Category Archives: Education

June 2020 — online breech learning opportunities

We have a number of online and upcoming learning opportunities available for you.

The Practising Midwife, June 2020

No more hands off the breech” is published in this month’s The Practising Midwife. In this article, I argue that we need to reconsider the way we use Mary Cronk’s famous phrase, “Hands off the breech!,” along with some other commonly held beliefs that may not be helpful.

I’d love to hear what you think about this and how it relates to your experience.

Consultant Midwife Emma Spillane and I are also speaking at the Northern Maternity and Midwifery Online Festival on Tuesday 23 June. I will be talking about improving the safety of breech birth through research, and Emma will be speaking about implementing a breech birth service.

Finally, our Vimeo channel features a couple new videos created to help student midwives learn about research, through the lens of improving breech safety. I’ve posted them below. The settings enable you to share and embed if you would like.

The first video explains one of the studies published as part of this Trio of Breech Articles, an open-access special issue from the journal Birth: Issues in Perinatal Care.

Shawn

Video analysis and Algorithm paper published!

Practical insight into upright breech birth from birth videos: a structured analysis” is now available on-line! (Reitter, Halliday and Walker, 2020, Birth – https://doi.org/10.1111/birt.12480) This paper represents a few years of hard work by Anke Reitter, me and our Research Assistant, Alexandra Halliday. It contains insights into birth timings and the mechanisms as observed in upright breech birth videos. The Physiological Breech Birth Algorithm is also included.

Download Algorithm

We look forward to much debate and discussion! Please share with anyone concerned about safe vaginal breech birth.

Love,

Shawn

Traduit par: Isabelle Brabant et Caroline Daelmans

Becoming a Breech Specialist and Setting up a Breech Service within the NHS

Since the publication of the 2017 RCOG guidelines on the Management of Breech Presentation, mothers have, in theory, been given more choice in their options relating to mode of birth.  Unfortunately, anecdotally this does not seem to be the case for all.  Many units across the UK do not have dedicated services for mothers found to have a breech presentation at or near term.  Therefore, they are potentially missing out on receiving balanced information regarding their choice of mode of birth.  Finding out your baby is in a breech presentation at this late stage of pregnancy can be upsetting for some, birth plans have been discussed and made, excitement is building for the new arrival and then suddenly this seems to all be turned upside down.  More decisions have to be made, that’s if the choices are offered to parents.  Having a dedicated breech clinic, run by those knowledgeable and experienced in breech presentation, can help to allay some of the worries and concerns experienced by parents and ensure all evidence-based options are discussed in a balanced way.  The clinic enables a two-way dialect between healthcare practitioner and mother in a supportive environment.  In the current financial climate of the NHS it can be difficult to set up new services, however, the mother’s well-being must come first.  Additionally, the skill of the practitioner is key to ensuring safety.  The RCOG states:

“The presence of a skilled practitioner is essential for safe vaginal breech birth.”

And

“Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.”

But with the decline in the facilitation of vaginal breech birth over the past two decades how do we ensure as healthcare practitioners that we are skilled to facilitate such births?  This post aims to describe one way to increase knowledge, skill and experience in this field and how to set up a breech service within an NHS Trust to ensure mothers really do have all the options open to them for mode of birth with a breech presentation.

Teaching physiological breech birth at City, University of London

The first step to gaining knowledge and experience is to become involved in teaching.  This has many benefits including, increasing your comprehension and embedding that information so you can pass it on to others; enables people to recognise you as breech specialist and it helps to build confidence when discussing with colleagues and parents alike.  The more you are teaching the greater your understanding and the more people will recognise you within this role as a breech specialist.  It is vital to keep your own skills up to date if you are putting yourself forward as a specialist, teaching both locally and assisting with teaching through the Breech Birth Network, CIC will help you keep up to date with the latest evidence and move things forward within your own constabulary.  The team at the Breech Birth Network, CIC are very keen to support others to teach on our Physiological Breech Birth courses.  You can read the following blog post for more information on the benefits of teaching Physiological Breech Birth with the Breech Birth Network, CIC. 

Other ways to get involved with teaching are within the University and to the students coming through the local hospitals, these are the midwives of the future and this is where the biggest change is going to come from.  Likewise, speak with the lead Consultant Obstetrician for new doctors starting in your Trust to see if you can teach them a shorter session on their induction days.  This enables the new doctors coming into the hospital an awareness of what will be expected of them in terms of offering choice and ensures they have an understanding of both the mechanisms of breech birth and recognising complications.  Additionally, setting up a weekly morning teaching session for thirty minutes ideally after handover so those finishing the night shift and those starting the day shift can both attend.  This can be done as a case discussion or a scenario using a breech birth video.  You could even use a breech birth proforma (if you have one) and ask those attending to complete the proforma whilst watching a video to see if they understand about the timings for a physiological breech birth and when to intervene.  Speak to the Practice Development team and ask if you can teach the breech sessions on the mandatory training days too – moral of the story…teach, teach, teach!!

Of course, with all this knowledge and skills you are teaching you need to put it into practice.  Put yourself forward at every opportunity to attend breech births both to facilitate them yourself and to support others to gain confidence in facilitating vaginal breech births.  Clinical experience is essential.  Research has shown, to maintain skills and competence the breech specialist should attend between three to ten breech births every year (Walker, 2017Walker et al, 2017Walker et al, 2018).  In some smaller units this may be difficult to achieve but by making yourself available to attend births you will have a far better chance at getting these numbers in practice.  There is also evidence which suggests that you can create the same complex pattern recognition by watching videos of vaginal breech births, both normal and complicated, as you can by attending breech births in real-life (Walker et al, 2016).  Watching videos has the added benefit that you can rewind and re-watch parts of the video to ensure understanding and further analysis.

Setting up a breech birth service would be an excellent next step.  Firstly, find a Consultant Obstetrician who is supportive of physiological breech birth and who would help to lead on service development with you.  This has to be a multi-disciplinary approach other wise it just won’t be sustainable or safe.  The best way to move such services forward is with consultant support and input, don’t try and do it on your own.  A breech birth clinic is a good starting point for any service development, this will provide midwife-led and consistent counselling for parents attending the clinic.  Depending on the size of the hospital, running the clinic once a week should be adequate initially.  Setting up a dedicated email address for all referrals to be sent to is a great way to ensure referrals are not missed and there is a clear pathway set out. The following is an example of such a pathway:

Breech service referral process at St George’s University Hospital NHS Foundation Trust

Referrals can be made by any healthcare practitioner, but it is a good idea to link in with the sonographers performing the ultrasound scans.  They may be able to send the details of the mother via email immediately following the scan and give the parents an information leaflet.  This avoids any delay with the referral being made by another healthcare practitioner and ensures the counselling remains consistent.  Moreover, the development of ‘breech teams’ is supported in the literature to ensure there are breech specialist midwives and doctors on every shift, or on-call, to support the wider team to gain their clinical skills to facilitate vaginal breech births and increase safety for mother and baby.

To further develop the service and your own skills you could complete a midwife scanning course.  This will enable you to scan mothers referred into the breech service to check presentation before sending for a detailed scan.  The advantages of this is that mothers could be referred into the clinic earlier, from thirty-four weeks gestation based on identification on palpation.  Research has shown mothers find it difficult making decisions about mode of birth for breech presentation so late in pregnancy and would benefit from earlier referral and discussion.  Referrals made at thirty-four weeks gestation with a bedside midwife scan to assess presentation, would enable the counselling to begin sooner giving more time for decision-making.  An additional advantage of being able to scan is following mothers up after successful external cephalic version (ECV).  Seeing mothers, a week after successful ECV enables you to scan the mother to ensure the baby has remained in a head-down position avoiding unexpected breech births.  An adjunct to the scanning course would be to learn to perform ECV’s.  This enables a fully midwife-led service and research has indicated comparable rates of success for ECV’s performed by Midwives and those performed by Obstetricians.  It is also cheaper for the Trust to have ECV’s performed by Midwives!

Governance and audit are the final steps to take to building the specialist breech midwife role and for service development.  This is often seen as the mundane part of the job, but you will benefit greatly by doing this, not just from immersing yourself in all the research but by knowing your service inside and out.  Knowing what needs to be changed and what has improved.  The first step in governance change is to write the guidelines incorporating physiological breech birth, new evidence relating to breech presentation, service development, the breech clinic, referral pathways and training.  An example of a current guideline can be found via this link.  Develop an information leaflet to give to parents which contains the latest evidence in relation to breech birth options.  It can be given to the mothers either by midwives in the clinic and/or by the sonographers after their ultrasound confirming breech presentation.  The following can be used as an example and is editable for use in your organisation.

Breech information leaflet developed by the Breech Birth Network, CIC

Finally, audit, audit, audit!  Before, after and everything in between!  This is your evidence that things need to change and, once the service is developed, the outcomes since you implemented all the aspects of the service.  It will also act as evidence of safety which the governance team within the organisation will want to see.  Audit rates of planned caesarean, emergency caesarean, planned VBB, successful VBB, neonatal outcomes, maternal outcomes, uptake of ECV, success rate of ECV etc.  All before and after the service.  It is also a good idea to obtain service user feedback.  Developing a simple questionnaire such as this one enables you to easily send and receive feedback regarding the service.  Feedback from service users is the most powerful way of moving services forward and supporting change within an organisation, it also enables you to develop the service dependent on the needs of the parents using it.  The process of audit and user feedback is continuous throughout the time running the service.  However, it is important analyse and present the result at regular opportunities such as at local level with clinical governance days and meetings and at a wider national level at conferences and in journals.

Whilst it can seem daunting and places you in a seemingly vulnerable position, starting your journey as breech specialist is an extremely rewarding one which will enable you to learn and develop new skills not just clinically but operationally and strategically.  It will give you a stepping stone into research, audit and teaching, build your confidence as a practitioner and most of all, empower you to provide the best evidence-based care for those families who need that knowledge and support at a crucial time in their pregnancy to help them to make the right decision on mode of birth for them and their breech baby.

Following the implementation of all that has been discussed in this post, the results within the large teaching hospital I work are as follows:

  • Planned caesarean section increased from 55.8% (n=43) to 62.9% (n=66);
  • Unplanned caesarean section decreased from 42.9% (n=33) to 24.8% (n=26);
  • Vaginal breech birth increased from 1.3% (n=1) to 12.3% (n=13)

All results are for those over thirty-six weeks gestation, there were no differences in neonatal mortality or morbidity prior to or following the implementation of the service.  This is a positive change and shows how supporting vaginal breech birth in a safe environment can increase the normal birth rate.  The results are after a year of implementing the service and will hopefully continue to improve as time goes on and more midwives and doctors become more confident to facilitate breech births.

Emma

International Maternity Expo Award Nominees

The Breech Birth Network are delighted to announce both Shawn and Emma have been shortlisted for awards at the International Maternity Expo Awards. We are both very honoured to have been shortlisted in the following categories:

Dr Shawn Walker – shortlisted for the Research Innovation Award and the Improving Safety Award

 

Dr Shawn Walker has been shortlisted for both the Research Innovation Award and the Improving Safety Award for her work in improving the knowledge, skills and training around Physiological Breech Birth. Shawn has published a number of research articles highlighting the importance of effective training, the development of experienced breech teams and pracical insights into upright breech birth. Shawn is currenty writing proposals for further essential research into Physiological Breech Birth to further improve safety and choice for mothers and their babies as well as practiotioners facilitating such births.

 

Emma Spillane – shortlisted for the Practice Innovation Award

Emma has been shortlisted for the Practice Innovation Award for her work in setting up a breech birth service in the large London teaching hospital she works in. The service supports mothers in their choices regarding mode of birth for breech presentation at term. Emma is also completing her Masters research in Breech Childbirth Preferences of Parents to further support service provision and support for parents choices.

We would both like to thank those who nominated us. It is a privilege and an honour to have been recognised for the work we are both doing.

Shawn and Emma

Seeking your thoughts on further research…

Image by Kate Evans

Emma Spillane is seeking your thoughts on a new piece of research prior to its submission for ethics approval. If you have experienced a breech pregnancy within the last 5 years in the UK, either yourself or your partner, or you work with pregnant women in a non-medical capacity (e.g. doula, antenatal teacher, breastfeeding supporter, etc.), I would love to hear from you.

I am conducting research as part of my Masters exploring breech childbirth preferences of expectant parents to understand if there is demand for breech birth services within the NHS and explore the factors which influence parents decision-making. At this stage, I would like your feedback on the suggested design of the trial, to ensure that the information resulting from the research will be useful to those considering breech options. For those of you who would like to remain with the project I am forming a Breech Advisory Group provide feedback at further stages in the project such as analysing the results.

If you are interested in participating in my research in this way, please read the plain text summary of the project below and complete a short survey by following the link after the research summary.

Discussing breech birth in Ethiopia

STUDY SUMMARY

Approximately 3-4% of babies at term present in the breech position (bottom or feet first) (Impey et al. 2017). The Royal College of Obstetricians and Gynaecologists’ (RCOG) most recent clinical guideline on Management of Breech Presentation recommends that pregnant women should be offered choice on mode of birth for breech presentation at term(after 37 weeks’ gestation) (Impey et al, 2017).  Despite this recommendation, only 0.4% of all breech babies in the UK are born vaginally (Hospital Episode Statistics, 2017), and this figure includes pre-term breech births where breech presentation is more common (Impey et al. 2017).  These statistics suggest that either the demand for vaginal breech birth is low, or the choice of mode of birth is not being consistently offered.  This study aims to explore this enigma by providing empirical evidence necessary to inform maternity services on the requirement of breech birth services. 

Current evaluations of demand for vaginal breech birth services have been limited by the quality and impartiality of information parents are able to access via their maternity services.    For example, research has shown that women have difficulties finding information to support their choices and are pressured into making the decision based upon practitioner preference (Petrovska et al, 2016).  An investigation carried out in the Netherlands, found that one third of parents would prefer to have their babies born vaginally (Kok, 2008).   However, little is currently known about parents’ preferences in England.  

This research will evaluate the extent of expectant parents’ preferences for vaginal breech birth prior to counselling, and the factors that influence these preferences, using personal interview surveys (Bhattacherjee, 2012).  All women presenting with suspected breech presentation at a large London based teaching hospital – St George’s University Hospital NHS Foundation Trust – will be given information about this study along with their Trust approved mode of birth information leaflet during their routine antenatal appointment at 36 weeks of pregnancy.  As per Trust clinical protocol, women with suspected breech presentation will be offered a referral for an Obstetric Ultrasound Scan (OUSS) for confirmation of fetal presentation.  During this routine OUSS appointment, either prior to or following the scan taking place, parents will be approached by the researcher and invited to take part in an interview on their preferred mode of birth and the reasons behind these preferences. Both parents, if present, will be interviewed separately.  Parents will already have been given information about the study in the form of a Participant Information Sheet PIS) by the clinician referring them for an OUSS. The timing of the interview has been chosen because it fits with the participating Trusts usual pathway of care. Parents are informed there may be long waiting times due to OUSS being arranged at short notice.

The findings from this research will provide evidence on the following:

  1. the demand for a vaginal breech birth service, based on written information prior to individualised counselling;
  2. the factors influencing this demand, which can be used to improve shared decision-making training and taken into account when planning future research; and
  3. a predicted service planning model for a fully integrated breech continuity team within the host Trust.

Data on parents’ preferences for mode of birth will be reported descriptively as a percentage. Qualitative data regarding parents’ reasons for their preferences of mode of birth will be analysed thematically.

https://www.surveymonkey.co.uk/r/8VR9J2K

Emma

New Canadian breech guidelines published

new guidelineA new SOGC Clinical Practice Guideline No. 384 — Management of Breech Presentation at term has been published. It echoes the latest RCOG guideline in promoting accurate and supportive informed consent discussions. One of the main authors, Andrew Kotaska, has written extensively about this before: Informed consent and refusal in obstetrics: a practical ethical guide.

The SOGC guideline frames counselling around mode of childbirth for a breech baby within the context of human rights, especially in the ‘Key Messages:’

A woman’s choice of delivery mode should be respected.

The risk of planned vaginal breech birth is acceptable to some women with a term singleton breech fetus.

Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should be provided with the best possible in-hospital care. 

The summary of evidence related to safety is similar to that provided by the RCOG and a good reference for anyone counselling women about their breech childbirth options. A notable difference is the recommendation that,

Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour.

https://twitter.com/SisterShawnRM/status/1143838688637542400

As with the RCOG guideline, the new SOGC guideline recognises the importance of skill and experience to the safety of vaginal breech births. One of the SOGC’s summary statements is:

Vaginal breech birth requires a high degree of skill and support. To avoid the increased risk of out-of-hospital vaginal breech birth, women who choose planned vaginal breech birth should be accommodated in-hospital. To facilitate this, referral to more experienced centres, back-up on-call arrangements, and continuing medical training in vaginal breech birth skills should be promoted (very low).

(Very low refers to the quality of evidence in relation to this recommendation.) The RCOG also recommends antenatal referral to a centre with more skill and experience if necessary. Later in the SOGC text, the authors point out:

Many newly qualified obstetricians do not have the experience necessary to supervise a breech TOL [trial of labour]. Mentoring by more senior colleagues will be necessary if they are to attain these skills. As women will continue to request planned VBB and precipitous breech births occur in all settings, theoretical and hands-on breech birth training using models should remain part of basic obstetrical and midwifery training and of traingin programs such as ALARM, ALSO, and MORE ob.

I am particulary interested in recommendations made regarding how to support breech skill development because Competence and Expertise in Physiological Breech Birth was the topic of my PhD.

In our integrative review of the Effectiveness of vaginal breech birth training strategies (2017), inclusion of breech birth as part of an obstetric emergencies training package without support in practice was negatively associated with subsequent attendance at vaginal breech births, meaning practitioners attended fewer breech births. None of the evaluations of training packages included clinical outcomes, so it was not possible to determine whether they had an effect on safety. But the evidence suggests that support and mentorship in practice is likely to be key to giving less experienced practitioners the confidence to support breech births and gain the skills in practice.

Research on Expertise in physiological breech birth and the Deliberate acquisition of competence in physiological breech birth suggest that mentorship is indeed very important, but that this does not always take the form of senior colleagues supporting newly qualified colleagues. Maintaining classical hierarchies — such as expecting senior obstetricians to have breech skills while younger colleagues, or midwives, not to — can promote a form of alienating authority, which inhibits the development of generative expertise.  Among practitioners who had deliberately developed competence to support breech births, younger, highly motivated practitioners often had to leave their primary clinical setting to acquire knowledge, skills and new techniques, which they brought back with them. The fact that they needed to do this suggests that they had not been being mentored at home.

One of the things I love about working in the UK is the long history of multi-disciplinary working. Although some teams work more effectively than others, it means that a person wishing to birth their breech baby with an experienced midwife in attendance does not have to choose between a home birth and an obstetrically-managed hospital birth. The obstricians I work with recognise the skill with physiological birth that their midwifery colleagues bring into the room — and we are grateful for their skill with surgical and very complicated births. We keep each other safe.

Given that referral to experienced centres is recommended in both RCOG and SOGC guidelines, more research is needed about how this works in various settings. What happens if a woman is referred elsewhere, but that hospital cannot or will not accept her for care? What are the economic implications? What defines an ‘experienced centre?’ In some hospitals, such as in Frankfurt Germany, the vaginal breech birth rate can be as high as 6-11% of the total birth rate due to women travelling to experienced providers, compared to 0.4% of the total birth rate in the UK.

We also need to consider and study other potential solutions to skill redevelopment. For example, why expect women to travel away from their known and trusted care team — why not shift professionals instead? I am employed primarily by a university, but I have a contract with one NHS Trust and am completing a contract with another by request, so that I can support them to develop their breech services. Mobility of providers also happens when obstetric trainees rotate between training centres. Sadly, I have heard numerous stories from senior obstetric trainees who have acquired breech experience in one hospital, only to be blocked from using that experience by their senior colleagues in another, a case of hierarchical and alienating authority. Similarly, many midwives have spent time abroad and delivered dozens of breech babies, but have had to stand aside when a woman is diagnosed in labour with a breech because the woman is now considered ‘an obstetric case.’ Women are often not informed when skill and experience is available because these remain invisible and under-utilised, especially in midwives and younger obstetric colleagues.

Throughout the UK, many new breech services are being developed. Breech clinics, like the one at the Royal London, ensure women get consistent counselling by breech-experienced practitioners. They also provide an environment where trainees can learn this skill. Many hospitals are developing ‘breech teams‘ so that vaginal breech births and those attending them can be supported by confident and competent members of the team — this includes experienced midwives. Training activities to support these new teams emphasise the elements available literature suggests will be effective — repetition and reflection — especially using birth videos for team debrief and simulation training. Gradually, we are supporting each other to reintroduce breech skills and consider new ways of sustaining them in order to be able to offer the care our countries’ leading guidelines recommend.

— Shawn

References

García Adánez J et al 2013. Recuperación del parto vaginal de nalgas y versión cefálica externa. Progresos Obstet. y Ginecol. 56, 248–253.

Hickland P et al 2018. A novel and dedicated multidisciplinary service to manage breech presentation at term; 3 years of experience in a tertiary care maternity unit. J. Matern. Neonatal Med. 31, 3002–3008.

Homer C S E et al 2015. Women’s experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 15, 89.

Kidd L et al 2014. Development of a dedicated breech service in a London teaching hospital. Arch. Dis. Child. – Fetal Neonatal Ed. 99, A20–A21.

Kotaska A 2017. Informed consent and refusal in obstetrics: A practical ethical guide. Birth 44, 195–199.

Kotaska A, Menticoglou S 2019. No. 384-Management of Breech Presentation at Term. J. Obstet. Gynaecol. Canada 41, 1193–1205.

Larsen J W, Pinger WA 2014. Primary cesarean delivery prevention: a collaborative model of care. Obstet. Gynecol. 123 Suppl, 152S.

Louwen F et al 2017. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans? Int. J. Gynecol. Obstet. 136, 151–161.

Maier B et al, 2011. Fetal outcome for infants in breech by method of delivery: experiences with a stand-by service system of senior obstetricians and women’s choices of mode of delivery. J Perinat Med 39, 385–390.

Marko K I et al 2015. Cesarean Delivery Prevention. Obstet. Gynecol. 125, 42S.

Petrovska K et al 2016. Supporting Women Planning a Vaginal Breech Birth: An International Survey. Birth 43, 353–357.

Reitter A et al 2018. Is it reasonable to establish an independent obstetric leadership in a small hospital and does it result in measurable changes in quality of maternity care? Z. Geburtshilfe Neonatol.

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.

Walker S 2017. Competence and expertise in physiological breech birth. PhD Thesis. City, University of London.

Walker, S., Breslin, E., Scamell, M., Parker, P., 2017. Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth 44, 101–109.

Walker S, Scamell M, Parker P 2018. Deliberate acquisition of competence in physiological breech birth: A grounded theory study. Women and Birth 31, e170–e177.

Walker S, Parker P, Scamell M 2018. Expertise in physiological breech birth: A mixed-methods study. Birth 45, 202–209.

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.