome Measures in Effectiveness Trials Initiative Handbook. The project was prospectively registered on July 2, 2020 in the Core Outcome Measures in Effectiveness Trials (COMET) data base (reference number 1593). A list of potential outcomes was created based on a systematic review of studies evaluating interventions for peripartum management at or near term (≥34 weeks of gestation), including decisions regarding timing and type of onset of labor, intrapartum care, and mode of delivery. The list was entered into a two-round Delphi survey with predefined consensus criteria. Participants (n = 67) included clinicians, researchers, lay persons with experience of childbirth (patient representatives), and other stakeholders. A consensus meeting was held to reach a final agreement. RESULTS Response rates were 82.1% (55/67) and 92.7% (51/55) for the first and second Delphi rounds, respectively. In total, 17 outcomes were included in the final core outcome set, reflecting mortality, health or morbidity, including asphyxia, central nervous system status, infection, neonatal resuscitation and admission, breastfeeding and mother-infant interaction, operative delivery due to fetal distress, as well as birthweight and gestational age. Two of these outcomes were suggested by patient representatives. CONCLUSIONS The Swedish Perinatal Core Outcome Set (SPeCOS) study involved a broad circle of relevant stakeholders and reached consensus on a minimal set of perinatal outcomes that should be collected and reported in a standardized way in all future studies on management of labor and delivery at or near term, regardless of the specific population or condition studied. This could improve obstetric research, evidence synthesis, uptake, implementation, and adherence, as well as clinical practice, audit, and comparisons in childbirth care.
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Affiliation(s)
- Julia Savchenko
- Department of Obstetrics and GynecologyStockholm South General Hospital (Södersjukhuset)StockholmSweden
- Department of Clinical Science and EducationStockholm South General Hospital (Södersjukhuset), Karolinska InstitutetStockholmSweden
| | - Malin Asp
- Swedish Infant Death FoundationStockholmSweden
| | - Marie Blomberg
- Department of Obstetrics and Gynecology and Department of Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Charlotte Elvander
- Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Anna Hagman
- Prenatal Care and Reproductive Health UnitGothenburgSweden
| | - Cecilia Pegelow Halvorsen
- Department of Clinical Science and EducationStockholm South General Hospital (Södersjukhuset), Karolinska InstitutetStockholmSweden
- Neonatal Unit, Sachs' Children and Youth Hospital, SödersjukhusetStockholmSweden
| | - Pelle Lindqvist
- Department of Obstetrics and GynecologyStockholm South General Hospital (Södersjukhuset)StockholmSweden
- Department of Clinical Science and EducationStockholm South General Hospital (Södersjukhuset), Karolinska InstitutetStockholmSweden
| | - Maria Nelander
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Béatrice Skiöld
- Department of NeonatologyKarolinska University HospitalStockholmSweden
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Sophia Brismar Wendel
- Department of Obstetrics and GynecologyDanderyd HospitalStockholmSweden
- Department of Clinical SciencesKarolinska Institutet, Danderyd HospitalStockholmSweden
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Walker S, Spillane E, Stringer K, Meadowcroft A, Dasgupta T, Davies SM, Sandall J, Shennan A. The feasibility of team care for women seeking to plan a vaginal breech birth (OptiBreech 1): an observational implementation feasibility study in preparation for a pilot trial. Pilot Feasibility Stud 2023; 9:80. [PMID: 37173798 PMCID: PMC10175899 DOI: 10.1186/s40814-023-01299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/10/2023] [Indexed: 05/15/2023] Open
Abstract
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 prior to proceeding with a planned pilot randomised controlled trial. METHODS Our design was an observational implementation 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), within existing resources (costs), while maintaining low neonatal admission rates (safety) and adequate recruitment rates (trial feasibility). Participants included women > 37 weeks pregnant with a breech-presenting foetus, requesting support for a vaginal breech birth following standard counselling, and staff involved in the study. No randomisation occurred in this first stage of feasibility work. RESULTS Thirteen National Health Service sites were recruited. A total of 82 women planned births in the study. Sites with a breech specialist midwife recruited at double the rate of sites without (0.90/month, 95% CI 0.64-1.16 vs 0.40, 95% CI 0.12-0.68). 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, 95% CI 0.732-0.958) and by staff who met additional proficiency criteria at 67.5% (27/40, 95% CI 0.509-0.814). Fidelity criteria were more consistently met by staff who also met proficiency criteria. There were four neonatal admissions (4.9%, 4/82), including one serious adverse outcome (1.2%, 1/82). CONCLUSIONS A prospective observational cohort of OptiBreech collaborative care, which could potentially support nested or cluster randomisation, appears feasible in sites willing to establish a dedicated clinic and strategically develop further proficient members of staff, with back-up plans for supporting rapidly progressing births. Randomisation procedures remain to be feasibility tested. It is funded by the NIHR (NIHR300582).
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Affiliation(s)
- Shawn Walker
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK.
- Women's and Children's Services, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Rd, London, SW10 9NH, UK.
| | - Emma Spillane
- Kingston Hospital NHS Foundation Trust, Galsworthy Road, Surrey, Kingston upon Thames, KT2 7QB, UK
| | - Kate Stringer
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH, UK
| | - Amy Meadowcroft
- Northern Care Alliance NHS Foundation Trust, Royal Oldham Hospital, Rochdale Road, Oldham, Greater Manchester, OL1 2JH, UK
| | - Tisha Dasgupta
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK
| | - Siân M Davies
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK
| | - Jane Sandall
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK
| | - Andrew Shennan
- Department of Women & Children's Health, Faculty of Life Sciences & Medicine, School of Life Course and Population Sciences, King's College London, London, SE1 7EH, UK
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Spillane E, Walker S, McCourt C. Optimal time intervals for vaginal breech births: a case-control study. NIHR OPEN RESEARCH 2022; 2:45. [PMID: 36811097 PMCID: PMC7614205 DOI: 10.3310/nihropenres.13297.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Emma Spillane
- Maternity Services, Kingston NHS Foundation Trust, Kingston upon Thames, London, KT2 7QB, UK
| | - Shawn Walker
- Women and Children's Health, King's College London, 10th floor North Wing, St Thomas' Hospital, London, SE1 7EH, UK
- Women and Children's Services, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Christine McCourt
- Centre for Maternal & Child Health Research, City, University of London, 1 Myddleton Street, London, EC1R 1UB, UK
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Comparing apples and oranges? Variation in choice and reporting of short-term perinatal outcomes of term labor: a systematic review of Cochrane reviews. Eur J Obstet Gynecol Reprod Biol 2022; 276:1-8. [DOI: 10.1016/j.ejogrb.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/20/2022] [Indexed: 11/18/2022]
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Walker S, Dasgupta T, Shennan A, Sandall J, Bunce C, Roberts P. Development of a core outcome set for effectiveness studies of breech birth at term (Breech-COS)—an international multi-stakeholder Delphi study: study protocol. Trials 2022; 23:249. [PMID: 35379305 PMCID: PMC8978154 DOI: 10.1186/s13063-022-06136-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Women pregnant with a breech-presenting foetus at term are at increased risk of adverse pregnancy outcomes. The most common intervention used to improve neonatal outcomes is planned delivery by caesarean section. But this is not always possible, and some women prefer to plan a vaginal birth. A number of providers have proposed alternative interventions, such as delivery protocols or specialist teams, but heterogeneity in reported outcomes and their measurements prevents meaningful comparisons. The aim of this paper is to present a protocol for a study to develop a Breech Core Outcome Set (Breech-COS) for studies evaluating the effectiveness of interventions to improve outcomes associated with term breech birth.
Methods
The development of a Breech-COS includes three phases. First, a systematic literature review will be conducted to identify outcomes previously used in effectiveness studies of breech birth at term. A focus group discussion will be conducted with the study’s pre-established Patient and Public Involvement (PPI) group, to enable service user perspectives on the results of the literature review to influence the design of the Delphi survey instrument. Second, an international Delphi survey will be conducted to prioritise outcomes for inclusion in the Breech-COS from the point of view of key stakeholders, including perinatal care providers and families who have experienced a term breech pregnancy. Finally, a consensus meeting will be held with stakeholders to ratify the Breech-COS and disseminate findings for application in future effectiveness studies.
Discussion
The expectation is that the Breech-COS will always be collected in all clinical trials, audits of practice and other forms of observation research that concern breech birth at term, along with other outcomes of interest. This will facilitate comparing, contrasting and combining studies with the ultimate goal of improved maternal and neonatal outcomes.
Trial registration
Core Outcome Measures in Effectiveness Trials (COMET) #1749
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Walker S, Reitter A. The structure of breech revolutions, a response to: "Upright breech birth: New video research risks reviving Friedman's curse". Birth 2022; 49:16-18. [PMID: 34931718 DOI: 10.1111/birt.12602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/11/2021] [Accepted: 10/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Shawn Walker
- Department of Women and Children's Health, Faculty of Life Sciences & Medicine, King's College London, London, UK.,Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Anke Reitter
- Obstetric and Prenatal Medicine Department, Hospital Sachsenhausen, Academic Teaching Hospital of the Goethe-University Frankfurt, Frankfurt, Germany
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