Objective: Refine the programme theory for OptiBreech Care Design: Concurrent mixed methods implementation process evaluation Setting: 6 NHS hospitals in England participating in the OptiBreech 1 Feasibility Study Sample: 15 women planning a vaginal breech birth at term and 6 breech lead midwives Methods: Outcomes were recorded on case report forms and descriptively analysed. Interviews were recorded, transcribed and analysed using the Theoretical Framework of Acceptability. Iterative analysis informed subsequent interviews and the on-going process of implementation across sites. Main Outcome Measures: Acceptability of service delivery models and their outcomes. Results: Actively recruiting Trusts implemented services through a dedicated clinic and/or a proficient intrapartum support service, organised and provided primarily by a Breech Specialist Midwife. While we identified challenges, this model has achieved 93% fidelity to the intervention’s goal of ensuring attendance of OptiBreech-trained professionals at vaginal breech births, and it is highly acceptable to women. Our initial suggested model of a multi-disciplinary team composed of 5 obstetricians and 5 midwives does not appear feasible, due to very low overall current breech experience levels and the context of current pressures on NHS services. Conclusions: Appointment of a Breech Specialist Midwife, whose role is to co-ordinate a dedicated clinic, training and a proficient intrapartum care team, appears to be highly acceptable to women. This model appears to be a feasible implementation strategy, in order to test the safety and effectiveness of OptiBreech Care in a clinical trial, but further work needs to be done to develop sustainability.

Background: Effective clinical escalation on recognition of maternal or fetal deterioration is a crucial component of maintaining safety in intrapartum settings. Objective: To overview systematic reviews on interventions for escalating care around birth. Search strategy: Reviews published 2015 to 2021. Sources searched included eight databases. Selection criteria Reviews involving randomised controlled trials on the clinical impact on mothers and neonates, process outcomes, and/or qualitative evidence on stakeholders’ perspectives on intervention. Where gaps were found other types of review evidence were considered. Data collection and analysis Cochrane approaches applied including in evaluating evidence quality. Results Seven systematic reviews and one scoping review were relevant for in-depth review: six were on clinical impact, and two on perspectives (studies from 16 countries, over 909,027 pregnancies/births of undefined risk). In comparison with no intervention, early warning systems trigger tools and team training in obstetric emergencies were evaluated. Various measures of clinical impact were used, only one on time-to-treat. We found that most evidence was of low to very-low quality because of study limitations and imprecision as outcomes are rare, and overall failed to find a clinical improvement favouring early warning systems trigger tools or training. Qualitative studies captured challenges in implementing trigger tools. Reviews of women’s perspectives or other types of care escalation were searched but not identified. This is not to suggest studies don’t exist. Conclusions Conclusions cannot be made on clinical effect of interventions to escalate care around birth as review evidence is limited. Evaluations need to consider use of proxy outcomes.