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 […]
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.
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.
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.
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 Project. See 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
- 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.
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
So pleased to receive news via Twitter that physiological breech birth skills are being taught in Bangladesh! Tanya (@midwifeinbd) is doing a wonderful job collaborating with obstetric colleagues to change the way breech is taught and enable active breech birth.
Videos used in the training described above include The mechanisms, simplified, The Birth of Leliana and Shoulder Press and Gluteal Lift. You can read about ‘prayer hands‘ in this blog about assisting the birth of the arms.
Thank you once again to the mothers, midwives and doctors who have shared videos and birth images to enable health care practitioners all over the world learn these important skills.
This Tuesday, 1 March 2016, Breech Birth Network travelled to Portsmouth again. The guest speaker was lovely doctor Ms Arti Matah, who spoke about an obstetrician’s view of vaginal breech birth, and led a lively discussion around whether the breech team / care pathway model might work for Portsmouth. Watch this space! I am incredibly impressed with the commitment Portsmouth midwives have shown to developing sound breech skills to support women who choose to birth their breech babies actively.
The skill which captured the group’s imagination most was how to resolve a situation where the head is extended and impacted at the inlet of the pelvis. My research suggests that identification of optimal mechanisms is a core skill for practitioners attending breech births. Therefore our approach to teaching this skill is:
- Identification of optimal mechanism — The aftercoming fetal head normally rotates to the oblique/transverse diameter as it enters the pelvic brim, just like the cephalic-presentation head does when engaging.
- Identification of deviation from optimal mechanism — In this complication, the fetal head is pinned in the anterior-posterior diameter, with occiput anterior, over the maternal symphysis publis, and chin or brow on the sacral promontory. The bottom of the fetal chin is felt like a ‘bird beak,’ pointing towards the sacrum. The maxilla bones are difficult/impossible to reach, so flexing the head using the usual techniques will be a challenge.
- Restore the mechanism — See below.
The RCOG guideline suggests delayed engagement in the pelvis of the aftercoming head should be managed using one or both of the following techniques:
Suprapubic pressure by an assistant should be used to assist flexion of the head. Given our understanding of the head as impacted at the pelvic brim and our goal of restoring the mechanism by rotating the head to assist engagement, we suggest that the goal of suprapubic pressure should initially be to encourage this rotation. This mirrors the understanding we have of suprapubic pressure to resolve a shoulder dystocia by rotating the impacted shoulder off the symphysis pubis. Forcible pressure on an impacted fetal head is unlikely to be beneficial for the baby.
The Mauriceau-Smellie-Veit manoeuvre should be considered, if necessary, displacing the head upwards and rotating to the oblique to facilitate engagement. We use a doll and pelvis to explore why this elevation and rotation prior to re-attempting flexion is necessary. Watch the video below to see this demonstrated.
When a woman is birthing her breech baby actively, we facilitate the head to enter the pelvis using the same principles. Watch the video below, where Midwife Olivia Armshaw is teaching how to intervene in the case of an extended head at the inlet, when the woman is birthing on hands/knees. In this video, the midwives are discussing how maternal movement – in this case, the woman shuffling her bottom back towards the midwife slightly – helps to elevate the head off the pelvic inlet to facilitate engagement, a technique we learned from the midwives of Sheffield. The principles – elevate, rotate & flex the head – are the same.
Thank you to the Practice Development Team at Portsmouth for organising the day. And thanks to the following midwives for assisting with the day:
- Claire Reading, midwife in Somerset, who shared her breech experience gained working abroad, and facilitated one of the hands-on stations
- Olivia Armshaw, midwife from Gloucester, who facilitated one of the learning station and presented on the process of developing a breech team in her local area
- Tess McLeish, midwife from Lewisham who helped the day run smoothly
Our one sadness on this study day was that we were not joined by any of Portsmouth’s obstetric staff, aside from Ms Arti Matah, who needed to leave early because she was good enough to present at the study day following a night on-call. Across the UK, midwives are trying to engage their obstetric colleagues in a discussion about how to improve things for breech babies and their mothers, and we really need more doctors to come to the table for that discussion to result in a service which is as safe as possible.
BONUS was meeting and relaxing with Midwife Jenny Hall in Portsmouth after the study day!
Feedback from the Study Day:
“the group work was excellent Overall I thought the day was was a good balance of theory to practical”
“very interactive. realistic rather than textbook. real life experiences.”
“perfect study day. Interesting and kept my attention all day!!!”
“visual with the film clips and hands on with the doll and pelvis. Was very good to see normal and abnormal films and great discussion with colleagues to share experiences and what to do in that situation.”
“I also thought Shawn’s attitude to breech was very refreshing. I half expected it to be a bit like “you can have a vaginal breech no matter what”. this was not the case. She had a very safe and sensible approach.”
This post builds on my primary research, Standards for maternity care professionals attending planned upright breech births: A Delphi study. The research reports an experienced panel’s consensus on the skills required for midwives and obstetricians supporting physiological breech births. The practical content of the article is my personal application of one of the findings to clinical teaching.
“Health professionals attending upright breech births should be competent [to assist] rotation of the fetal back to anterior (when the mechanism has deviated from normal)” (p 5). 77% of the panel agreed that this is an important skill. This standard of competence combines two skills: 1) recognising deviation from normal mechanisms; and 2) assisting by restoring the mechanism to normal.
- Recognising deviation from normal mechanisms
Within the past two weeks, two people have discussed with me concerns about an incorrect understanding of the correct position for the fetal back when a woman is in a hands/knees position. First, a Practice Development Midwife (PDM) says she advocates teaching breech in ‘only one way’ (eg. lithotomy) because people get confused. A midwife attending training advocated for hands/knees positioning, but when questioned about where the fetal back should be, replied, “The fetal back remains uppermost.” Similarly, a student I am mentoring in practice attended sessions on breech at university. Her lecturer suggested hands/knees may be a more advantageous positioning, but later she is told, even in hands/knees, “The fetal back remains uppermost.” The student had worked out that this couldn’t be correct and sought more information. Excellent critical thinking, Charlotte!
These are signs of a practice in transition, and the PDM and Charlotte are right to be concerned. Rotating the fetal back uppermost in a hand/knees position is a dangerous but not uncommon mistake. Even in textbooks, such as this German textbook for midwives (Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Göbel & Hildebrandt, 2007), the woman’s position is changed, but the professional is still following the rule of, “The fetal back remains uppermost.” (Just to reassure you, once the arms are born, they advocate rotating the fetal body 180° so that the head is born occiput-anterior.)
A physiology-based understanding of the normal mechanisms comes from closely observing spontaneous births which are not interrupted. In a spontaneous breech birth, the most common and most optimal (a.k.a. ‘normal’) rotation of the fetal back is to anterior after the sacrum is born, regardless of the position of the mother.
The simplest way for teaching this aspect of the mechanisms I learned from midwife Jenny Davidson. The baby should rotate “tum to bum.” In other words, the baby’s tummy (stomach/front torso) should be facing the mother’s bum (bottom/posterior), no matter what position the mother is in. If those teaching breech can adopt this language to describe mechanisms and positioning, fewer dangerous misunderstandings, and more flexible thinking mayoccur. Teaching breech as a set of rote manoeuvres leads to automatic behaviours, which are sometimes counter-productive. In my research, I am observing that the path to acquiring breech competence and expertise involves learning to problem-solve in complex, unique clinical situations, often un-learning ‘rules’ that one was taught in skills/drills — because the rules don’t always work (eg. ‘the fetal back remains uppermost’ does not apply in every situation). Experienced professionals replace inflexible rules with more flexible understandings and principles, over a period of time, and through much reflection with peers and mentors. Perhaps teaching should be about patterns and principles, rather than prescriptions?
2. Assisting rotation of the fetal back to anterior — restoring the mechanisms to normal
You should rarely have to do this, but if you do, this principle may be helpful: “Rotation, not traction.” You can assist rotation with your fingers on the bony prominences of the baby’s pelvic girdle, as for any breech manoeuvre. Consider as you do what is happening at the inlet of the pelvis – have the shoulders already engaged, or are they just beginning to enter the pelvic brim?
Safe facilitation of physiological breech births depends on the ability to determine when intervention will be beneficial, and when it is unnecessary and potentially harmful. A breech baby will normally rotate spontaneously, with the back to the anterior (“tum to bum”), as the shoulders engage in the transverse diameter of the pelvic inlet. Pulling or manipulating prior to this spontaneous rotation could cause problems. But if the rotation is to the posterior, it may be beneficial for attendants to intervene at this point rather than rotate an occiput-posterior head mid-pelvis. Or at least 77% of an experienced panel think so …
Gibes E & Hildebrandt S (2007) Geburtshilfliche Notfälle: vermeiden – erkennen – behandlen, Thieme
Questions for reflection:
- Watch the videos in this collection. Identify the normal mechanisms, beginning with descent of the sacrum transverse (to the mother’s side). As you are watching, identify which way you will expect the rotation to occur, anticipating the normal rotation. Did the baby rotate as you expected?
- Imagine you are attending one of the births in the videos and quietly communicating with a colleague who has no previous breech experience, about what you are expecting to see, and what to document during the birth. What do you whisper to your colleague? Do this simultaneously with your colleague/fellow student as you both watch the video
Watch this obstetrician (Diego Alarcon) facilitate a complete breech birth. He is touching more than is advocated by physiological breech-experienced providers – the mechanism has not yet deviated from normal – but his hands tell you what he is thinking. The baby’s right foot is behind the left, indicating that rotation is tending in this direction – sacral anterior, good. However, he is closely guarding this. Watch when he puts the forefinger of his right hand on the baby’s right hip bone to ensure that the rotation will occur in a counter-clockwise direction when the contraction begins. His actions are gentle, not forceful, and they work with the mother’s expulsive efforts.
In this birth, as the sacrum is born, it is mostly transverse (normal), but somewhat posterior, to the mother’s left. The baby does not rotate to sacrum anterior, as we would expect as the arms enter the pelvis to be born. The obstetrician (Michel Odent) recognises that the mechanism has deviated from normal and immediately intervenes to restore the mechanism by sweeping down the anterior arm under the symphysis pubis, across the baby’s face.
This video is much more hands-on than a physiological approach, but it provides a good example of a normal mechanism of sacral rotation following rumping when the mother is in a supine position — and how to assist, because the midwife’s (Renata Hillman) hands are positioned to assist rotation using the bony prominences of the fetal pelvis.
Tonight, I met with some students from the local midwifery school who are preparing for their final OSCE. How exciting! They wanted to review mechanisms and manoeuvres so that they feel confident performing for their exams.
The students will be expected to demonstrate their knowledge of supine/lithotomy skills, so we created a new video to help them remember what we practised.
For those wanting to review the mechanisms when a woman is in a supine position, this video, filmed with midwifery students at the University of Salford last year, may also be helpful.
The next study group, for professionals, students or women in and around Norwich, will be on Monday, the 8th of February, from 10am – 1pm. For more resources to prepare for OSCE’s, click on the OSCE tag.