Category Archives: In the community

Avoiding ‘us versus them’ when breech births go wrong

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

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

11 April 2024, Kelly Bonner, BBC News NI

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

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

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

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

Unusual practice for whom?

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

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

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

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

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

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

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

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

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

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

From our training in Kilmarnock:

What was the most useful part of this training? 

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

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

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

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

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

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

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

What does ‘slow and delayed’ mean?

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

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

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

quoted in 11 April 2024, BBC News NI

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

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

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

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

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

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

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

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

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

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

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

What about the placenta?

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

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

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

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

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

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

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

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

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

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

What is expertise, and who is an expert?

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

My own credentials / expertise to comment are:

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

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

ROLE INCREDULITY

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

What should we focus on?

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

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

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

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

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

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

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

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

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

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

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

Meanwhile, babies are needlessly dying.

— Shawn

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

2023: The year in review

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Happy new year!

Looking back on 2023, we at Breech Birth Network would like to celebrate another year of collaborative work to make vaginal breech birth safer — for those who choose this mode of birth, and those who have no choice.

Within the past year, our instructors have delivered our fully evaluated training day to fourteen healthcare services in the UK, covering Scotland, Wales and England. This has provided hands-on instruction to over 700 clinicians. We have also delivered training abroad in several different countries. Our online course has reached over 1500 subscriptions globally.

We also delivered the course for the first time as a joint event with the Royal College of Obstetricians and Gynaecologists. This first event was over-subscribed, drawing 105 participants from across the UK and abroad.

OptiBreech Leads have also used our resources to deliver internal training to staff at sites participating in that research.

We also want to celebrate midwife Rosemary Umolu, who has assisted us by co-ordinating trainers for our study days over the past year. She did all this while completing her Masters in midwifery exploring what human factors affect the management of breech delivery. Congratulations Rosemary!

Rosemary’s project was inspired by her experience as a student midwife with a breech delivery that took just under 20 minutes to resolve. The event  ended with Rosemary performing a maneuverer called a shoulder press to free the baby’s head. Although both mother and baby were clinically well at time of discharge, the incident  inspired Rosemary to conduct a Scoping Review exploring what human factors affect our decision-making skills during critical events. What was once seen as another mode of delivery is now viewed by many clinicians as a medical emergency that needs to be managed. The scoping review found human factors such as communication, fear, confidence and expertise all play a significant role in the management of vaginal breech births. However, simulation training and dedicated breech teams may help improve confidence in midwives and obstetricians and their ability to manage physiological breech births successfully. In doing so, we encourage women to birth more autonomously and confidently, trusting in their body and being fully informed about their choices.

As a community interest company, all of our profits are channeled back into activities that support our aims. We have supported several new instructors to gain experience delivering the training by paying their expenses and a small daily rate for their time to teach alongside our most experienced instructors. We have paid for student midwife research assistants working on the OptiBreech project, enabling that work to progress and those midwives to develop capacity for a clinical academic career. We have supported breech researchers to attend conferences to present their work. And we have paid open access fees so that breech research can reach all of those who need it the most.

But we’ve also been in transition. We’re an incredibly small team, and a few changes in administrative support has been a challenge. At the end of the year, we finally appointed a permanent operations manager, Rebecca Rivers, who will be settling into the role in the coming months. Welcome Rebecca!

We’ve also been aware for some time that the online training platform we are using is clunky and not meeting learners’ needs for ease of access, community and discussion. Sorry about this. If anyone knows an educational technologist with a passion for disseminating breech research and practice, please direct them our way!

But finally, we have recently transitioned to a new online learning platform, which we are very excited about! This platform will operate through a browser and an app, making access easy. And it will provide much more opportunity for discussion and community-building, to enable our breech providers to learn from each other. To ease this transition, we’ve automatically enrolled anyone who has ever purchased our online course in the new space for one year.

Looking forward to 2024, we can already see it is going to be a busy one! We have six study days booked across the UK for the first three months of the year and expect this to continue. Demand is growing as clinicians learn how our systematic approach can help them to keep breech births safe, especially for novice attendants who may only be exposed through training before needing to manage an unexpected situation.

The Vaginal Breech Birth study day at the RCOG will run again this year on 9 May 2024. Trainees are able to get half of the course fees reimbursed through their training budgets.

Our new online platform also makes it easier to share our online training with universities who train midwives and doctors. We trialed this in 2023, and in 2024 we will be launching a package just for students, which they can access via their universities. Watch this space!

Wishing you all a happy and healthy new year!

Shawn Walker

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. 

Piece of cake …

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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

Jean-Christophe Lafaille and the HBA3C

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This story about a woman’s home birth after 3 caesarean sections (HBA3C) caused a bit of a Twitter storm earlier this year. OB Prof Jim Thornton has written about his involvement here – his post and the comments below it will give you a sense of what the outrage was all about. What they won’t tell you is that a significant number of maternity service users and professional advocates active in the #matexp campaign called for an end to the storm, just as they are calling for an end to disrepectful care and divided professional camps. Their work is very worthy of your attention.

What interests and concerns me is that criticism and debate around this woman’s story seems to centre on:

  1. the woman’s decision to birth her baby at home attended by midwives, after having had three previous caesarean sections; and
  2. the woman’s memory that the midwife “told me I COULD have a natural birth no matter how many sections I’d had!” – and the near universal interpretation that this permission (for lack of a better word) equates to reassuring her that it was somehow the safest or the best option.

Conspicuously absent is discussion about the woman’s description of care leading to her first 3 caesarean sections .. “As I was naive I thought I had to do what they said” .. “I was determined to have my VBAC. Until the doctor told me I was going to kill myself and my baby. So a scheduled CS was made for 38+4.” In my experience of working with women requesting support for what some might call extreme birth choices, disrespectful, coercive and often non-evidence based experiences of maternity care usually precede such apparently extreme decisions. Moderate risk-taking behaviour by a woman keen to collaborate with her care providers has been over-ruled by someone who feels they know best.

Strictly speaking, her midwives were correct: a woman CAN have a natural birth no matter how many sections she has had .. or she can try. This descriptive statement says nothing about the risk/benefit balance of such a choice, which her caregivers would certainly have discussed in detail. Women are supported to choose the mode of birth which is best for them, or they aren’t. Women are supported to choose the location of their birth, or they aren’t. ‘Risking out’ is an entirely different model of decision-making. And supporting women to exercise their own power and autonomy in low- to moderate-risk situations will potentially create fewer high-risk situations further compromised by lack of trust and respect between women and caregivers.

I would like to see more professional discussion around how we counsel women making very complex birth choices. This conversation is often difficult for health professionals because it requires an admission of vulnerability. The nature of complexity means several things could be going on at once, some of which may be new and unfamiliar and thus require more time and consideration for an appropriate response. But the nature of birth is that a crisis can emerge very quickly, and that time may not available. Experience helps. But who has a hefty bulk of experience supporting VBA3Cs?   Experience of complications is particularly valuable in such work – but how many midwives who have actually experienced a uterine rupture at home are still practising? Professionals in these situations are always out on a limb.

Does this mean health professionals should never support women making choices which increase the complexity of caring for them in labour? What should professionals’ attitudes be to such choices? One tweeter opined that the NHS should not support VBAC’s at home, because brain damaged babies cost the NHS a fortune and, “There is a limit to what you can do with other people’s money.” What exactly did the woman in question do with ‘other people’s money,’ except use the minimum required for such a birth? Should a woman be forced to have surgery because otherwise her baby might cost the health system too much? Is this really a route we want to go down as a society?

All of the outrage about women making apparently ‘risky’ birth choices contrasts with societal reactions when men make make similarly risky lifestyle choices. Stories about mountain climbers always send a chill up my spine, and one that particularly affected me was the disappearance of Jean-Christophe Lafaille during his ill-fated winter climb up Makalu in 2006. I casually stumbled upon an article in some large-circulation magazine, containing a haunting photo of his wife and 4-year-old son. I was struck by the look of loss and longing in their eyes, probably because in 2006 I had two sons of my own of a similar age. I often wonder how his wife and son are doing now.

While mountain climbers are not immune to criticism from their own community as well as those outside it, they are also glorified and funded by large companies. They usually climb with teams of people, so it is not just their own lives they are responsible for (although in the case of J-C L it was). The captivating stories of their exploits are used to promote merchandise. Even people who would never dream of scaling Makalu find their tales inspiring. The makers of the film Everest, due to be released this week, are banking on it.

Perhaps Jean-Christophe Lafaille can help shed some light on the essential humanness of risk-taking and some women’s deep desire for contact with their most basic – and essential – self:

“I find it fascinating that our planet still has areas where no modern technology can save you, where you are reduced to your most basic – and essential – self. This natural space creates demanding situations that can lead to suffering and death, but also generate a wild interior richness. Ultimately, there is no way of reconciling these contradictions. All I can do it try to live within their margins, in the narrow boundary between joy and horror. Everything on this earth is a balancing act.” (reference)

While maternity services are about safety, they should never be about enforcing some presumed collective version of what is safe onto everyone, suppressing in the process the inherently creative and often risk-taking human spirit, as well as the potential discovery of benefits in these non-mainstream choices. Nations have mountain rescue services because people will continue to climb mountains. And women will continue to want to birth their babies, sometimes in extreme circumstances. I am comfortable with my role ‘on the ground,’ so to speak, providing the standardised care which institutional systems offer and most women are happy with. I am also comfortable supporting women who metaphorically want to scale a mountain, and I will continue trying to find what sort of equipment, sustenance, maps and guidance will help them be as safe as possible while being boundary-testing humans in all their glory. I hope that maternity services can find a way through which enables more women to ‘be themselves’ in birth, as safely as possible, with an open acceptance by women and health professionals that in some instances, this may in fact come with some greater risk. I hope that maternity services can provide care which meets women’s spiritual as well as physical needs, and that judgements and coercion can recede into the past. Every woman who gives birth – however she does it – is a hero.

Shawn

(Originally written on 12 April 2015. Publication postponed due to professional blizzards.)

Related resources –

You may be interested in this article, co-written with Mariamni Plested. Plested M, Walker S (2014) Building confident ways of working around higher risk birth choices. Essentially MIDIRS 5(9):13-16 – (Archived at City Research Online)

See also the Mama Sherpas film