Yesterday was International Day of the Midwife. I saw but didn’t participate in the social media celebrations. Not because I wasn’t feeling it, but because my clinical academic midwife life was full to the brim. This included:
Supporting a planned OptiBreech vaginal breech birth through the night and until the birth occurred in the morning;
Allowing my little dog to take me for a walk to support my physical and mental health;
Taking a massive nap; and
Spending a wild evening in on my sofa, knitting a jumper for my son Waldo the Stonemason and listening to a Miss Marple audio book.
If you feel exhausted just reading that list, you’re as human as me!
A team is not a group of people that work together. A team is a group of people that trust each other.
– Simon Sinek, shared by Céline, an attendee at my VIDM presentation
This feasibility study is undoubtedly the most challenging and most rewarding thing I have ever done in my life. Being a research leader means being a change leader, and change is never easy. The OptiBreech Project is proposing a paradigm change in the way we support vaginal breech birth. This means a change from promoting caesarean section (CS) to supporting each individual women’s choice of mode of birth, in line with NICE Guidance. And it means a change from using unreliable ‘selection criteria,’ which are also inconsistent with the concept of individual choice, to relying on specialist expertise to respond to unfolding and infinitely unique circumstances.
Being a breech specialist is not easy. In addition to a lot of time spent on-call, it’s not like working in a low-risk midwifery setting, where you can anticipate 90% of women will have the normal birth that they want. Many women are heart-broken when they find out their baby is breech. We can support them to plan an elective CS, and some women are happy about this, but many are very disappointed, even when they feel this is the best option for them and their baby. For those who want to plan a vaginal birth, but only if the baby is head-down, baby turning (ECV, external cephalic version) is only successful up to 50% of the time. We are still there for women when it does not work.
For those who want to plan a vaginal breech birth, the barriers sometimes seem impossible. It’s not uncommon for women to make an informed decision to plan a physiological breech birth (PBB) and return to clinic in tears because of the way someone has spoken to them, be that another health care professional, a friend or family member, or an unkind stranger on social media with opinions about the wisdom of their choice. The criticism, judgement and stigma can feel very heavy at such a vulnerable time. Our interviews with women on the study indicate they have felt supported to change their minds and plan an elective CS in these circumstances. Of course we can and do facilitate women changing their minds, but we can’t take away the hurt women feel when they wished for more support to make a different choice.
Birthing people who stick with their choice to birth vaginally despite such ubiquitous doubt frequently want reassurance that everything will be okay. Of course, we can never guarantee a perfect outcome. We can only guarantee that we are doing our best to increase the chances we will get professionals with enhanced training and experience to their birth. We believe this will improve outcomes for these births (that is the premise of the research), but we will not know until many OptiBreech births have occurred. And we all have to be prepared for a higher need for intrapartum CS to achieve a safe outcome for breech babies, even when trying for a vaginal birth.
Those of us supporting women who choose physiological breech births face similar criticism and judgement on a regular basis. Sometimes the lack of respect and unkindness feels overwhelming, and it is tempting to succumb to despair. I find it helps to remember that behaviour like this comes from a place of fear, a belief that doing things differently could have disastrous outcomes. Nobody wants this, and nobody wants to be responsible for it. In difficult times, I lean into the support I feel from many wonderful midwifery and obstetric colleagues, who help bring me back to a place of compassionate understanding. Only by opening to understanding each other can we move towards trust and safety — physical, emotional and spiritual safety in each others’ hands.
Listening to my ‘Joy and Love’ playlist helps too. Here’s a mini playlist of my favourite Resistance Revival Chorus songs, for anyone who needs them today.
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 2018 — open access version) indicates that the three elements which develop and sustain expertise in breech birth are:
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.
Our breech clinic is 9 months old and we did our 50th ECV today! 27 were successful (54%) 20 women then had vaginal deliveries, 4 caesareans, 3 births pending! 24 elective caesareans. And 8 vaginal breech births. Supporting maternal choice all the way @RLHMaternity
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:
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.
Next Thursday evening (25/1/18), King’s College London will host an opening night gathering to celebrate the launch of the Birth Rites collection installation throughout the the Guy’s campus. The event is free and open to the public, but you have to book.
“And I assure you that it was a very startling thing for me to hear a woman describing her feelings as she gave birth in the same words used by Bucke to describe cosmic consciousness or by Huxley to describe the mystic experience in all cultures and eras or by Ghiselin to describe the creative process or by Suzuki to describe the Zen satori experience.” – Abraham Maslow, describing ‘peak experiences’
“Terese crowning in ecstatic childbirth” from Ina May Gaskin’s book ‘Ina May’s guide to childbirth’ Hermione Wiltshire, 2008, black and white photograph. Birth Rites Collection.
Birth Rites is the first and only collection of contemporary art dedicated to the subject of childbirth. Works in the collection explore the intersection of emotional and technological experience of birth in 21st century culture.
Artist book ‘Cock’s Comb’ screen printed by Helen Knowles, bound by Helen Johnson and made in collaboration with teenage parents at Salford Women’s Centre. The book explored the teenage mothers language they used for the body and their experiences of childbirth by incorporating their drawings and writings, it also made reference to ‘The midwives Book’ written by Jane Sharpe in 1734, the first English midwifery text written by a woman. Detail of artist book ‘Cock’s Comb’ screen printed by Helen Knowles, bound by Helen Johnson and made in collaboration with teenage parents at Salford Women’s Centre.
The images are powerful and challenging, especially for those who are not used to seeing women’s faces and bodies transformed by the work of labour and birth. They provoke, and some are uncomfortable, controversial.
‘Yoga positions for Birth’ 2008 by Hermione Wiltshire. Photographic installation. Birth Rites Collection.
But this is the purpose of art. Private, hidden moments are public for a flash. And we’d love to hear your thoughts about it. If you are near London next Thursday, please do join us.
My work requires me to be able to speak to many audiences: midwives, obstetricians, paramedics, policy makers, birthing families. Increasingly working across cultural boundaries constantly challenges me to check my assumptions, to learn new ways of communicating. I don’t always get things right. I was recently asked by an education leader in an organisation I had worked with if I would consider eliminating gendered pronouns in my teaching videos. The request was warm, genuine and respectful. And it reflects the policy emerging within some maternity care professional organisations, particularly throughout North America.
I struggled with what I perceived to be a request to eliminate woman and mother in favour of gender-neutral language, and this blog is my attempt to be open and honest about this struggle. Some of my reactions are personal. I am a white cis-female who has given birth and raised my children as their mother. I have been privileged to have a good education and financial security. But my name is Shawn, and about once a week someone asks me how I ended up with a guy’s name, or addresses me via e-mail as Mr Walker, or expresses surprise that I appear to be a woman. It’s annoying, but I get it.
I’ve been using Ms, even when I have to write it in as an option, since I was a teenager. I had to do this yesterday, and the 1970’s have been over for at least 30 years. I have never changed my surname, even after marriage. And now that I know it’s a thing, would probably prefer that e-mailers use Mx rather than assume Mr. Although I have mothered four children (ages 6-16) who are growing up in Norwich, I live mostly 2 hours away in London and travel a lot for work. I am frequently asked who looks after my children when I am gone. No one ever asks their fathers, who are their main carers, when they travel for work. I am also American, but my accent has drifted across the Atlantic enough to be not quite English to English ears and quite English to non-English people. When I visit my parents in the US, people who don’t know me well refer to me as The English Lady. Thankfully, no one has ever referred to me as The English Pregnant Patient. I am enormously privileged and secure by chance and circumstance, but I also find myself in-between at times.
So why does gender neutral language in maternity care not feel obviously right to me? Certainly, referring to a group attending antenatal classes as parents rather than mums and dads feels right, because many combinations of parents make up families these days. But I feel a sense of loss as I contemplate dropping women and/or mothers completely from the way I teach and talk about my work.
Certainly, some of it is cultural. I am aware of advocacy for recognition of non-binary sex, gender and sexuality in the UK, and many things have changed for the better. But in general the midwifery profession still sees itself collectively as aspiring to woman-centred care, certainly in the UK and internationally if the collaborative Lancet Series in Midwifery is anything to go by. The etymology of “midwife” is “with woman.” Midwifery has a natural affinity with feminism in its aspirations to reduce inequalities, and this inherently involves recognising women as a class of people who are exposed to unequal and sometimes actively oppressive cultural and health care dynamics. In 2015, Glosswitch suggested, “Gender-neutral language around reproduction creates the illusion of dismantling a hierarchy – when what you really end up doing is ignoring it.” Elephant Circle, responding to MANA’s decision to shift to gender-inclusive language, made it clear that they are “committed to promoting the additive use of gender-neutral language in traditionally woman-centric movements.” I agree that use of exclusively gender-neutral language has at least potential to harm through erasure, but its additive use has clear potential to promote compassion and inclusion.
But I do question why it is so uncomfortable to have traditionally female-associated language transition into catch-all terms. When I was training, during a placement on the Intensive Care Unit, the senior nurse on the ward was a man. Senior nurses and midwives in the UK are often called Sister. Once, about to call him Sister, I caught myself and asked, “What should I call you?” Without hesitation, he said, “Call me Sister.” Then he told me off for wearing my jumper on the ward. My hesitation bothered me. But his professionalism and completely unthreatened acceptance of Sister as the gender-neutral term in the profession he had chosen impressed me. Male midwives have always done this. They are midwives.
What doesn’t impress me is when someone refers to a group containing both women and men as guys. This came up in a social media group for mothers who work in academia. Despite feedback from students voicing that it makes them uncomfortable, many people answered that guys is gender-neutral and, essentially, there are more important problems that require addressing so they were not going to go to the bother of changing their language. Guys will be gender neutral when it feels equally comfortable to refer to the same group or a group of men as gals. When taxi drivers no longer ask me if Shawn isn’t usually a guy’s name. Men was definitely neither gender- nor colour-neutral when the words “all men are created equal” sparked a revolution, and it still isn’t.
But it is very common, especially among male doctors, to refer to a group of midwives as girls, as in, “The girls will look after you …” It is incredibly tricky to challenge this language without being dismissed as an over-sensitive ranty feminist, the one with the problem, the one whose political correctness gets in the way of co-operating on more important problems. Yet if I do not change my own language in referring to birthing people primarily (but not exclusively) as mothers and women, I fear I will simultaneously be regarded as insensitive and possibly transphobic.
Some of my frustration also comes from years of being an ally in a different minority struggle. I would like every health care professional using predominantly gender neutral language in their practice to also normalise breech presentation. Every time you demonstrate the mechanisms of labour, do it with the baby coming out both ways. Always say, “Babies are born head-first or bottom-, knee- or foot-first.” Because they are, or they could be. I can’t tell you the number of times that people have said they would like to support breech birth, but it requires too much time and effort (see the “more important problems” excuse above).
Many professionals who hold the power to change things have even suggested that spending the extra time and/or resources it would require to ensure women who want to birth breech babies vaginally are attended by skilled, experienced professionals would be an unequal and thus unfair application of resources for such a small number of people (1:25-30 mothers at term carry a breech baby). Other rarer conditions, especially those which require expensive fancy-pants technology rather than more people-time, don’t seem to be affected by such arguments. In our over-stretched and over-aware maternity services, giving more to one seems to come at the cost of another.
I am genuinely grappling with the implications of the language I use, involving my family and colleagues in conversations, changing bits which feel right and remaining open to how my language may continue to change. I don’t feel there are “more important problems.” But I am not yet convinced that using exclusively gender-neutral language to ensure that a (non-woman) minority will not feel uncomfortable, will not mask another invisible injustice towards women. Inclusivity has to be both gender-acknowledging AND gender-neutral, rather than exclusively gender-neutral, until we know that losing gender specificity will do no harm to women. I am convinced by the research suggesting health professionals need to use more inclusive language and communicate with LGBTQIA+ families more sensitively and competently. I’ve seen no research assuring me that removing all gendered pronouns from the language around maternity care will do no harm to women. Until I am assured, I will continue to take an additive approach rather than an exclusively gender-neutral one.
For me, for now: More inclusive language is welcome, and in my work I will strive to include gender-neutral language alongside the gendered language that is embraced by the majority. I recognise that not everyone who gives birth is a woman, and I’m going to consciously use alternatives more often, just like I am consciously using people and folks where others are still using guys. When I do use women, especially in a group of parents, I am going to try to include other descriptors to acknowledge both women who want or need me to see the way their gender influences their experience, and people who need to know that I welcome them, and want to include and care for them, whatever their gender or lack of it.
And I hope that when inclusive birth professionals describe normal birth, they refer to the physiological birth of a baby who emerges spontaneously at term, head, bottom, feet or knees first, so that people who are pregnant with breech babies no longer feel they are abnormal or a freak for wanting to birth their breech babies. Just imagine what will happen when the families you teach attend their appointments expecting that they will give birth normally like everyone else, unless a genuine problem emerges! When I describe a person’s birth video, I am going to continue to describe them using the pronouns they use to describe themselves.
But I have a practical problem: I spend a lot of time talking about the way two pelvises interact with each other during a breech birth. I need to distinguish between the fetal/baby’s pelvis and the birthing person’s pelvis, and how they operate together as what the professionals in my research called the Mother-Baby Unit. Birther-Baby unit doesn’t feel right; it feels like I’ve separated the birthing body from the loving carer and sustenance-giver. Birthing is the ultimate reproductive act; but it is also a major bit of parenting. A time of being and becoming. Merriam-Webster‘s on-line dictionary tells me that the verb mother means “to give birth,” “to give rise to,” or “to care for or protect like a mother.” It feels right (to me) that mother itself has the potential to transition to gender-neutral. Not all of those who mother a child are women, nor do all women mother a child. (And not all people who father a child are men, nor do all men father a child.) I am asking those who wish for a more inclusive language to consider whether mother could be the mother of all inclusive terms. Such a concept may be just as radical as shifting gendered pronouns out of maternity services.
Folks, I am asking you to consider my use of mothering as a gender-neutral verb for giving birth, and to see such acceptance of maternal descriptors for the birth act as a radical act of solidarity with the women around you who remain a second sex. Women who have had to live with male descriptors being used as gender-neutral, but almost never vice versa, their entire lives. Women in every country of the world whose genders and embodied existences are immutably determined by others’ sexual (ab)use of them, women who are made to birth children against their will. Because no one should have to mother against their will. Mothering should always be a role one chooses, during pregnancy, birth and sometimes after. I’m remaining open to new possibilities as our language and culture shift. But for the moment, I ask you to be with me in considering the radicalism in mother-centred care, the importance of understanding women as a class of people despite infinite diversity within that group, and the need to explore and challenge the discomfort arising when descriptors historically associated with the female sex are used as gender-neutral terms in our brave new world. I in turn will recognise your radical acceptance and compromise, while I continue to check my inclusion of gender-neutral language.
I have shared my thoughts in good faith, wanting to do well by all I work with. I welcome you to comment here in order to help me and others continue learning and growing, but please as always, practice compassionate understanding in your response.
P.S. I am a Unitarian. But I love unisex-named medieval mystics, especially when they are mother enough to be challengingly gender-fluid the 14th century without a position statement, awesome enough to be the first woman to have her book published in the English language, and their own self enough to depict Jesus as the bad-ass Mother that he was, inclusive of caesarean section imagery (how did she know how important this would be?) Go Jules!
Now that my PhD is submitted, I am in the process of registering Breech Birth Network as a Community Interest Company. This business structure will enable 1) the accounts to be separate from mine; 2) all of the profits to be channelled back into the breech training, research and advocacy work we do; and 3) accountability, as the annual financial report is publicly available.
I really need an accountant who is either experienced with all of the following or able and keen to become experienced:
Filing individual UK tax returns
Filing individual USA tax returns (I am required to do this)
Filing Community Interest Company Tax returns in the UK
Understanding the company’s obligations when earning revenue by providing training outside of the UK and helping us to meet them
Prayer hands – breech births make more sense to me than tax returns!
I need this to be one person; continuity of relationship is important to me. I would like to work with a person who feels great supporting what we are doing with Breech Birth Network. Maybe you/they feel passionately about the physiological breech cause for your/their own personal reasons, or have a general commitment to the advancement of human rights in childbirth and respectful maternity care.
Obviously, I am expecting to compensate such a person appropriately.
Do you know someone? Are you possibly this someone? PM if you are using the form below. Please help me find my tax angel so I can spend more time recording voiceover for training videos!
The government are currently consulting on a potential shift to a rapid resolution and redress scheme for severe avoidable birth injury. Such an initiative was recommended by the recent National Maternity Review (Better Births, 2016), based on feedback from families and health care professionals.
Here’s why I think it’s a good idea:
The current system often requires lengthy and adversarial court proceedings in order for families to receive compensation. Litigation is the last thing parents need when their child has been injured.
Families have to prove negligence in order to get the financial support they need to care for their child. This is often directed at an individual, when we know that most problems are systemic in nature.
Local investigations mean learning is only disseminated at Trust-level. The nation-wide scheme would include a national database to identify learning which can be disseminated.
Globally, we need systems based upon relationship and response, care and mutual responsibility — and not just in maternity. A shift from adversarial litigation to collective responsibility in a rapid resolution and redress scheme is a step in the right direction.
Update, 24 August 2016: Following protests from the local and international communities, Dekalb Medical has reinstated the ability of Dr Bootstaylor and the See Baby Midwifery team to support planned vaginal breech births. Thank you to all who stood by the team and helped achieve this important result.
21 August 2016: Within the past two weeks, restrictions have been imposed on two highly experienced breech birth providers, suddenly, and without apparent cause. They are currently not allowed to attend breech births in hospitals where they have done so successfully for many years. These restrictions have been imposed by others who hold power within the institutions. The providers who have stood by women now need women, families and other professionals to stand by them.
On 7 September, a protest will be held in Los Angeles, California, at Glendale Adventist Medical Centre, which recently issued an outright ban on vaginal breech birth – The Rally Against Vaginal Breech Birth Ban. Glendale’s Dr Wu is a highly experienced breech birth attendant who supports not only women but other providers to gain skills.
If you attend the rally, or write a letter of support, and you tweet, use #bringbreechback – I will link to these tweets within this post.
The See Baby team of Atlanta, Georgia, have also been restricted. Their ban includes water birth and VBAC, as well as breech birth. Read more about their situation on the See Baby Blog. To support the See Baby team, I have written the letter below, sent to the Director of WI Services at Dekalb Medical. Please add your voice to protest this backward decision, addressed to the Director and copied to Julia Modest of the See Baby team, so that they are aware of the support of the international community.
To: [The Powers that Be, names and addresses removed now that resolution has been achieved]
I am writing to express my concern and disappointment at the recent, sudden decision of Dekalb Medical to issue a blanket ban on water births, breech births and vaginal births after caesarean section (VBAC), facilitated by the internationally regarded See Baby team. Such a decision directly contradicts the recent, positive movement to recognise birthing women’s agency and autonomy, as summarised in this recent statement from the ACOG Committee on Ethics:
“Forced compliance – the alternative to respecting a patient’s refusal of treatment – raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.” 1
The ban on water births and VBACs contradicts practices throughout the developed world, in which the tide is flowing very much in the opposite direction. My area of specialist knowledge is breech practice, where the tide is also turning, as reflected in the recent ACOG Practice Bulletin No. 161: External Cephalic Version, which also acknowledges the renewed interest in vaginal breech delivery as part of the movement to reduce the primary caesarean section rate.2 The change around breech birth is much more dependent on the skills of people like Dr Bootstaylor to light the way, due to many obstetricians having abandoned the art of obstetrics over the past several decades in favour of surgical deliveries.
The most recent ACOG Committee Opinion concerning “Mode of term singleton breech delivery,” written in 2006 and reaffirmed in 2016 makes clear, “The American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider.”3 This is also reflected in the FAQ information ACOG provides publicly to women.4 Dr Bootstaylor is one of the most experienced breech delivery providers in the country, and satisfies every criteria associated with a lower risk of adverse outcomes for vaginally born breech babies 5,6. I was privileged to teach breech skills alongside Dr Bootstaylor at a seminar hosted by Dekalb Medical in May of this year, which was attended by obstetricians and midwives from several surrounding states. This sudden decision will undoubtedly have local ramifications for the women whose birth plans revolved around Dr Bootstaylor and his very competent team of midwives. The restrictions will also have historic ramifications. Dekalb’s actions remove the option of vaginal birth from women pregnant with a breech fetus, and they also remove the option of health professionals to learn breech skills in a responsible and sustainable way, in a hospital setting with a highly experienced mentor.
Many women in the population served by Dekalb Medical go on to have one or more further children. The increased maternal and fetal risks associated with multiple caesarean sections are well-documented7, and removing the ability of this population to make an informed decision to avoid a first or subsequent caesarean section could be considered reckless. The high caesarean section rate is a contributing factor to the fact that the US is the only country in the developed world where maternal death rates increased between 1990 and 2013.8 While the decision to ban water birth, breech birth and VBAC was no doubt based on apparent increased short-term risks, the absolute risks of all of these choices are lower than they have ever been. I would ask Dekalb Medical to consider the increased recognition courts are giving to women’s right to autonomy, informed choice and respectful care9,10. In other settings, coroners and experts have specifically implicated lack of access to hospital-based care in the deaths of breech babies born at home 11,12. Dr Bootstaylor is one of the few obstetricians who truly work in harmony with other practitioners to make sure the door is always open.
Giving birth is a physiological process, not a treatment provided by a medical professional. In no other area of medicine are institutions or professionals ethically able to require patients to undergo surgery in order to access care at a time when their health is at risk. The choice of surgical intervention must always remain informed and freely made, or else it is coercion. As summarised in ACOG Committee Opinion No. 439, Informed Consent: “Consenting freely is incompatible with being coerced or unwillingly pressured by forces beyond oneself. It involves the ability to choose among options and select a course other than what may be recommended.”13
It is reasonable for Dekalb Medical to take a position and issue a recommendation to women regarding these options, if your experts feel they represent a higher risk of which women should be informed. That is the professional course of action. But disabling informed refusal of caesarean section is a clear case of medical coercion. Forbidding water birth is a disregard of the preference and comfort of hundreds of women, which will cause them emotional distress, with no evidence that such action will improve physical health outcomes for them or their babies.
Dr Bootstaylor and his See Baby Midwifery team are shining lights in safe, compassionate, woman-centred care. As Dekalb Medical were issuing this ban, I was writing about this team by invitation for an edited volume on sustainable maternity care. They are an exemplar of safe, sustainable breech care, a model for others to replicate. In my opinion, they still are exemplary and will still be featured. Although now the enduring lesson will be of how politics, power and money can undermine even the best practice and principles in medicine and midwifery.
Please may I ask that you forward this letter to the powers that be involved in the decision-making process to suspend these vital and exemplary services? I look forward to hearing that this dangerous and unethical action has been reconsidered.
Summary: The risk of maternal death from cesarean delivery compared to vaginal delivery is 2.7% vs 0.9%. Placental abnormalities (such as abnormal adherence, with consequent bleeding and possible hysterectomy) are increased with prior cesarean vs vaginal delivery, and risk continues to increase with each subsequent cesarean delivery.
Summary: A jury in Alabama unanimously returned a verdict in favour of a couple who experienced mistreatment and a lack of options in their hospital-based care, with an award including punitive damages of $16 million.
Following Sunday’s workshop in Asheville, Dad and I drove to Atlanta, Georgia. I kept him content by taking him out to dinner and buying him a pint of Shock Top. This strategy was successful, and the next morning we arrived at DeKalb Medical, home of the truly wonderful and amazing SeeBaby team. An opportunity to meet one of my obstetric heroes, Dr Brad Bootstaylor!
Dr Bootstaylor set the tone of this half-day study day by describing the facilitation of breech birth as a “healing force that goes beyond that mother and that birth.” This philosophy, or as Dr Bootstaylor describes it, “a certain headspace,” clearly permeates the See Baby team. SeeBaby Midwifery is dedicated to providing options and support to women and families in this birth community. Patients travel near and far, for birth options such as Water Birth, VBAC, Vaginal Twin Birth and of course, Vaginal Breech Birth (singleton & twin pregnancies).
We were also joined by Certified Professional Midwife (CPM) Charlotte Sanchez, another breech-experienced midwife in this community, who shared valuable reflections on some of the births she has attended. Charlotte also teaches other health professionals about the safe facilitation of breech births. Hopefully we will cross paths again soon. Thank you for coming along, Charlotte!
Shawn Walker, Charlotte Sanchez & Dr Brad Bootstaylor
Save the Baby! Video-based simulations, sweeping down a nuchal arm
Tomecas practising breech skills
My presentations included the mechanisms of breech birth — the key to understanding when intervention is needed in physiological breech birth — and active strategies for resolving complicated breech births, as well as ‘Save the Baby’ simulations, where participants resolve complications in real time with birth videos.
Following this, the See Baby midwifery team and Dr Bootstaylor led a panel discussion on ways forward for breech in Atlanta and surrounding areas. CNM Anjli Hinman identified one barrier as insurance company’s requirement that providers sign a statement saying that they are ‘experienced’ at vaginal breech birth in order to offer this service. However, ‘experienced’ remains undefined. This is a persistent problem. Our international consensus research suggest competence to facilitate breech births autonomously probably occurs at around 10-13 breech births attended, although this varies according to individual providers, the circumstances in which they work and the complications they encounter during this period.
Following the workshop, participants took a tour of the SeeBaby facilities at DeKalb. I would have liked to have joined them, but I had a message from Dr David Hayes in Asheville. Jessica’s waters had broken, and her breech baby was on the way. Because he is the best dad in the world*, my old man turned the car around and drove me 3 and a half hours back to Asheville. (* Don’t tell him I said this. He’s already big- and bald-headed enough.)
Taking breech training into the Blue Ridge Mountains of North Carolina …
We had to make a pit stop at a Motel 6 around 11 pm, but my Dad and I arrived in Asheville in time to have grits for breakfast. Asheville is an amazing town with a real ‘alternative’ feel about it, so I was anticipating a very receptive crowd. Already, what was supposed to be one study day on Sunday turned into two, as more doctors wanted to attend but it was already fully booked.
So at Harvest Moon Woman’s Health we had a 4-hour condensed training on Saturday, attended by one board-certified obstetrician, one resident at a local hospital, two family practice doctors from South Carolina, and a handful of midwives. This was followed by the full-day training on Sunday with midwives who came from as far as Tennessee and Virginia. With 39% of the respondents (across all of the six training days) indicating they had NEVER had any training in vaginal breech birth, the need and demand for such training was very strong.
We again discussed the subtle difference between these two ways of performing the manoeuvre often referred to as Frank’s Nudge:
Sub-clavicular pressure and bringing the shoulders forward to flex an extended head
Pressure in the sub-clavicular space, triggering the head to flex
The first of these involves rotating the shoulders forward, as described by Louwen and Evans (Evans 2012), minimally lifting the baby, and initiating flexion in the thoracic and cervical spine. This action is often performed with a rocking motion, nudging the aftercoming head around the pubic bone, mimicking the way a head is normally born, in reverse. Mary Cronk used a ‘stuck drawer’ metaphor to describe why rocking rather than steady pressure is sometimes more effective. Participants felt that the description ‘shoulder press‘ is effective for communicating the simpler manoeuvre (#2), where the head has stopped at the outlet of the pelvis. South Carolina Midwife Gayling Fox then suggested the term rock’n’roll manoeuvre for the other skill (#1), more useful where the dystocia has occurred at higher levels of the pelvis. Only in Asheville! I have to admit, the phrase is both fun and functional …
The law of ‘attracting breeches’ was in full swing in the mountains, as OB-GYN Dr David Hayes reported having received multiple enquiries from women seeking support for a vaginal breech birth, just from having hosted this training. In addition to being a sensitive and woman-centred obstetrician, David is an experienced breech catcher, having worked in both high-risk Western settings and abroad with Medecins Sans Frontiers. While he was open to physiological breech methods due to his familiarity with physiological birth in general, he had never attended a breech where the woman birthed in an upright position.
One of the women who contacted him was full-term with her first baby in a frank breech position (both legs extended). David asked if I would attend to support the birth in a teaching capacity, if available. Although we still had a couple more stops on the road trip, I tend to believe what will be, will be … if the stars align in just the right way … I said, Yes!
The original plan was to provide one Philadelphia-based study day while I was in town for the 20-year reunion of the Kelly Writers House, and the showing of our film on ‘Upright breech birth’ at the ACOG Annual Meeting. If being-with-breech teaches you anything, it is to go with the flow, as things rarely unfold as expected. The two main events conflicted, and the original study day was fully booked within a week or two of the listing. The demand for breech training spread quickly north and south, from Montreal to Atlanta. Clearly, many in North America are keen to develop skills and change the current breech culture.
Finally, the obstetricians join us! (They are always invited.) I was so pleased that three board-certified obstetricians attended this training. This is a big deal in Philly, one of the largest cities in America, where the midwives were unable to identify a single hospital-based practice where they can refer women who want to explore a vaginal breech birth. Big journeys begin with small steps.
Although I have been reassured that every evaluation of this training indicates those attending increase their confidence in supine/lithotomy breech delivery as well asupright techniques, I sometimes worry that our physiological birth-based approach might alienate doctors who work in settings where 90% of women have epidurals in labour. But I guess midwives who work in out-of-hospital settings have felt the same way for years, as their training has been determined by obstetricians whose challenges and location-specific resources are very different. We had great discussions, and there feels a real potential for future collaborative working in this area. (And of course I am wondering if the law of ‘attracting breeches‘ will take effect … ) 😉
The Philadelphia training was hosted by Lifecycle WomanCare, and organised by their Clinical Director, CNM Julie Cristol, who also has a passion for helping others to develop their physiological birth skills for normal birth. Thank you, Julie! Their practice is located in a beautiful building, right next to the original Bryn Mawr Birth Centre. I was so pleased to be able to have a brief tour of their home.
In Philly, we had a 3-hour half-day event because that is what fit everyone’s schedules this time around. Unfortunately, my old friend Christy Santoro was unable to attend because she was at a birth! See you next time, Christy. I enjoyed making new acquaintances and hope to see the Lifecycle crowd again. Didn’t get time to take many pictures because we spent our limited time together talking breech and research, then Dad and I departed for our 9-hour drive to Asheville! Epic …