Category Archives: Study Days

Breech in Belfast

Consultant Obstetricians Niamh McCabe and Jacintha Costa, and Breech Specialist Midwife Jacqui Simpson

The Breech Birth Network visited Belfast this weekend. Dr Anke Reitter FRCOG of the Krankenhaus Sachsenhausen and I taught a day-long physiological breech study day at the Royal Victoria Hospital for over 40 obstetricians and midwives.

The day was organised by Consultant Obstetricians Janitha Costa and Niamh McCabe, enthusiastic upright physiological breech practitioners, and Senior Registrar Shaun McGowan. The team have recently published outcomes associated with their breech clinic (Hickland et al 2017 and Costa 2014).

Our study day increasingly emphasises pattern recognition and decision-making through the use of real breech birth videos, especially videos of complicated births. We watch, deliberate and critique – with compassionate understanding, respect and humble appreciation. These brave health professionals and women have allowed themselves to be vulnerable and exposed in order that others may learn, and we are very grateful.

We have also moved away from using heavy and expensive simulation models and rely instead on doll and pelvis models. These enable us to see what is happening from all angles and embed the theory of the manoeuvres we are teaching. We operate on a see one (the theoretical presentation), do one (hands-on with one of the instructors), teach one (of your colleagues) model. This helps build confidence to carry on teaching the techniques in the local setting.

Our preferred models (it’s a great idea to have some on hand if you are organising a study day or implementing this training in your local setting) are:

Fetal Doll Model; and

Cloth Pelvic Model; or

Female Pelvis Model

Final announcement: Blogging has resumed because … I submitted my PhD a couple weeks ago! Hurrah!

Shawn

Krankenhaus Sachsenhausen is also on Facebook!

Visca les natges! Barcelona breech training

(See the Catalan version of this article below …)

This week (21-22 March 2017), the Breech Birth Network was in the beautiful city of Barcelona, at the invitation of the obstetricians and midwives of Hospital Sant Pau. Our team expanded for the occasion! Midwife Maria Segura translated all of our teaching slides into Catalan. And Cardiff-based midwife Carmen Rubio ensured everyone had an opportunity to receive hands-on help when practising manoeuvres to assist women birthing in upright positions.

I love studying and teaching physiological breech birth most because when a health professional learns how breech works, they learn how all birth works. Despite its apparent applicability for only a small proportion of the total population, skill in the art of facilitating breech birth resonates throughout a professional’s entire birth practice, their collaborative work with colleagues and within institutions.

Our experience in Barcelona made this clear. Hospital Sant Pau is in a period of transition, trying to increase the rates of normal birth. Breech birth is a part of that, but midwives are also working to establish the first midwifery-led birth centre in Catalunya. The hospital has recently established a new guideline enabling obstetricians to support physiological breech birth, including women who choose to birth without an epidural. To enable women to have a choice of pain relief for physiological birth without epidural, the hospital team are considering offering nitrous oxide (Entonox) for the first time. And for some of those attending this week’s training, our videos were their first exposure to women birthing in a kneeling position. One obstetrician suggested they could prepare for the change in breech practice by facilitating kneeling positions for cephalic births!

Dr Arianna Bonato, one of the external OB-GYNs attending the training, told me she feels that a breech birth is the most beautiful birth to see, because the physiology is so visible. I agree! This visibility makes possible learning about physiological birth in general within the microcosm of breech.

The way that a neurologically intact baby assists his own birth, the intuitive movements of a mother who feels safe and uninhibited, and the consequences of interventions in the mother-baby dance, to facilitate or disrupt, are all much more exposed. As Carmen Rubio reminded me, breech births demand calm wisdom in the birthing space like no other.

“Give it a wiggle” / “Donar una sacsejada” !

I have no doubt Hospital Sant Pau’s open-minded and forward-thinking approach will attract many more women to birth in this hospital, and that their midwifery unit will also thrive when it is opened. A blessing for the women of Barcelona. I look forward to staying in touch and learning from their experience of implementing these new practices!

Thank you to Consultant Obstetrician Ma Carmen Medina Mallen, and Maria Segura, for their work in organising the Breech Birth Network training this week. Hospital Sant Pau will be auditing their outcomes for term breech presentation over the next year, as part of our international evaluation of Physiological Breech Birth training.

— Shawn

Elevate & Rotate from Shawn Walker on Vimeo.


Many thanks to midwives Carmen Rubio and Maria Segura for the translation of this blog into Catalan!

Aquesta setmana (21-22 de Març 2017), la Xarxa pel Part de Natges va estar a la bonica Ciutat de Barcelona, com a invitació dels ginecòlegs i llevadores de l’Hospital de Sant Pau. El nostre equip va créixer per l’ocasió! La llevadora Maria Segura va traduir totes les diapositives de la sessió al català i la llevadora Carmen Rubio, amb seu a Cardiff, va garantir que tothom pogués tenir l’oportunitat de rebre ajuda en la pràctica de les maniobres per assistir les dones que vulguin donar a llum en posicions verticals.

Hospital Sant Pau

M’agrada estudiar i ensenyar el part de natges de manera fisiològica, sobretot, perquè quan els professionals aprenen el funcionament d’aquest, també ho fan sobre els fonaments de donar a llum. Encara que la seva aparent aplicació sigui per una petita proporció de la població, l’habilitat en l’art de facilitar els naixements de natges ressona a través de tota la pràctica professional, així com a la feina de col·laboració entre companys i al conjunt de les seves institucions.

La nostra experiència a Barcelona ho va deixar ben clar. L’Hospital està a un període de transició, intentant incrementar les xifres del part natural. El part de natges forma part d’això, però les llevadores, a més, estan treballant en la línia de crear la primera casa de naixements pública a Catalunya. L’Hospital ha establert recentment un nou protocol que permet als obstetres reconsiderar el part de natges de forma fisiològica, incloent-hi la voluntat de les dones que vulguin donar a llum sense epidural. A més, l’equip de l’Hospital està en vies d’introduir l’Òxid Nitrós (Entonox) per primera vegada, com un altre recurs d’analgèsia per les usuàries de part. Per alguns dels participants a la formació, va ser la seva primera vegada en veure, a través dels vídeos, a dones donant a llum en posició vertical. Una de les ginecòlogues va suggerir que es podrien preparar pel canvi en la pràctica de l’atenció al part facilitant més activament la posició vertical als naixements dels nadons que es troben en presentació cefàlica.

La Dr. Arianna B. una de les obstetres/ginecòlogues que va atendre la formació, em va dir que sentia que el naixement de natges és molt bonic d’observar, perquè en ell es pot veure clarament la fisiologia del part. I estic d’acord! Aquesta claredat és la que ha permès aprendre del part fisiològic en general des del microcosmos de les natges.

La forma en què un nadó neurològicament sa assisteix el seu propi naixement, els moviments que intuïtivament fa la mare quan se sent segura i desinhibida, i quines són les conseqüències de facilitar o interrompre la dansa entre mare i fill són molt clarament exposades. Com la Carmen Rubio em va recordar, el part de natges demana com cap altre, la saviesa calmada de l’espai en el qual es dóna a llum.

No tinc cap dubte que la ment oberta i de pensament avançat de l’Hospital de Sant Pau atraurà moltes més dones a aquest Hospital i que la seva Casa de Naixements serà també popular quan l’obrin. Una benedicció per les dones de Barcelona. Estic desitjant estar en contacte i aprendre de l’experiència en la implementació d’aquestes noves pràctiques.

Moltes gràcies als membres de l’equip obstètric, la Ma Carmen Medina Mallen i a Maria Segura, pel seu esforç organitzant la formació de la Xarxa pel Part de Natges. L’Hospital de Sant Pau auditarà durant l’any vinent els resultats dels parts en presentació de natges com a part de la nostra avaluació internacional respecte la formació del Naixement Fisiològic de Natges.

— Shawn, Carmen & Maria

Wales and the breech

Cardiff midwife Carmen Rubio spots the nalgas!

This week, we’ve been doing our breech thing in Wales. First Powys, at the Royal Welsh Showground in Builth Wells, and then on to Aberystwyth to deliver our RCM-approved Physiological Breech Birth study day. I had some help to deliver the training in Powys from a new member of the Breech Birth Network team: Emma Spillane, Lead Midwife for the Carmen Suite Birth Centre of St. George’s, London. Emma brings both breech and NHS leadership experience to the team and is a fantastic skills educator. Welcome, Emma!

Emma Spillane, Shawn Walker & Shelly Jones at the Royal Welsh Showground (early in the morning …)

Midwifery in Wales is a different kettle of fish to much of the rest of the UK. Powys has no obstetric unit, and care is entirely midwifery-led for women at low and moderate risk. Births take place at home or at a midwifery-led unit, unless the women travel to an obstetric centre out of choice or by referral. Improving skills to facilitate undiagnosed breech births, in settings where the transfer time may be well over an hour, was the priority for these midwives. The focus of our training is on using physiological principles (#giveitawiggle). But we also explored the potential for collaborative working across boundaries to provide continuity for women requesting a breech birth. Thank you to Lead Midwife Shelly Jones of the Powys Teaching Health Board for organising the day!

Tanya Burchill practising manoeuvres with Emma Spillane during a break

Dr Liliana Docan giving instruction on manoeuvres

Aberystwyth is an obstetric unit, but at 600 births per year also maintains close ties with larger units nearby, especially Carmarthen. The guidelines around breech and ECV are currently being reviewed in this area, and the hope is that future guidelines will include more recent evidence around 1) support for informed choice of breech birth; 2) use of upright birthing positions; and 3) increased involvement of midwives in both physiological breech and ECV practice. A visible care pathway is needed in this sparsely populated area, where providing the full spectrum of care relies on close collaborative working between smaller and larger units. Thank you to Senior Midwife Rucha Eldridge of Bronglais Hospital/Ysbyty Bronglais for organising the study day! And thank you to Aber obstetrician Liliana Docan and clinical skills educator Nicole Gajlikowska for your enthusiasm and help with hands-on practice of upright manoeuvres.

Given the level of interest and the number of attendees from different areas of Wales and the English border, we expect Breech Birth Network will be returning soon. If you have breech experience and would like to become involved in teaching and leading change for breech within Wales, we would love to hear from you! We can lend our experience and fully evaluated course materials to your efforts. You can contact us using the form below.

Shawn

Aberystwyth

The Netherlands and the breech

Midwifery Lecturers Merel Schoemaker and Bahar Goodarzi

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.

Midwifery Lecturers from the universities of the Netherlands

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.

Shawn

References

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

Training in Norwich: 14 January 2017

Simulations in Christchurch, NZ, October 2017

Simulations in Christchurch, NZ, October 2017 – photo by Tina Hewitt

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.

Eventbrite - Physiological breech birth study day - Norwich

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.

studying breech in Salford, 2016

studying breech in Salford, 2016

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 ProjectSee 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


Facilitators:

  • 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.


References

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

Final Stop: Atlanta

See Baby panel discussion

See Baby panel discussion

From Asheville to Atlanta, home of the SeeBaby team!

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 demonstrating breech skills

Dr Bootstaylor demonstrating breech skills

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.

groupFollowing 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 …

Shawn

Thank you to Tomecas Gibson Thomas for use of some of the photos she took during the workshop!

Stop 4: Asheville

Brunch with the Masterchief at Tupelo Honey Cafe

Brunch with the Masterchief at Tupelo Honey Cafe

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.

A few of the participants in the Saturday workshop

A few of the participants in the Saturday workshop

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 Sunday crowd

The Sunday crowd

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 …

Shawn

References:

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)

 

Stop 3: Philadelphia

ACOGfilmOnto 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.

bcflags2Although 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 … ) 😉

Lifecycle WomanCare

Lifecycle WomanCare

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 …

Shawn

Second stop: Tillsonburg, Ontario

Celebrating Norfolk Roots Midwifery!

Celebrating Norfolk Roots Midwifery!

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!

 

Midwife Joanna Nemrava came from British Columbia to share breech skills!

Midwife Joanna Nemrava came from British Columbia to share breech skills!

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.

 

Teaching in Tillsonburg; photo: Sheila Stubbs

Teaching in Tillsonburg; photo: Sheila Stubbs

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!

practising

practising breech manoeuvres

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!

Shawn

a walk around beautiful Tillsonburg

a walk around beautiful Tillsonburg

First stop: Montreal

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.

Wall mural depicting the Maison de naissance, Côte-des-Neiges

Wall mural depicting the Maison de naissance, Côte-des-Neiges

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.

Certified Midwives Sinclair Harris, Mounia Amine, Sylvie Carignan, and Sylvie Saunier

Certified Midwives Sinclair Harris, Mounia Amine, Sylvie Carignan, and Sylvie Saunier

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)

Certified Midwife Bronwen Agnew

Certified Midwife Bronwen Agnew

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 …

CPM and doula Rivka Cymbalist with the world's youngest breech catcher

CPM and doula Rivka Cymbalist with the world’s youngest breech catcher

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!

Shawn

Evaluating breech training in North America

ShawnPortsmouthBusy 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:

Kirkpatrick model

Image from : http://www.kirkpatrickpartners.com

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).

networklearningThose 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:

  1. How can vaginal breech birth skills be revived within communities which have few or no experienced providers?
  2. 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!

Shawn

P.S. Of course, we aren’t the only source of physiological breech birth training. Others include:

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.

The midwives of Portsmouth and the aftercoming fetal head

Claire Reading sharing her skills

Claire Reading sharing her skills

This Tuesday, 1 March 2016, Breech Birth Network travelled to Portsmouth again. The guest speaker was lovely doctor Ms Arti Matah, who spoke about an obstetrician’s view of vaginal breech birth, and led a lively discussion around whether the breech team / care pathway model might work for Portsmouth. Watch this space! I am incredibly impressed with the commitment Portsmouth midwives have shown to developing sound breech skills to support women who choose to birth their breech babies actively.

The skill which captured the group’s imagination most was how to resolve a situation where the head is extended and impacted at the inlet of the pelvis. My research suggests that identification of optimal mechanisms is a core skill for practitioners attending breech births. Therefore our approach to teaching this skill is:

  1. Identification of optimal mechanism — The aftercoming fetal head normally rotates to the oblique/transverse diameter as it enters the pelvic brim, just like the cephalic-presentation head does when engaging.
  2. Identification of deviation from optimal mechanism — In this complication, the fetal head is pinned in the anterior-posterior diameter, with occiput anterior, over the maternal symphysis publis, and chin or brow on the sacral promontory. The bottom of the fetal chin is felt like a ‘bird beak,’ pointing towards the sacrum. The maxilla bones are difficult/impossible to reach, so flexing the head using the usual techniques will be a challenge.
  3. Restore the mechanism — See below.

ShawnPortsmouthThe RCOG guideline suggests delayed engagement in the pelvis of the aftercoming head should be managed using one or both of the following techniques:

Suprapubic pressure by an assistant should be used to assist flexion of the head. Given our understanding of the head as impacted at the pelvic brim and our goal of restoring the mechanism by rotating the head to assist engagement, we suggest that the goal of suprapubic pressure should initially be to encourage this rotation. This mirrors the understanding we have of suprapubic pressure to resolve a shoulder dystocia by rotating the impacted shoulder off the symphysis pubis. Forcible pressure on an impacted fetal head is unlikely to be beneficial for the baby.

The Mauriceau-Smellie-Veit manoeuvre should be considered, if necessary, displacing the head upwards and rotating to the oblique to facilitate engagement. We use a doll and pelvis to explore why this elevation and rotation prior to re-attempting flexion is necessary. Watch the video below to see this demonstrated.


When a woman is birthing her breech baby actively, we facilitate the head to enter the pelvis using the same principles. Watch the video below, where Midwife Olivia Armshaw is teaching how  to intervene in the case of an extended head at the inlet, when the woman is birthing on hands/knees. In this video, the midwives are discussing how maternal movement – in this case, the woman shuffling her bottom back towards the midwife slightly – helps to elevate the head off the pelvic inlet to facilitate engagement, a technique we learned from the midwives of Sheffield. The principles – elevate, rotate & flex the head – are the same.


Thank you to the Practice Development Team at Portsmouth for organising the day. And thanks to the following midwives for assisting with the day:

  • Claire Reading, midwife in Somerset, who shared her breech experience gained working abroad, and facilitated one of the hands-on stations
  • Olivia Armshaw, midwife from Gloucester, who facilitated one of the learning station and presented on the process of developing a breech team in her local area
  • Tess McLeish, midwife from Lewisham who helped the day run smoothly

Our one sadness on this study day was that we were not joined by any of Portsmouth’s obstetric staff, aside from Ms Arti Matah, who needed to leave early because she was good enough to present at the study day following a night on-call. Across the UK, midwives are trying to engage their obstetric colleagues in a discussion about how to improve things for breech babies and their mothers, and we really need more doctors to come to the table for that discussion to result in a service which is as safe as possible.

Shawn Walker, Olivia Armshaw & Jenny Hall

Shawn Walker, Olivia Armshaw & Jenny Hall

BONUS was meeting and relaxing with Midwife Jenny Hall in Portsmouth after the study day!

— Shawn

Further Study Days are listed under Events. View our Training page for more information.

Feedback from the Study Day:

“the group work was excellent Overall I thought the day was was a good balance of theory to practical”

“very interactive. realistic rather than textbook. real life experiences.”

“perfect study day. Interesting and kept my attention all day!!!”

“visual with the film clips and hands on with the doll and pelvis. Was very good to see normal and abnormal films and great discussion with colleagues to share experiences and what to do in that situation.”

“I also thought Shawn’s attitude to breech was very refreshing. I half expected it to be a bit like “you can have a vaginal breech no matter what”. this was not the case. She had a very safe and sensible approach.”

Laura Latina: new study day co-ordinator

Laura picI’m pleased to introduce a new co-ordinator for the Breech Birth Network study days: Laura Latina, MSc, RM. Laura is now taking the lead on organising study days, and if you would like to make an enquiry, you can contact her on the form below. Read more about Laura in her own words below.

I love being a midwife. I believe midwifery is an art; the art of empowering women in discovering their capacity of giving birth.

I work at St Thomas hospital as a caseload midwife. I advocate and believe in normal births. I like working closely together with women. My relationship with women and her partner is based on respect and trust. Empowering her and the partner to make their informed choice is also important for me. In my work I prioritise continuity of care; this means I look after women since the beginning of the pregnancy, during birth and post-natal. Pregnancy and birth are a journey; accompanying women and being part of this journey it’s amazing!

Lara at homeI have worked in all settings: midwife led unit, consultant led unit, home and as independent midwife. I encourage women to believe in their bodies and in their babies and I feel full of oxytocin when they have a positive birth experience.

My interest in vaginal breech births has started from my work in developing countries. I have been in many countries of Africa and Afghanistan where I assisted, supervised and taught to more than 30 vaginal breech births also in upright positions.

I love teaching too; I have participated to trainings as facilitator and as ALSO instructor.

My experience in Africa encouraged me to deepen my knowledge in developing countries, for this reason I own a MSc in Reproductive & Sexual Health Research at London School of Hygiene and Tropical Medicine.

I love reading and teaching and I am also interested in research.

I love spending long time chatting in front of a coffee and I go often to walk in a park!

 

Read more about Breech Birth Network study days on the pages below:

 

A craftsman’s job

Two weeks, two inspirational obstetric colleagues, two very welcoming UK cities. So much commitment to improve the system for breech babies and their mothers.

eclipse tweetOn the 20th of March, Dr Elie Azria of the Hôpital Paris Saint Joseph and Descartes University, joined me in Dundee, Scotland, to teach through the eclipse! The French and Belgians have continued to support breech births in the last 15 years, responding to the Term Breech Trial (TBT) with a prospective observational study (PREMODA, 2006) which involved over twice the number of planned breech births (VBB) than the TBT, and demonstrated no statistically significant difference in outcomes between those who planned a VBB and those who planned a caesarean section (CS). Azria was the lead author on a follow-up analysis of the data examining factors associated with adverse perinatal outcomes in the PREMODA data.

AzriaIn our Breech Birth Network study day, Azria presented new research concerning whether breech presentation is an independent risk factor in preterm breech birth, with interesting results which we hope to see published soon. He also gave an inspiring presentation on the “Traps of Evidence Based Medicine,” using the example of term breech delivery, building on his work to reconcile the need for maternal autonomy and medical responsibility in shared decision-making about mode of childbirth.

from http://hustleandgrind.co/

from http://hustleandgrind.co/

I always enjoy teaching with experienced practitioners who come from a different practice culture. Practice constantly improves and evolves from sharing these different ways, if we are open to learning from each other. Azria pointed out that, sadly, even within a culture where support for VBB has remained standard, the use of CS is on the rise. As he described, “Breech delivery is a craftsman’s job,” an art as well as a science. Learning breech skills requires commitment, dedication and practice, which not everyone is willing to offer. Nor are many people keen to take the risk of learning in the current risk-averse climate of maternity care.

Read more about How singleton breech babies are born in France, from the AUDIPOG network (Lansac et al 2015).

Julie Woodman (Queen Alexandra) & Miss Nicola Lack (UCLH)

Julie Woodman (Queen Alexandra) & Miss Nicola Lack (UCLH)

On the 27th March, I was joined by Miss Nicola Lack, Consultant Obstetrician from University College London Hospital NHS Trust. Lack gave a fantastic presentation on the research base for counselling about mode of childbirth with a breech presenting baby. One of the problems with a decimated skills base is that, while we may have a strict set of inclusion criteria for what constitutes ‘normal’ for a VBB, it may be quite difficult to find someone who can actually assess those criteria at a moment’s notice on labour ward, eg. a hyperextended neck on ultrasound. Breech skills are not just the manoeuvres which may be used around the time of birth. Skilled practice also involves the ability to provide detailed individualised counselling and make relevant antenatal assessments, as well as on-going interpretation throughout pregnancy and labour.

Portsmouth

photo by Michelle Ball

Lack’s presentation drew extensively from her own experience of working in the UK and Africa, as well as her understanding of medico-legal issues and constraints caused by a litigious practice culture. She explained how, when counselling, we really need to talk about the potential benefits of VBB as well as the risks. For example, she reflected on how, when she first qualified as an obstetrician in 1999, placenta percreta was relatively rare. Now, she and her colleagues encounter it approximately once a week or fortnight, due to the increase in CS rate. That’s very concerning. Lack also facilitates a postnatal birth reflections clinic, where she has had the opportunity to learn how women feel about breech childbirth experiences, both CS and VBB, after the event.

Midwives Michelle Ball and Shawn Walker

with my Twitter friend @Shelly_RM

My one sadness on both days was that, despite the best efforts of the organisers and the high calibre of the obstetric speakers at the events, so few obstetric colleagues attended the study days. This is a real problem. Midwives are increasingly advocating for women to have the realistic option of a well-supported VBB if that is their informed choice, but this needs to be a collaborative effort. I urge our obstetric colleagues to come to the table to learn and work with us, so that the women and babies we care for, and we as professionals, can benefit from the best possible support of the wider multi-disciplinary team.

Thank you to Consultant Midwife Phyllis Winters of the Montrose Maternity Unit and Julie Woodman of the Queen Alexandra Hospital in Portsmouth for organising the study days.

Shawn

Turning breech upside down

February 2015

Yesterday, approximately 50 midwives and obstetricians shared some love for breech babies in Preston by hosting a Physiological Breech Study day!

prayer handsThe day was organised by inspirational Consultant Midwife Tracey Cooper, with the help of midwives Emma Ashton and Emma Gornall, and we felt so welcome! Collaborating with their obstetric colleagues, these midwives have led changes in Preston, where guidelines now advise midwives to use hands and knees maternal positioning for all undiagnosed breech births occurring outside the obstetric unit, including the MLBU and home births. In these settings, obstetric beds are not usually available. Adverse outcomes have occurred across the UK because midwives who have only been trained in lithotomy manoeuvres, following guidelines mandating the lithotomy position, have instructed women to lie on the floor, either to perform a hasty and unnecessary vaginal examination, or to ‘manage’ the birth in the way that feels most familiar. As a result, women have then abandoned the most physiologically advantageous forward kneeling position in order to accommodate health professionals. When a woman is supine on a flat surface, the baby’s body cannot hang the way it does in true lithotomy position, and this may cause difficulties with the birth and/or delivery of the head.

Learning to negotiate nuchal arms when women are upright

Learning to negotiate nuchal arms when women are upright

I have been encouraging midwifery leaders to address this problem for some time, after becoming aware of such troubling events occurring not infrequently. In addition, I performed an audit covering a 20-month period in my previous practice setting, and the results indicated that 80% of the breech presentations diagnosed for the first time in labour occurred among otherwise low-risk women under midwifery-led care. This population does not routinely receive a third trimester scan in the UK, and the research does not necessarily indicate that doing routine scans would improve outcomes. However, it does suggest that each midwifery-led setting should have a plan in place to ensure all midwives have setting-appropriate training for managing unanticipated breech births, and that women have access to skilled and supportive counselling and care when this occurs. As more births are occurring in midwifery-led settings following the recommendations of the 2014 NICE Intrapartum Care guidelines, this forward planning will be more and more important, to promote safe physical and psychological outcomes for women and babies.

If you would like to read more about undiagnosed breech or antenatal detection of breech presentation, click on the links.

Emma Ashton, Gerhard Bogner, Olivia Armshaw, Tracey Cooper & Shawn Walker

Emma Ashton, Gerhard Bogner, Olivia Armshaw, Tracey Cooper & Shawn Walker

We were privileged to be joined by Dr Gerhard Bogner of Paracelsus Medical University in Salzburg, Austria. Bogner shared his experience of trailblazing for breech in Austria by introducing the practice of all fours (im Vierfüßer) breech births, which he has been studying in singletons and twins, with good outcomes. We look forward to the publication of Bogner’s twin data, later in the year. (Read more about Bogner’s work on ResearchGate or Pubmed.)

Breech101These international gatherings always prompt discussions about differences in practices. Some audience members were surprised to find that midwives in Austria perform a vaginal examination every hour! Therefore, the evaluation of ‘second stage’ is determined by dilatation. In contrast, visitors from Sheffield – Midwife Helen Dresner-Barnes and Consultant Obstetrician Julia Bodle – explained how in Sheffield, vaginal examinations are not routinely performed during breech labours. Progress is evaluated by observing the woman’s spontaneous expulsive effort, and if she is bearing down for some time without any noticeable descent, this would be considered an arrest in the second stage of labour necessitating a caesarean section. Such differences raise interesting discussions around why we do what we do – for safety? for measurement? for documentation? for protection in case of litigation? And what effects such seemingly neutral interventions may have – interfering with physiology? lowering the threshold for CS with or without benefit? reassuring or undermining the woman and her health professionals? We may not have all the answers, but at least we are beginning to ask the questions.

Thanks also to Lisa Walton of Blackpool and Oli Armshaw of the University of Western England for helping make the day a success.

Shawn

The mechanisms, simplified

January 2015 – See below for videos explaining the mechanisms of breech birth in different maternal positionsdemonstrating

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.

 

Good luck with your exams, student midwives!

Shawn

Taking a break .. not quite at the edge of the bed.

Taking a break .. not quite at the edge enough to hang & flex!

Jude Jones and Stacey Lee actively understanding women’s birthing positions

Loving breech babies in Ayrshire

with Dr Susanne Albrechtsen (left)

with Dr Albrechtsen (left)

The Dutch in Old Amsterdam do it .. not to mention the Finns .. The folks in Bergen, Norway, do it .. They’re not even second twins …

This Valentine’s Day over 100 obstetricians, midwives, student doctors and student midwives assembled at Crosshouse Hospital in Kilmarnock to show some love to breech babies.

explaining the way 'prayer hands' help maintain alignment of the fetal head

explaining the way ‘prayer hands’ help maintain alignment of the fetal head

We were privileged to be joined by Dr Susanne Albrechtsen, Head of Obstetrics at Haukland Hospital in Bergen, Norway, home of Jørgen Løvset. She has written extensively about the practical management of breech presentation and authored several epidemiological articles. Dr Albrechtsen is responsible for the Norwegian breech guidelines, and shares her expert knowledge of breech and operative vaginal deliveries through practical training throughout Scandinavia and beyond (details available through the Norwegian Medical Society). Her hospital in Bergen, which currently enjoys a CS rate of 13%, is a mecca for trainees hoping to improve their hands-on skills. Haukland, with an annual birth rate of 5000, sees 150-200 breech deliveries per year and Dr Albrechtsen herself has attended over 500 breech deliveries. IMG_0173

How do they do it? Dr Albrechtsen tells us: “You just have to decide that it is good for babies to be born vaginally, unless there is clearly a problem, and commit yourself to developing the skills to enable that to happen.” As she explained, a normal vaginal birth is an important programming event with life-long consequences. Evidence is growing about the links between caesarean section and future disease in the child, such as Type 1 diabetes, asthma, allergies, gastroenteritis and obesity (see Ulander et al, 2004). Dr Albrechtsen also presented her epidemiological data, demonstrating the way CS rates and rates of vaginal birth have changed over the last 40 years in Scandinavia. Particularly interesting were the way the Finns have been able to make a dramatic change within a few years, simply by making the decision to do so.

Dr Michele Mohajer, Royal Shrewsbury

Dr Michele Mohajer
Royal Shrewsbury

Dr Michele Mohajer, whose unit in Shropshire currently enjoys a 14.3% CS rate, shared with us the work of her breech clinic and her extensive experience with ECV, having performed over 1500 procedures herself, in addition to attending hundreds of breech deliveries in her career. It is reassuring to know that these skills are being maintained by expert practitioners.

Feedback from the day suggested that those attending had concerns about managing an undiagnosed breech birth, and interest in developing skills had been driven by recent experiences. This is a real concern. Approximately 3-4% of babies present breech at term, and 25-30% remain undiagnosed until labour. Consequently, an undiagnosed breech presents in labour approximately 1:100 of all births. It is in everyone’s interests that we do our best to support all women wishing to make the informed choice to labour with their breech babies, putting plans in place so that skills can be developed for when women cannot make a measured decision.

working it out together

working it out together

In my view, organising small on-call teams for breech, involving both doctors and midwives, is the best way to accomplish the re-introduction of breech skills. Some research and professional opinion supports this view (Kotaska 2009, Maier et al 2011). Neither all doctors nor all midwives will be confident and keen to attend a breech birth. Ideally all staff involved will be both, but at least one well-prepared and experienced person at every breech birth is essential, for both safety and the reassurance of the woman involved. At the conference, we also reviewed the mechanisms of breech birth, counselling for informed choice, and how to help in a complicated breech birth, particularly when the woman births in an upright position. I’ve noticed more doctors attending these study days each time we do it. One young obstetrician said to me, “I needed you here about a week ago, when I got hauled over the coals for supporting a woman to [successfully] have her breech baby vaginally.” This threatening cultural atmosphere needs to change. We need obstetricians and midwives who are willing to develop the skills to facilitate breech birth in the safest possible way.

Let’s do it .. Let’s fall in love … with breech babies

This study day  was organised by Geraldine Butcher, Consultant Midwife for Ayrshire and Arran, and a passionate advocate for the rights of women to make informed decisions about how to have their babies. Feedback from the study day:

“It has been a very fruitful day for me and I will use the presentations and practice to update my own. I will feel more confident in supporting upright breech birth.”

“It gives me more confidence to promote breech delivery and services surrounding breech as an option.”

“Video scenarios were very helpful. Recent undiagnosed breech presentations have encouraged us to review / update knowledge.”

Shawn

 

Bottoms Down Under

‘Into the Breech’ Workshops in Perth and Melbourne, December 2013

IMG_0088

Anke Reitter, Danielle Freeth, Rhonda Tombros, Andrew Bisits

This month has seen a small series of Australian workshops, hoping to increase confidence among those already working to modernise breech birth in Australia. The ‘Into the Breech’ conferences were instigated by Dr Rhonda Tombros, an academic lawyer with an interest in human rights and the mother of a breech born baby, and organised by Barbara Glare. The conferences coincided with a six month research fellowship visit by Dr Anke Reitter (FRCOG) of the Frankfurt team, whose MRI research will soon be published, concerning changes in pelvic diameters with maternal position changes.

The Perth workshop, on 3 December, was held in the Perth Zoo and was opened by midwife Danielle Freeth, also the mother of two breech babies. As for obstetricians, it was quality rather than quantity on this occasion. One of the participants, Dr Liza Fower, Head of Obs and Gynea at the Armadale Hospital, gained significant experience facilitating breech birth in South Africa and has been able to continue to offer support. She also contributed to one of our practical workshops with some useful tips.

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Anke Reitter frisking Andrew Bisits .. while demonstrating how to release stuck nuchal arms.

Dr Andrew Bisits (FRANZCOG) presented in Perth, on pathways for women and complications. Bisits is one of the Directors of the ALSO (Advanced Life Support in Obstetrics) course in Australia, which will be updated to include emergency manoeuvres when a woman is in an upright position. He and his team, including Midwifery Professor Caroline Homer, have launched an intensive course for professionals in Australia, the BABE (Become a Breech Expert) course. I am very much hoping to bring this course to the UK at some point in the future, and in the meantime will be ensuring that the information presented at the Breech Birth Network study days is in line with the systematic approach they are developing.

Melbourne attracted more consultant obstetricians, GP obstetricians and a lively group of midwives. Many conversations occurred during the break, suggesting a critical mass in this location, likely to move on with a more organised and collaborative approach to supporting women with breech presenting babies. This may require more working together across traditional boundaries if women are to have adequate support for viable choices, especially as breech services are reintroduced among teams with minimal recent experience.

Dr Rhonda Tombros

Dr Rhonda Tombros

A highlight of both days was Dr Rhonda Tombros’ presentation on the legal aspects of informed consent and negligence focusing specifically on issues around breech birth. We all hope she writes this up for publication in the near future.

Although I present at these conferences (in this case, on the evidence base and ‘normal for breech’), I find them invaluable to developing my own practice. The two messages I found most interesting with this visit concerned timings and episiotomy.

Timings: Bisits and Reitter gave increased focus to achieving a prompt delivery, suggesting that 3 minutes from the birth of the umbilicus to the birth of the aftercoming head is ideal. “Three minutes is ideal, you are probably okay with five, but after that most babies will experience some sort of compromise.” This aspect has not been previously emphasised at the conferences I have attended, but the intense dialogue which has developed between midwives and obstetricians supporting breech has revealed differences. It seems that timings are almost taken for granted in obstetric training for breech, whereas midwives have a much higher tolerance for a ‘wait and see’ approach, emphasising the ‘hands off the breech’ philosophy. In reviewing the anecdotal experiences where breech is being reintroduced, the current consensus among our small collective of professionals is that, while a ‘wait and see’ approach will often result in a spontaneous resolution, it will also more often result in a severely compromised baby when that spontaneous resolution does not occur. Therefore, following the birth of the umbilicus, if the birth does not continue to progress promptly or you are not confident of the condition of the baby, intervening to facilitate the birth is recommended, using the systematic approach we are advocating:

  • Exif_JPEG_PICTURETry to sweep down the arms in front of the face
  • If not possible, rotate in the direction of the nuchal arm (modified Lovesets)
  • Ensure the head is aligned with the body and the mother’s birth canal
  • Deliver the head using classic or modern techniques to achieve flexion

The skill of an experienced practitioner is in holding back from intervening when the birth is progressing normally, balanced with effective intervention when it is not, and developing this judgement is a key aspect of breech training days.

Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Michelle Underwood, Anke Reitter, Shawn Walker, Barbara Glare

Episiotomy: In Melbourse, Consultant Midwive Michelle Underwood presented data from the Westmead Clinic which she runs with Dr Andrew Pesce in Sydney. While all of their statistics were fascinating – especially demonstrating a reduction in CS for breech from 90% to 63% in the first year of the clinic – I was intrigued by their stats on perineal damage. It seems that, compared to all births, the breech births have the highest rate of episiotomy AND the highest rate of intact perineum. This suggests to me that the majority of perineal damage from vaginal breech births may be iatrogenic, which is not surprising given that cutting a timely episiotomy is an over-emphasised part of some obstetric training for breech (Deering et al 2006), as is the use of forceps.

But is it necessary, or helpful (in most cases)? In his own practise, Bisits avoids episiotomy because he feels the perineum has an active role in encouraging breech babies to remain well flexed throughout the birth. Reitter also discussed her own personal stats – three (3) episiotomies cut in the last 10 years, a period which has included management of over 300 breech births and countless cephalic complications. The episiotomy rate in her unit in Frankfurt is exceptionally low overall. Change was accomplished when the Lead Obstetrician (Prof Frank Louwen) insisted that episiotomies would not be cut unless absolutely necessary, and that each episiotomy would need to be justified personally to him. That’s what leadership can do.

Shawn

A Different Birth

664730Brighton Breech Conference, 11 November 2014

Wow! On my way home to Norwich after an amazing day in Brighton.

The day was organised by Jenny Davidson, currently Acting Deputy Head of Midwifery at the Royal Sussex Hospital in Brighton. Jenny is an inspirational midwife, and doing great things to empower both midwives and women with breech babies. She’s nearing the end of a PhD and started the study day off with a research round-up, exploring why the heavily criticised Term Breech Trial has had such an impact on breech practice, and presenting other evidence which widens the discussion and decision-making process for breech. (See Premoda and Toivonen for a start, but Jenny had several pages of references.) The increasing amount of qualitative research revealing women’s experiences of breech pregnancy and childbirth was also discussed. (See Guittier for a start.)

Following this, Benna Waites discussed ‘talking breech’ – how we counsel women with breech-presenting babies. She stressed the importance of recognising that the risks to women of CS are not inconsequential, and of remaining non-judgemental even when women are making decisions which professionals may not feel are the ‘right’ ones. Benna, author of the ‘breech bible’ – Breech Birth – is a Consultant Clinical Psychologist, as well as the mother of a breech-born baby. She brings these important perspectives into her presentations. I hope that well-informed, deeply immersed service user advocates like Benna can in the future participate more fully in discussions around national guidelines, such as those written by NICE and RCOG.

Jane Evans continues to inspire a new generation of midwives presenting her excellent knowledge of the mechanisms of breech birth, and how to assist when help is required, built upon decades of clinical practice. Jane has authored many articles, but her more recent publications in Essentially MIDIRS should be essential reading for professionals seeking to modernise their breech practice.

Today was the first time I have had the opportunity to hear from Dr Michele Mohajer, co-author of this UK-based study) and Consultant Obstetrician at the Royal Shrewsbury Hospital in Shropshire. Michele has run a breech clinic there since 1997, where both breech and ECV have been well supported. Her ECV success rate is excellent, approximately 60%. She shared with us several of her methods for increasing the likelihood of succeeding. There are few things I like more than hearing someone with excellent clinical skills discuss their techniques. I especially admired Dr Mohajer’s discussion of the influence of gaining the woman’s trust and co-operation to her success rates. Her ECV films were excellent and a really useful practice update. I hope Dr Mohajer is also able to reach wider audiences to share her classic obstetric skills. Women who wish to have their babies turned deserve for the practitioners attempting this to have success rates as high as possible.

Hopefully others will share their personal highlights from the day. And (although this study day was sold out), we all look forward to more obstetricians and midwives attending future study days. Please do get involved, share your experiences, develop your services. As several people remarked today, it really does feel like the green shoots of change are growing for breech.

Shawn

Breech updating

(Another post in response to discussion on the Coalition for Breech Birth Facebook Page.)

Breech births are few and far between, and there are very few ‘experts’ in the world to learn from, so staying updated is a real challenge. Especially if you do not live and work near others who are supporting breech births regularly.

Updating has two purposes: keeping up to date with current evidence and best practice; and reminding yourself how to use skills you use infrequently. Many breech babies, especially those whose mothers are active and upright (e.g. knees/elbows), can be born spontaneously. But those who cannot need calm, considered help in a timely manner. The same applies to external cephalic version – ECV. Both practices benefit from regular performance and knowledge sharing among those who are practicing.

Here are my suggestions on keeping your practice as safe and supportive as possible:

  1. Attend study days. Many individuals offer study days to develop breech skills. Breech Birth Network days concentrate on lots of practical skills, but also have an emphasis on care pathway planning in the UK, aiming to encourage more Trusts to adopt an organised, committed approach to breech.
  2. Share your work. If you are doing research or working with breech and would like to share your experiences, get in touch and present at one of the study days. I am not an expert, but an experienced and passionate believer in the idea that the more we share, the more we talk about it, the more normal it becomes. The best study days have a wide variety of speakers and reflect a wide community dedicated to developing and sharing skills.
  3. Share your experiences. If you learned something at a breech birth you attended that might help us to make our practice safer, share it! Publish it if appropriate, but if you need to share anonymously to protect your client’s and your confidentiality, I can give you space on this blog. It is wonderful and encouraging to hear stories of triumphant breech births where the baby just fell out singing. But we need to hear the stories of doubt and sadness as well, and often these are the ones you learn the most from.
  4. Create your own network. It’s been so valuable to me to have colleagues who I can phone up to debrief the breech births I’ve attended. I learn so much more by doing this. And so valuable to hear their stories, how they have approached certain complications, how they support women, their thoughts on what makes breech birth safe. Keep a record of these sessions and document them; they are part of your professional updating. Write an article about what you have learned together, so that others can respond to it. We need more voices talking about breech skills.
  5. Organise your own study day. Bring the conversation to you. Empower those local to you to share their skills by asking them to present. Inspire your local community to think more about breech.

If you don’t have anyone local to ask questions or debrief with, my number is 07947819122 (in the UK) and I’m always happy to listen. I’m sure most of us are. Good luck!