Last month I spent ten days in Southern Ethiopia volunteering for a charity, Midwives@Ethiopia (M@E). The charity provides training for Ethiopian midwives and supports rural health centres to improve their standards. This involves providing them with much needed essential equipment to help in the quest to improve maternal and neonatal morbidity and mortality. My main role during the trip was to assist with the week training programme which was designed to teach midwives to safely manage obstetric emergencies in low resourced settings. I was asked to teach vaginal breech birth and thought that this was the perfect place to run the Breech Birth Network’s Physiological Breech Birth study day, which teaches normal physiology and the skills to resolve complications of a breech birth (Walker et al, 2017).
Discussing normal mechanism
In rural health centres in Ethiopia, the midwife’s hands are their tools and so what could be more perfect than to teach them a new concept to managing breech births where they could use their ‘tools’ to safely resolve complications should they arise. But also, to teach upright positioning of a breech birth which gives up to a 70% chance of the birth happening spontaneously (Louwen et al, 2017). I was very nervous about the training, partly because this was such a new concept to the midwives, birthing in upright positions. “Women do not do that,” I was told. They informed me that women were “not cooperative” and therefore they gave birth in lithotomy positions. I was not sure whether this was the case or if it was more to do with the well-known obstetric phenomenon of there being a bed in the centre of the room, so the person will just get on it because they think that is the right thing to do. Or a lack of antenatal education on the importance of being mobile in labour. This made me more nervous because upright breech birth was going to be so far from what they were used to doing and seeing, a bit radical! The language barrier may also be an issue as well as the cultural differences, but I had nothing to lose and I really wanted to teach something which I believed would undoubtedly make a difference to mothers and their babies as well as to the midwives.
Second stage birth room in Uddo Health Centre
I started the day talking about the midwives experiences they have had of breech births. Unsurprisingly to me all the midwives in the room had witnessed and facilitated breech births, there is no scanning available and so most breech presentations are
undiagnosed. There is also limited access to health care for women and s ECV to turn the baby to a head down position is not usually an option. There were thirty-seven midwives present from different health centres and some from the main hospital in Dilla. Their experience ranged from eight weeks qualified to seven years qualified however some had very limited clinical experience in this time. Such as Getnet, the head of midwifery at Dilla University, he had six months clinical experience and has been working non-clinically for five years teaching midwives. I was struck by their stories of how women would walk for miles in labour to access help from a health centre because their labour had been obstructed, the breech presenting baby would be half born and they needed assistance to complete the birth of the baby. If they called an ambulance it could take hours to reach them, if it arrived at all, and they could then have a two, three, four hour or more transfer time to the nearest hospital for obstetric assistance. It is no wonder the maternal and neonatal morbidity and mortality rates are so high. However, the Government is working hard at improving the morbidity and mortality rates with the help from the WHO and other organisations such as M@E and they have met their goal of increasing safety for mothers and babies early which is a fantastic effort and must be recognised.
Nenko, M@E’s main contact in Ethiopia who works with WHO
Health officers such as Nenko are vital in the quest to improve maternal and child health. They work very closely with the WHO and charities to bring training and help from other areas to improve safety for mother and child.
After finding out about their experiences I taught the normal mechanisms of a breech birth. I emphasised how birthing in upright positions will assist with the birth, widening the pelvis by up to 1.9cm (Reitter et al, 2016). I used a flexible pelvis to demonstrate this at every opportunity and referred it to cephalic birth as well, so they could see how women birthing in upright positions can help for all births. I had the help of two excellent midwifery lecturers, Kiddist and Shimeles. Kiddist is a lecturer at Awassa University about three hours north of Dilla, she has many years of experience and left Ethiopia briefly to complete her Masters in Amsterdam. Shimeles has seven years of clinical experience before becoming a lecturer at Dilla University and is now interested in moving into research. Their English was excellent, so they were able to help with the translation, this was a very new way of teaching breech birth for them to, but they were enthralled listening intently and repeating everything I was saying in Amharic to ensure understanding.
Kidist and Shimeles, Ethiopian Midwifery Lecturers
Something which I have always found very surprising is the lack of knowledge about the normal mechanism of a breech birth, like I found so many times when teaching in the UK, the Ethiopian Midwives were also unclear about the normal mechanisms prior to the training. This was evident by their answers to the pre-course training questionnaire which I had asked them to complete prior to starting the training. Twenty-two of the midwives thought that as the Frank breech passes through the ischial spines of the maternal pelvis, the fetal sacrum is normally anterior. This is the most common thought, although the actual answer is sacrum transverse. This is misconception is possibly due to traditional breech training focussing on telling practitioners that the back must be uppermost, however the rotation to sacrum anterior occurs after the birth of the buttocks so the rotation is visible and should be noted as a reassuring sign of progress.
After lunch it was time to teach how to quickly recognise complications and resolve them working with physiology. During breakfast I had given two other M@E volunteers a crash course on the resolution of complications, so they would be able to assist with the teaching during the day. When I spoke about and taught a complication I would show the manoeuvre for resolving the complication by teaching Shimeles and then ask him to show the group with me. Shimeles was then able to assist with the teaching which meant we had more time to ensure all participants were able to correctly perform the manoeuvre and had good understanding of what they were doing. I was pleasantly surprised at how enthusiastic everyone was and how well they picked up these new manoeuvres. I started with simple shoulder press, I talked through when to use it and how to perform it and showed them videos of the manoeuvres being used. They found this particularly useful. They then all took it in turns to come up and perform the manoeuvre with either myself, Haf or Shimeles. This was a simple manoeuvre for assisting with the birth of the fetal head if it is deflexed at the outlet possibly due to the cord being around the neck or to speed up the birth due to a fetal concern. It was a manoeuvre they all felt they could use in practice which was easy to perform and very effective. I then taught shoulder press with ‘rock and roll’ which they thought was very amusing. Again, I taught Shimeles, he translated and performed the manoeuvre with me and then the group practiced. Shoulder press with ‘rock and roll’ can be used for a head in the mid-pelvis which has not fully flexed or if simple shoulder press has not been successful. Many of the midwives preferred this version of shoulder press to the simple shoulder press because they felt more secure holding the baby in this way.
It was lovely to see such enthusiasm for learning something new and the ‘light-bulb’ moment when they understood how birthing in upright positions can reduce the need for intervention which, for them, working in such low resourced settings and with extremely long transfer times in to an obstetric facility, was so important to have skills which would surely help to successfully assist breech births and potentially reduce harm to mother and baby. I held onto this enthusiasm as I continued through the course of the afternoon teaching how to recognise and resolve a compound arm by sweeping down the anterior arm. How to recognise and resolve using rotational manoeuvres with ‘prayer hands’, an anterior nuchal arm or bilateral nuchal arms. This is the complication which they found the hardest to grasp, the manoeuvre requires rotation to sacrum transverse, sweeping down the anterior arm under the pubic bone before rotating back to ‘tum to bum’. It required much more practice than the other manoeuvres but after a few attempts each they also were able to resolve this complication confidently.
After the arm complications came the head complications. The most feared of complications by healthcare professionals in any country is an extended head at the pelvic inlet. This was also true here in Ethiopia, where on the pre-training survey many commented about this complication:
“…delayed engagement of the after-coming head to save both fetal and maternal life.”
It was clear this complication was misunderstood as it is by so many healthcare professionals. It is due to the lack of knowledge about the physiology of a breech birth that this complication is so feared and difficult to manage. One of the questions on the pre-training questionnaire asks about how a practitioner would resolve delayed engagement of the aftercoming head, the answers confirmed the lack of knowledge and understanding of the complication. If this is not taught to healthcare practitioners how are they supposed to resolve the complication?
“after deliver of arm and lower extremities then deliver the head by MSV manoeuvre/procedure”
“…with piper forceps, by doing cervical incision.”
“Apply MSV…manoeuvre to deliver the head if after this manoeuvre still the head is not deliver apply piper forceps.”
“We use MSV manoeuvre and simultaneously apply supra pubic pressure.”
I taught them how to use a manoeuvre called ‘elevate and rotate’ describing the physiology behind why the head does not engage and becomes impacted at the pelvic inlet on the sacral promontory. Once they understood this, the manoeuvre came easily to them. They watched it on a video and had many goes at practicing it. This manoeuvre was so important for all of them to learn but in particular those working in rural health centres. Having heard the stories they shared throughout the day about obstructed breech births and not being able to resolve these complications, I knew that even if a woman had spent hours walking in labour for assistance, it may be too late to save the baby, but these manoeuvres could still help to save the mother. It really struck me how their challenges were so much different to ours back in the UK, how lucky we were to have obstetric assistance at our finger tips within minutes. It puts everything into perspective and changes your views on many things within midwifery when you hear these stories and challenges which they face every day when they go to work.
At the end of the day I was given a traditional Ethiopian applause and cheer, I knew at this moment I had taught them all something which they could use, something that would really make a difference to their practice not only with breech birth but quite possibly with cephalic births too. I hope to return to Ethiopia next year and be able to train more midwives these invaluable skills, so they can help more mothers and babies safely enter this world whatever position they decide to present in!
— Emma Spillane