Category Archives: Activism

First stop: Montreal

Earlier this month (May 2016), I completed a road trip from Montreal to Atlanta to share the results of our international consensus research (Walker et al 2016), explain how it can be used to guide practice and education, and deliver physiological breech birth training based on that research to approximately 130 health professionals and other birth workers.

Wall mural depicting the Maison de naissance, Côte-des-Neiges

Wall mural depicting the Maison de naissance, Côte-des-Neiges

The goal was to enable these professionals to learn new skills, equip them to continue learning using an on-line Virtual Community of Practice, and empower them to disseminate the knowledge to others in their local communities. I met so many wonderful people, and feel confident they will work to extend the availability of skilled support for planned vaginal birth. I am going to tell the story of this amazing road trip in a blog mini-series. I hope you will join us … there is a special surprise at the end! 😉

The first workshop was attended by Certified Midwives from Quebec, Ontario, Maine, and Massachusetts, as well as doulas and CPMs from these communities. In Quebec, midwives work mostly in community settings and are not legally able to attend breech births except in emergencies (undiagnosed). However, some of the midwives have begun to work with obstetricians who will accept planned breech births, and they are working towards woman-centred, physiological care for these women. They also want to ensure emergency skills training is up-to-date, including physiologically-based strategies appropriate to midwifery-led settings.

Certified Midwives Sinclair Harris, Mounia Amine, Sylvie Carignan, and Sylvie Saunier

Certified Midwives Sinclair Harris, Mounia Amine, Sylvie Carignan, and Sylvie Saunier

As physiological breech birth gradually becomes the standard of practice, especially for midwives, breech skills will increasingly be taught by trainers who may or may not have much breech clinical experience themselves, much like they are now. It is therefore important that trainers be able to become ‘qualified’ to teach physiological breech methods, in the same way they teach supine-based emergency delivery techniques, and that they are teaching methods underpinned by research and consensus. Several skills trainers from throughout Quebec attended the workshop, and by using the resources made available, hope to disseminate the training to others in their local communities. I especially enjoyed meeting Sinclair Harris, the grandmother of this midwifery community, who has nurtured so many young midwives and is still actively teaching. Sinclair completed her RN training at St Mary’s in London. ❤️

Anyone in Quebec interested in receiving training

in the facilitation of physiological breech births —

 contact Andrea Houle, the RSFQ Agente de Formation.

(contact form below)

Certified Midwife Bronwen Agnew

Certified Midwife Bronwen Agnew

The midwives told me that use of ‘prayer hands’ in rotational manoeuvres to release the arms struck a chord with them. The shoulder press manoeuvre also made sense, but some midwives felt that the two disctint versions of this manoeuvre needed independent descriptive terms, to capture subtly different techniques which are applicable in various circumstances. This cluster of manoeuvres have been taught as “Frank’s Nudge,” in honour of Frankfurt obstetrician Professor Frank Louwen. But because research indicates eponyms (named after people rather than descriptive terms) can lead to confusion and inadequate documentation, we try to use a description which ‘does what it says on the tin’ in the Breech Birth Network training, and we continually listen to feedback about what works to help novices learn breech better. More on the distinction between these manoeuvres coming up in a future blog …

CPM and doula Rivka Cymbalist with the world's youngest breech catcher

CPM and doula Rivka Cymbalist with the world’s youngest breech catcher

Following the workshop, midwife Bronwen Agnew was kind enough to take me on a tour of the Maison de naissance, Côte-des-Neiges. This local birth centre is housed in a wonderful old rectory building, complete with wooden floors. It reminded me of my grandmother’s house, warm and simple. A beautiful place to give birth! Thank you, Bronwen.

The Montreal workshop was organised by Montreal doula and CPM, Rivka Cymbalist, and held at Studio L’équilibre en mouvement, ave Van Horne, a wonderful venue. We also enjoyed lunch at Rivka’s cafe, Caffe della Pace. Thank you, Rivka and family for your hospitality! If you are ever in Montreal, I also recommend relaxing at La Société Textile, a crafts shop / café where you pay by the hour to hang out, work on your knitting/sewing project, and drink unlimited tea from the kitchen. What more could a midwife ask for?

The current plan is to provide a 2-day breech train-the-trainers course in Toronto in late July / early August 2017, involving myself and some of the midwives who have taken the training this year and will be disseminating the skills in their communities. This is due to abundant feedback from the participants that they would like the training to be longer to allow for more discussion, reflection, fellowship and hands-on practice — of course we support all of the above! Follow this blog or the Breech Birth Network Facebook page to keep updated on our plans.

Tomorrow: Join us as we travel to Tillsonburg, Ontario!

Shawn

Evaluating breech training in North America

ShawnPortsmouthBusy packing … leaving London for the US on Friday. Originally, I planned to attend the celebration of 20 Years of the Kelly Writers House and my college reunion at Penn, as well as the annual ACOG meeting where our film on upright breech birth is being shown, followed by a family wedding. But it turns out the first two conflicted, so instead I will be spending half of my holiday teaching breech in collaboration with other health professionals along the east coast of the US and Canada. With ‘renewed interest’ in vaginal breech birth from the ACOG, and Canadian SOGC guidelines fully supporting planned breech birth since 2009, the will to revive breech skills is in full swing in North America!

Some of the health professionals and birth activists collaborating to provide breech training in their communities include:

  • Atlanta, Georgia – See Baby Midwifery is dedicated to providing options and support to women and families in the 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). The SeeBaby Team will lead a panel discussion on ways forward in the support of vaginal breech birth, and Dr Brad Bootstaylor is collaborating on the analysis of the evaluation data from this series of training days. (Places available.)
  • Asheville, North Carolina – This is a community which values co-operation, and the study days here have been organised collaboratively by obstetricians, CNMs, CPMs and doulas. Dr David Hayes of Harvest Moon Women’s Health is also contributing to the analysis of the evaluation data. Thanks especially to Kathleen Davies and Jennifer White.
  • Philadelphia, Pennsylvania – Thank you to Julie Cristol, CNM, of Lifecycle WomanCare for enabling this workshop.
  • Tillsonburg, Ontario – Thank you to Christine McGillis and Sheila Stubbs for making this workshop happen in Ontario.
  • Montreal, Quebec – Thank you to Rivka Cymbalist for organising this workshop and raising awareness of the need to increase vaginal breech birth options in this community. (Places available.)

The training provided by Breech Birth Network is different from obstetric emergencies training because it is based on physiological birth principles, including the importance of maternal movement in facilitating the birth process. Decisions on when or whether to intervene in a breech birth are determined by careful observation of the unfolding mechanisms, recognition of deviations from the norm and strategies to restore the mechanism. These strategies include maternal movements, as well as hands-on help from birth professionals. In Breech Birth Network training, which follows recommendations outlined in primary research with experienced professionals, birth videos are central resources, enabling both experienced and inexperienced professionals to develop and expand their pattern recognition skills, even in communities where actual breech births remain a rarity. Therefore, the training is supplemented by secure access to the resources and videos, which cannot be downloaded, but can be used to refresh training by those who attend the hands-on workshops when preparing for a birth within their local teams — the Virtual Community of Practice (VCOP).

Thank you to the women, midwives and obstetricians who have made this possible in order to increase the safety of breech birth for others.

Training programmes are often evaluated according to Kirkpatrick’s hierarchy, which has 4 levels:

Thorough evaluations of breech birth training packages are lacking. Evaluating impact of training on maternal/neonatal outcomes is a longer-term project, easier to achieve when considering the effect of training within one site, rather than professionals working in many different contexts; we have plans to begin such a project later in the year. However, for this series of study days in North America, we are collecting data on how many breech births those participating have attended in the year before and after training (change in behaviour), as well as changes in confidence levels before and after training (change in learning).

networklearningThose attending these training days include obstetricians, CNMs, CPMs, students, and birth activists keen to support cultural change in their communities. The results of the evaluation will help us to determine whether providing breech birth training based on conceptual understanding of physiological principles, within a community of practice/network learning model, will increase women’s access to the option of vaginal breech birth by increasing provider confidence and skills to provide this service.

The evaluation data will also contribute to answering two fundamental questions, which will require on-going research in the future:

  1. How can vaginal breech birth skills be revived within communities which have few or no experienced providers?
  2. How does training based on physiological principles impact the safety of breech birth for mothers and neonates?

Thank you to all the health professionals participating in this training and evaluation. I am looking forward to meeting you and learning from your communities!

Shawn

P.S. Of course, we aren’t the only source of physiological breech birth training. Others include:

We advocate that all professionals including breech within their sphere of practice access breech training from multiple providers, consider the underlying principles and how they fit with your own understanding and experiences of birth, and maintain an open mind.

“No time to put a plan in place”

Thinking through the practicalities of breech advocacy.

Midwives and obstetricians who would like give women with breech presenting babies more support to plan a vaginal breech birth (VBB) need to think through the wider picture of how this happens in order to become effective advocates. In my experience of doing breech advocacy throughout the post-Term Breech Trial era, women often get in touch after 38 or 39 weeks to try to organise support for a VBB. Achieving this requires quite a bit of discussion and negotiation in quite a short period of time.

This post makes visible some ‘common experiences’ in women’s vaginal breech birth journeys. Services differ in every area, so it won’t be every woman’s experience. And increasingly, forward-thinking NHS Trusts are working with advocacy organisations (such as the Coalition for Breech Birth, Breech Birth UK and BBANZ) to develop woman-centred care pathways which meet women’s needs rather than restrict their choices, like this team in Sheffield.

Common experience Other possibilities
33 weeks Antenatal clinic visit. Midwife or woman suspects breech. Woman told not to worry, most babies will turn. Informed about / referred for moxibustion treatment. Not associated with risk of harm. Shown to reduce breech and CS when used with acupuncture. Shown to reduce use of syntocinon before and during labour regardless of presentation. (Coyle et al, Cochrane Review, 2012)
36 weeks Palpation in antenatal clinic. Midwife suspects breech and refers for USS. Woman receives counselling re: ECV, to return at a later date. Is told discussion re: mode of birth will occur after unsuccessful ECV. One-stop shop breech clinic. Scan, counselling and ECV performed by a midwife or doctor with specialist training. If unsuccessful/declined, mode of birth preference documented. To return for further counselling.
37 weeks Counselling repeated by a different professional, who may have different personal preferences. External cephalic version attempted. If unsuccessful, asked to return for counselling re: mode of birth in consultant clinic. Returns to breech clinic for second attempt at ECV. Sees same practitioner, who is also part of the breech birth team. After unsuccessful/declined second attempt, confirms choice of mode of birth. Wider team made aware of planned VBB.
38 weeks Returns to antenatal clinic and sees another consultant or registrar. Majority of UK hospitals reluctant to support planned VBB. Advised to have CS. In some cases, a managed breech delivery in lithotomy is offered. Woman and her birth partner prepare for the up-coming birth.
39 weeks + After a return visit to antenatal clinic to attempt to negotiate support for an active VBB, meeting yet another consultant, and lots of research on the internet, woman seeks out external sources of support for VBB. Advocate (Supervisor of Midwives, doula, independent midwife) attempts to liaise with hospital staff, who ask, “Why do they all leave it to the last minute? There’s no time to put a plan in place now! Returns to breech clinic at 41 weeks to revisit choice of mode of birth, taking factors such as fetal growth and length of pregnancy into consideration. Talks to the same or another experienced member of the breech team.

Questions for reflection:

  • Consider your current work setting. If a woman tells you she would like to consider a VBB but is not receiving support to plan one, what can you do?
  • Who needs to be involved in her plan?
  • Who will support you to support her? To what extent are you comfortable being involved?
  • How can you build a local breech team, who can be ready to meet this need when it arises?
  • Consider working with your team to develop an informational resource for women, like this leaflet from King’s College Hospital.

Please share your positive experiences and good examples of breech teams in the comments.

Shawn

References:

Beuckens, A., Rijnders, M., Verburgt-Doeleman, G., Rijninks-van Driel, G., Thorpe, J., Hutton, E., 2016. An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives. BJOG An Int. J. Obstet. Gynaecol. 123, 415–423. doi:10.1111/1471-0528.13234

Catling, C., Petrovska, K., Watts, N.P., Bisits, A., Homer, C.S.E., 2015. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery. doi:10.1016/j.midw.2015.12.008

Coyle ME  Peat B, S.C.A., 2012. Cephalic version by moxibustion for breech presentation (Review). Cochrane Database Syst. Rev. doi:10.1002/14651858.CD003928.pub3

Walker, S., Perilakalathil, P., Moore, J., Gibbs, C.L., Reavell, K., Crozier, K., 2015. Standards for midwife practitioners of external cephalic version: A Delphi study. Midwifery 31, e79–e86. doi:10.1016/j.midw.2015.01.004

Piece of cake …

This week, the NHS Trust where I work is honouring the great work of our Maternity Services with a day-long celebration. This includes a bake-off. I have never participated in a bake-off in my life. I don’t really bake much at all. But Victoria Cochrane and I were inspired.

In addition to our wonderful colleagues, we also had celebrations of our own. To begin with, amazing Matron Victoria recently managed to secure funding to purchase mobile ultrasound scanners — for use by the same Community Group Practices which have just been shortlisted for an RCM Better Births award! These scanners in the community will make it easier for women to find out if their baby is breech without having to journey to the hospital, and help minimise the number of women who find out their baby is breech in labour. This will mean more women have the opportunity to consider an external cephalic version (ECV), and/or have a choice of mode of delivery for their breech baby.

Victoria and I have also co-authored an article in The Practising Midwife this month, where we advocate that midwives adopt a ‘plan or scan’ policy to reduce the potentially negative impact of unexpected breech in labour. By this we mean, either inform women antenatally that there is a risk (approximately 1:100-1:150) of an unexpected breech in labour, and encourage them to think about what they would do in that situation, or consider adopting a policy of third trimester presentations scans for low-risk women. We also advocate identifying a group of obstetricians and midwives willing to be called upon to attend a breech birth — a breech team. No need for a 24-hour rota; just identifying a team and involving one of them wherever possible will begin to make a difference. We could do with more research on women’s experiences of unexpected breech in labour as well.

So, the cake:

cake

Black cherry jam …

 

Maybe it will make it into the hospital newsletter!

Congratulations also to the Sheffield Breech Birth Service, which has also been shortlisted for an RCM Award for Excellence in Maternity Care. The team have been providing continuity and a realist option for women wishing to plan a vaginal breech birth for years, and are a model of what can be achieved when midwives and obstetricians work together to deliver a high quality, safe and respectful service.

Breech advocacy work is a long-term commitment. Things don’t change overnight. Sometimes, we just continue to keep breech on the agenda, reminding ourselves and others that breech does not equal an automatic CS. Midwives and obstetricians continue to stand up for the right of women to choose their mode of birth after balanced counselling and a realistic offer of support for all options.

How did it take me so many years to discover marzipan sculpture?

How did it take me so many years to discover marzipan sculpture?

Shawn

Who decides what is right?

Like many, I’ve been dismayed by the on-line report of the RCM’s recent legal birth conference.

And I’ve been so thankful for the very clear-headed response of Birthrights.

As a midwife I regularly work with women who decide that continuous monitoring (CTG) is not the ‘right’ choice for them, despite our guidelines and recommendations that it is advisable for breech-presenting babies in labour. Of course I have the skills and competency to care for them without it, and of course I would strongly recommend they reconsider if the clinical situation were unclear without it. I felt completely deflated that a leading barrister was quoted as saying something which suggested that if I offer women the choice to do what they, rather than the professionals, feel is ‘right,’ I could be putting my registration at risk.

In offering women real choices and standing by them when they make unpopular ones, I might now be accused of promoting an ‘ideology of normality.’ Did those words really come out of the mouth of someone who sits on the NMC panel, at an RCM conference? Someone wake me up.

How could anyone who talks to student midwives today get the idea that they are only exposed to normality? While universities are doing their best to ensure they get some exposure, the students I meet across the UK are usually gagging to see more ‘normal’ births. If they are graduating with no understanding of how to read a CTG, it is definitely not because they haven’t seen them used. It is likely because their mentors are overstretched and have not had the time to mentor them fully during placements. If they cannot cope with a PPH, it is probably because they have been sent running after the ever-increasing paperwork while the PPH’s are happening, rather than being facilitated to gain experience and understanding in the moment.

I originally trained in the US, mostly in out-of-hospital settings, freestanding midwifery led units and home births. Exclusively ‘normal’ settings where almost all women chose physiological third stages. My experience of managing the not infrequent PPH’s in these environments, and having the time to debrief, reflect and consolidate those skills with continuity from my mentors over time, gave me great confidence in my own midwifery fundamentals. My experience of managing shoulder dystocias without an emergency buzzer arm’s reach away did the same.

To speak of an ideology of normality is almost sinister next to the claims that the NHS is not obligated to provide a home birth service, and that women should be told they may not have this choice. The Birthplace in England study demonstrated clearly that home births for low-risk women are significantly more cost effective than births in a consultant unit, for all women they significantly decrease levels of intervention (improving outcomes for women), and for women who have previously had a baby the outcomes for baby are just as good as in hospital.

So why is it that home birth services across England are frequently unreliable or unavailable to women, when at the same time non-evidenced-based, expensive uses of technology or other interventions are being used? For example, routine third trimester scans. They do not improve outcomes, and they increase unnecessary interventions (more cost). Yet they are still being used in some Trusts, requiring resources to schedule, administer, interpret and counsel. There are many other examples, reflecting a pervasive ideology and resource allocation agenda very divergent from what most midwives understand as ‘normality.’

So don’t be surprised if midwives, frustrated by unfair and non-evidence-based resource allocations and increasing cut-backs, start doing weird things like attending home births on days off because they cannot bear to keep letting women down. A friend of mine is fond of quoting Ina May Gaskin in times like this: “People are often punished for doing the right thing.”

Reminder: This is my personal view, and not that of the Trust that I work for (which incidentally is not one of the many Trusts which currently offer routine third trimester scans).

Update: 19/7/13 Turns out the RCM doesn’t endorse the comments made by the speakers they invited to their Legal Birth Conference who were quoted without challenge in the only report published about the conference on the RCM website. Somewhat confusing, but Cathy Warwick clarifies. Good to have the salient points clarified, but when the home birth service is unreliable about 50% of time (as reported in an MSLC meeting) in your local area (not my workplace), it’s hard to share the view that resource shortages which jeopardise the HB service are an ‘extreme situation’ with which women should have patience.

Further clarification: I still love the RCM and I’m still a member, still hanging in there, hoping for better for midwives, midwifery and women.

A letter to birth workers who want to help

Antenatal teachers, group leaders, doulas, complementary therapists:

If you and women you work with aren’t happy with the support in your area … If you don’t feel you can tell women breech birth is an option because you don’t know if there is anyone who is able to help them … find out!

If you have a Consultant Midwife, start there. Otherwise, phone the Labour Ward Manager and/or speak with a Supervisor of Midwives (you can be put in touch with one by anyone who answers the phone). Liaise with your Maternity Services Liaison Committee. Ask questions. Find out what is done, and what could be done, for a woman interested in the option of vaginal breech birth.

There are many, many midwives out there despondent that they cannot use or develop skills to support normal breech birth. And many women who do not know how to get in contact with midwives who would be willing to support them if they asked.

One of the biggest challenges facing maternity care today is lack of continuity. Inspirational independent midwives like Mary Cronk and Jane Evans were able to develop relationships with women. Women were able to find them, trust them, and birth safely with them.

Today, most of us work in a culture which has normalised anonymous, short-lived and superficial relationships in most areas — being “nice” is not the same as being “known.” How are women to find the midwives who want it to be different? We need birth workers who are willing to help us build bridges, help link together professionals and women with common purpose. Who are the midwives (and doctors) in your area that women will find most helpful in this situation? The more experience professionals get, the more confident they will feel to inspire change within the system.

Be the change. Keep asking questions. Know that although the culture makes professionals seem distant, midwives need and want connection as much as women do, and birth workers can often do a lot to help make these connections.