Dr Anke Reitter and Dr Shawn Walker of the Breech Birth Network will teach together in Barcelona on 23 April at Hospital de la Santa Creu i Sant Pau. Please share with your obstetric and midwifery colleagues. Materials will be translated into Spanish for participants. Click the image below for more information on how to register.
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.
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.
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.
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.
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:
In 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.
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
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
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.
Bank charges £852
NET PROFIT £866
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.
A 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.
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.
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.
This week, I ventured into a Twitter discussion around routine induction of labour for everyone at 39 weeks, initiated by obstetrician Ed Prosser-Snelling with this tweet, if you want to check out the thread:
Because this is the place I collect my controversial thoughts, and because this obviously affects the extremely narrow window of possibility for vaginal breech birth, here are my thoughts:
I actually think it’s not a bad idea to enable women who want it to have access to elective IOL from 39 weeks, regardless of their risk level (or indeed fetal presentation). The research is pretty clear that it does not increase CS rates. It appears to reduce perinatal mortality but increase neonatal admissions (Stocks et al 2012). My main, deep and passionate commitment is for women to be in control of their mode of birth and birth experiences as much as possible.
My biggest concern about committing services to making more medical options more easily accessible is that, at the moment, accessing the most evidence-based care for optimal physiological birth is not easy. Providing more medical interventions will divert resources and attention from achieving this. Not every woman has continuity of midwifery care, an intervention backed up by multiple systematic reviews, which also reduces preterm birth, total fetal loss and neonatal death (see Sands statement on Continuity of Carer). Midwifery CoC is a government-backed, national priority (see Better Births) and is requiring major reorganisation of services everywhere. Sometimes, to do things properly, concentrating on one big change at a time does help. It also helps when trying to determine which intervention is responsible for any observed changes.
Similarly, women who would like to plan a vaginal breech birth are not provided with care that the evidence base says will give them the best chance of a good outcome — an experienced attendant — effectively making this choice unavailable in most locations. And women who would like to await spontaneous labour past the locally decided date for routine IOL face judgement and resistance — not from all health care professionals, but from many.
I spend a good deal of my professional life supporting women who are actively seeking help to plan a birth that clearly involves more risk than awaiting spontaneous labour after 39 weeks. I know plenty of women are prepared to accept some element of increased neonatal risk in their holistic assessment of what is right for them, but that they are easily shamed into changing their minds. (If anyone is asking themselves why they don’t meet them, bear in mind most of them will stop talking about what they really want when they pick up on judgmental attitudes about their choices. Then they will seek support elsewhere, or just accept what’s on offer. It is emotionally exhausting for them and for those midwives and obstetricians who try to help them pick up the pieces.)
Midwives everywhere will also be worrying about the ever-narrowing window of normality during childbirth. What exactly will be a midwife’s sphere of practice in a world of routine induction at 39 weeks? Most guidelines indicate we’re not supposed to perform a cervical sweep on a nullip until after 40 weeks and a multip after 41? Who will give birth in midwife-led units? Home birth? Will it be reasonable to plan anything other than an OU birth? Midwives will also be concerned about hidden costs they can’t quite put into words (or a cost-utility analysis), things like the time spent scheduling and rescheduling IOL, time spent counselling women who are upset about ‘having to be induced,’ time spent scheduling additional appointments with consultant midwives or consultant obstetricians for women who have declined induction, time spent debriefing women who feel traumatised by an IOL process that felt out of control, etc.
Expanding the offer of IOL to 39 weeks requires careful, multi-professional collaboration because it has massive implications for women, the service, and the role of the midwife. What women need to have a satisfying induction (Coates et al 2019) is not something that can be provided for all women currently undergoing induction now — how will we provide it for more? The history of obstetrics is replete with well-meaning people implementing plausibly beneficent interventions ASAP, but also many instances in which unanticipated harms are discovered as consequences late in the day. I want world in which birthing families have more options, not less. But I would like to take things slowly, carefully so that we:
- Research the effects of implementing this policy thoroughly. Let’s do thorough PPI work to ensure all of the outcomes that all stakeholders are worried about are eventually accounted for. Let’s ensure midwives are part of the team that designs rather than just delivers the research, so they can take an equal part in confidently implementing & disseminating it. Ten years later, let’s look back and be able to confidently say, “Look what we’ve done!” with one tone of voice or another …
- Co-design an information and consent process with women who have had positive and negative experiences of IOL. Women would be informed at 37 weeks that the risk of stillbirth increases from 39 weeks with clear, consistent information, including infographics. They would be offered a scheduled induction, and if they decline, neither them nor their midwife (if otherwise low-risk) would be required to justify this decision.
- Co-design services which give women maximum control over the timing of their induction. Have some ‘scheduled’ slots for women who prefer that and some for arising medical indications. And tell everyone else that they can put themselves on the waiting list for medical induction whenever they want to after 39 weeks, to be seen on a first-come-first-serve basis. If we have capacity to do this many IOL, we ought to have capacity to offer greater flexibility. One of the things women regret losing with scheduled IOL is the ability to trust their instincts as they are becoming parents. Ensure at each visit women know how to access IOL if they want it, but don’t hound women who choose not to join this queue.
- See this as a ‘choice’ issue and not a stillbirth reduction ‘target.’ Targets which require everyone accept the intervention in order to achieve the target outcome will reduce, rather than expand, choice.
Finally, I feel that midwives need to lead on research that contributes to our knowledge about IOL, rather than seeing it as ‘the realm of the abnormal,’ and thus obstetric territory. If we are offering IOL closer and closer to 39 weeks, this is more ‘normal’ than ‘abnormal,’ especially as we know outcomes for live babies are best after 39 weeks. For example, we have Cochrane Reviews on cervical sweeps and nipple stimulation (see Evidence-Based Birth blogs on membrane sweeps and breast stimulation to stimulate labour).
Many women would like the ability to request a sweep earlier than 40 weeks, and they certainly will want this if induction at 39 weeks is routine. Might this help, or harm, or are there trade-offs? Might pumping breast milk after 38 weeks improve spontaneous birth and breastfeeding rates? Might these traditional midwifery approaches have potential to help women retain more control over initiation of their labour and consequently their choice of birth setting? Researching and changing midwifery practice related to cervical ripening for women at term who wish this would, in my opinion, be a more manageable and likely more widely acceptable first step than scheduling more hospital-based inductions. It would also dovetail nicely if a policy of offering induction at 39 or 40 weeks does become routine.
We are thrilled at the interest these pins are receiving. We have created them to make it easy to identify people who have attended our Physiological Breech Birth study day and are either on a breech team or working with Breech Birth Network to create a breech team in their work setting. More information below, with the form to request pins at the bottom of this post. We are going to maintain this criteria strictly so that it is meaningful, but we will consider additional designs in the future.
Expertise is generative — it generates comparatively good outcomes, and confidence and competence among colleagues. The role of a breech team is to develop expertise in order to support the entire team to support vaginal breech births safely.
Breech teams enable the development of expertise within organisation because team members work flexibly to attend breech births when they occur, enabling them to acquire clinical experience. Once new team members develop their own skill and experience, they continue to attend births as an extra layer of support for the wider maternity care team, maintaining their own expertise while promoting confidence and safety.
Some Trusts have a specific on-call system. But most find that making their breech team visible is enough to introduce cultural change supporting the development of expertise. One simple way to do this is to designate a breech team (including obstetricians and midwives) and post a list of people and how to contact them in a prominent position on the labour ward. Make it an expectation, backed up by the Trust guideline where possible, that someone from this team is involved in any episode of breech care wherever possible. Sometimes it is not possible. But most of the time it is, even without a rigid on-call system.
A team member should be involved from the moment a term breech is diagnosed, whether antenatally or in labour. Individuals who have developed generative expertise counsel very differently from those who are still developing their skills or are not keen on breech birth. “Facilitating an informed consent discussion that demonstrates respect for maternal intelligence and autonomy, while being realistic about the inability to guarantee a perfect outcome” is also a skill that develops with practice (Walker et al 2016, p11 — open access version).
These pins will increase the visibility of breech teams by reminding women that physiological breech births are supported, countering negative portrayals in the media and social discourses of risk, and remind maternity staff that involvement of the breech team is available and expected.
Breech team lanyard pins will be available for FREE from the Breech Birth Network, CIC. To wear the pins:
- Each member of your team who wears a pin must have attended one of our Physiological Breech Birth study days. If this hasn’t happened yet, you can easily book a study day at your hospital.
- Your team must contain at least one person who has taught breech skills with us on our Physiological Breech Birth study days (more information on how to do this is on the page). The network pays your expenses to do this, but we need to confirm we are on the same page with the skills and content. Teaching is also one of the mechanisms through which breech expertise develops.
To order pins for your team, contact us using the form below.