Author Archives: midwifeshawn

About midwifeshawn

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

Induction of labour and … everyone

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:

  1. 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 …
  2. 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.
  3. 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.
  4. 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.

Shawn

Breech Team Lanyard Pins!

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.

In a few weeks, we will receive our new breech team pins from @madebycooper, based on our Breech Birth Network training booklet cover image by Merlin Strangeway (Drawn to Medicine).

We have created these pins because my research (Walker et al 2018open access version) indicates that the three elements which develop and sustain expertise in breech birth are:

  • affinity
  • visibility
  • relationship

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.

Walker S, Parker P, Scamell M, 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209. https://doi.org/10.1111/birt.12326

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).

Walker S, Parker P, Scamell M, 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209. https://doi.org/10.1111/birt.12326

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.

Love,

Shawn

 

 

Upcoming conferences

You and your colleagues may be interested in these two upcoming conferences, led by obstetricians. First, a two-day breech conference in Denmark featuring a number of internationally known teachers and researchers:

Denmark 2019

And in November, Breech Birth Network will be offering physiological breech training alongside the British Intrapartum Care Society Conference in Leicester.

BICS 2019

 

Seeking your thoughts on new research …

BBN

Illustration by Kate Evans

We are seeking your thoughts on two new pieces of research currently in the development stage. If you have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, or you work with pregnant women in a non-medical capacity (e.g. doula, antenatal teacher, breastfeeding supporter, etc.), we would love to hear from you.

Emma Spillane would like your feedback on an Information Leaflet for people pregnant with breech-presenting babies. The leaflet will be used in research to determine an approximate level of demand for vaginal breech birth, with balanced counselling and adequate support.

elevate&rotate

Talking through elevate and rotate

Shawn Walker is preparing an application for a large grant to fund a pilot randomised controlled trial. No term breech trials have been published since 2000 (Hannah et al). The team around this project would like to gather a Breech Advisory Group composed of people who have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, and non-medical birth workers, such as doulas and antenatal teachers. At this stage, we would like your feedback on the suggested design of the trial, to ensure that the information resulting from the research will be useful to those considering breech options. For those of you who would like to remain with the project if funding is obtained, we will send regular updates with opportunities to provide feedback at stages like final project design, advertising the trial and analysing the results.ShawnPortsmouth

If you are interested in participating in our research in this way, please complete the form below and one of us will be in touch.

Bruxelles et le siège

Training in Lewisham on November 12 — Book here.

“We believe that we do well what we do often.” – Caroline Daelemans

Drs Caroline Daelemas and Sara Derisbourg

Contact Hōpital Erasme Clinique du Siège on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be.

This month I visited Hōpital Erasme, in Brussels, Belgium. Led by Lead Obstetrician Caroline Daelemans, Erasme began to offer a dedicated Breech Clinic in December 2015. Much of the organisation and development of the clinic has been done by Dr Sara Derisbourg, who continues to research the impact of instituting a dedicated breech service.

I came to Brussels to provide our usual physiological breech study day. The breech team has transitioned to using physiological methods, including upright maternal positions (Louwen et al 2016), after attending training in Norwich in 2017. They now needed the rest of the team to understand the philosophy behind this approach. But the day began with Caroline describing the impact of instituting a dedicated Breech Clinic, and this was particularly exciting for me.

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

My own research concerning the development of breech competence and expertise, and the recovery of these skills within a service, indicates that developing a core team with significant experience is the most effective method of safely offering a vaginal breech birth service (Walker et al 2016). This skilled and experienced core is more important than the ‘selection criteria’ that are used to predict the likelihood of a good outcome (but in fact are not very predictive). Skill and experience facilitate good outcomes and enable other colleagues to develop competence (Walker et al 2018). The Erasme team even encourage other health care professionals to come with their clients and attend them in labour with their support, to encourage the growth of breech skills.

The need for new ways of organising care has been emphasised in an on-line survey of Dutch gynaecologists just published by Post et al (2018, Does vaginal breech delivery have a future despite low volumes for training?): “Potential suggested alterations in organization are designated gynecologists within one centre, designated teams within one region or centralizing breech birth to hospitals with a regional referral status. Training should then be offered to residents within these settings to make the experience as wide spread as possible.”

Daphne Lagrou of Médecins Sans Frontières demonstrates shoulder press

Daelemans and Derisbourg began with a small team of 5 people. This has gradually expanded and now includes eight members who together provide 24/7 cover for all breech births within the hospital. Women with a breech presentation are referred by colleagues and increasingly by other women. The environment at Erasme is ideal because the hospital has a very positive approach to physiological birth in general, and a 15% overall caesarean section rate in 2017. This compares to 20.2% in Brussels and much higher in many places globally.

Practising collaborative manoeuvres for resolving head extension at the inlet of the pelvis (elevate & rotate)

What has the Breech Clinic changed? Before the introduction of the clinic, the planned vaginal breech birth rate was 7.19%, and in just a few years this has climbed to 42.7% of all breech presentations. Neonatal outcomes have remained stable. Actual vaginal breech births have climbed from 4.2% to 35.96% of all breech presentations within the hospital. The success rate for planned vaginal breech birth is 76.3%, which suggests that within experienced teams, the emergency caesarean section rate is also reduced. (The RCOG guideline suggests about 40% of planned breech births end in CS.)

All of this is very impressive. The message is clear: a physiological approach and an organised care pathway, including a breech clinic and experienced on-call team, can reduce the caesarean section rate significantly without negatively impacting neonatal outcomes. We should all look out for Derisbourg’s papers when they are published.

If you are a woman seeking support for a physiological breech birth, or a health care professional looking to refer a woman to the breech clinic, they can be contacted on Tel 00 32 2 5553325, or siege.clini-obs @ erasme.ulb.ac.be. Caroline Daelemans will be teaching with me in Lewisham, London, on 12 November.

— Shawn

India and the breech

Missed our Facebook Live event with Fernandez Hospitals? Watch the recording here:

PMET student Arunarao Pusala receives her training certificate in Karimnagar

This month I am in Hyderabad, India, visiting Dr Evita Fernandez and UK Consultant Midwives Indie Kaur and Kate Stringer. Today at 5pm IST (that’s 11.30 GMT), we will be having a Facebook Live discussion on Breech Birth in India. This will be followed by hands-on workshops on the 12th and 19th in Hyderabad.

with Senior Midwives Theresa and Jyoti

The Fernandez Hospitals are at the forefront of compassionate maternity care on a large scale in India. The Stork Home facility has been beautifully designed and rivals some of the best midwifery units in the UK. But Dr Evita and her team of doctors and midwives are very ambitious. They want to revive vaginal breech skills so that women can confidently choose this option. How will this work in Hyderabad? Join us for a discussion.

Midwives and doulas support women together in the beautiful Stork Home facility in Hyderabad

From Arunarao: “My special thanks to dr Evita ,lndie mam Kate mam and Shawn mam for the opportunity to participate in BREECH BIRTH WORKSHOP at karimnagar.i am so panic about breech presentation and breech birth before I come to professional midwifery training, know iam very excited to assist the spontaneous and assisted breech birth,because now I came to know breech also has its own mechanism and always always we have to respect those mechanism and iam aware of the manoeuvres to apply whenever it’s needed.thank you all of you mam iam so blessed to have a teaching faculty like you.” Thank you Arunarao — you really got it!

Shawn