Author Archives: midwifeshawn

About midwifeshawn

Midwife with a special interest in complex normality, especially breech.

student midwife literature reviews

My name is …, I’m a third year student midwife at X University and I am about to begin my literature review, I have decided to focus on vaginal breech birth. I haven’t finalised my question yet as I feel I need to read some more research to be able to word it correctly but I’m really interested in vaginal breech birth and practictoner skill. I’m ambitiously hoping my review might encourage the trust I work in to trial a breech birth team. I was wondering if you might be able to point me in the direction of any research regarding practitioner skill or breech birth teams? I understand we need much more research, but in your opinion is there any particular area that is really lacking in research that would support a move towards normalising vaginal breech births? I appreciate this is a very busy time for everyone having to work from home and understand you may not have time to respond to me at the moment but I’m so excited at the idea that don’t want to leave any stone unturned, any advice you have would be very appreciated.  

Hope to hear from you soon!

(Thank you for permission to share this exchange.)

Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre

Hello, 

Thank you for your message and your interest.

I write about this topic constantly https://breechbirth.org.uk/publications/. My PhD thesis contains a section on it, although this is a few years old now. Reference lists to my publications will help get you started. We also include information on building competence in the Breech Birth Network on-line training.

You could do a review on breech teams, breech clinics or midwife involvement in breech care. We need someone to lead some sort of consensus project to produce something like this for breech midwives: https://www.networks.nhs.uk/nhs-networks/diabetes-midwives/documents/NHSDAKC%20Midwives%20Standards.pdf That is a long-term project that will require funding, support and networking with key stakeholders, such as the RCM and RCOG. But it starts with a literature review.

You could do a literature review around midwives’ roles, any literature about competencies already out there, any evidence about the roles that midwives are taking, any evidence about outcomes associated with midwife-attended breech births (there is some in one of the TBT follow-up studies, I think by Su?).

My advice would be, whatever you do, treat it as a first step in becoming an expert in this area yourself. While it is great to try to convince your Trust they can do this, eventually, someone is going to need to actually put themselves on call and attend the births. So while you understandably feel at the beginning of a journey, see yourself as starting and committing to that journey, rather than trying to convince someone else to 😊 It may take years, but the breech revolution is a looooong-term game, requiring all of us to take small steps, with patience, but continuing to move forward, inch by inch. You will be constantly running into a wall. We turn to each other for support, do not give in to despair, and keep going. Eventually, enough of us running into the same wall will knock it down.

Another option is to do a review of outcomes associated with breech clinics and breech teams. This would be very valuable, but it will require a ‘no stone unturned’ approach indeed. This is because content about clinics and teams is usually embedded in articles, rather than listed as a key word. So you would have to do a general search on ‘breech presentation’ after 2000, eliminate obviously irrelevant articles and duplicates, then do searches on the words ‘team’ and ‘clinic’ and other related words such as ‘on-call’ and ‘stand-by,’ within the abstract and text of the articles themselves. It’s not as simple as a PICO search on randomised controlled trials, but it would pull together the general trends associated with clinics and teams (for ECV as well as VBB results), demonstrating a need for further research focusing on these as interventions themselves.

To that end, make sure you are using a Reference Management Software programme. I use Mendeley. If you are going to become a breech specialist yourself, you will need to be very familiar with the literature and have it easy to hand when you want to apply for funding or write up your work. Do that now and begin to build your library of evidence, organised to help you make your arguments.

And choose a topic that you are interested in going on to do further research about because a literature review is the first step. Aim to write a literature review that you can publish, even in a student midwife journal, but ideally more. You are not doing a ‘student midwife literature review.’ You are doing a literature review. There’s no reason your first go need be any less worthy than any medical or post-graduate student doing a literature review for the first time, many of which get published. Your work and your mind are just as worthy, and when you spend time doing something properly, you have insight others can learn from.

Once you graduate, begin to identify sources of funding for the next stages. Research/breech practice is a great combination because it gives you some flexibility (e.g. not responsible for as many clinics/shifts) and helps move practice forward.

If you’ve done our on-line training, you can begin to become involved in assisting with training through BBN. Continual review and engagement is the best way to continually develop your confidence. We have on-line seminars frequently.

Best wishes,

Shawn

Training evaluation published

Breech Birth Network are pleased to announce the publication of an evaluation of our physiological breech birth training, conducted in eight NHS hospitals across England and Northern Ireland. Click on the image below to read the full evaluation.

Highlights

  • Multi-disciplinary training, involving NHS midwives and obstetricians
  • Only training to have demonstrated an increase, rather than a decrease, in vaginal breech births following delivery of the training package, although this was not statistically significant
  • Use of upright positions at birth increased significantly
  • Pilot data: no adverse outcomes among births attended by someone who had completed the training, compared to a background rate of 7%
  • Pilot data: perineal outcomes similar to cephalic births

Congratulations to midwife Stella Mattiolo, who collected and analysed this data as part of her Masters in Research.

Nuchal cord and the breech

Two questions:

  1. Should we screen for nuchal cord using ultrasound when a woman is planning a vaginal breech birth? and
  2. What should we do with the information if we do identify a nuchal cord on ultrasound?

‘Nuchal cord’ means that one or more loops of umbilical cord are wrapped around the baby’s neck, during pregnancy or birth. Checking for nuchal cord prior to external cephalic version (ECV) or during risk assessment prior to a vaginal breech birth (VBB) is both common and controversial.

cord-leg entanglement, image: Dr Pricilla Ribeiro-Huguet

What is known:

  1. Nuchal cords are common, especially for breech presentation. For example, in this study (Wong & Ludmir, 2006), where someone specifically looked for a nuchal cord prior to an attempt at ECV, 34/75 (45.3%) babies were spotted wearing their cord as a necklace. They attempted the ECVs without this information. More babies with nuchal cords had transient (temporary) heart rate abnormalities, and their ECVs were less likely to be successful. But none of them had an emergency caesarean birth because of the way their heart rate was affected by attempting ECV.
  2. This really good summary of Nuchal Cord and Its Implications (Peesay 2007) indicates that at birth, as many as 30% of all babies could have a nuchal cord.
  3. It may cause problems in some pregnancies and/or births, but visual assessment by ultrasound does NOT help us to predict which ones. (… in general. Unless, as in this paper by Hinkson et al 2019, there are 6 loops of nuchal cord visible. Wow!)
the baby's head is being born with two loops of nuchal cord around the neck
double nuchal cord, image: Shawn Walker

What is not known: Does a nuchal cord increase the risk associated with an ECV or vaginal breech birth? We just don’t know if, or by how much, presence of a nuchal cord increases the risk. This is one reason neither of the RCOG guidelines (ECV, Management of Breech) indicate nuchal cord should be identified, or used as an exclusion criteria, for either of these. In fact, they don’t mention ‘nuchal cord’ or ‘cord around the neck’ at all.

When there is clinical uncertainty, we just say … there is clinical uncertainty. We can’t guarantee it won’t be a problem, but we have no clear evidence that it is likely to cause a problem.

Other guidelines often do say something like, “exclude nuchal cord.” This means, “Look for it with ultrasound to make sure it isn’t there.” But it’s not clear what one is supposed to do if you identify it IS there. And if a clinician has not looked for it, or has not spotted it, and it ends up being there and causing a problem during birth, have they been negligent? It’s a slippery slope.

cord-leg entanglement, image: Dr Anke Reitter

In my own clinical experience, breech babies born vaginally quite often have one or sometimes two loops of nuchal cord around their neck at birth. My gut feeling is that these babies more often needed help to flex the head, for example with a shoulder press, but that this was not more difficult than when the cord is not there.

I also checked our video study (Reitter, Halliday & Walker 2020) database of 42 breech births with ‘good’ outcomes. Among these, 8/42 (19%) had a cord wrapped at least once around the neck. Among these 8, 5/8 had help with the arms, and 6/8 had help to flex the head. This was slightly higher than the overall averages in the whole dataset. In the dataset, there were also 2 cases of leg entanglement, 1 case of arm entanglement, and 1 cord prolapse, where the cord comes out first.

It seems plausible that cord entanglement, whether around the neck or another body part, could interfere with the normal mechanisms of a vaginal breech birth. These babies may then require more assistance to be born safely, which is not itself a problem, as long as that assistance is provided in a timely fashion. It also seems plausible that in some case, a tight or short cord entanglement could cause problems that would put the baby at risk. But the kind of potential problems Peesay describes are all very likely to be picked up with the kind of close monitoring (growth scans, fetal heart rate monitoring, etc.) that every known breech baby received antenatally and/or in labour.

I’ve also added a ‘cord’ tag to several videos in our video library. If you’ve taken our Physiological Breech Birth course, you can search the library to watch several videos where cord entanglements feature and are resolved.

In summary, these are my recommendations:

  1. Don’t routinely go looking for a nuchal cord in otherwise uncomplicated pregnancies.
  2. If you do spot a nuchal cord, explain the clinical uncertainty with regard to its implications.
  3. Offer and attempt ECV if the person chooses this.
  4. Offer and support a VBB if the person chooses this.
  5. When attending a VBB with a known/suspected nuchal cord in labour:

  1. interpret fetal heart monitoring in light of this;
    • interpret descent in light of this;
    • anticipate the cord could interfere with the mechanisms, which may require your assistance; and
    • review all of your tools for assisting the head to flex.

I’d love to know others’ thoughts and experiences?

Shawn

NICE Guideline consultation on Induction of Labour

Another NICE Guideline that mentions care for breech presentation has been put out for comment. This time it is Inducing Labour. Many fine colleagues are collating responses to the guideline in general, but I would like views on the specific section related to induction of labour in breech presentation.

I have prepared a response, based on previous feedback from women and birthing people. Please let us know how you feel about this, and whether you would word anything differently.

Induction of labour is controversial, and even more controversial for breech presentation. I have tried to word the response in such a way that reflects the need for more informed choice, rather than more induction per se.

Some other resources:

Response to Draft Guideline:

p.10, line 6 “Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]” Cannot locate evidence for this recommendation in evidence review. This statement is vague. Not generally recommended by who? Why? Induction of labour for breech presentation is common outside of the UK. 

p.10, line 14 “Discuss the possible risks of induction with the woman.” Also vague. What are the risks? A systematic review has been done, so women can be offered evidence-based information rather than general reluctance. https://www.ejog.org/article/S0301-2115(17)30578-X/fulltext

p.10, line 5 Suggest the section on ‘Breech Presentation’ is re-written to reflect the ethos of informed choice and discussion, in a similar manner to the section on ‘Previous caesarean birth.’ Otherwise, the service is inequitable. A guideline on IOL with breech presentation is only applicable to women who have chosen to plan a vaginal breech birth. The guideline should reflect and respect this, using neutral, non-judgemental language.

For example:

1.2.19 Advise women with a baby in the breech position, who have chosen to plan a vaginal breech birth, that:

  • induction of labour could lead to an increased risk of emergency caesarean birth, compared to spontaneous breech labour
  • induction of labour could lead to an increased risk of neonatal intensive care unit admission for the baby, compared to spontaneous breech labour
  • the methods used for induction of labour will be guided by the need to reduce these risks. See the recommendations on Methods for inducing labour.

1.2.20 If delivery is indicated, offer women who have a baby in the breech position a choice of:

  • an attempt at external cephalic version, immediately followed by induction of labour if successful
  • caesarean birth or
  • induction of labour in breech presentation

Take into account the woman’s circumstances and preferences. Advise women that they are entitled to decline the offer of treatment such as external cephalic version, induction of labour or caesarean birth, even when it MAY benefit their or their baby’s heath.

Current wording in Draft Guideline is:

Breech presentation

1.2.19 Induction of labour is not generally recommended if a woman’s baby is in the breech position. [2008, amended 2021]

1.2.20 Consider induction of labour for babies in the breech position if:

  • delivery is indicated and
  • external cephalic version is unsuccessful, declined or contraindicated and
  • the woman chooses not to have an elective caesarean birth.

Discuss the possible risks associated with induction with the woman. [2008, amended 2021]

I Jornada de Atención Integral al Parto de Nalgas, 18 de Junio 2021

objetivos del curso

  • El servicio de Obstetricia del Hospital Sant Pau se caracteriza por su amplia trayectoria en la asistencia integral al parto de nalgas mediante una atención multidisciplinar.
  • El objetivo de esta jornada es dar a conocer la asistencia al parto de nalgas y sus alternativas así como cualificar a los profesionales que lo deseen para atender un parto de nalgas y aprender a resolver posibles complicaciones.
  • Para ello contaremos con expertas internacionales con amplia experiencia en la asistencia al parto de nalgas.

La inscripción incluye documentación del curso, traducción simultánea de las ponencias en inglés y diploma de asistencia. Inscripción de a la Jornada a partir del enlace:

Jornada completa:

http://docencia.recercasantpau.cat/ca/enllac-a-inscripcio/322

Módulo teórico:

http://docencia.recercasantpau.cat/ca/enllac-a-inscripcio/321

Plazas limitadas. Se admitirán por orden riguroso de inscripción. Se aceptarán anulaciones hasta el 01/06/2021. Por gastos de anulación, se devolverá el 85% del importe de la inscripción

Email contacto: nalgas@santpau.cat

PhD Fellowship Opportunity

This week, the NIHR (UK based) announced a PhD Fellowship opportunity. A Fellowship is designed to support a researcher to gain experience and training in doing research, and to support the research itself. It’s a great opportunity. Advertisement pasted below.

If you are reading this after any of these calls have closed, the same organisations may have a more recent call.

NIHR-Wellbeing of Women Doctoral Fellowships (Round 6)

Provide the opportunity to undertake exciting and impactful research that will underpin a researcher’s development as an independent future leader. The Doctoral Fellowship funds researchers to undertake a PhD

Wellbeing of Women is delighted to have partnered with the National Institute for Health Research (NIHR) to jointly fund one Charity Partnership Doctoral Fellowship.

All NIHR Fellowships provide the opportunity to undertake exciting and impactful research that will underpin a researcher’s development as an independent future leader. The Doctoral Fellowship funds researchers to undertake a PhD.

NIHR Charity Partnership Fellowships offer researchers the opportunity to be part of an active and supportive community, drawing on the enormous benefits and opportunities of cross-sector working.

For more details please see: https://www.wellbeingofwomen.org.uk/funding-opportunities/nihr-wellbeing-of-women-doctoral-fellowships

Update: Here’s another

HEE/NIHR ICA Clinical Doctoral Research Fellowship

The Clinical Doctoral Research Fellowship (CDRF) funds health and social care professionals to undertake a PhD and professional development in parallel, alongside continued professional practice.

The scheme is part of the HEE/NIHR Integrated Clinical Academic (ICA) Programme.

CDRFs are available to health and social care professionals (excluding doctors or dentists) who are registered with an ICA eligible regulatory body.

For more details please see: https://www.nihr.ac.uk/funding/heenihr-ica-clinical-doctoral-research-fellowship/27181?source=chainmail

If you are considering training to be a researcher and/or clinical academic who does breech research, we would love to hear from you. There are many challenges in breech research. For example, variations in when the breech is diagnosed make recruitment challenging. Sometimes dramatic variations exist between centres in external cephalic version success rates, vaginal breech birth experience and whether or not breech presentation has a dedicated care pathway. This can make recruiting sites difficult, and it is difficult to reach an adequate sample size within single-centre studies. But we have experience in navigating some of these challenges and are keen to collaborate with others.

For example, in the OptiBreech Project, we are building a database designed to support a large, multi-site observational cohort study with multiple embedded trials along the breech care pathway. Some of the questions women or potential researchers have told us would be useful to answer include:

  • Does moxibustion work in a UK context, and what does it cost? This could be tested as a trial within the cohort.
  • Rebozo sifting / positional exercises / homeopathy / hypnosis — do they influence the rate at which babies turn head-down, or the success rate of external cephalic version? This could be tested as a trial within the cohort.
  • Does provision of an ECV service by a Breech Specialist Midwife change the outcomes of the service? And what does it cost compared to an obstetric service? This could be tested as a trial within the cohort.
  • Should we offer cervical sweeps to women with breech-presenting babies? Are they helpful? Safe? From when should we offer them? This could be tested as a trial within the cohort.
  • Does offering induction of labour for women with a breech-presenting baby who desire a vaginal breech birth affect modes of birth and/or outcomes? This could be tested as a trial within the cohort

If you’d like to consider applying for this or another source of funding for breech research, you are welcome to be in touch to discuss!

Shawn

Video Library Access

From 1 May 2021, access to the Physiological Breech Birth video library on Vimeo, hosted by Breech Birth Network, will only be available through our on-line training programme.

Although we’ve always offered a year’s access with training, we’ve never changed the password. But it’s been over a year since we have been able to deliver any in-person study days.

If you have purchased the on-line training, you will have access to the complete training for a year, as well as the Vimeo video library. The password to the library will be posted within the training programme, so you can continue to access the videos you use in training. If you attend an in-person training, you will be given access to the on-line training for one year.

If your organisation uses our videos, someone from your organisation will need to be enrolled onto our on-line course. Institutional rates are available if you would like all of your staff to have access to the course and the video library.

Thank you for making such good use of the training materials we’ve worked hard to create. May the breech babies find you and be safe in your hands.

Shawn

Visits and elective placements for students

Emma and I frequently receive requests for elective placements from students keen to experience midwifery practice related to breech birth. We wrote this post to provide some guidance into what you can do if you would like to gain more breech exposure.

Elective placements are tricky for a number of reasons:

  1. At the moment, COVID-19.
  2. A lot of administrative paperwork for a short placement.
  3. We need to prioritise students from our local universities.
  4. Direct work with women with a breech-presenting baby is only a small part of what we do.
  5. No guarantee there would be any breech births during this period and/or that permission would be given for you to attend.
  6. You will not be able to gain hands-on experience on an elective placement.

If you would like to spend your elective placement learning more about working with breech presentation, our on-line course is a great place to start. You will gain more exposure to the way breech births work, in a shorter period of time, than most midwives do in their careers. You will gain insight into how women and birthing people can be counselled to ensure informed decision-making. And you will learn how others have implemented change to the way breech works in their local hospitals.

You could structure your own elective placement, including the following:

  1. Completing the Physiological Breech Birth on-line training.
  2. Working with your local practice development midwives to attend any local training provided to qualified midwives, doctors or medical students, for example mandatory training activities.
  3. Arranging to observe local counselling for breech presentation in your antenatal clinic. This may require you to liaise with the Antenatal Clinic Matron to find out about the local breech care pathway.
  4. Attending presentation scans. You will need to find out where and by whom these are done in your local unit.
  5. Observing external cephalic versions. Where and by whom are these done in your local unit?
  6. Reading through publications related to physiological breech birth so you really understand the principals and evidence base.
  7. Make a video about some aspect of breech management. If we include it in our training, you get lifetime access for free! Think about what women you encounter need more information about. Or what your fellow students need to learn about breech that you have learned through your placement. Practice finding evidence-based answers to the questions posted to these forums.
  8. Hang out on-line in forums related to breech birth, such as Breech Birth Network’s FaceBook page and Instagram, Breech Birth UK, Breech Birth Australia and New Zealand, and the Coalition for Breech Birth. This will give you insight into women’s and providers’ concerns and experiences.
  9. Writing a commentary article for a midwifery practice journal, such as TPM’s Student Midwife, summarising your self-made elective placement and what you learned.

Finding out the answers to all of these questions and/or completing these activities will give you insight into how the breech care pathway works for the women you care for. In some locations, this care is provided through an organised clinic and the path is clear. In other sites, care is more fragmented, and it may be harder to determine what the pathway is. But this in itself is useful because you will be able to see the work that needs to be done!

Another benefit of crafting your own placement in your local setting is that, when your colleagues know of your interest in breech, you are more likely to be involved in actual breech births. This is called “attracting breeches,” and you can read more about it in this research.

We are very keen to support students but need to be realistic about how we might be able to do that at the moment.

— Shawn and Emma

Image: Danish midwifery student Pernille Ravn on her elective placement, demonstrating the movement of baby to mother’s abdomen when performing the shoulder press manoeuvre

New training videos from the Hospital of Southern Denmark

The team at Sygehus Sønderjylland, the University Hospital of Southern Denmark, has created a wonderful new series of training videos for upright breech birth. We are thrilled to be able to share them with you!

The creation of the videos was led by obstetrician Kamilla Gerhard-Nielsen, who also led the implementation of the upright breech concept in the hospital and its introduction in Denmark.

They also host a FaceBook page. Image: Obstetricians Katrin Loeser and Kamilla Gerhard-Nielsen

Saturday at 2pm: Consultation on Draft NICE Antenatal Care Guideline

Update 17 March: This was our final submission.

You are invited to an open discussion about the Draft of the new NICE Antenatal Care Guideline. Breech Birth Network would like to collect the views of families who have experienced a breech presentation at term and care providers on the draft guidance.

Josephine and Thiago talk about their experience of Ulysse’s breech birth at Erasme Hospital in Brussels

The NICE Antenatal Care Guideline covers the detection of breech presentation (how midwives and obstetricians pick up that your baby is breech) and how a known breech presentation at term should be managed by your care providers.

The recommendations are based on outcomes that are considered ‘critical’ and ‘important.’ A discussion of how the committee has prioritised outcomes and decided upon a recommendation is included in the Evidence Reviews.

This is a first meeting. A second will be held in March to review the results of this meeting and any written responses Breech Birth Network has received, before the deadline at the end of March. At the meeting we will:

  1. Help you understand what the guideline and evidence reviews are saying.
  2. Ask you how you feel about the recommendations.
  3. Ask you if you would like to provide any feedback to the committee, which we will include in a collective response.

If you are unable to attend this meeting, you are also welcome to:

  • engage in this discussion by posting a comment on this blog page;
  • contact us using the e-mail form below to provide non-public feedback;
  • or leave a comment on our FaceBook group page, where we will post a link to this invitation.

Note: We have observed that some of the women we work with have experienced distress or sometimes trauma in their breech pregnancies. If your experience makes it uncomfortable to participate in a group event, and you would like to have a 1:1 meeting with someone from the Breech Birth Network, please contact us using the e-mail form below.

Meeting Details

Shawn Walker is inviting you to a scheduled Zoom meeting.

Topic: Consultation on draft NICE Antenatal Guideline
Time: Feb 13, 2021 02:00 PM London

Join Zoom Meeting
https://us02web.zoom.us/j/88695973178?pwd=U0k2MVg3cSs5eUd0Z29ONjJIbjIzZz09

Meeting ID: 886 9597 3178
Passcode: Zja8zR

Links to Draft Guidance

Breech Birth Network’s fully-evaluated, evidence-based Physiological Breech Birth training is now on-line! Including dozens of videos of real breech births. CPD certificate provided upon completion. Covering:

Simple Shoulder Press
  • types of breech presentation
  • maternal birth positions, normal mechanisms
  • normal timings of emergence
  • normal fetal characteristics during emergence
  • using maternal movement and effort to avoid delay
  • assisting newborn transition
  • delay on the perineum
  • assisting legs, arms and heads to be born
  • developing and sustaining local expertise
  • implementation examples
  • woman-centred counselling