Author Archives: midwifeshawn

About midwifeshawn

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

The virus and the breech

 

We would like to share with you our strategy for dealing with the uncertainties caused by the COVID-19 pandemic.

We have recently had a study day cancelled days before the event. This was understandable given the rapidly changing situation for NHS Trusts. We arranged refunds, including offering travel refunds to the clinical skills educators who were helping to deliver the day and developing their own skills. But we crunched the numbers and realised that we will be bankrupt if we do this again! Therefore, we have developed the following policy:

For NHS Trusts or other organisers who cancel events, we will re-arrange a suitable date when it is safe to deliver the training. We cannot return any payments that have already been made. We encourage Trusts to follow the local and national guidance on cancelling social events and meetings.

Similarly, if events are cancelled or individuals are not able to attend due to cancellation or personal reasons, we will you enable to attend another training at another date of your choice in the future. But we cannot return payments that you have made for training.

Thank you for understanding this decision, given the uncertain situation at the moment. We are essentially a two-woman operation, with additional help on the occasional study day.

Wishing you and your loved ones safety,

Shawn & Emma

 

Video analysis and Algorithm paper published!

Practical insight into upright breech birth from birth videos: a structured analysis” is now available on-line! (Reitter, Halliday and Walker, 2020, Birth – https://doi.org/10.1111/birt.12480) This paper represents a few years of hard work by Anke Reitter, me and our Research Assistant, Alexandra Halliday. It contains insights into birth timings and the mechanisms as observed in upright breech birth videos. The Physiological Breech Birth Algorithm is also included.

Download Algorithm

We look forward to much debate and discussion! Please share with anyone concerned about safe vaginal breech birth.

Love,

Shawn

Traduit par: Isabelle Brabant et Caroline Daelmans

Vancouver physiological breech workshop

Next month, I will be a Visiting Scholar at the University of British Columbia. This will include a workshop on my research and physiological breech birth practice, delivered alongside Andrew Kotaska, lead author of the Canadian breech guideline, and a highly respected obstetric and midwifery faculty.

Please share this information with any Canadian OBs and Residents who want to extend their skills to facilitate safe vaginal breech births. The course is accredited for MOC 3. Bookings can be made on-line.

Stockholm and the breech

This weekend, I have been lucky enough to visit Stockholm, Sweden, at the invitation of the Södersjukhuset (BB SÖS), with Dr Andrew Kotaska, author of the 2019 Canadian breech guideline. We delivered training in breech research and practice to obstetricians and midwives from across Stockholm, a contribution to their recent effort to establish city-wide guidelines.

Breech Team Leader Tove Wallström and Breech Midwife Monica Berggren

The day was organised by senior obstetrician Julia Savchenko (pictured with Andrew above). Julia and fellow senior consultant Tove Wallström lead the Labour Ward and the SÖS breech team. These inspirational women presented their local audit results, showing how their vaginal breech births have increased from 9 in 2014 to 50 so far in 2019. Almost all women give birth in an upright position, and all births are attended by a breech-experienced obstetrician and a breech-experienced midwife from the breech team.

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

It was exciting to see a ‘Breech Team‘ service working so well in the largest maternity hospital in Stockholm. The team are able to take referrals for women pregnant with a breech-presenting baby at term who wish to give birth at SÖS. They can also provide training for other teams in Sweden who wish to improve the safety and delivery of their own services, using their own resources and presentation materials provided by the Breech Birth Network.

To ask about referral or training, please contact Julia and Tove using the form below.

Typical Swedish post-birth meal — a step up from British tea and toast!

Each family places a pin in the board to celebrate their birth as she leaves SÖS

Busy hospital!

For more information about training outside of Sweden, please see our Booking a Study Day page.

For information about training or referrals for a vaginal breech birth in Sweden, contact Julia and Tove:

Annual Report of Accounts: 2018

community interest companies logoIn December 2017, Breech Birth Network was incorporated as a Community Interest Company. This means the company is a not-for-profit, constituted to benefit the community and is asset-locked. Profits are channelled back into the activities in the community interest. The Intellectual Property, such as teaching presentations and videos created from those donated by women and practitioners, belongs to the CIC, and if the company dissolves must be donated to one of two designated charities.

This month, Breech Birth Network, Community Interest Company, submitted its first accounts to Companies House, via our accountant. In the interests of transparency, we are sharing our accounting reports here, along with the description of CIC activities we have provided to Companies House. Thank you to those who have paid to attend our study days during this period. As you can see, sharing these skills and information requires substantial funding. You enable us to do what we do.

Trading and Profit and Loss Account for the Period 1 December 2017 to 31 December 2018

Shawn Walker was the only named Director of the CIC during this period. Emma Spillane was appointed a Director in May 2019.

Sales £19,361

Cost of sales £8,115

Purchases £2,252 — This includes purchases of teaching equipment and printing of training manuals.

Sub contractors £1,563 — This includes fees paid to collaborators, such as consultant obstetricians who teach on our study days, and illustrators.

Teaching fees £4,300 — This includes a set daily rate paid to Shawn Walker and Emma Spillane for each complete day of teaching. A total of 35 complete days and many more shorter conference presentations were delivered by Shawn and Emma during this accounting period.

GROSS PROFIT £11,246

Expenditure (£9,528)

Insurance £373 — We are required to have insurance to meet NMC requirements while teaching in a professional capacity.

Conference costs £99

Post and stationery £25

Travelling £5,870 — This includes expenses related to travel for Shawn, Emma, collaborators and clinical skills trainers who are developing their skills to disseminate training locally.

Repairs and maintenance £149

Training £363

Research £303 — This includes fees paid to Research Assistants to help with the before-and-after study of the Physiological Breech Birth Training Package.

Computer costs £894 — This includes IT fees related to maintaining the Vimeo site where our teaching resource videos are shared, this blog and other software required to create the resources we use.

Sundry expenses £62

Accountancy £493 — We felt this needed to be done properly now that the company is registered as a CIC, to ensure we are not in breach of any legal standards. We are midwives, not accountants.

Depreciation of tangible fixed assets

Plant and machinery £92

Computer equipment £386 — Shawn and Emma both carry an encrypted laptop to transport the sensitive birth videos we use to teach. Our presentations are too large to transport on a data stick because of the number of images and videos.

Entertainment £419 — When we meet in the evening for a planning meeting or after a training day with guests.

SUBTOTAL £1,718

Finance costs

Bank charges £852

NET PROFIT £866

 

FORM CIC34
PART 1 – GENERAL DESCRIPTION OF THE COMPANY’S ACTIVITIES AND IMPACT

In the space provided below, please insert a general account of the company’s activities in the financial year to which the report relates, including a description of how they have benefited the community. 

Breech Birth Network, Community Interest Company, was incorporated as a CIC on 1 December 2017. During the period from 1/12/17 to 31/12/18, Breech Birth Network provided 35 days of physiological breech birth training, within the UK and other parts of Europe. This enabled the training to reach approximately 1500 health care professionals. We provided printed training manuals and an on-line video database containing breech birth videos and recorded training presentations, made available for on-going revision to each of these health care professionals. We reimbursed travel expenses for 19 different clinical skills trainers, to enable them to gain confidence teaching alongside the Director, Shawn Walker, and Training Co-ordinator, Emma Spillane, in order to disseminate the training in their local settings. We donated two doll and pelvis models to the Fernandez Institute in Hyderabad, India, to support their efforts to develop a breech birth service. We funded a before-and-after evaluation of the breech training package, which is currently being analysed, and other small research-related expenses. And we provided free advice and support to women seeking support for a vaginal breech birth and health services seeking to provide better support, including reflective supervision of other health care professionals attending vaginal breech births.

PART 2 – CONSULTATION WITH STAKEHOLDERS

Please indicate who the company’s stakeholders are; how the stakeholders have been consulted and what action, if any, has the company taken in response to feedback from its consultations? If there has been no consultation, this should be made clear.

Our stakeholders include service user advocates, such as women who have experienced a breech pregnancy, and health care professionals who may attend vaginal breech births. Health care professionals complete a feedback form following each training day, and results are incorporated into on-going iterations of the training package. The Director, Shawn Walker, and the Training Co-ordinator, Emma Spillane, have both undertaken PPI (Patient and Public Involvement) activities concerning their breech-related research projects.

PART 3 – DIRECTORS’ REMUNERATION 

The accounts indicate that £4300 was paid in teaching fees for the provision of 35 days of teaching. The Director, Shawn Walker, was paid £3200 of this amount, in addition to travel expenses. There were no other transactions or arrangements in connection with the remunerations of directors, or compensation for director’s loss of office, which require to be disclosed.

PART 4 – TRANSFERS OF ASSETS OTHER THAN FOR FULL CONSIDERATION

No transfer of assets other than for full consideration has been made.

New Canadian breech guidelines published

new guidelineA new SOGC Clinical Practice Guideline No. 384 — Management of Breech Presentation at term has been published. It echoes the latest RCOG guideline in promoting accurate and supportive informed consent discussions. One of the main authors, Andrew Kotaska, has written extensively about this before: Informed consent and refusal in obstetrics: a practical ethical guide.

The SOGC guideline frames counselling around mode of childbirth for a breech baby within the context of human rights, especially in the ‘Key Messages:’

A woman’s choice of delivery mode should be respected.

The risk of planned vaginal breech birth is acceptable to some women with a term singleton breech fetus.

Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should be provided with the best possible in-hospital care. 

The summary of evidence related to safety is similar to that provided by the RCOG and a good reference for anyone counselling women about their breech childbirth options. A notable difference is the recommendation that,

Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour.

https://twitter.com/SisterShawnRM/status/1143838688637542400

As with the RCOG guideline, the new SOGC guideline recognises the importance of skill and experience to the safety of vaginal breech births. One of the SOGC’s summary statements is:

Vaginal breech birth requires a high degree of skill and support. To avoid the increased risk of out-of-hospital vaginal breech birth, women who choose planned vaginal breech birth should be accommodated in-hospital. To facilitate this, referral to more experienced centres, back-up on-call arrangements, and continuing medical training in vaginal breech birth skills should be promoted (very low).

(Very low refers to the quality of evidence in relation to this recommendation.) The RCOG also recommends antenatal referral to a centre with more skill and experience if necessary. Later in the SOGC text, the authors point out:

Many newly qualified obstetricians do not have the experience necessary to supervise a breech TOL [trial of labour]. Mentoring by more senior colleagues will be necessary if they are to attain these skills. As women will continue to request planned VBB and precipitous breech births occur in all settings, theoretical and hands-on breech birth training using models should remain part of basic obstetrical and midwifery training and of traingin programs such as ALARM, ALSO, and MORE ob.

I am particulary interested in recommendations made regarding how to support breech skill development because Competence and Expertise in Physiological Breech Birth was the topic of my PhD.

In our integrative review of the Effectiveness of vaginal breech birth training strategies (2017), inclusion of breech birth as part of an obstetric emergencies training package without support in practice was negatively associated with subsequent attendance at vaginal breech births, meaning practitioners attended fewer breech births. None of the evaluations of training packages included clinical outcomes, so it was not possible to determine whether they had an effect on safety. But the evidence suggests that support and mentorship in practice is likely to be key to giving less experienced practitioners the confidence to support breech births and gain the skills in practice.

Research on Expertise in physiological breech birth and the Deliberate acquisition of competence in physiological breech birth suggest that mentorship is indeed very important, but that this does not always take the form of senior colleagues supporting newly qualified colleagues. Maintaining classical hierarchies — such as expecting senior obstetricians to have breech skills while younger colleagues, or midwives, not to — can promote a form of alienating authority, which inhibits the development of generative expertise.  Among practitioners who had deliberately developed competence to support breech births, younger, highly motivated practitioners often had to leave their primary clinical setting to acquire knowledge, skills and new techniques, which they brought back with them. The fact that they needed to do this suggests that they had not been being mentored at home.

One of the things I love about working in the UK is the long history of multi-disciplinary working. Although some teams work more effectively than others, it means that a person wishing to birth their breech baby with an experienced midwife in attendance does not have to choose between a home birth and an obstetrically-managed hospital birth. The obstricians I work with recognise the skill with physiological birth that their midwifery colleagues bring into the room — and we are grateful for their skill with surgical and very complicated births. We keep each other safe.

Given that referral to experienced centres is recommended in both RCOG and SOGC guidelines, more research is needed about how this works in various settings. What happens if a woman is referred elsewhere, but that hospital cannot or will not accept her for care? What are the economic implications? What defines an ‘experienced centre?’ In some hospitals, such as in Frankfurt Germany, the vaginal breech birth rate can be as high as 6-11% of the total birth rate due to women travelling to experienced providers, compared to 0.4% of the total birth rate in the UK.

We also need to consider and study other potential solutions to skill redevelopment. For example, why expect women to travel away from their known and trusted care team — why not shift professionals instead? I am employed primarily by a university, but I have a contract with one NHS Trust and am completing a contract with another by request, so that I can support them to develop their breech services. Mobility of providers also happens when obstetric trainees rotate between training centres. Sadly, I have heard numerous stories from senior obstetric trainees who have acquired breech experience in one hospital, only to be blocked from using that experience by their senior colleagues in another, a case of hierarchical and alienating authority. Similarly, many midwives have spent time abroad and delivered dozens of breech babies, but have had to stand aside when a woman is diagnosed in labour with a breech because the woman is now considered ‘an obstetric case.’ Women are often not informed when skill and experience is available because these remain invisible and under-utilised, especially in midwives and younger obstetric colleagues.

Throughout the UK, many new breech services are being developed. Breech clinics, like the one at the Royal London, ensure women get consistent counselling by breech-experienced practitioners. They also provide an environment where trainees can learn this skill. Many hospitals are developing ‘breech teams‘ so that vaginal breech births and those attending them can be supported by confident and competent members of the team — this includes experienced midwives. Training activities to support these new teams emphasise the elements available literature suggests will be effective — repetition and reflection — especially using birth videos for team debrief and simulation training. Gradually, we are supporting each other to reintroduce breech skills and consider new ways of sustaining them in order to be able to offer the care our countries’ leading guidelines recommend.

— Shawn

References

García Adánez J et al 2013. Recuperación del parto vaginal de nalgas y versión cefálica externa. Progresos Obstet. y Ginecol. 56, 248–253.

Hickland P et al 2018. A novel and dedicated multidisciplinary service to manage breech presentation at term; 3 years of experience in a tertiary care maternity unit. J. Matern. Neonatal Med. 31, 3002–3008.

Homer C S E et al 2015. Women’s experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 15, 89.

Kidd L et al 2014. Development of a dedicated breech service in a London teaching hospital. Arch. Dis. Child. – Fetal Neonatal Ed. 99, A20–A21.

Kotaska A 2017. Informed consent and refusal in obstetrics: A practical ethical guide. Birth 44, 195–199.

Kotaska A, Menticoglou S 2019. No. 384-Management of Breech Presentation at Term. J. Obstet. Gynaecol. Canada 41, 1193–1205.

Larsen J W, Pinger WA 2014. Primary cesarean delivery prevention: a collaborative model of care. Obstet. Gynecol. 123 Suppl, 152S.

Louwen F et al 2017. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans? Int. J. Gynecol. Obstet. 136, 151–161.

Maier B et al, 2011. Fetal outcome for infants in breech by method of delivery: experiences with a stand-by service system of senior obstetricians and women’s choices of mode of delivery. J Perinat Med 39, 385–390.

Marko K I et al 2015. Cesarean Delivery Prevention. Obstet. Gynecol. 125, 42S.

Petrovska K et al 2016. Supporting Women Planning a Vaginal Breech Birth: An International Survey. Birth 43, 353–357.

Reitter A et al 2018. Is it reasonable to establish an independent obstetric leadership in a small hospital and does it result in measurable changes in quality of maternity care? Z. Geburtshilfe Neonatol.

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.

Walker S 2017. Competence and expertise in physiological breech birth. PhD Thesis. City, University of London.

Walker, S., Breslin, E., Scamell, M., Parker, P., 2017. Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth 44, 101–109.

Walker S, Scamell M, Parker P 2018. Deliberate acquisition of competence in physiological breech birth: A grounded theory study. Women and Birth 31, e170–e177.

Walker S, Parker P, Scamell M 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209.