 Okay, now I will be introducing this keynote presenter with Sean Walker. Sean Walker, RMH PhD, is a clinical academic midwife. She is based at King's College London, where she is an NHL Advanced Fellow and Senior Research Fellow. She is currently conducting feasibility work for a clinical trial of Obdibute Care, a complex intervention based on her team's previous research about physiological bridge birth practice and service delivery. Clinically, she works as a Honorary Consultant Midwife at Chelsea and Westminster Hospitals, NHS Foundation Trust, where she coordinates the Interpartum Bridge Team and the Bridge Clinic at the West Middlesex Hospital. For the information about her work, you can be found at this website. I will post on the web chat, bridgebirth.org.uk and optibridge.uk. Thank you, Ellie. Thank you very much, Sean, and I will give you. Okay, so thanks so much, those of you who've come to hear this presentation. As Ellie explained, I'm currently about halfway through with three-year NIHR Advanced Fellowship, which is funding my training in clinical trials and looking at the feasibility of doing another term bridge trial based on team care for bridge births and the use of bridge specialist midwives who have experience in training of physiological bridge birth. So what is physiological bridge birth? A definition is an approach to facilitating vaginal bridge birth centered on the optimization and restoration of normal physiological processes, including upright positioning. And we say that because, I mean, I have to say, when I first started doing this research, I thought that what I was researching was upright bridge birth. And it very soon became clear to me that that it was a tool and not a rule of physiological bridge birth. That the main focus of any physiological birth is to optimize the physiological process. And sometimes women are on their back, sometimes they're on their side. And lots of women like to be up on their knees, but that is a tool and not a rule. So how do you feasibility test for a trial? The outcomes we are looking for in our feasibility test are, are we able to provide trained and proficient attendance? Now, as you can imagine, this is a bit of a challenge at the moment after decades worth of depletion and skills. So that's a feasibility question. Do they provide consistent care? That's a fidelity question. Do they provide care in a way that's acceptable to women and staff? So it's acceptability. And do we maintain low neonatal admission rates? That's a safety question. In this bit of the observational study, we're not looking at extensive safety data. We're just basically looking at any neonatal admissions or neonatal deaths. We haven't had any neonatal deaths within 28 days. And we have had a level of neonatal admissions that's similar to the UK average for all births. But the bigger collection of safety data will come in the actual trial. So this is a kind of precursor to a trial where you test to see if it's going to be possible to do a trial. And do we get adequate recruitment rates? And that's a feasibility question. Now, what are the needs of the service and the research? We need to have counseling by a trained and proficient team member, intrapartum care by a trained and proficient team member. We have to have training for the opti-breach team member and the wider team, service development and risk management and recruitment. And what is a breach clinic? We have found that the sites that have breach clinic have better recruitment rates because every woman with a breach pregnancy is going through those clinics. And a breach clinic is a dedicated space and time to see women with suspected or confirmed breach presentation. It's staffed by midwives and obstetricians with a special interest in training. We do bedside ultrasound scans, counseling. Moxibustion referral from 34 weeks is part of our guideline at Chelsea. And external catholic versions, which are certainly at Chelsea and West Middlesex, are done by midwives and birth planning. No matter what your mode of birth. The original plan in the feasibility study was for the funding for the release of staff for training five obstetricians and five senior midwives. And along with a breach lead obstetrician and breach lead midwife, this was going to be in-person training followed by cascade training. I got my grant award notice in the middle of March, 2020. And there was a few other things going on right at that time. So as you can imagine, the events associated with COVID-19 severely impacted research across the country and in the trial. It was very difficult to organize in-person training. So what actually happened was I put in an entire online training package online. We are now starting to go back to one-to-one training. Clearly it was then cascaded by specialists internally who could cascade the training locally. And it was primarily done by a breach specialist midwife, either formally or informally. I always knew that I would have a significant role at my trust. But what we found is that that role ends up being really significant no matter what trust it is. And the ones that are significantly participating in the feasibility study, that role seems to be really significant. So what we do is breach specialist midwives. So we do counseling and birth planning along with other clinic duties. So a typical clinic day for me at West Middlesex Hospital will be presentation scans that are referred from community suspected breach presentations from 9 to 10, from 10 to about 12.30. I will have follow-up appointments for people that we know are breached. So they're having a bit further counseling about whether they want to turn the baby or planning their mode of birth. And then in the afternoon, external catholic versions. And then being on call for births and organizing the interpartum care. So if I am seeming a little bit slow today, it's because I've actually been out through the night with a birth that ended at 5.08. And I've only recently managed to get a shower for the day. So I've made it in time. So I was with that woman. So she was actually a self-referral. So we keep track of where women are coming from, whether they're referred by their midwife internally, their obstetrician, a staff member from another hospital who might be referring to us, or other women themselves referring to us. And we're finding that 20 participants actually come from outside of our OptiBreach hospitals and they find out through the website where they can access OptiBreach care. So we do face-to-face training with the OptiBreach team and wider multidisciplinary team to facilitate reflections on births that other people's into and the recruiting for the trial. So this is a very unique trial because we are now, what I'm presenting is about our observational phase to see if we can provide team care with the sites who demonstrated they were able to provide team care. We are now in a pilot trial where we're randomizing to OptiBreach care or standard care. And it's a very unique study in that the vast majority of our principal investigators, that's the person who leads the study locally, are midwives. And traditionally, principal investigators have always been obstetricians and midwives will help collect the research data. This study is actually led by midwives with myself as a chief investigator and with local principal investigators. But we always work hand-in-hand with our breach lead obstetrician at each site and they will be aware of whose planning of vaginal breach of birth and have checked in with them on any additional counseling that is needed. They do a second review to make sure we're not missing anything that we need to take into consideration for the birth. So if you look, so at the time I prepared this presentation, there were 68 women planning a VPD. I know that we are at over 70 now. And if you see that the three main sites which are now currently in the trial, the first three sites, they each had a formal specialist midwife that was a recognized post and that was part of our job descriptions. And two of us had a dedicated specialist clinic. The third did not have a dedicated specialist clinic, although that is in progress. But interestingly, because their midwife had so much experience, that site received the bulk of referrals. And in fact, they got multiple referrals from their site that didn't have a specialist midwife or a team. So if you see, but then there are people who were kind of informally functioning as a specialist midwife. And one of the sites, I also support one of the other hospitals in London. So I went to a birth there last week. So I'm kind of an outside support that I come in on an honorary contract and support them to develop their skill. And in site G, we're having a natural experiment called Breach Specialist Midwife Goes on Maternity Leave. So far their site have recruited two people as she's awaiting the arrival of her baby. So she's very pleased with her team. Sorry, I went too fast. So the mode of birth. So at the time I prepared this, there were 63 births that had occurred. There were 49% were vaginal breach births. 3.2 were forceps breach. So there were assistance with forceps to the aftercoming head. 3.2 were infallic births, because that is one of the outcomes 12% of babies. If you just wait to go into labor with more tips, 12%, we'll just turn to head down. We had one where everybody was very worried because someone saw the neck to failed versions. There was a bit of worry, but we were very clear that the evidence doesn't say we should be excluding a trial of labor, a new cohort. And indeed, as I was getting off the bike, I got a text to say babies, they're water-backed. Urgency caesarean section is 28.6%. So that is in the V-back emergency C-section rate and elective caesarean section rate. Some of those are for indication and some people change their mind. Opti-breach is not about promoting vaginal breach birth as the best option. And in fact, the women who contributed to the design of the study didn't want the study to find a best-opted choice that was right for them. And so women always have the option to change their mind and have an elective section. And we've had all sorts of things like that happen. Sometimes people will change their mind, change them back, and that's okay. What we actually find is that when you start increasing choice for vaginal breach birth, your elective section rate goes up as well because some people just want to go straight to elective. The vaginal birth rate goes up as well. So if you look at how this compares to our gold standard in the UK is Oxford for external catholic version. And they have clearly have a much higher vaginal rate after external ECV with 82%. The instrumentals 28. Any vaginal birth through that clinic is 43.6%. And that includes all of the ECV attempts because most unsuccessful ECVs have a caesarean section. So in terms of our feasibility outcomes, you can see the definition of what we consider efficient. They've completed our physiological breach birth training package, which is through the breach birth. Attended at least 10 vaginal breach births, including resolution of complications. Attended or taught in simulation at least three vaginal breach births within the past year. And they need to say that they need to self-assess themselves as competent to autonomously attend births. Now we say autonomously, that doesn't mean that we're not working as an MDT team. This is very much about creating space for physiological birth on the labor ward where we're all working in harmony. You know, that is still a goal because any change, if you are a research leader, you are also a change leader. And that, you know, that's a process. That's not something that happens overnight just because we suddenly have a vaginal breach birth study. So far we're doing well. Someone was present throughout the second stage who had completed the training 90.9% of the time. And that's consistent with other continuity of care models. We have to counsel women that there's always going to be a degree of unpredictability. And what we hope is that through the annual mandatory training, the strategies that we use filter across the entire team. Everyone has completed the enhanced training. And if you give birth very quickly, we sometimes did make sure someone's there. So someone was present who met all of these proficiency criteria, which I think are quite stringent by today's standards, 23% of the time. So we think that that's really pretty good. We're happy with that, especially given that some of the sites started out saying, we don't think we're going to be able to meet that at all. We can get someone there who's done the training, but we don't actually have anyone who meets. And this is oftentimes including their consultant body. Okay, so it's a dire state, a state of breach services at the moment. And so we're just trying to figure out how we get from A to A to start something that is safe. The maternal birth position was upright 72.7. So that isn't something we have a target for. It's just basically, yes, we're providing that as an option. We can see that that is happening. We use maternal movement and effort always as a frontline strategy stalls. So we follow the physiological breach with algorithm that was based on our previous research, but we use something we call continuous cyclic pushing. That means that once the pelvis begins to be born, we keep things moving. Most women will keep it moving themselves. But like say it causes and you'll hear me say something like, okay, well done. Now take a deep breath and when you're ready, push again or give it a wiggle. You want to move that baby down and that keeps things moving. We're not doing hold your breath push while self pushing continuously for five minutes. We are doing continuous cyclic pushing where it more actively mimics the kind of several pushes per contraction that women do physiologically. So we, it wasn't necessary to do that. So 18% of the time those were births that needed no intervention whatsoever. Yes, we did use encouragement about 67% of the time and then 15% for whatever reason that wasn't recorded. Wasn't used or maybe someone was using different strategies. So there were 31 successful vaginal beach births and was there less than five minutes between the birth of the pelvis and the birth of the head? Yes, 80 almost 88%. We've changed that for rumping to rumping. So if you see in the picture, that's what we call rumping other than the birth of the pelvis because we realize that we are further research. Which you can see on the right, especially the study done by Emma's plane, which looked at retrospective records and compared for death or neonatal admission. And it's much longer range and higher risk association with on the perineum as well as delay following the birth of the umbilicus more so than the. So we really want to keep things moving once the baby comes down onto the perineum. And that's what I usually counsel women about as well because they need to know if you are going to have an apesia, that's usually when I'm going to suggest that it's a good idea. Because the baby has stalled on the perineum and we really need to keep things moving at that point. So safety data neonatal admission or neonatal death. For the trust they were able to give us from the 2 years previous to off the breach in those years there were 61 vaginal breach birth 13% of them were admitted to higher level care. And there were 2 neonatal deaths for a composite outcome of 16% neonatal admission or death at the 9 off the breach sites. For general breach births had a 9.1% admission rate. And if you were looking at it prospectively the national average is 5 per all babies at term. And it was 5% including the emergency cesarean. So safety data is severe morbidity or mortality. We have had one that we know about in the observational study that as severe and so of the actual vaginal breach births there was one severe outcome where the baby was admitted for more than four days and had an apgar of less than four at five minutes. And in the term breach trial the rate was 5.5% and promoter was 1.6%. The promoter was a prospective observational study so that would have been all planned breach births. So our rate is also at the moment 1.6% for the total planned prospective births. We're also doing interviews with women try to get a range of voices. So we look across sites. We look for vaginal breach births as well as like for forceps births cesarean sections and elect sections where women have changed their minds. That's where we knew there were difficulties. As you might imagine with a study like this there are frequently strong opinions about the way that things should be done. It's not always smooth sailing. Some women have chosen to give more outside of the midwife fledged unit although our protocol is to record the unit. We look at some slowly recruiting sites and one where there was a neonatal admission. For our analysis we're using the theoretical framework of acceptability which looks at different ways of judging how acceptable a service is for participants or staff. And I'm just going to have a and the three main kind of themes that we identified that were needs that women have of the service and mechanisms and why we decided to focus on breach specialist midwives because they were the mechanisms by which women were able to have these needs met. The first was balanced information. They needed access to skilled breach care and shared responsibility. So balanced information. It's very clear in the interviews with women that they are getting balanced information from the counseling. Certainly when I counsel women I use a pro forma. I say the same thing every time according to what our guidelines and the RCOG guidelines say about risk. I say it in a non emotive fashion in a non judgmental fashion. It's all on an open hand and you can choose what you want. And they're saying things like nothing was sort of pushed on me. She didn't sugarcoat anything. She she told me exactly what the potential risks could have been but also what the benefits could be. So they really appreciate that they're getting the full access to information. But they're saying that oftentimes it costs there's a big opportunity cost for women to get that information. Especially a lot of women who've had to transfer from outside into our trust. They have had a hard time accessing the information on their own. They feel that they haven't gotten balanced information until they entered that a. Now they're not getting the same type of counseling from everyone at the hospital. So they are recording different levels of information. But what they're saying about the breach specialist midwife. One of the things that I was really surprised about is that they really liked when we talked them through the potential complications in detail. And exactly what we would do if they had got stuck, if the arms got stuck, if we did need to do an appeasier to me. That detail was reassuring to them because they could and they could make a decision about whether they were. Rather than just people tend to feel really panicky when you say the babies had to get trapped because that's an image of like. And then what and if you don't kind of talk about how you're going to resolve that that could take a short amount of time or a long amount of time. And that is somewhat what the skill depends on the skill. They are saying that. The access to skilled breach care. They are needing kind of outside help to help them put in touch with the skilled breach care. So if you have a specialist that women feel like, oh, there's going to be. You're likely that someone will be at my birth who is familiar with each birth is actually supported. The last interview that I did, the woman said, I think they were really looking forward to it. And that actually makes a really big difference for women to know that actually my birth is going to be attended by people who are looking forward to supporting me having this birth. Rather than people who are judging me and upset that I'm choosing to have a breach birth and feeling put out that I'm making this choice that that's important. And it was easier. So the women who were booked at up to each site and just were automatically referred to the beach specialist midwife found it really easy. They didn't have the same conflicts and kind of difficulties accessing support. And so that was that was made it more acceptable to them. Now, one of the things that we've identified and some students of mine have done a systematic review, which also indicates women who want to plan a vaginal breach birth have a enormous emotional burden placed on them. And even, you know, just about every interview that we have done confirms the same qualitative data that women receive a lot of judgment. They have criticism from their friends and family. They have criticism from providers. And when we have meetings of our involvement group, it's very frequent that someone will cry. Even people who've had very good outcomes just because they've been so stressed by the way that people have spoken to them and the trauma that it has caused that people were so upset about their decision to plan a vaginal breach birth. And ask them, well, why are you doing that and things like that? So I just think that we need to be really mindful of that. And if we're going to say that this is a choice, it needs to be a genuine choice and people shouldn't have to feel that they have to actually fight their care providers in order to access it. But one of the things that we find is that when you have a team that is saying, well, we can't give you an absolute guarantee, but we will do our best to be there. So for example, last evening I was getting texts from the woman whose birth I was at this morning saying, okay, so the consultant said that if you're not there, then someone from her team would look after me. Is that right? Is there going to be experience there? And I said, look, we can never offer you 100% guarantee. I'm going to do my best to get there. Members of my team are going to do my best to get there. But at the end of the day, birth is unpredictable. So you have to be willing to deal with me. And so I said, I suggest that what you do is you close your eyes and visualize that everything is aligning and everything is being set up as much as we possibly can support you. And she said, okay, that's really reassuring. And I kid you not 10 minutes later, her partner called me and said that her waters had broken. So clearly she was feeling a strong need to feel like everything was in place. And then once she realized it was, she could relax and go into labor. But what they say is that instead of everyone telling them basically you're putting your baby at risk and this is your responsibility, having a breach team that's willing to be on call for them is a matter of sharing responsibility. They still know that it's their informed decision. They ultimately, they live with their decisions, any adverse outcomes that they need to live with for the rest of their lives. Those are their decisions to live with. But knowing that there are people there who have practiced, done extra training and are prepared to be there makes a really big difference to the amount of trust they feel. And that extended to the rest of the team, unless they spoke to people where that expressed the judgment and disapproval of their decisions. Then they started really focusing on the breach specialist mid weapon thing. I don't want anyone else with this person. Whereas if they had good interactions, they trusted that all of the team was there working together to be with them. And they were mixed views for the teams, which made sense to us because the teams are still very much developing. Like I said, COVID has had a massive impact. There has not been extra staff time to release people for training the way that we anticipated. We're doing the best that we can, but it's not exactly how we anticipated. So we have frequent public involvement and engagement meetings. Many participants have emphasized that the value of more information and more time. They want earlier information about breach presentation. So a lot of women are told don't worry, don't worry, your baby could still turn. But actually, if your baby is breached at 33 weeks, there's still a significant chance if it's your first baby that it's going to be breached at 36 weeks. So about 25% of them will turn. So it's fair to women to say if they want information, to give them information earlier so that they can make informed decisions about turning what they want to do. So what we know, I'm going to wrap up now, is that an OptiBridge specialist midwife operationalized within the service is highly acceptable to women. And we've just been awarded a grant to try to increase the impact of this research that more sites will develop for each specialist midwife roles. The more formalized, visible and local the role is the more it meets women's needs for access to balance information and share responsibility. And it's a really good implementation strategy. So I've now begun telling sites it won't get off the ground unless you have a breach specialist midwife because we're just not seeing it work. Unless you have someone taking responsibility to lead in this way in collaboration with the breach lead-ups to Trisha. So how will the role develop over time? We don't know how will it transition to become less dependent on one person and how long will it take? Like I said, we're really pleased that the site where the breached specialist midwife is on maternity leave is continuing to support breach births. Really happy for them. What is the best way for the multidisciplinary team to work together? And of course our ultimate goal is to find out what are the safety outcomes? But in order to find out if we've made breach births safer, we actually have to have some breach births. When you do a trial, you have something called a logic model. I won't bore you with it, but this is how all of the different pieces work together to result in the outcome for this complex intervention known as OptiBridge care. In our pilot trial, there are 104 women across four sites. With the aim is to increase the vaginal birth rate for those who want it by providing a safer special option of vaginal breach birth, a high acceptance rate of ECV and a high success rate of ECV. And we obviously won't be sharing the results until they're in because this is a trial. A few of these women have already given births. So we're already halfway through the well over halfway through the recruitment of 52 women of given birth. So we're feeling good about our ability to recruit to a future trial. Thank you so much for your time. And I'm really happy. Oh, well, this is what standard care is in OptiBridge care. But I'm really happy to answer any questions that you have about the work that I'm doing and share anything that you want to share. You can come on in or type whichever you prefer. Selene, there are a lot of U.S. midwives who are practicing palpation skills. What do you mean by that? I mean, because we always use palpation prior to any scans and in labor prior to any vaginal examination. So our palpation skills are really important. And even though I've been scanning for some time, I actually think that the scanning improves my palpation skills from the immediate feedback. So my hands and my mini scanner kind of work symbiotically now. But do you want to say more about what you want to know about mid-for-free practice as far as palpation goes? Diana, Paul Bardrone is saying that she feels we're lucky in Europe that vaginal breach birth hasn't been lost. One thing I would say, Diana, is despite I'm obviously in Europe, I'm not 100% sure that it hasn't been. I certainly don't feel like I feel that we are rediscovering breach birth with this trial and this study. I feel that it is every day I realize how much actually has been lost that hasn't been shared and can't be shared in training because of it having been underground for quite so long. But there are certain guiding light sites in Europe certainly that are doing quite a lot of good support, which is wonderful. So Ella Cain from Norfolk is saying, how are you recruiting for additional sites? At the moment I'm not actively recruiting for additional sites because we have nearly 20 sites in the observational study. So it's more of a, if people are coming to me and to us and saying they want to get involved, then we kind of put them on a list for the next time I go to put an amendment in. There is quite a lot of sites that haven't managed to open as well because again there have been difficulties with COVID and the R&D department. Birmingham Women's is just about to come on board as another trial site because you have to participate in the observational study and demonstrate that you can put a team in place before you can come on to the trial. But once the trial is over and we know the results and we know whether the trial steering committee has made a decision that it is feasible to do this in a large trial, then we will be looking for further sites for the substantive trial at the same time as looking for money for the substantive trial. So Selene is saying, thinking about places without U.S. facilities. Okay. And the choice for birth location, like I said, we, everyone, one of the things that was important to women was that they, women retained as much choice as possible. So women, we say, you know, what we're really trying hard to do is create space for physiological breach birth on a multidisciplinary unit. But there have been several women who have given birth on midwifery units and several women who have given birth at home. And that choice is definitely available to women in the U.K. Because one of the ways that U.K. National Health Service care differs from, say, that in the U.S. is that the National Health Service owes a duty of care to every woman. So for example, we have had women who were booked under private care who've come out of private care because private care in the U.K. doesn't actually owe a duty of service. If they feel that they can't offer a vaginal breach birth, they just say, we can't offer you a vaginal breach birth at our facility. Whereas the NHS has a duty to provide care for women regardless of their choices. So, and Catherine is saying, are you familiar with the Vaginal Breach Initiative at George Washington University Hospital? Yes, very much so. And that's a wonderful multidisciplinary team. Any practicing skills about ECV? But is there practicing skills about ECV? Yes, so certainly I do ECVs along with other Breach Specialist midwives in the project. And that I know there's a huge tradition in the Netherlands of midwives doing ECVs. And I would like to bring it as a kind of national competency that we have that is uniform throughout the U.K. We have kind of trust level approved competencies, but we really need to do that at a national level. So Diana said she's speaking from Paris where it's an option in many places to still offer it, but not so many midwives. Yes. And the other thing is physiological breach birth is not necessarily so the different centres that practice breach birth throughout Europe. The rates of using, for example, induction and augmentation and enabling women to be upright and active versus on their backs and stirrups mandated that all varies considerably from centre to centre. So I work with quite a few hospitals, one in the Erasm hospital in Brussels, where they use upright techniques and in Amsterdam, OLVG, where I'm going in July, we do a lot of work together. And open role in Denmark where we were at the end of March teaching obstetricians from all over Scandinavia where about 85% of women who have a breach presenting baby attempt of a Janet breach birth and they tend to prefer the upright method. They're doing huge amounts of teaching and it was wonderful. So Celine taught ECV to doctors, but it was not allowed to do it to midwives and seemed not part of the practicing field. Yes, again, and I think that was considered by the International Confederation of Midwives whether ECV would become a midwife skill, and it was not voted on to be one of the and I think along with ultrasound. So very much so we consider these skills extended midwifery roles. So just like any other extension of practice. So in the UK, there is a tradition of specialist midwives. We have diabetic specialist midwives, perineal specialist midwives, perinatal mental health specialist midwives. So we have a large number of specialist midwives who are considered to have specialist expertise in their practice area. And a lot of my early research focused on exactly what are the competencies that a midwife needs to have any CV competence and to attend upright vaginal breach births. So that's what we are doing kind of translating that then into practice. So we have the kind of consensus based guidelines. Now what does it look like to implement the consensus based guidelines about how you train midwives to fulfill these roles and then what are the outcomes once you do implement it. And so we're kind of in between two and three at the moment in terms of implementing it and evaluating what the outcomes are when you have implemented it. So Ellie is saying that we need to start wrapping up. And I thank you very, very much for the time that you've spent coming to listen to this presentation. And you can of course follow us on the OptiBreach website. You can follow that for updates. And you can, the physiological breach training is available via the Breach Breath Network. Okay, thank you very much, Sean. And thank you everyone for joining us.