Barriers and facilitators for implementation of OptiBreech collaborative care: A qualitative study as part of an implementation process evaluation.

PROBLEM: Lack of opportunity for breech training and clinical experience reduced professional confidence and expertise in supporting vaginal breech birth. BACKGROUND: OptiBreech collaborative care is a care pathway for breech presentation at term that aims to enable improve safety through person-centred care and improved training opportunities for maternity professionals, within dedicated clinics and intrapartum support. In feasibility work, barriers and facilitators to team implementation were observed by team members. AIM: This study sought to describe factors affecting optimal future implementation and safety of OptiBreech care. METHODS: Semi-structured interviews were conducted with staff members at 13 OptiBreech trial sites (17 midwives and 4 obstetricians, n=21), via video conferencing software. The Theoretical Domains Framework (TDF) was used to identify factors impacting team implementation. Themes identified in the TDF were refined in reflexive discussion and grouped into key facilitators, key barriers, and dynamic factors (which span both barriers and facilitators). The interviews were then coded, analysed, and interpreted according to the refined framework. FINDINGS: The key facilitators were broadly categorised within skill development, beliefs about capabilities, and social support from the wider multidisciplinary team. Key barrier categories were resources, social obstacles, and fears about consequences. Dynamic factor categories were individual responsibility, training, and attending births. CONCLUSION: While some factors affecting implementation were specific to the individuals and cultures of certain Trusts, recommendations emerged from analysis that are more widely applicable across multiple settings. These should be considered going forward for future service implementation, and in the next stage of OptiBreech clinical trials.

Not too fast, not too slow: A review of historical trends in vaginal breech time management.

PROBLEM: A lack of consistent professional guidance on when to intervene during emergence (buttocks and anus visible at the introitus to birth of the head) in vaginal breech birth (VBB). BACKGROUND: Hypoxia and asphyxia are common complications of VBB, especially due to umbilical cord compression around the time of emergence. AIM: To gain insight into VBB time management trends, the evidence behind these practices and how they may have influenced outcomes. METHODS: Literature review of obstetric textbooks published between 1960 and 2000 contained in the Wellcome Collection and Royal College of Obstetricians and Gynaecologists Library in London. FINDINGS: 90 textbooks were reviewed. Recommendations for 'safe' intervals between birth of the umbilicus and the head ranged from 5 to 20 min. Many sources focused only on the time required to deliver the head, with 'up to 10 min' being the most common interval described. The review found no mention of cord compression causing concern earlier in breech births than once the umbilicus itself is delivered, nor any evidence to support the recommendations. DISCUSSION: These findings demonstrate a long-term pattern across the second half of the 20th century, whereby birth attendants were urged not to rush emergence nor delay intervention but were given little clear guidance on optimal timings. CONCLUSION: Clear, evidence-based guidance should be provided in breech training materials to avoid unnecessary hypoxic injuries, and this guidance should be rigorously evaluated.