Category Archives: Breech Skills

Rotational manoeuvre to release breech nuchal arms

flat hands

In June, I spent a week in the Netherlands working with a committed group of lecturers. The midwifery universities of the Netherlands share a common curriculum, and following our meeting last year, they agreed to incorporate physiological breech birth into their training programme. My visit was to support the midwifery lecturers to implement the new skills into standard midwifery training.

While in Amsterdam, I collaborated with Midwifery Lecturer Bahar Goodharzi of Academie Verloskunde Amsterdam Gröningen (AVAG) to create a short series of films demonstrating the rotational arm manoeuvre we teach in Breech Birth Network study days. We agreed that this is a tricky manoeuvre to learn and teach, but it is incredibly effective in practice so worth the effort of learning. I’ve collected our short demonstrations in the film below, along with information about how to recognise that this manoeuvre is required.

Note: If you have difficulty rotating the baby initially, you may have to elevate the baby slightly to a higher station, so that the shoulder girdle rises above the pelvic inlet. It can then rotate to engage in the transverse diameter.

Thank you to Emma Spillane of St George’s Hospital in London, who has helped to refine the way we teach this manoeuvre following her own experiences of successfully using it in practice.

For a poetic description of what it is like to encounter this complication for the first time as a midwife or doctor, read Nicole Morales’ blog, The prose of no rotation and no descent: rotating to free the arms.

You can download the Physiological Breech Birth Algorithm here.

Midwifery Lecturers of the Netherlands, June 2018

— Shawn

I’m honored to be asked to be the guest writer this week on breech.  Shawn Walker is an international inspiration to those doing breech work around the world in various settings providing tools for breech birth to be safer and more accessible.

breech glassMy journey to breech started with the breech homebirth of my daughter, Nilaya, who is now 12 years old.  I was a student midwife just starting to catch babies here in the U.S. and had my first two head down babies steeped in a culture of home birth where twins and breech were normal. The choice to birth my third baby breech at home was not difficult.  I did not have to fight for it.  I just did it.   It was through this birth that I became invested in understanding and preserving this part of the craft of midwifery.  


Getting experience and quality training in breech has been a challenge.  I’ve had to seek out workshops and conferences from across the United States, take online international courses, and work to understand the mechanics of knowing normal vaginal breech birth.    Even though I am an instructor at our local midwifery school and have developed the curriculum here for breech birth, I still have limited hands-on experience that is slowly growing through the years.  As a Spinning Babies Approved Trainer, I get many referrals for breech parents and help them to navigate breech late in pregnancy through counseling, bodywork, and midwifery skills.  It is amazing what skills one picks up with their hands from seeing so many families and palpating so many breech presentations. Being able to have breech immersion of any sort can help keep the knowledge and skills alive.  

We are at a crossroads here in the U.S. for breech where in state after state, midwives are being limited by laws for attending breech and have not had a bar set for what breech birth competency looks like.  We might have a small list of skills, but with breech complications, we know that the refined skills can make a difference in outcomes.  If we have the ability to show experience, understanding, and investment in training, we might set a different course for breech, and midwives might actually set the bar for competency and have influence on other professions.  I am interested in how we can provide a more thorough understanding of what Shawn Walker deems “Respecting the Mechanisms” and “Restoring the Mechanisms” of breech.  In this way, I also believe that we can shift the paradigm of “No normal breech” to “Know normal breech.”  The international breech community, in how it is detailing the mechanisms of breech birth, can actually be a model to those doing vertex deliveries!  One of the reasons for a higher cesarean rate here in the U.S. is fear of a shoulder dystocia  In understanding the mechanisms of normal and restoring these mechanisms at all levels of the pelvis could reduce interventions and improve outcomes.  There is value for all births in utilizing gravity and mobility to increase diameters of the pelvis or to safely reduce fetal diameters when presented WITH complications.   Respecting that the reflexes of a baby being born are also part of the mechanisms of normal birth may not be seen with a vertex baby, but we know that babies help themselves to be born.     

As the international breech community discusses developing breech birth centers and (re)teaching breech, I’ve worked on how I can document my own road to competency and compiled these ideas in the format of the student paperwork for the North American Registry of Midwives (NARM).  I naively thought I would just submit them for review, but the interest of a larger community has to also be there.  There must be more conversations in the community over how such documentation can be useful and how to avoid potential pitfalls of its use.  I have called it “Breech Competency Documentation” so that it provides a way for birth workers to document skill acquisition as well as experience.  One could choose to keep the documentation on file for themselves or even to be part of a larger program.  

I am sharing below three out of four documents I created that are works in progress and open for suggestions.  I want to create a community conversation and am posting these publicly as birth workers in various countries have asked me for such information which I find valuable.  As we gain more knowledge about breech, these skills checklists can be updated to reflect the current knowledge.  

The first document, which is modeled after the NARM skills list, is a compilation of the current skills being developed in the international breech community.  I acknowledge that some Qualified Breech Preceptors may practice differently, but these skills are about developing  a baseline for understanding upright normal breech and upright breech complications.  

The second document, which is modeled after the NARM requirements for becoming a Certified Professional Midwife (CPM), outlines experience for assisting and being a primary student under observation of a Qualified Breech Preceptor.  I originally considered requiring higher numbers of birth / experiences / skills on these lists, but I then realized that it as going to be quite difficult to acquire those numbers of breech deliveries because of the overall low percentage of babies who are breech at term.   I decided that we must focus on quality of skills and of each birth attended and included the ability to use retrospective births that can be debriefed and reviewed with the preceptor.

The second document, which is modeled after the NARM skills list, is a compilation of the current skills being developed in the international breech community.  I broke down the skill categories starting with breech pregnancy, normal vaginal breech birth, complications at the different levels of the pelvis, and small section of postpartum care.   

The third document is for the student / midwife to list retrospective births they may have had and document the process of review with a Qualified Breech Preceptor.  This allows previous births to be able to be integrated and reframed within this format.

The fourth document I have started but not posted and it is pivotal in the overall conversation of Breech Competency Documentation regarding who would or would not qualify as a Qualified Breech Preceptor.  Through this documentation I believe we must point to the Delphi Study and its baseline as being above 20 breech births.  However, attending a certain number of births without any complication may not lead to more competence than someone who has had fewer births but had to resolve complications.  As I was creating this paperwork as a student of breech birth, I questioned whether it should be a document developed in more detail between preceptors and experts.  

http://breechbirthsd.com/wp-content/uploads/2014/08/3-9-2018-Breech-Certification-Checklist_rev.pdf

http://breechbirthsd.com/wp-content/uploads/2014/08/3-9-2018-Breech-Competency-Documentation-Application.pdf

http://breechbirthsd.com/wp-content/uploads/2014/08/3-9-2018-Breech-Competency-Certification_Form-777-778.pdf

I want to thank all of the people who helped me review the skills list for Breech Competency Documentation including Gail Tully, Diane Goslin, Shawn Walker, and Vickii Gervais.  I also want to thank Rindi Cullen-Martin for helping me with formatting and making the changes.  Both of us as breech mothers have an investment in continuing this work.  This work has also been influenced by the international breech community including Jane Evans, Mary Cronk, Anke Reitter, Frank Louwen, Maggie Banks, Anne Frye, Betty-Anne Daviss, Mary Cooper, Peter J. O’Neill, Andrew Bisits, Stuart Fischebein, and many others.

  Nicole Morales, LM CPM is a midwife with a home birth practice in San Diego, California.  She is a Spinning Babies Approved Trainer, an instructor at Nizhoni Institute of Midwifery and a Certified Birthing From Within Mentor.  She and other breech mothers have worked on the website breechbirthsd.com to compile information for families and providers navigating breech pregnancy and birth. 

What is the evidence for shoulder press / Frank’s Nudge?

Learning shoulder press in Montreal with Isabelle Brabant

As physiological breech practice gains acceptance, guidelines are changing to reflect this change in practice. One of the questions those updating guidelines often ask is: What is the evidence? For example, what is the evidence for the shoulder press manoeuvre we teach in Physiological Breech Birth study days?

To answer this question, we have to consider what level of evidence underpins breech practice in general. To my knowledge, no breech manoeuvres have been tested in randomised controlled trials. A recent Cochrane Review looked at ‘Quick versus standard delivery’ for breech babies and found no reliable studies to inform practice.

Image from Louwen et al 2017, Does breech delivery in an upright position instead of on the back improve outcomes and avoid caesareans? Open Access, click on image for full report. Artwork by Chloe Aubert

Observational studies that contain clear descriptions of the methods of management used in that setting reported alongside perinatal outcomes contain one form of evidence. A problem with observational studies is that even when ‘classical methods’ are reported, the meaning of that expression varies between settings. So studies from Canada, for example, are not necessarily generalizable to settings in the UK because standard practice varies between the two continents. A notable exception is the study of outcomes associated with upright breech birth reported by the Frankfurt team (Louwen et al 2017), in which a very clear description of the ‘Frank’s Nudge’ manoeuvre is provided, alongside excellent perinatal outcomes associated with upright maternal positions.

Another type of evidence is the support of a ‘responsible body of similar professionals.’ This is related to the Bolam test for clinical negligence in English tort law (Bolam v. Friern Hospital Management Committee), which holds that, “there is no breach of standard of care if a responsible body of similar professionals support the practice that caused the injury, even if the practice was not the standard of care.” In our research with 13 obstetricians and 13 midwives who had attended a self-reported average of 135 breech births each (Walker et al 2016), 73% of those participating agreed or strongly agreed that health professionals attending upright breech births should be competent to assist by:

  • sub-clavicular pressure and bringing the shoulders forward to flex an extended head; and
  • pressure in the sub-clavicular space, triggering the head to flex.

Additionally, 86% agreed or strongly agreed that an essential skill was:

  • moving infant’s body to mum’s body, so that infant’s body follows the curve of the woman’s sacrum

This research avoided the use of names such as ‘shoulder press’ and ‘Frank’s Nudge’ in favour of descriptions because not everyone uses the same terms, or refers to the same actions even if they do.

Evidence for manoeuvres also comes from evaluations of training programmes, both breech-specific and obstetrics emergencies courses. In our review of the effectiveness of vaginal breech birth training strategies (Walker et al 2017a), we found no published studies demonstrating an association between any training strategy and improvement in perinatal outcomes. The evidence base for the PROMPT training programme, widely used in the UK, comes from a study that did demonstrate an association with training and a subsequent reduction in low 5-minute Apgar scores and HIE (Draycott et al 2006). But that study questionably excluded outcomes for breech births, and because of this the breech methods in PROMPT cannot be said to be evidence-based, although the programme’s overall approach of multi-disciplinary working and clear communication remains important.

Most obstetrics emergencies training programmes have been evaluated at the level of change in confidence and/or knowledge. Our Physiological Breech Birth training programme, which includes shoulder press, has also been evaluated at this level in published research and demonstrated good results (Walker et al 2017b).

Finally we have the most recent RCOG guideline (Impey et al 2017), which states: “The choice of manoeuvres used, if required to assist with delivery of the breech, should depend on the individual experience/preference of the attending doctor or midwife.”

— Shawn

Breech holiday, Frankfurt – from Olvindablog

Justifying to a seven-year-old Anubis why I’m going to Germany for my week off – and missing mothers’ day, helped crystallise objectives and motivation for this busman’s holiday* (*a form of recreation that involves doing the same thing that one does at work). “I’m going to see some babies be born bottom-first.” “Don’t you see that […]

via Breech holiday, Frankfurt — Olvindablog

Running start

frank breech

In Physiological Breech Birth training, we teach breech practice according to the consensus statements developed with experienced professionals in Principles of Physiological Breech Birth Practice (Walker, Scamell & Parker, 2016), including:

Care providers should not disturb women’s spontaneous movements in an otherwise normally progressing breech birth.

Mother-led positioning offers the greatest physiological advantages.

Sometimes maternal-led positioning is most conducive; sometimes judicious guidance is appropriate, especially to help resolve delay.

When facilitating a physiological breech birth, care providers proactively use maternal position (or change in position) to promote normal descent.

The pictures below demonstrate asymmetrical maternal movement in a normal breech birth, in which the mother assumes an upright, kneeling position, with freedom to move her torso up and down as she feels the need. Study of effective, spontaneous maternal movements during successful breech births teaches professionals about all normal birth. Instinctive maternal movement can be read as purposeful and meaningful, in light of radiological evidence of changes in pelvic diameters (Reitter et al, 2014) — rather than counter-productive and needing professional interruption or guidance.

In this picture series, the mother spontaneously lifts one of her legs into an asymmetrical, ‘running start’ position. If a professional detects a slight delay in descent, it may be appropriate to suggest a change of position by raising one leg or the other, as a first-line intervention, a ‘maternal manoeuvre,’ before hands-on intervention. Often a change in maternal position, or rhythmic maternal movement (“give it a wiggle”) will prompt spontaneous descent to resume.

This mother is raising and lowering her torso with the aid of her partner’s thighs.

Dropping her torso, arching her back and tucking her hips under.

Moving her hips back towards her heels.

Squatting back onto her heels. This creates maximum space in the pelvic outlet as the breech passes through the ischial spines. The mother will not ‘sit’ on her baby, preventing the birth, but will instead raise her hips again when she instinctively feels the urge to do so.

Rising up again, arching her back. Creating space in the pelvic inlet as the shoulders and head enter.

Squatting back down. Spontaneous movements constantly change pelvic diameters as the baby rotates through.

Torso and hips rise up as baby rumps. Thrusting hips forward has a protective effect on the perineum and opens the inlet to assist engagement of shoulders/head. ‘Fetal ejection reflex.’

Pressure as baby descends. The mother drops her torso down again.

Moving into Running Start. The baby has not completely rotated to sacrum-anterior. The mother spontaneously lifts the leg on the side of the fetal legs, creating further space to assist rotation of the torso and descent of the anterior arm.

Significant descent occurs with the next contraction.

Running start continues to make space for gravity to do it work.

Almost there.

Straight to his mother’s arms.

The physiological process of welcome continues without interruption.

Thank you to the mother, who gave permission for her birth photos to be used for educational purposes; and to her family and midwives. One of these images appeared in the article, Unexpected Breech: What can midwives do?, in The Practising Midwife.

Training in Norwich: 14 January 2017

Simulations in Christchurch, NZ, October 2017

Simulations in Christchurch, NZ, October 2017 – photo by Tina Hewitt

To kick off the new year, Breech Birth Network are providing a study day in Norwich on 14 January 2017. If you’ve been wanting to encourage your obstetric colleagues or trainees to attend training, this will hit the spot. Our teaching team includes Dr Anke Reitter, FRCOG, Shawn Walker, RM, Victoria Cochrane, RM, and Mr Eamonn Breslin, MRCOG. Send your colleagues the link to our Eventbrite booking page, with a personal invitation! Or download a poster for your work environment.

Eventbrite - Physiological breech birth study day - Norwich

This study day for obstetricians, midwives, paramedics and students will provide an engaging and interactive update on professional skills to facilitate physiological breech births, planned or unexpected. The study day would be especially useful for clinical skills teachers who want to include physiological breech methods in professional skills updates or student lessons, due to access to resources after the workshop. The focus is on collaborative, multi-professional working to improve the safety of vaginal breech birth using the skills of all maternity care professionals.

Training will include:

* A research update given by leading researchers in the field, including Dr Anke Reitter, FRCOG, IBCLC of Frankfurt

* Thorough theoretical and hands-on explanations of how breech babies journey through the maternal pelvis in a completely spontaneous birth (the breech mechanisms), enabling you to distinguish between normal progress and dystocia

* Hands-on simulation of complicated breech births and resolutions, using narratives and videos of real breech complications, to enable you to practice problem-solving in real time

* Models of breech care that work within modern maternity services

* An accompanying booklet containing handout versions of all of the slides and resources used in the training

* One year’s access to the on-line learning space following the training, to continue viewing and reflecting on birth videos (one per month) in a secure forum, and resources for sharing teaching with professionals in your practice community

* Lunch and refreshments

Registration begins at 8:30 for a 9:00 start

Hosted by the University of East Anglia University Midwifery Society. Profits from the study day will benefit the UEA Midwifery Society annual charity, the Orchid ProjectSee here for directions to the Edith Cavell Building, and to Norwich from further afield.


Feedback from study days in Christchurch & Auckland, October 2016:

My main concern was lack of training of staff leading them to believe that breech birth is an emergency. Our RMOs and MWs loved the day and I think feel more empowered. — SMO (Consultant Obstetrician, Senior Medical Officer)

Thank you so much, this has been the best study day ever! — Midwife

Information was clear and concise and well presented. Myths dispelled and physiological VBB and when to intervene very clearly explained. Methods to resolve when there are issues during delivery explained and demonstrated. Clear examples given with supporting video and photographs. Extremely valuable. — RMO (Registered Medical Officer)

Honest, real explanations. How to intervene in a timely manner as opposed to be hands off the breech. — Midwife

Thank you for a brilliant day of teaching and training. You covered a lot of material not taught as part of our training and it has been valuable. — RMO

Learning about manoeuvres to use in upright position, eg. shoulder press; visual components have been amazing, the broken down physiology of a breech birth. — Midwife


Facilitators:

  • Dr Anke Reitter, FRCOG
  • Shawn Walker, RM, MA
  • Victoria Cochrane, RM, MSc
  • Mr Eamonn Breslin, MRCOG

Dr Anke Reitter, FRCOG, IBCLC, is the lead Consultant Obstetrician and Fetal-Maternal Medicine Specialist at Krankenhaus Sachsenhausen, Frankfurt am Main. Although originally from Germany, she worked in India and the United States during her medical studies, and in England (including Liverpool) for 4 years during her obstetric training. After returning to Germany, she specialised in perinatal medicine. Prior to her move to Krankenhaus Sachsenhausen, where she initiated a new breech care pathway in a unit which had not supported breech births for years, Reitter practiced in the Obstetrics and Gynaecology department at the University Hospital Frankfurt. A large observational study of the hands/knees breech births in Frankfurt is due to be published soon in the FIGO journal. Her special interests lie in breech, multiple pregnancies, high risk pregnancies and prenatal ultrasound. She is an internationally known speaker, teacher and researcher in several areas, but especially breech birth.

Shawn Walker, RM, MA is a UK midwife and PhD candidate researcher who studies how professionals learn skills to safely facilitate breech births. Clinically, she has worked in all midwifery settings – labour wards, freestanding and alongside birth centres, and home births. She led the development of a breech clinic pathway at the James Paget University Hospital (2012-2014), where she worked as a Breech Specialist Midwife. Her research focus on breech birth is part of a wider interest in complex normality – working with obstetric colleagues to enable women at moderate and high risk to birth and bond physiologically where possible. She currently works as a bank midwife at the Norfolk & Norwich University Hospitals NHS Foundation Trust, in addition to periodic teaching, consultancy and breech support across the UK and internationally.

Victoria Cochrane, RM, MSc is the Consultant Midwife for Normality at the Chelsea and Westminster NHS Trust. RM, MSc, Supervisor of Midwives. The majority of her clinical career has been working in and developing caseload and continuity models for women and their families in the community.  She is deeply passionate about working with colleagues to support women making pregnancy and birth choices that sit outside of routine guidance.  In her current role she works to support normality for women in all aspects of pregnancy and birth. Breech presentation became a special interest in 2009 when her daughter spent a few weeks in that position at the end of pregnancy; it’s amazing what one can learn in a short space of time when faced with challenging choices.  This led to carrying out a cross-site service evaluation of the management of undiagnosed breech for her MSc dissertation.


References

Reitter, A., Daviss, B.-A., Bisits, A., Schollenberger, A., Vogl, T., Herrmann, E., Louwen, F., Zangos, S., 2014. Does pregnancy and/or shifting positions create more room in a woman’s pelvis?Am. J. Obstet. Gynecol. 211, 662.e1-662.e9.

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

Walker, S., Scamell, M., Parker, P., 2016. Principles of physiological breech birth practice: a Delphi study. Midwifery 43, 1-6. FREE DOWNLOAD until 13 December.

Walker S, Cochrane V (2015) Unexpected breech: what can midwives do? The Practising Midwife, 18(10): 26-29