Category Archives: Activism

Avoiding ‘us versus them’ when breech births go wrong

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This week, BBC News Northern Ireland reported on a coroner’s inquest concerning a breech birth:

“Baby death inquest hears breech delivery method very unusual practice.”

11 April 2024, Kelly Bonner, BBC News NI

In this blog, I reflect on how this inquest has been reported. I do so with the understanding that not everything that is reported is 100% accurate. But once it is in print, we must deal with it.

I acknowledge the significant grief and devastation the parents of Troy Brady have experienced; they deserve justice and clarity. I also acknowledge the trauma Dr Sharma and colleagues have experienced, as their undoubtedly best intentions fell short of the desired outcome. I will offer some alternative ways we can learn from this tragic event, in the hope that our professions can prevent similar avoidable harm in the future.

Claim: Upright maternal positions are ‘very unusual practice’ for breech births.

The article’s headline caption is that, “The delivery position used by a doctor for a baby boy who was in a breech position was a ‘very unusual practice’, an expert [consultant obstetrician] has told an inquest.” The obstetric consultant expert who made this claim also testified that she has ‘delivered 30 breeched [sic] babies in her career and does not consider herself experienced in breech delivery.’ Another consultant obstetrician, from Scotland, further testified: “Breech delivery on all fours isn’t something we do in Scotland. It’s simply not something we’re experienced in. We would normally deliver the baby in lithotomy position.”

Unusual practice for whom?

These witnesses have made a classic type II error – when one assumes that something does not exist or is uncommon simply because one has not encountered it. One only needs to do a basic literature search to uncover the evidence for how ‘usual’ or ‘unusual’ upright maternal positions are for vaginal breech births.

In fact, almost all (if not all) UK primary research concerning how to improve the safety of vaginal breech birth is being done by people who regularly practice upright breech birth. Research about caesarean section is NOT research about how to improve the safety of actual vaginal breech births. Research about identifying breech babies or trying to turn them head-down in pregnancy (external cephalic version) is NOT research about how to improve the safety of actual vaginal breech births.

PubMed Search: ((vaginal breech birth) AND (safety)) AND (UK)

Breech Birth Network’s Physiological Breech Birth training is the only training that has been evaluated in NHS hospitals that has demonstrated a change in knowledge and behaviour following training (2017 & 2021). The training includes how to safety assist upright breech births. Upright maternal position is taught as a “tool and not a rule” in a clinician’s vaginal breech birth skillset. Nonetheless, among a sample of clinicians who have experience facilitating vaginal breech births in BOTH supine/lithotomy and upright positions, the outcomes demonstrate a clear preference for upright positions once clinicians have received this training, with good outcomes compared to those who have not.

In 2022, Deputy Director of Midwifery Emma Spillane published her case control study covering eight years of vaginal breech births in a London teaching hospital (2012 – 2020). Neither she nor I worked at this site during the study period. In this sample of 45 births, 43% occurred in upright maternal birthing positions, and 56% were facilitated by midwives.

The OptiBreech feasibility studies and pilot trial are the only prospective observational studies of vaginal breech births to be conducted in the UK since the Term Breech Trial was published in 2000. Over 70% of OptiBreech births occurred in upright positions, when the births were attended by clinicians who had appropriate training to support women to birth in the birthing position of their choice. In qualitative studies with women, they also reported more balanced counselling, detailing the risks and benefits of all options, from breech specialist midwives working in OptiBreech clinics. (This was another concern in the Brady case.)

Who is ‘we’? And who decides what ‘we do’ in Scotland?

Baby Elliott, born at Forth Valley Royal Hospital in Scotland.

While no research has reported maternal birth positions for vaginal breech births in Scotland, it is categorically wrong to say that it is ‘not done’ in Scotland, let alone in Northern Ireland. The OptiBreech team recently published a birth story from a woman very keen to share her experience, specifically to raise awareness of the need to ensure more maternity care providers in Scotland have training in upright breech birth.

Within the past two years, Breech Birth Network has been commissioned to deliver the Physiological Breech Birth Study Day in Kilmarnock, Glasgow and Dumfries. Within our training, we use videos provided by women who have given birth in upright positions in Scotland. Every time we do teach, we ask attendants about their prior experience. Upright breech birth experience is invariably reported in Scotland, as it is at all English, Welsh and Northern Irish hospitals where we teach. Multiple members of our teaching team are based in Scotland, where they practice – you guessed it! – upright breech birth.

From our training in Kilmarnock:

What was the most useful part of this training? 

Excellent explanation of mechanisms of breech birth and the manoeuvres to assist if needed.
All content was excellent, including new videos not available on online course. But most useful part was tapping into [the instructor's] first hand experience, both of clinical VBB and of establishing breech service with shared expertise.

What is one thing you intend to change about your practice based on this training?

Knowing that breech babies need to be born quickly and not waiting hands off the breech if there isn't clear descent.

How would you like to see this training influence practice in your organisation?

We are already using some of content/resources in modified way to introduce physiological breech birth. I hope we can have formal in house study days and support to adopt the algorithm in our guideline in coming years.
Feedback from Breech Birth Network Physiological Breech Birth Study Day in Kilmarnock, 2023

It is true than many providers in Scotland, such as those that supported Sandy MacMillan’s birth, do not have formal training in upright breech birth. Despite clear demand from women for this option, upright breech-experienced clinicians who wish to introduce the fully-evaluated, evidence-based training available face resistance from decision-makers who keep repeating: “Breech delivery on all fours isn’t something we do in Scotland. It’s simply not something we’re experienced in. We would normally deliver the baby in lithotomy position.” And it becomes a self-fulfilling prophecy …

Upright breech-experienced providers who have been safely attending vaginal breech births over the past seven years have been writing to me over the past few days to ask for help in addressing the extraordinary resistance they are experiencing due to this sensationalised media, based on a statement made by a self-described non-breech-experienced obstetrician, about a birth that occurred in 2016. Let’s take a deep breath before a fear-driven reaction distracts from the very real issues raised in this case.

What does ‘slow and delayed’ mean?

Jane Brady told the inquest during her evidence that Troy was delivered up to his neck in the all-fours position and was “hanging there, just hanging there”.

Her husband John Brady described the labour as “shocking”.

“I was waiting for someone to step in and save the day. It seemed as if no-one knew what they were doing,” he said.

quoted in 11 April 2024, BBC News NI

The harrowing events described by Troy Brady’s parents are the most consequential issue in this case. We (Breech Birth Network and the OptiBreech Collaborative) have been raising awareness of the dangers of delay in vaginal breech births to the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives for a few years now.

Impey L, Murphy D, Griffiths M, Penna L, on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation (Green-Top Guideline 20b). 2017

It is important to remember that this birth occurred in 2016. While many providers of vaginal breech education had been teaching upright breech methods by that point, the majority of teaching focused heavily on a ‘Hands Off the Breech’ approach. In the early 2000’s, upright maternal positioning was taught almost as a panacea. Based on the belief that it was safer to avoid touching the baby, proponents advocating putting the woman in an all fours position so that gravity could help the baby be born without the need for hands-on manoeuvres. As result, many people tried this, and discovered that in fact, hands-on manoeuvres are often needed.

The RCOG first introduced guidance on timings in the 2017 update of their guidance, based on professional opinion. Prior to this, the approach emphasised ‘Hands Off the Breech,’ but with no guidance on indications to intervene, how to intervene in upright births, or optimal time intervals.

Our mutual observation that reluctance to intervene was resulting in avoidable adverse outcomes prompted Dr Anke Reitter and I to undertake our first video study. This attempted to accurately describe, for the first time, the ‘normal’ parameters for vaginal breech births, based on evidence rather than professional opinion. During the process of conducting this study, I systematised the approach we were then teaching into the first Physiological Breech Birth Algorithm, focusing on our recommendation that the birth should be complete within 7 minutes of rumping (both buttocks and anus visible on the perineum), 5 minutes of the birth of the fetal pelvis, and/or 3 minutes of the birth of the umbilicus.

“In my reading of the case, delivery was slow and delayed,” she said.

“Manoeuvres were not deployed by Dr Sharma and that made me feel that he didn’t have an awful lot of experience in this type of birth.

“When things went wrong it was obvious that Dr Sharma hadn’t been trained on how to manoeuvre the baby and there was a delay.”

Dr Alyson Hunter, quoted in 11 April 2024, BBC News NI

We first taught using the Physiological Breech Birth Algorithm at a study day in Belfast, Northern Ireland, in October 2017. This was the first study day in the world to introduce this algorithmic approach. Yes, we also introduced upright birthing positions and what manoeuvres are effective when using these positions. But after 14 years of doing research in this area, my strong opinion is this: While upright birthing positions are often preferred by the women and clinicians who use them, the biggest impact on the safety of vaginal breech birth comes from improvements to our understanding of what constitutes ‘normal’ progress, especially the normal time frames of emergence.

This sensationalised journalism will potentially result in a backlash against all those who have been using and teaching physiological breech birth methods. The most tragic outcome if this occurs is that women like Sandy MacMillan will continue to request support for upright breech births, and well-intentioned clinicians like Dr Sharma will continue to support their reasonable request, but without access to high-quality training about how and when to intervene in these types of births. As a result, we will continue to have inquests that include testimony like that above. The solution to an adverse outcome based on lack of appropriate training in a widely used practice is NOT to restrict training and practice.

What about the placenta?

The paediatric pathologist and neonatologist expert in this inquest also described problems with the placenta that likely impacted this birth:

During the inquest hearing, experts told the court that Troy had a “smaller than usual” placenta and that it was not “operating as it should be”.

Dr Caroline Gannon, a paediatric and perinatal pathologist, said it is known that “placenta infection and placenta deficiency can cause brain damage”.

Consultant neonatologist Dr David Sweet told the inquest Troy’s reduced reserves meant he was “less able to deal with vaginal delivery”.

However, he said there was “no clue” there was a risk to Troy.

“No one could have known he had a deficient placenta,” he added.

“Having half a placenta is like having one lung instead of two – he’s going to get into difficulty quicker,” he said.

Baby death inquest hears breech delivery method very unusual practice, BBC News NI, 11 April 2024

I am absolutely in agreement with the neonatologist. Some breech babies are breech because there is an underlying problem, and unfortunately, we cannot always identify when this is the case. But it is MUCH more likely when a baby is premature, born at 33 weeks rather than about 40 weeks. In OptiBreech physiological breech birth practice, we teach that, exactly as the neonatologists describes, smaller babies are more likely to get into difficulty quicker. And therefore, attendants must be even more swift to assist the birth.

Again, the issue is not with the maternal position – all of us who practice upright breech birth regularly have attended multiple successful upright preterm breech births.

What is expertise, and who is an expert?

The obstetric consultant expert who made the headline claim also testified that she has ‘delivered 30 breeched [sic] babies in her career and does not consider herself experienced in breech delivery.’

My own credentials / expertise to comment are:

Search conducted Sunday, 14 April 2024. To make it easy, I’ve circled the links to my work. The other two links are work by close colleagues.
  • I am one of the most experienced vaginal breech birth attendants in the UK. I have attended well over 50 vaginal breech births (I stopped counting). I have also contributed to the safe care of at least double that number, because for many, an in-labour caesarean birth is the safest option when a deviation from normal occurs. Knowing how to identify this is part of the skill of an experienced vaginal breech birth attendant.
  • My experience includes management of complicated breech births (eg. needing to use hands-on manoeuvres to deliver the baby) where the woman is in an upright position, as well as those where the woman is in a supine position. To me personally, neither is ‘very unusual practice.’
  • I am the only clinician in the country who has led multi-centre studies of planned vaginal breech births. My OptiBreech work included 13 NHS sites in England and Wales, 199 planned vaginal breech births, and 96 actual vaginal breech births.
  • I teach vaginal breech birth skills personally to over 1000 experienced maternity care providers each year, through a training course developed out of research and thoroughly evaluated. I lead a team of similarly experienced clinicians who help teach this course, and it is constantly developing based on our frequent reflections and the research.
  • I lead an international community of practice. My visibility in this arena means that I frequently debrief clinicians and women who have experienced poor outcomes with vaginal breech births. While this is one of the saddest and most difficult aspects of my role as a public expert, it also enables me to identify patterns across a wide range of practice cultures. This in turn helps me to focus my research on the areas most likely to impact safety if we improve them.
  • My PhD was titled, “Competence and Expertise in Physiological Breech Birth,” giving me some confidence in my ability to identify this.
  • Finally, I continue to research the ‘problem’ of how to make vaginal breech birth as safe as possible from a variety of perspectives, using multiple scientific methods. If you search ‘vaginal breech birth’ on any research database, you will find my work among the top 10 primary research publications. If you search ‘upright breech birth’ on ANY search engine, it would be impossible to miss my work in this area.

But I am a midwife. I am rarely called upon to provide formal ‘expert witness’ nationally or even locally, in risk management activities. This is likely due to what Diehl and Dzubinski describe as ‘Role Incredulity.’ People expect consultant obstetricians to be experts in vaginal breech birth, even when they are giving testimony that they are not. Whereas, due to the rarity with which midwives are perceived as clinical experts in complex births, a midwife who is an actual expert in vaginal breech birth will frequently face doubts about her capacity. This is my daily lived experience.

ROLE INCREDULITY

In a male-privileged culture, people may assume women are not in charge. Outsiders may mistake women in a stereotypically make role – leader, engineer, tech support, lawyer, physician – for a stereotypically female role, such as administrative support, court reporter, nurse, or wife. This mistaken assumption is called role incredulity, and even when others learn the woman’s actual role, the effects may linger in doubts about her capacity. (p 18)

What should we focus on?

In my expert opinion, focusing on the following information is most likely to impact the safety of future vaginal breech births, regardless of the maternal birthing position:

“In my reading of the case, delivery was slow and delayed,” she said.

“Manoeuvres were not deployed by Dr Sharma and that made me feel that he didn’t have an awful lot of experience in this type of birth.

“When things went wrong it was obvious that Dr Sharma hadn’t been trained on how to manoeuvre the baby and there was a delay.”

Dr Alyson Hunter, quoted in 11 April 2024, BBC News NI

Continuing to focus on the upright birthing position, with antagonism directed against those who support women’s choice to use this position, is a distraction from the real safety issue. That is, the continuing dogmatic, non-evidence-based belief that ‘hands off the breech’ until at least 5 minutes have passed from the birth of the pelvis (RCOG, 2017) will result in a ‘safer’ delivery. This is simply false, ignored by most experts, and dangerous when novices blindly follow it. But it continues to be taught, along with the promotion of lithotomy birthing positions, usually with much confidence and shroud-waving by people who have actually attended very few, if any, vaginal breech births.

Secondary analysis SPSS means table, 14 April 2024, of Spillane’s Optimal Time Intervals for Vaginal Breech Births dataset.

The table above was created from our archived dataset of Spillane’s Optimal Time Intervals for Vaginal Breech Births study. It demonstrates that in control cases (good outcomes), assistance is provided in all cases well before the 3 minutes from the umbilicus recommended in current RCOG guidance. There is less difference, and less ability to modify this difference, in the length of time taken to perform manoeuvres. Swifter intervention is a modifiable behavioural factor.

This is directly relevant to John Brady’s description of his baby being born up to the neck and then “hanging there, just hanging there.” Even an untrained parent can see that there is something very, very wrong with this approach. Please, listen to him!

For a cross-cultural comparison, the Danish national guideline has now eliminated the instruction to ‘let the baby hang’ after the birth of the arms, regardless of the position the mother is in. This is not helpful, as it does not result in head flexion. Only manual assistance can help flex the aftercoming head, and delaying this is potentially harmful.

While there is evidence to suggest swifter intervention results in better outcomes, especially when attendants are novices and less likely to perform manoeuvres confidently, this teaching continues to be attacked, disbelieved and dismissed in favour of ‘us versus them’-style debates about maternal birthing position. This is a hardship for those of us who are continually striving to improve the safety of vaginal breech birth and respect women’s right to give birth as they choose.

Meanwhile, babies are needlessly dying.

— Shawn

Secondary analysis SPSS means table, 14 April 2024, of Spillane’s Optimal Time Intervals for Vaginal Breech Births dataset. Compared to the differences between controls and cases (good and adverse outcomes), less obvious differences exist in time-to-intervention intervals between supine and upright births.

Why use more retrospective data and modelling to support universal third trimester scanning when prospective data suggests the implementation of specialist vaginal breech birth teams is equally likely to impact outcomes? — The OptiBreech Project

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Investing in staff and their skill development will achieve the same, if not better, results and should be the priority.

This a response to a recently published report in PLOS Medicine suggesting that implementation of universal third trimester ultrasound scanning in pregnancy improves outcomes for babies and mothers.

Why use more retrospective data and modelling to support universal third trimester scanning when prospective data suggests the implementation of specialist vaginal breech birth teams is equally likely to impact outcomes? — The OptiBreech Project

Reflections on International Day of the Midwife, 2022

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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:

This is the dress I made for Professor Jim Thornton’s retirement party, which I couldn’t attend due to another breech birth!
  • Supporting a planned OptiBreech vaginal breech birth through the night and until the birth occurred in the morning;
  • Conducting two interviews for the Wellcome Biomedical Vacation Scholarship at 9.30 and 11.00 — amazing candidates this year!;
  • Receiving the news that the OptiBreech team has been awarded a £15k ESRC Impact Acceleration Grant;
  • Receiving and responding to the news that both my funder and my employer have received complaints that the OptiBreech Project is ‘promoting vaginal breech birth;’
  • Being a keynote speaker in the Virtual International Day of the Midwife 2022 conference at 2 pm;
  • 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

OptiBreech

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.

When I sit down to eat some dark chocolate and peanut butter because I’ve worked my butt off today …

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.

Breech Team Lanyard Pins!

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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:

  • 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

Birth Rites collection launch at King’s

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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.

— Shawn

Can “mothering” be gender-neutral?

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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.

Shawn

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!

Accountant Needed!

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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:

  1. Filing individual UK tax returns
  2. Filing individual USA tax returns (I am required to do this)
  3. Filing Community Interest Company Tax returns in the UK
  4. 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!

Love,

Shawn

Consultation: Rapid resolution and redress scheme for severe birth injury

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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.

Consultation is open until May 26, 2017.

Shawn

Stand up for those who stand up for you

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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.

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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.

Other related blogs:

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.

On July 21, 2016, John Shelton issued a press release congratulating 83 of Dekalb’s physicians for being named as “Top Doctors” in Atlanta magazine — including Dr Brad Bootstaylor.

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PLEASE WRITE TO ADD YOUR VOICE

20 August 2016

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.

Kind regards,

Shawn Walker, RM

  1. American College of Obstetricians and Gynecologists. Refusal of medically recommended treatment during pregnancy. Committee Opinion No. 664. Obs Gynecol 2016;127:e175–82.
  2. American College of Obstetricians and Gynecologists. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol 2016;127(2):e54–61.
  3. American College of Obstetricians and Gynecologists. Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. Obs Gynecol 2006;108(1):235–7.
  4. American College of Obstetricians and Gynecologists. If Your Baby Is Breech, FAQ079 [Internet]. 2015 [cited 2016 Aug 20];Available from: http://www.acog.org/Patients/FAQs/If-Your-Baby-Is-Breech
  5. Su M, McLeod L, Ross S, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003;189(3):740–5.

Summary: The presence of an experienced clinical at delivery reduced the risk of adverse perinatal outcome (OR: 0.30 [95% CI: 0.13-0.68], P=.004).

  1. Walker S, Scamell M, Parker P. Standards for maternity care professionals attending planned upright breech births: A Delphi study. Midwifery 2016;34:7–14.

Summary: An expert panel consensus opinion that attendance at approximately 10-13 vaginal breech births is advisable for achieving basic competence, and 3-6 per year with mantaining competence.

  1. Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179–93.

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.

  1. Schumaker E. Maternal Death Rates Are Decreasing Everywhere But The U.S. [Internet]. Huffingt. Post. 2015 [cited 2016 Aug 20];Available from: http://www.huffingtonpost.com/2015/05/28/maternal-death-rate-in-the-us_n_7460822.html
  1. Birthrights. UK Supreme Court upholds women’s autonomy in childbirth: Montgomery v Lanarkshire Health Board [Internet]. Blog: Protecting Human rights childbirth. 2015 [cited 2016 Aug 20]; Available from: http://www.birthrights.org.uk/2015/03/uk-supreme-court-upholds-womens-autonomy-in-childbirth-montgomery-v-lanarkshire-health-board/

Summary: Women have a right to information about ‘any material risk’ in order to make autonomous decisions about how to give birth.

  1. Pascussi C. Mom Sues for Bait & Switch in Maternity Care [Internet]. Blog: BirthMonopoly. 2016 [cited 2016 Aug 20]; Available from: http://birthmonopoly.com/caroline/

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.

  1. Kotaska A. Commentary: routine cesarean section for breech: the unmeasured cost. Birth 2011;38(2):162-4.
  2. Powell R, Walker S, Barrett A. Informed consent to breech birth in New Zealand. N Z Med J 2015;128(1418):85–92.
  3. American College of Obstetricians and Gynecologists. Informed consent. ACOG Committee Opinion No. 439. Obs Gynecol 2009;114:401–8.

Final Stop: Atlanta

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From Asheville to Atlanta, home of the SeeBaby team!

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!

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.

groupFollowing 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.)

Tomorrow: We return to Asheville for the birth of Leliana …

Shawn

Thank you to Tomecas Gibson Thomas for use of some of the photos she took during the workshop!