Breech training in Paris, November 30 & December 1. Places still available. Download complete poster for more information.
Training in Lewisham on November 12 — Book here.
“We believe that we do well what we do often.” – Caroline Daelemans
Contact Hōpital Erasme Clinique du Siège on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be.
This month I visited Hōpital Erasme, in Brussels, Belgium. Led by Lead Obstetrician Caroline Daelemans, Erasme began to offer a dedicated Breech Clinic in December 2015. Much of the organisation and development of the clinic has been done by Dr Sara Derisbourg, who continues to research the impact of instituting a dedicated breech service.
I came to Brussels to provide our usual physiological breech study day. The breech team has transitioned to using physiological methods, including upright maternal positions (Louwen et al 2016), after attending training in Norwich in 2017. They now needed the rest of the team to understand the philosophy behind this approach. But the day began with Caroline describing the impact of instituting a dedicated Breech Clinic, and this was particularly exciting for me.
My own research concerning the development of breech competence and expertise, and the recovery of these skills within a service, indicates that developing a core team with significant experience is the most effective method of safely offering a vaginal breech birth service (Walker et al 2016). This skilled and experienced core is more important than the ‘selection criteria’ that are used to predict the likelihood of a good outcome (but in fact are not very predictive). Skill and experience facilitate good outcomes and enable other colleagues to develop competence (Walker et al 2018). The Erasme team even encourage other health care professionals to come with their clients and attend them in labour with their support, to encourage the growth of breech skills.
The need for new ways of organising care has been emphasised in an on-line survey of Dutch gynaecologists just published by Post et al (2018, Does vaginal breech delivery have a future despite low volumes for training?): “Potential suggested alterations in organization are designated gynecologists within one centre, designated teams within one region or centralizing breech birth to hospitals with a regional referral status. Training should then be offered to residents within these settings to make the experience as wide spread as possible.”
Daelemans and Derisbourg began with a small team of 5 people. This has gradually expanded and now includes eight members who together provide 24/7 cover for all breech births within the hospital. Women with a breech presentation are referred by colleagues and increasingly by other women. The environment at Erasme is ideal because the hospital has a very positive approach to physiological birth in general, and a 15% overall caesarean section rate in 2017. This compares to 20.2% in Brussels and much higher in many places globally.
What has the Breech Clinic changed? Before the introduction of the clinic, the planned vaginal breech birth rate was 7.19%, and in just a few years this has climbed to 42.7% of all breech presentations. Neonatal outcomes have remained stable. Actual vaginal breech births have climbed from 4.2% to 35.96% of all breech presentations within the hospital. The success rate for planned vaginal breech birth is 76.3%, which suggests that within experienced teams, the emergency caesarean section rate is also reduced. (The RCOG guideline suggests about 40% of planned breech births end in CS.)
All of this is very impressive. The message is clear: a physiological approach and an organised care pathway, including a breech clinic and experienced on-call team, can reduce the caesarean section rate significantly without negatively impacting neonatal outcomes. We should all look out for Derisbourg’s papers when they are published.
If you are a woman seeking support for a physiological breech birth, or a health care professional looking to refer a woman to the breech clinic, they can be contacted on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be. Caroline Daelemans will be teaching with me in Lewisham, London, on 12 November.
Missed our Facebook Live event with Fernandez Hospitals? Watch the recording here:
This month I am in Hyderabad, India, visiting Dr Evita Fernandez and UK Consultant Midwives Indie Kaur and Kate Stringer. Today at 5pm IST (that’s 11.30 GMT), we will be having a Facebook Live discussion on Breech Birth in India. This will be followed by hands-on workshops on the 12th and 19th in Hyderabad.
The Fernandez Hospitals are at the forefront of compassionate maternity care on a large scale in India. The Stork Home facility has been beautifully designed and rivals some of the best midwifery units in the UK. But Dr Evita and her team of doctors and midwives are very ambitious. They want to revive vaginal breech skills so that women can confidently choose this option. How will this work in Hyderabad? Join us for a discussion.
From Arunarao: “My special thanks to dr Evita ,lndie mam Kate mam and Shawn mam for the opportunity to participate in BREECH BIRTH WORKSHOP at karimnagar.i am so panic about breech presentation and breech birth before I come to professional midwifery training, know iam very excited to assist the spontaneous and assisted breech birth,because now I came to know breech also has its own mechanism and always always we have to respect those mechanism and iam aware of the manoeuvres to apply whenever it’s needed.thank you all of you mam iam so blessed to have a teaching faculty like you.” Thank you Arunarao — you really got it!
In June, I spent a week in the Netherlands working with a committed group of lecturers. The midwifery universities of the Netherlands share a common curriculum, and following our meeting last year, they agreed to incorporate physiological breech birth into their training programme. My visit was to support the midwifery lecturers to implement the new skills into standard midwifery training.
While in Amsterdam, I collaborated with Midwifery Lecturer Bahar Goodharzi of Academie Verloskunde Amsterdam Gröningen (AVAG) to create a short series of films demonstrating the rotational arm manoeuvre we teach in Breech Birth Network study days. We agreed that this is a tricky manoeuvre to learn and teach, but it is incredibly effective in practice so worth the effort of learning. I’ve collected our short demonstrations in the film below, along with information about how to recognise that this manoeuvre is required.
Note: If you have difficulty rotating the baby initially, you may have to elevate the baby slightly to a higher station, so that the shoulder girdle rises above the pelvic inlet. It can then rotate to engage in the transverse diameter.
Thank you to Emma Spillane of St George’s Hospital in London, who has helped to refine the way we teach this manoeuvre following her own experiences of successfully using it in practice.
For a poetic description of what it is like to encounter this complication for the first time as a midwife or doctor, read Nicole Morales’ blog, The prose of no rotation and no descent: rotating to free the arms.
You can download the Physiological Breech Birth Algorithm here.
I’m honored to be asked to be the guest writer this week on breech. Shawn Walker is an international inspiration to those doing breech work around the world in various settings providing tools for breech birth to be safer and more accessible.
My journey to breech started with the breech homebirth of my daughter, Nilaya, who is now 12 years old. I was a student midwife just starting to catch babies here in the U.S. and had my first two head down babies steeped in a culture of home birth where twins and breech were normal. The choice to birth my third baby breech at home was not difficult. I did not have to fight for it. I just did it. It was through this birth that I became invested in understanding and preserving this part of the craft of midwifery.
Getting experience and quality training in breech has been a challenge. I’ve had to seek out workshops and conferences from across the United States, take online international courses, and work to understand the mechanics of knowing normal vaginal breech birth. Even though I am an instructor at our local midwifery school and have developed the curriculum here for breech birth, I still have limited hands-on experience that is slowly growing through the years. As a Spinning Babies Approved Trainer, I get many referrals for breech parents and help them to navigate breech late in pregnancy through counseling, bodywork, and midwifery skills. It is amazing what skills one picks up with their hands from seeing so many families and palpating so many breech presentations. Being able to have breech immersion of any sort can help keep the knowledge and skills alive.
We are at a crossroads here in the U.S. for breech where in state after state, midwives are being limited by laws for attending breech and have not had a bar set for what breech birth competency looks like. We might have a small list of skills, but with breech complications, we know that the refined skills can make a difference in outcomes. If we have the ability to show experience, understanding, and investment in training, we might set a different course for breech, and midwives might actually set the bar for competency and have influence on other professions. I am interested in how we can provide a more thorough understanding of what Shawn Walker deems “Respecting the Mechanisms” and “Restoring the Mechanisms” of breech. In this way, I also believe that we can shift the paradigm of “No normal breech” to “Know normal breech.” The international breech community, in how it is detailing the mechanisms of breech birth, can actually be a model to those doing vertex deliveries! One of the reasons for a higher cesarean rate here in the U.S. is fear of a shoulder dystocia In understanding the mechanisms of normal and restoring these mechanisms at all levels of the pelvis could reduce interventions and improve outcomes. There is value for all births in utilizing gravity and mobility to increase diameters of the pelvis or to safely reduce fetal diameters when presented WITH complications. Respecting that the reflexes of a baby being born are also part of the mechanisms of normal birth may not be seen with a vertex baby, but we know that babies help themselves to be born.
As the international breech community discusses developing breech birth centers and (re)teaching breech, I’ve worked on how I can document my own road to competency and compiled these ideas in the format of the student paperwork for the North American Registry of Midwives (NARM). I naively thought I would just submit them for review, but the interest of a larger community has to also be there. There must be more conversations in the community over how such documentation can be useful and how to avoid potential pitfalls of its use. I have called it “Breech Competency Documentation” so that it provides a way for birth workers to document skill acquisition as well as experience. One could choose to keep the documentation on file for themselves or even to be part of a larger program.
I am sharing below three out of four documents I created that are works in progress and open for suggestions. I want to create a community conversation and am posting these publicly as birth workers in various countries have asked me for such information which I find valuable. As we gain more knowledge about breech, these skills checklists can be updated to reflect the current knowledge.
The first document, which is modeled after the NARM skills list, is a compilation of the current skills being developed in the international breech community. I acknowledge that some Qualified Breech Preceptors may practice differently, but these skills are about developing a baseline for understanding upright normal breech and upright breech complications.
The second document, which is modeled after the NARM requirements for becoming a Certified Professional Midwife (CPM), outlines experience for assisting and being a primary student under observation of a Qualified Breech Preceptor. I originally considered requiring higher numbers of birth / experiences / skills on these lists, but I then realized that it as going to be quite difficult to acquire those numbers of breech deliveries because of the overall low percentage of babies who are breech at term. I decided that we must focus on quality of skills and of each birth attended and included the ability to use retrospective births that can be debriefed and reviewed with the preceptor.
The second document, which is modeled after the NARM skills list, is a compilation of the current skills being developed in the international breech community. I broke down the skill categories starting with breech pregnancy, normal vaginal breech birth, complications at the different levels of the pelvis, and small section of postpartum care.
The third document is for the student / midwife to list retrospective births they may have had and document the process of review with a Qualified Breech Preceptor. This allows previous births to be able to be integrated and reframed within this format.
The fourth document I have started but not posted and it is pivotal in the overall conversation of Breech Competency Documentation regarding who would or would not qualify as a Qualified Breech Preceptor. Through this documentation I believe we must point to the Delphi Study and its baseline as being above 20 breech births. However, attending a certain number of births without any complication may not lead to more competence than someone who has had fewer births but had to resolve complications. As I was creating this paperwork as a student of breech birth, I questioned whether it should be a document developed in more detail between preceptors and experts.
I want to thank all of the people who helped me review the skills list for Breech Competency Documentation including Gail Tully, Diane Goslin, Shawn Walker, and Vickii Gervais. I also want to thank Rindi Cullen-Martin for helping me with formatting and making the changes. Both of us as breech mothers have an investment in continuing this work. This work has also been influenced by the international breech community including Jane Evans, Mary Cronk, Anke Reitter, Frank Louwen, Maggie Banks, Anne Frye, Betty-Anne Daviss, Mary Cooper, Peter J. O’Neill, Andrew Bisits, Stuart Fischebein, and many others.
Emma Spillane, Training Co-ordinator at the Breech Birth Network, has attended six breech births in the last six months in an NHS hospital. Rebuilding breech skill is possible, guided by evidence about how breech competence develops. Emma writes about how she gained confidence in teaching and attending physiological breech births by assisting at Physiological Breech Birth study days.
In January 2017 I attended a Physiological Breech Birth study day in Norwich by Dr Shawn Walker and Dr Anke Reitter. Breech birth had always interested me from my first breech birth as a newly qualified midwife. I didn’t understand the physiology of breech birth at this time, it had always been taught as something abnormal, an obstetric emergency. I could never understand though, how breech birth could be so abnormal if babies were on occasion born like this. My interest had been piqued, and so a few years later, and a few more breech births later, I found myself on the study day to develop my knowledge and skills in vaginal breech birth.
The study day taught me the tools required for supporting women to have a physiological breech birth and to resolve possible complications whilst supporting physiology. Following the training I went and introduced myself to Shawn and told her of my interest in breech birth, I felt so inspired to start a breech birth service within the trust I work. On my return to work I started putting plans in place to develop a service within the trust. Shawn contacted me a few days later and invited me to help teach the hands on clinical skills on her next Physiological Breech Birth training day in South Wales. I jumped at the chance to attend and found it so useful to listen to the day again and then help with the hands on teaching. It helped to embed what I had already learnt previously and give me the confidence to teach the skills within my own trust.
I started talking about breech, a lot! Shawn continued to invite me to help on training days and with each one my confidence grew. I started viewing the videos differently. Instead of looking for what was ‘normal’ and ‘abnormal’ I started analysing them with a deeper understanding of the physiology. Shawn also encouraged me to start teaching parts of the presentation. Admittedly I was more than a little ropey to begin with but with Shawn’s nurturing and encouragement and the more I learnt from each training day, each time I attended my confidence grew. Eventually I was able to transfer this new knowledge, understanding and confidence into practice. I was asked to attend a breech birth!
I supported a woman with a physiological breech birth, along with a consultant obstetrician colleague and one other midwife. An arm complication occurred with the birth, and I was able to resolve using the manoeuvres I had learnt and taught on the course. The baby was born in good condition, and I felt relieved and elated! I immediately contacted Shawn to tell her about the birth but it had also sparked an interest in the consultant obstetrician who had attended. We debriefed from the birth and I spoke about the Breech Birth Network and the training it offers. I took the opportunity to ask if my obstetric colleague would like to be the lead consultant in my quest to set up a breech birth service, to which they agreed. It had taken me nine months – the length of a full term pregnancy – from when I first attended the training until this physiological breech birth. It was the birth of an exciting change in knowledge and culture.
Attending training days has not only helped to embed my own learning but it has given me the skills and confidence to set up a service within the trust I work, support women who choose to have a vaginal breech birth and support colleagues to facilitate breech births themselves. I have found repeating the information and skills has been the key to my learning and enabling change within practice. It has given me the confidence to attend births and increased the number of breech births within the trust by instilling confidence in others. If you would like to build your confidence in vaginal breech birth, develop a service within your trust and teach others I highly recommend coming along and helping at future training days. You can view a list of upcoming opportunities to help deliver training here. Please let us know by getting in contact via email or the contact form.
Research indicates that providing teaching is an important part of the development of breech expertise. Read more: Expertise in physiological breech birth: A mixed-methods study
As physiological breech practice gains acceptance, guidelines are changing to reflect this change in practice. One of the questions those updating guidelines often ask is: What is the evidence? For example, what is the evidence for the shoulder press manoeuvre we teach in Physiological Breech Birth study days?
To answer this question, we have to consider what level of evidence underpins breech practice in general. To my knowledge, no breech manoeuvres have been tested in randomised controlled trials. A recent Cochrane Review looked at ‘Quick versus standard delivery’ for breech babies and found no reliable studies to inform practice.
Observational studies that contain clear descriptions of the methods of management used in that setting reported alongside perinatal outcomes contain one form of evidence. A problem with observational studies is that even when ‘classical methods’ are reported, the meaning of that expression varies between settings. So studies from Canada, for example, are not necessarily generalizable to settings in the UK because standard practice varies between the two continents. A notable exception is the study of outcomes associated with upright breech birth reported by the Frankfurt team (Louwen et al 2017), in which a very clear description of the ‘Frank’s Nudge’ manoeuvre is provided, alongside excellent perinatal outcomes associated with upright maternal positions.
Another type of evidence is the support of a ‘responsible body of similar professionals.’ This is related to the Bolam test for clinical negligence in English tort law (Bolam v. Friern Hospital Management Committee), which holds that, “there is no breach of standard of care if a responsible body of similar professionals support the practice that caused the injury, even if the practice was not the standard of care.” In our research with 13 obstetricians and 13 midwives who had attended a self-reported average of 135 breech births each (Walker et al 2016), 73% of those participating agreed or strongly agreed that health professionals attending upright breech births should be competent to assist by:
Additionally, 86% agreed or strongly agreed that an essential skill was:
This research avoided the use of names such as ‘shoulder press’ and ‘Frank’s Nudge’ in favour of descriptions because not everyone uses the same terms, or refers to the same actions even if they do.
Evidence for manoeuvres also comes from evaluations of training programmes, both breech-specific and obstetrics emergencies courses. In our review of the effectiveness of vaginal breech birth training strategies (Walker et al 2017a), we found no published studies demonstrating an association between any training strategy and improvement in perinatal outcomes. The evidence base for the PROMPT training programme, widely used in the UK, comes from a study that did demonstrate an association with training and a subsequent reduction in low 5-minute Apgar scores and HIE (Draycott et al 2006). But that study questionably excluded outcomes for breech births, and because of this the breech methods in PROMPT cannot be said to be evidence-based, although the programme’s overall approach of multi-disciplinary working and clear communication remains important.
Most obstetrics emergencies training programmes have been evaluated at the level of change in confidence and/or knowledge. Our Physiological Breech Birth training programme, which includes shoulder press, has also been evaluated at this level in published research and demonstrated good results (Walker et al 2017b).
Finally we have the most recent RCOG guideline (Impey et al 2017), which states: “The choice of manoeuvres used, if required to assist with delivery of the breech, should depend on the individual experience/preference of the attending doctor or midwife.”