Justifying to a seven-year-old Anubis why I’m going to Germany for my week off – and missing mothers’ day, helped crystallise objectives and motivation for this busman’s holiday* (*a form of recreation that involves doing the same thing that one does at work). “I’m going to see some babies be born bottom-first.” “Don’t you see that […]
Last week I visited the Academie Verloskunde in Amsterdam to provide a train-the-trainer workshop for midwifery lecturers. The four universities in the Netherlands work together to teach a consistent curriculum across the country. Incorporation of physiological breech birth training into that curriculum was inspired by last year’s Teach the Breech 1st Amsterdam Conference. I was honoured that lecturers travelled from as far away as Groningen and Maastricht to attend the training, so they have a common understanding of how physiological breech birth is taught. Many of them have significant experience teaching breech themselves, so we will continue to learn from each other.
The train-the-trainer workshop followed a similar format to our RCM-approved Breech Birth Network study days, but we kept the focus on the mechanisms and manoeuvres to enable the midwifery lecturers to understand the new methods thoroughly in order to teach them to students. Midwifery lecturers already have such a deep understanding of anatomy and physiology, and I have never had so many great questions from one audience! Amazing engagement.
The Netherlands is a hotbed of breech activity and debate, from researchers such as obstetrician Floortje Vlemmix and midwife Ageeth Rosman, and obstetricians like Leonie van Rheenen-Flach and midwives like Rebekka Visser. Vaginal breech births have continued to be facilitated throughout the Netherlands, albeit at a diminished rate this century. Because clinicians have maintained the skill, a shift to more physiological principles of facilitation is not so seismic. A recent case report indicates such a shift is in progress.
Thank you to lecturers Bahar Goodarzi and Merel Schoemaker for organising the workshop and seeing me safely to the other side of Amsterdam on my bike after the training! I look forward to working more closely with them to develop a physiological breech training programme, appropriate for the Dutch context, incorporating the existing skills and knowledge of the very experienced obstetricians and midwives of the Netherlands.
Wildschut, H. I. J., van Belzen-Slappendel, H. and Jans, S. (2017), The art of vaginal breech birth at term on all fours. Clin Case Rep. doi:10.1002/ccr3.808
To kick off the new year, Breech Birth Network are providing a study day in Norwich on 14 January 2017. If you’ve been wanting to encourage your obstetric colleagues or trainees to attend training, this will hit the spot. Our teaching team includes Dr Anke Reitter, FRCOG, Shawn Walker, RM, Victoria Cochrane, RM, and Mr Eamonn Breslin, MRCOG. Send your colleagues the link to our Eventbrite booking page, with a personal invitation! Or download a poster for your work environment.
This study day for obstetricians, midwives, paramedics and students will provide an engaging and interactive update on professional skills to facilitate physiological breech births, planned or unexpected. The study day would be especially useful for clinical skills teachers who want to include physiological breech methods in professional skills updates or student lessons, due to access to resources after the workshop. The focus is on collaborative, multi-professional working to improve the safety of vaginal breech birth using the skills of all maternity care professionals.
Training will include:
* A research update given by leading researchers in the field, including Dr Anke Reitter, FRCOG, IBCLC of Frankfurt
* Thorough theoretical and hands-on explanations of how breech babies journey through the maternal pelvis in a completely spontaneous birth (the breech mechanisms), enabling you to distinguish between normal progress and dystocia
* Hands-on simulation of complicated breech births and resolutions, using narratives and videos of real breech complications, to enable you to practice problem-solving in real time
* Models of breech care that work within modern maternity services
* An accompanying booklet containing handout versions of all of the slides and resources used in the training
* One year’s access to the on-line learning space following the training, to continue viewing and reflecting on birth videos (one per month) in a secure forum, and resources for sharing teaching with professionals in your practice community
* Lunch and refreshments
Registration begins at 8:30 for a 9:00 start
Hosted by the University of East Anglia University Midwifery Society. Profits from the study day will benefit the UEA Midwifery Society annual charity, the Orchid Project. See here for directions to the Edith Cavell Building, and to Norwich from further afield.
Feedback from study days in Christchurch & Auckland, October 2016:
My main concern was lack of training of staff leading them to believe that breech birth is an emergency. Our RMOs and MWs loved the day and I think feel more empowered. — SMO (Consultant Obstetrician, Senior Medical Officer)
Thank you so much, this has been the best study day ever! — Midwife
Information was clear and concise and well presented. Myths dispelled and physiological VBB and when to intervene very clearly explained. Methods to resolve when there are issues during delivery explained and demonstrated. Clear examples given with supporting video and photographs. Extremely valuable. — RMO (Registered Medical Officer)
Honest, real explanations. How to intervene in a timely manner as opposed to be hands off the breech. — Midwife
Thank you for a brilliant day of teaching and training. You covered a lot of material not taught as part of our training and it has been valuable. — RMO
Learning about manoeuvres to use in upright position, eg. shoulder press; visual components have been amazing, the broken down physiology of a breech birth. — Midwife
- Dr Anke Reitter, FRCOG
- Shawn Walker, RM, MA
- Victoria Cochrane, RM, MSc
- Mr Eamonn Breslin, MRCOG
Dr Anke Reitter, FRCOG, IBCLC, is the lead Consultant Obstetrician and Fetal-Maternal Medicine Specialist at Krankenhaus Sachsenhausen, Frankfurt am Main. Although originally from Germany, she worked in India and the United States during her medical studies, and in England (including Liverpool) for 4 years during her obstetric training. After returning to Germany, she specialised in perinatal medicine. Prior to her move to Krankenhaus Sachsenhausen, where she initiated a new breech care pathway in a unit which had not supported breech births for years, Reitter practiced in the Obstetrics and Gynaecology department at the University Hospital Frankfurt. A large observational study of the hands/knees breech births in Frankfurt is due to be published soon in the FIGO journal. Her special interests lie in breech, multiple pregnancies, high risk pregnancies and prenatal ultrasound. She is an internationally known speaker, teacher and researcher in several areas, but especially breech birth.
Shawn Walker, RM, MA is a UK midwife and PhD candidate researcher who studies how professionals learn skills to safely facilitate breech births. Clinically, she has worked in all midwifery settings – labour wards, freestanding and alongside birth centres, and home births. She led the development of a breech clinic pathway at the James Paget University Hospital (2012-2014), where she worked as a Breech Specialist Midwife. Her research focus on breech birth is part of a wider interest in complex normality – working with obstetric colleagues to enable women at moderate and high risk to birth and bond physiologically where possible. She currently works as a bank midwife at the Norfolk & Norwich University Hospitals NHS Foundation Trust, in addition to periodic teaching, consultancy and breech support across the UK and internationally.
Victoria Cochrane, RM, MSc is the Consultant Midwife for Normality at the Chelsea and Westminster NHS Trust. RM, MSc, Supervisor of Midwives. The majority of her clinical career has been working in and developing caseload and continuity models for women and their families in the community. She is deeply passionate about working with colleagues to support women making pregnancy and birth choices that sit outside of routine guidance. In her current role she works to support normality for women in all aspects of pregnancy and birth. Breech presentation became a special interest in 2009 when her daughter spent a few weeks in that position at the end of pregnancy; it’s amazing what one can learn in a short space of time when faced with challenging choices. This led to carrying out a cross-site service evaluation of the management of undiagnosed breech for her MSc dissertation.
Reitter, A., Daviss, B.-A., Bisits, A., Schollenberger, A., Vogl, T., Herrmann, E., Louwen, F., Zangos, S., 2014. Does pregnancy and/or shifting positions create more room in a woman’s pelvis?Am. J. Obstet. Gynecol. 211, 662.e1-662.e9.
Walker, S., Scamell, M., Parker, P., 2016. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery 34, 7–14.
Walker, S., Scamell, M., Parker, P., 2016. Principles of physiological breech birth practice: a Delphi study. Midwifery 43, 1-6. FREE DOWNLOAD until 13 December.
Walker S, Cochrane V (2015) Unexpected breech: what can midwives do? The Practising Midwife, 18(10): 26-29
So pleased to receive news via Twitter that physiological breech birth skills are being taught in Bangladesh! Tanya (@midwifeinbd) is doing a wonderful job collaborating with obstetric colleagues to change the way breech is taught and enable active breech birth.
— Tanya (@midwifeinBD) June 1, 2016
Integrated training in Bangladesh: a midwifery teacher, a doctor & the Labour Room manager/nurse. pic.twitter.com/QbHsji1Ki6
— Tanya (@midwifeinBD) June 1, 2016
— Tanya (@midwifeinBD) June 1, 2016
— Tanya (@midwifeinBD) June 1, 2016
— Tanya (@midwifeinBD) June 1, 2016
— Tanya (@midwifeinBD) June 2, 2016
— Tanya (@midwifeinBD) June 10, 2016
Videos used in the training described above include The mechanisms, simplified, The Birth of Leliana and Shoulder Press and Gluteal Lift. You can read about ‘prayer hands‘ in this blog about assisting the birth of the arms.
Thank you once again to the mothers, midwives and doctors who have shared videos and birth images to enable health care practitioners all over the world learn these important skills.
Following Sunday’s workshop in Asheville, Dad and I drove to Atlanta, Georgia. I kept him content by taking him out to dinner and buying him a pint of Shock Top. This strategy was successful, and the next morning we arrived at DeKalb Medical, home of the truly wonderful and amazing SeeBaby team. An opportunity to meet one of my obstetric heroes, Dr Brad Bootstaylor!
Dr Bootstaylor set the tone of this half-day study day by describing the facilitation of breech birth as a “healing force that goes beyond that mother and that birth.” This philosophy, or as Dr Bootstaylor describes it, “a certain headspace,” clearly permeates the See Baby team. SeeBaby Midwifery is dedicated to providing options and support to women and families in this birth community. Patients travel near and far, for birth options such as Water Birth, VBAC, Vaginal Twin Birth and of course, Vaginal Breech Birth (singleton & twin pregnancies).
We were also joined by Certified Professional Midwife (CPM) Charlotte Sanchez, another breech-experienced midwife in this community, who shared valuable reflections on some of the births she has attended. Charlotte also teaches other health professionals about the safe facilitation of breech births. Hopefully we will cross paths again soon. Thank you for coming along, Charlotte!
My presentations included the mechanisms of breech birth — the key to understanding when intervention is needed in physiological breech birth — and active strategies for resolving complicated breech births, as well as ‘Save the Baby’ simulations, where participants resolve complications in real time with birth videos.
Following this, the See Baby midwifery team and Dr Bootstaylor led a panel discussion on ways forward for breech in Atlanta and surrounding areas. CNM Anjli Hinman identified one barrier as insurance company’s requirement that providers sign a statement saying that they are ‘experienced’ at vaginal breech birth in order to offer this service. However, ‘experienced’ remains undefined. This is a persistent problem. Our international consensus research suggest competence to facilitate breech births autonomously probably occurs at around 10-13 breech births attended, although this varies according to individual providers, the circumstances in which they work and the complications they encounter during this period.
Following the workshop, participants took a tour of the SeeBaby facilities at DeKalb. I would have liked to have joined them, but I had a message from Dr David Hayes in Asheville. Jessica’s waters had broken, and her breech baby was on the way. Because he is the best dad in the world*, my old man turned the car around and drove me 3 and a half hours back to Asheville. (* Don’t tell him I said this. He’s already big- and bald-headed enough.)
Tomorrow: We return to Asheville for the birth of Leliana …
Thank you to Tomecas Gibson Thomas for use of some of the photos she took during the workshop!
Taking breech training into the Blue Ridge Mountains of North Carolina …
We had to make a pit stop at a Motel 6 around 11 pm, but my Dad and I arrived in Asheville in time to have grits for breakfast. Asheville is an amazing town with a real ‘alternative’ feel about it, so I was anticipating a very receptive crowd. Already, what was supposed to be one study day on Sunday turned into two, as more doctors wanted to attend but it was already fully booked.
So at Harvest Moon Woman’s Health we had a 4-hour condensed training on Saturday, attended by one board-certified obstetrician, one resident at a local hospital, two family practice doctors from South Carolina, and a handful of midwives. This was followed by the full-day training on Sunday with midwives who came from as far as Tennessee and Virginia. With 39% of the respondents (across all of the six training days) indicating they had NEVER had any training in vaginal breech birth, the need and demand for such training was very strong.
We again discussed the subtle difference between these two ways of performing the manoeuvre often referred to as Frank’s Nudge:
- Sub-clavicular pressure and bringing the shoulders forward to flex an extended head
- Pressure in the sub-clavicular space, triggering the head to flex
- (Walker et al 2016)
The first of these involves rotating the shoulders forward, as described by Louwen and Evans (Evans 2012), minimally lifting the baby, and initiating flexion in the thoracic and cervical spine. This action is often performed with a rocking motion, nudging the aftercoming head around the pubic bone, mimicking the way a head is normally born, in reverse. Mary Cronk used a ‘stuck drawer’ metaphor to describe why rocking rather than steady pressure is sometimes more effective. Participants felt that the description ‘shoulder press‘ is effective for communicating the simpler manoeuvre (#2), where the head has stopped at the outlet of the pelvis. South Carolina Midwife Gayling Fox then suggested the term rock’n’roll manoeuvre for the other skill (#1), more useful where the dystocia has occurred at higher levels of the pelvis. Only in Asheville! I have to admit, the phrase is both fun and functional …
The law of ‘attracting breeches’ was in full swing in the mountains, as OB-GYN Dr David Hayes reported having received multiple enquiries from women seeking support for a vaginal breech birth, just from having hosted this training. In addition to being a sensitive and woman-centred obstetrician, David is an experienced breech catcher, having worked in both high-risk Western settings and abroad with Medecins Sans Frontiers. While he was open to physiological breech methods due to his familiarity with physiological birth in general, he had never attended a breech where the woman birthed in an upright position.
One of the women who contacted him was full-term with her first baby in a frank breech position (both legs extended). David asked if I would attend to support the birth in a teaching capacity, if available. Although we still had a couple more stops on the road trip, I tend to believe what will be, will be … if the stars align in just the right way … I said, Yes!
Tomorrow: Last stop: Atlanta. Or so we thought …
Evans J. Understanding physiological breech birth. Essentially MIDIRS. 2012;3(2):17–21. (Frank’s Nudge)
Walker S (2015) Turning breech upside down: upright breech birth. MIDIRS Midwifery Digest, 25(3), p325-330. (shoulder press)
Walker S, Scamell M, Parker P (2016) Standards for maternity care professionals attending planned upright breech births. Midwifery. Vol 34, p1-7. (using subclavicular pressure to flex the aftercoming head)
— JacquelineSequoia MD (@jsequoia) May 28, 2016
Onto the City of Brotherly (and Sisterly) Love …
The original plan was to provide one Philadelphia-based study day while I was in town for the 20-year reunion of the Kelly Writers House, and the showing of our film on ‘Upright breech birth’ at the ACOG Annual Meeting. If being-with-breech teaches you anything, it is to go with the flow, as things rarely unfold as expected. The two main events conflicted, and the original study day was fully booked within a week or two of the listing. The demand for breech training spread quickly north and south, from Montreal to Atlanta. Clearly, many in North America are keen to develop skills and change the current breech culture.
Finally, the obstetricians join us! (They are always invited.) I was so pleased that three board-certified obstetricians attended this training. This is a big deal in Philly, one of the largest cities in America, where the midwives were unable to identify a single hospital-based practice where they can refer women who want to explore a vaginal breech birth. Big journeys begin with small steps.
Although I have been reassured that every evaluation of this training indicates those attending increase their confidence in supine/lithotomy breech delivery as well as upright techniques, I sometimes worry that our physiological birth-based approach might alienate doctors who work in settings where 90% of women have epidurals in labour. But I guess midwives who work in out-of-hospital settings have felt the same way for years, as their training has been determined by obstetricians whose challenges and location-specific resources are very different. We had great discussions, and there feels a real potential for future collaborative working in this area. (And of course I am wondering if the law of ‘attracting breeches‘ will take effect … ) 😉
The Philadelphia training was hosted by Lifecycle WomanCare, and organised by their Clinical Director, CNM Julie Cristol, who also has a passion for helping others to develop their physiological birth skills for normal birth. Thank you, Julie! Their practice is located in a beautiful building, right next to the original Bryn Mawr Birth Centre. I was so pleased to be able to have a brief tour of their home.
In Philly, we had a 3-hour half-day event because that is what fit everyone’s schedules this time around. Unfortunately, my old friend Christy Santoro was unable to attend because she was at a birth! See you next time, Christy. I enjoyed making new acquaintances and hope to see the Lifecycle crowd again. Didn’t get time to take many pictures because we spent our limited time together talking breech and research, then Dad and I departed for our 9-hour drive to Asheville! Epic …
Tomorrow: We arrive in Asheville to teach breech in the Blue Ridge Mountains of North Carolina …
From Montreal, it was on to Tillsonburg, Ontario, ‘near Toronto’ — because in Canadian terms, within 3 hours is ‘near.’ The places around Tillsonburg are confusingly called things like London, Norwich, and Cambridge. The lovely Norfolk Roots Midwifery team gave me one of their bags to remember my visit. Can’t wait to take it back to Norfolk, England with me!
Again, the training was attended by midwives who came from various places throughout Canada and the US, including Alberta, British Columbia and Michigan, south of the border. I was privileged to meet Stacia Proefrock, a breech-experienced midwife from south-central Michigan. In addition to attending breech births, Stacia has experience teaching others about physiological breech birth and is the current president of the Michigan Midwives Association – a great person to be in touch with if you would like to organise a study day of your own in this area.
While in Ontario, I picked up a Deverra birth stool for use in teaching and births. The stool is visible in the photo to the right. I love their design, which features a wooden seat and 360º visibility. The Deverra birth stool is also completely portable; the legs unscrew and it comes in its own carry bag. When professionals are making the transition to active breech birth but can’t quite wrap their heads around facilitating a breech birth from behind the woman, I often recommend a birth stool as a good compromise — the woman remains mobile and upright, while the baby emerges facing a direction familiar to the attendant. While other birth stools are available, I am quite happy with this one, another reminder of my trip to Ontario!
At the end of each study day, we spend some time discussing how professionals acquire breech experience when breech births are not very common, including the concept of ‘attracting breeches,’ emerging in my current research. I know several of those attending this study day have sharpened their skills, reflected on the experiences they have already had, and are open to attracting breeches, so I look forward to seeing what happens among this group. Of course, in Ontario, activists have a great model in the Ottawa-based Coalition for Breech Birth and Midwife Dr Betty-Anne Daviss, who have worked together to enable midwife-facilitated breech births in hospitals in that area. Join forces with each other and work together for change!
The training was held in the house of author, speaker and birth activist Sheila Stubbs, who holds regular Birth Nerd gatherings in her home. The warmth and sisterhood in this community was very strong, and Sheila reminded me of Norwich’s beloved doula mother, Rachel Graveling. Thankfully, Sheila gave me a signed copy of her book for the Norwich Birth Group lending library.
Thanks also to Christine McGillis, who organised this training in Tillsonburg. ❤️
Tomorrow: On to Philadelphia, and the start of my Father-Daughter road trip!
Earlier this month (May 2016), I completed a road trip from Montreal to Atlanta to share the results of our international consensus research (Walker et al 2016), explain how it can be used to guide practice and education, and deliver physiological breech birth training based on that research to approximately 130 health professionals and other birth workers.
The goal was to enable these professionals to learn new skills, equip them to continue learning using an on-line Virtual Community of Practice, and empower them to disseminate the knowledge to others in their local communities. I met so many wonderful people, and feel confident they will work to extend the availability of skilled support for planned vaginal birth. I am going to tell the story of this amazing road trip in a blog mini-series. I hope you will join us … there is a special surprise at the end! 😉
The first workshop was attended by Certified Midwives from Quebec, Ontario, Maine, and Massachusetts, as well as doulas and CPMs from these communities. In Quebec, midwives work mostly in community settings and are not legally able to attend breech births except in emergencies (undiagnosed). However, some of the midwives have begun to work with obstetricians who will accept planned breech births, and they are working towards woman-centred, physiological care for these women. They also want to ensure emergency skills training is up-to-date, including physiologically-based strategies appropriate to midwifery-led settings.
As physiological breech birth gradually becomes the standard of practice, especially for midwives, breech skills will increasingly be taught by trainers who may or may not have much breech clinical experience themselves, much like they are now. It is therefore important that trainers be able to become ‘qualified’ to teach physiological breech methods, in the same way they teach supine-based emergency delivery techniques, and that they are teaching methods underpinned by research and consensus. Several skills trainers from throughout Quebec attended the workshop, and by using the resources made available, hope to disseminate the training to others in their local communities. I especially enjoyed meeting Sinclair Harris, the grandmother of this midwifery community, who has nurtured so many young midwives and is still actively teaching. Sinclair completed her RN training at St Mary’s in London. ❤️
Anyone in Quebec interested in receiving training
in the facilitation of physiological breech births —
contact Andrea Houle, the RSFQ Agente de Formation.
(contact form below)
The midwives told me that use of ‘prayer hands’ in rotational manoeuvres to release the arms struck a chord with them. The shoulder press manoeuvre also made sense, but some midwives felt that the two disctint versions of this manoeuvre needed independent descriptive terms, to capture subtly different techniques which are applicable in various circumstances. This cluster of manoeuvres have been taught as “Frank’s Nudge,” in honour of Frankfurt obstetrician Professor Frank Louwen. But because research indicates eponyms (named after people rather than descriptive terms) can lead to confusion and inadequate documentation, we try to use a description which ‘does what it says on the tin’ in the Breech Birth Network training, and we continually listen to feedback about what works to help novices learn breech better. More on the distinction between these manoeuvres coming up in a future blog …
Following the workshop, midwife Bronwen Agnew was kind enough to take me on a tour of the Maison de naissance, Côte-des-Neiges. This local birth centre is housed in a wonderful old rectory building, complete with wooden floors. It reminded me of my grandmother’s house, warm and simple. A beautiful place to give birth! Thank you, Bronwen.
The Montreal workshop was organised by Montreal doula and CPM, Rivka Cymbalist, and held at Studio L’équilibre en mouvement, ave Van Horne, a wonderful venue. We also enjoyed lunch at Rivka’s cafe, Caffe della Pace. Thank you, Rivka and family for your hospitality! If you are ever in Montreal, I also recommend relaxing at La Société Textile, a crafts shop / café where you pay by the hour to hang out, work on your knitting/sewing project, and drink unlimited tea from the kitchen. What more could a midwife ask for?
The current plan is to provide a 2-day breech train-the-trainers course in Toronto in late July / early August 2017, involving myself and some of the midwives who have taken the training this year and will be disseminating the skills in their communities. This is due to abundant feedback from the participants that they would like the training to be longer to allow for more discussion, reflection, fellowship and hands-on practice — of course we support all of the above! Follow this blog or the Breech Birth Network Facebook page to keep updated on our plans.
Tomorrow: Join us as we travel to Tillsonburg, Ontario!
Busy packing … leaving London for the US on Friday. Originally, I planned to attend the celebration of 20 Years of the Kelly Writers House and my college reunion at Penn, as well as the annual ACOG meeting where our film on upright breech birth is being shown, followed by a family wedding. But it turns out the first two conflicted, so instead I will be spending half of my holiday teaching breech in collaboration with other health professionals along the east coast of the US and Canada. With ‘renewed interest’ in vaginal breech birth from the ACOG, and Canadian SOGC guidelines fully supporting planned breech birth since 2009, the will to revive breech skills is in full swing in North America!
Some of the health professionals and birth activists collaborating to provide breech training in their communities include:
- Atlanta, Georgia – See Baby Midwifery is dedicated to providing options and support to women and families in the birth community. Patients travel near and far, for birth options such as Water Birth, VBAC, Vaginal Twin Birth and of course, Vaginal Breech Birth (singleton & twin pregnancies). The SeeBaby Team will lead a panel discussion on ways forward in the support of vaginal breech birth, and Dr Brad Bootstaylor is collaborating on the analysis of the evaluation data from this series of training days. (Places available.)
- Asheville, North Carolina – This is a community which values co-operation, and the study days here have been organised collaboratively by obstetricians, CNMs, CPMs and doulas. Dr David Hayes of Harvest Moon Women’s Health is also contributing to the analysis of the evaluation data. Thanks especially to Kathleen Davies and Jennifer White.
- Philadelphia, Pennsylvania – Thank you to Julie Cristol, CNM, of Lifecycle WomanCare for enabling this workshop.
- Tillsonburg, Ontario – Thank you to Christine McGillis and Sheila Stubbs for making this workshop happen in Ontario.
- Montreal, Quebec – Thank you to Rivka Cymbalist for organising this workshop and raising awareness of the need to increase vaginal breech birth options in this community. (Places available.)
This is a brief welcome message for those attending the Physiological Breech workshops.
The training provided by Breech Birth Network is different from obstetric emergencies training because it is based on physiological birth principles, including the importance of maternal movement in facilitating the birth process. Decisions on when or whether to intervene in a breech birth are determined by careful observation of the unfolding mechanisms, recognition of deviations from the norm and strategies to restore the mechanism. These strategies include maternal movements, as well as hands-on help from birth professionals. In Breech Birth Network training, which follows recommendations outlined in primary research with experienced professionals, birth videos are central resources, enabling both experienced and inexperienced professionals to develop and expand their pattern recognition skills, even in communities where actual breech births remain a rarity. Therefore, the training is supplemented by secure access to the resources and videos, which cannot be downloaded, but can be used to refresh training by those who attend the hands-on workshops when preparing for a birth within their local teams — the Virtual Community of Practice (VCOP).
Thank you to the women, midwives and obstetricians who have made this possible in order to increase the safety of breech birth for others.
Training programmes are often evaluated according to Kirkpatrick’s hierarchy, which has 4 levels:
Thorough evaluations of breech birth training packages are lacking. Evaluating impact of training on maternal/neonatal outcomes is a longer-term project, easier to achieve when considering the effect of training within one site, rather than professionals working in many different contexts; we have plans to begin such a project later in the year. However, for this series of study days in North America, we are collecting data on how many breech births those participating have attended in the year before and after training (change in behaviour), as well as changes in confidence levels before and after training (change in learning).
Those attending these training days include obstetricians, CNMs, CPMs, students, and birth activists keen to support cultural change in their communities. The results of the evaluation will help us to determine whether providing breech birth training based on conceptual understanding of physiological principles, within a community of practice/network learning model, will increase women’s access to the option of vaginal breech birth by increasing provider confidence and skills to provide this service.
The evaluation data will also contribute to answering two fundamental questions, which will require on-going research in the future:
- How can vaginal breech birth skills be revived within communities which have few or no experienced providers?
- How does training based on physiological principles impact the safety of breech birth for mothers and neonates?
Thank you to all the health professionals participating in this training and evaluation. I am looking forward to meeting you and learning from your communities!
P.S. Of course, we aren’t the only source of physiological breech birth training. Others include:
- Maggie Banks’ Breech Birth On-line Workshop
- Midwifery Today Conferences almost always include a full-day breech skills day facilitated by highly breech-experienced midwives
We advocate that all professionals including breech within their sphere of practice access breech training from multiple providers, consider the underlying principles and how they fit with your own understanding and experiences of birth, and maintain an open mind.
Tonight, I met with some students from the local midwifery school who are preparing for their final OSCE. How exciting! They wanted to review mechanisms and manoeuvres so that they feel confident performing for their exams.
The students will be expected to demonstrate their knowledge of supine/lithotomy skills, so we created a new video to help them remember what we practised.
For those wanting to review the mechanisms when a woman is in a supine position, this video, filmed with midwifery students at the University of Salford last year, may also be helpful.
The next study group, for professionals, students or women in and around Norwich, will be on Monday, the 8th of February, from 10am – 1pm. For more resources to prepare for OSCE’s, click on the OSCE tag.
You may also find this video helpful, made by Joy James, a midwifery lecturer at the University of Glamorgan:
And from Maternity Training International:
Yesterday, I was in snowy Salford – up north! Senior Lecturer and LME Elaine Uppal invited me with two goals: 1) to make sure her students thoroughly understood the mechanisms of breech birth in preparation for their vivas next week, and 2) to raise money for student electives abroad, particularly in Cambodia, where Elaine has a long-standing relationship with a midwifery twinning project.
After the study day, the students and I made two basic videos to assist their revision.
- Review this information with words and pictures: the mechanisms.
- Review some manoeuvres specific to upright breech: download How and When to Help.
Good luck with your exams, student midwives!