Author Archives: emmaspillane

New Information Leaflet

Providing evidence-based information to parents throughout the pregnancy, birth and post-partum journey is an essential part of the role of all healthcare professionals working in maternity services.  However, evidence suggests in some areas of maternity, such as the highly politicised area of vaginal breech birth, the information provided to parents is biased towards that of what the system supports or the individual healthcare professional providing the counselling prefers.  A compelling ethical and legal requirement exists to provide the evidence to parents which they have a right to receive, as discussed by Kotaska et al (2007).

An international qualitative survey by Petrovska et al (2017) surveyed women who had a breech presentation and were seeking support for their choice of mode of birth.  Petrovska et al (2017) examines how mothers found inadequate system and clinical support for vaginal breech birth which impeded their access to unbiased information on their options for mode of birth and the care they received.  In a paper written by Powell et al (2015) they also found that parents were often given unbalanced information.  This lack of balanced information was a motivating factor in developing an information leaflet for parents identified with a breech presentation at or near the end of their pregnancy.  The development of an information leaflet is supported by many papers such as that by Guittier et al (2011) and Sloman et al (2016) who also found parents were often provided with biased information. We hope the development and provision of useful, unbiased information material will assist with decision making and enable parents to make an informed choice of their options with a breech presentation.

 

Since setting up a breech service within the Trust I work I have seen the difference in counselling techniques and the information provided to parents.  As part of my clinical role I meet parents for birth options discussions, often parents seeking support to use a Birth Centre for labour and birth despite having either medical or obstetric complexities which means the recommendation would be to labour and birth on the obstetric unit.  Many of these discussions are with mothers who have had a previous caesarean section often for breech presentation in their first pregnancy.  In nearly all of these cases the parents say they were never given the option to have a vaginal breech birth and yet the NMC Code states:

2.3 encourage and empower people to share in decisions about their treatment and care

2.4 respect the level to which people receiving care want to be involved in decisions about their own health, wellbeing and care

2.5 respect, support and document a person’s right to accept or refuse care and treatment

6 Always practise in line with the best available evidence

To achieve this, you must:

6.1 make sure that any information or advice given is evidence-based including information relating to using any health and care products aor services

Nursing and Midwifery Council, The Code

Having not been given the option of a vaginal breech birth the practitioners counselling them were breaching the NMC Code. Furthermore, the RCOG (2017) Management of Breech Presentation Guidelines state:

Clinicians should counsel women in an unbiased way that ensures a proper understanding of the absolute as well as relative risks of their different options. [New 2017]

It is alarming that despite this guidance, and in light of more recent evidence which has emerged on the suitability of vaginal breech birth for selective pregnancies, that parents are still not being given all their options and more importantly the impact it is having on their future pregnancies.

The information leaflet has been developed in response to the acknowledged lack of balanced information available to parents. To ensure the information is evidence-based it includes data from the RCOG (2017) guidelines as well as other research sources such as that from Louwen et al (2016) and the NICE Caesarean Section Guideline (2013).  The information leaflet was circulated to healthcare professionals of all grades (midwives, SHO’s, Registrars and Consultants) as well as parents who had experienced a breech presentation previously.  They were asked to comment via a SurveyMonkey on the information which was provided in the leaflet to ensure it was easy to understand, informative, evidence-based and unbiased. The leaflet is provided below in both PDF leaflet form as well as an MS Word format, so healthcare professionals are able to download and edit for use in their own healthcare organisation. 

Providing this readily available resource for parents and healthcare professionals is invaluable for ensuring the correct information is easily accessible and shared to not only support parents in making an informed choice about their options, but also for assisting with the counselling healthcare professionals provide to those in their care. If you have any questions or comments about the information leaflet, please do not hesitate to contact us on the contact form provided below.

— Emma

 

Breech Birth Training in Ethiopia

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).

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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.

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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.

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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.

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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.

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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.

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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

Building confidence and changing practice through participation on training days

Emma Spillane

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.

Claire Reading, Emma Spillane and Shawn Walker

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.

Emma

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