Category Archives: Standards for upright breech

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. 

Assisting rotation of the fetal back to anterior in a breech birth

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.

  1. 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!

Geburtshilfliche Notfälle, Göbel & Hildebrandt, 2007

Geburtshilfliche Notfälle, Göbel & Hildebrandt, 2007

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

tum2bumYou 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 …

Shawn

References:

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

 

Videos:

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.