Category Archives: Study Days

Breech in Belfast

Consultant Obstetricians Niamh McCabe and Janitha Costa, and Breech Specialist Midwife Jacqui Simpson

The Breech Birth Network visited Belfast this weekend. Dr Anke Reitter FRCOG of the Krankenhaus Sachsenhausen and I taught a day-long physiological breech study day at the Royal Victoria Hospital for over 40 obstetricians and midwives.

The day was organised by Consultant Obstetricians Janitha Costa and Niamh McCabe, enthusiastic upright physiological breech practitioners, and Senior Registrar Shaun McGowan. The team have recently published outcomes associated with their breech clinic (Hickland et al 2017 and Costa 2014).

 

Our study day increasingly emphasises pattern recognition and decision-making through the use of real breech birth videos, especially videos of complicated births. We watch, deliberate and critique – with compassionate understanding, respect and humble appreciation. These brave health professionals and women have allowed themselves to be vulnerable and exposed in order that others may learn, and we are very grateful.

We have also moved away from using heavy and expensive simulation models and rely instead on doll and pelvis models. These enable us to see what is happening from all angles and embed the theory of the manoeuvres we are teaching. We operate on a see one (the theoretical presentation), do one (hands-on with one of the instructors), teach one (of your colleagues) model. This helps build confidence to carry on teaching the techniques in the local setting.

Our preferred models (it’s a great idea to have some on hand if you are organising a study day or implementing this training in your local setting) are:

Fetal Doll Model; and

Cloth Pelvic Model; or

Female Pelvis Model

Final announcement: Blogging has resumed because … I submitted my PhD a couple weeks ago! Hurrah!

Shawn

Krankenhaus Sachsenhausen is also on Facebook!

Visca les natges! Barcelona breech training

(See the Catalan version of this article below …)

This week (21-22 March 2017), the Breech Birth Network was in the beautiful city of Barcelona, at the invitation of the obstetricians and midwives of Hospital Sant Pau. Our team expanded for the occasion! Midwife Maria Segura translated all of our teaching slides into Catalan. And Cardiff-based midwife Carmen Rubio ensured everyone had an opportunity to receive hands-on help when practising manoeuvres to assist women birthing in upright positions.

I love studying and teaching physiological breech birth most because when a health professional learns how breech works, they learn how all birth works. Despite its apparent applicability for only a small proportion of the total population, skill in the art of facilitating breech birth resonates throughout a professional’s entire birth practice, their collaborative work with colleagues and within institutions.

Our experience in Barcelona made this clear. Hospital Sant Pau is in a period of transition, trying to increase the rates of normal birth. Breech birth is a part of that, but midwives are also working to establish the first midwifery-led birth centre in Catalunya. The hospital has recently established a new guideline enabling obstetricians to support physiological breech birth, including women who choose to birth without an epidural. To enable women to have a choice of pain relief for physiological birth without epidural, the hospital team are considering offering nitrous oxide (Entonox) for the first time. And for some of those attending this week’s training, our videos were their first exposure to women birthing in a kneeling position. One obstetrician suggested they could prepare for the change in breech practice by facilitating kneeling positions for cephalic births!

Dr Arianna Bonato, one of the external OB-GYNs attending the training, told me she feels that a breech birth is the most beautiful birth to see, because the physiology is so visible. I agree! This visibility makes possible learning about physiological birth in general within the microcosm of breech.

The way that a neurologically intact baby assists his own birth, the intuitive movements of a mother who feels safe and uninhibited, and the consequences of interventions in the mother-baby dance, to facilitate or disrupt, are all much more exposed. As Carmen Rubio reminded me, breech births demand calm wisdom in the birthing space like no other.

“Give it a wiggle” / “Donar una sacsejada” !

I have no doubt Hospital Sant Pau’s open-minded and forward-thinking approach will attract many more women to birth in this hospital, and that their midwifery unit will also thrive when it is opened. A blessing for the women of Barcelona. I look forward to staying in touch and learning from their experience of implementing these new practices!

Thank you to Consultant Obstetrician Ma Carmen Medina Mallen, and Maria Segura, for their work in organising the Breech Birth Network training this week. Hospital Sant Pau will be auditing their outcomes for term breech presentation over the next year, as part of our international evaluation of Physiological Breech Birth training.

— Shawn

Elevate & Rotate from Shawn Walker on Vimeo.


Many thanks to midwives Carmen Rubio and Maria Segura for the translation of this blog into Catalan!

Aquesta setmana (21-22 de Març 2017), la Xarxa pel Part de Natges va estar a la bonica Ciutat de Barcelona, com a invitació dels ginecòlegs i llevadores de l’Hospital de Sant Pau. El nostre equip va créixer per l’ocasió! La llevadora Maria Segura va traduir totes les diapositives de la sessió al català i la llevadora Carmen Rubio, amb seu a Cardiff, va garantir que tothom pogués tenir l’oportunitat de rebre ajuda en la pràctica de les maniobres per assistir les dones que vulguin donar a llum en posicions verticals.

Hospital Sant Pau

M’agrada estudiar i ensenyar el part de natges de manera fisiològica, sobretot, perquè quan els professionals aprenen el funcionament d’aquest, també ho fan sobre els fonaments de donar a llum. Encara que la seva aparent aplicació sigui per una petita proporció de la població, l’habilitat en l’art de facilitar els naixements de natges ressona a través de tota la pràctica professional, així com a la feina de col·laboració entre companys i al conjunt de les seves institucions.

La nostra experiència a Barcelona ho va deixar ben clar. L’Hospital està a un període de transició, intentant incrementar les xifres del part natural. El part de natges forma part d’això, però les llevadores, a més, estan treballant en la línia de crear la primera casa de naixements pública a Catalunya. L’Hospital ha establert recentment un nou protocol que permet als obstetres reconsiderar el part de natges de forma fisiològica, incloent-hi la voluntat de les dones que vulguin donar a llum sense epidural. A més, l’equip de l’Hospital està en vies d’introduir l’Òxid Nitrós (Entonox) per primera vegada, com un altre recurs d’analgèsia per les usuàries de part. Per alguns dels participants a la formació, va ser la seva primera vegada en veure, a través dels vídeos, a dones donant a llum en posició vertical. Una de les ginecòlogues va suggerir que es podrien preparar pel canvi en la pràctica de l’atenció al part facilitant més activament la posició vertical als naixements dels nadons que es troben en presentació cefàlica.

La Dr. Arianna B. una de les obstetres/ginecòlogues que va atendre la formació, em va dir que sentia que el naixement de natges és molt bonic d’observar, perquè en ell es pot veure clarament la fisiologia del part. I estic d’acord! Aquesta claredat és la que ha permès aprendre del part fisiològic en general des del microcosmos de les natges.

La forma en què un nadó neurològicament sa assisteix el seu propi naixement, els moviments que intuïtivament fa la mare quan se sent segura i desinhibida, i quines són les conseqüències de facilitar o interrompre la dansa entre mare i fill són molt clarament exposades. Com la Carmen Rubio em va recordar, el part de natges demana com cap altre, la saviesa calmada de l’espai en el qual es dóna a llum.

No tinc cap dubte que la ment oberta i de pensament avançat de l’Hospital de Sant Pau atraurà moltes més dones a aquest Hospital i que la seva Casa de Naixements serà també popular quan l’obrin. Una benedicció per les dones de Barcelona. Estic desitjant estar en contacte i aprendre de l’experiència en la implementació d’aquestes noves pràctiques.

Moltes gràcies als membres de l’equip obstètric, la Ma Carmen Medina Mallen i a Maria Segura, pel seu esforç organitzant la formació de la Xarxa pel Part de Natges. L’Hospital de Sant Pau auditarà durant l’any vinent els resultats dels parts en presentació de natges com a part de la nostra avaluació internacional respecte la formació del Naixement Fisiològic de Natges.

— Shawn, Carmen & Maria

Wales and the breech

Cardiff midwife Carmen Rubio spots the nalgas!

This week, we’ve been doing our breech thing in Wales. First Powys, at the Royal Welsh Showground in Builth Wells, and then on to Aberystwyth to deliver our RCM-approved Physiological Breech Birth study day. I had some help to deliver the training in Powys from a new member of the Breech Birth Network team: Emma Spillane, Lead Midwife for the Carmen Suite Birth Centre of St. George’s, London. Emma brings both breech and NHS leadership experience to the team and is a fantastic skills educator. Welcome, Emma!

Emma Spillane, Shawn Walker & Shelly Jones at the Royal Welsh Showground (early in the morning …)

Midwifery in Wales is a different kettle of fish to much of the rest of the UK. Powys has no obstetric unit, and care is entirely midwifery-led for women at low and moderate risk. Births take place at home or at a midwifery-led unit, unless the women travel to an obstetric centre out of choice or by referral. Improving skills to facilitate undiagnosed breech births, in settings where the transfer time may be well over an hour, was the priority for these midwives. The focus of our training is on using physiological principles (#giveitawiggle). But we also explored the potential for collaborative working across boundaries to provide continuity for women requesting a breech birth. Thank you to Lead Midwife Shelly Jones of the Powys Teaching Health Board for organising the day!

Dr Liliana Docan giving instruction on manoeuvres

Aberystwyth is an obstetric unit, but at 600 births per year also maintains close ties with larger units nearby, especially Carmarthen. The guidelines around breech and ECV are currently being reviewed in this area, and the hope is that future guidelines will include more recent evidence around 1) support for informed choice of breech birth; 2) use of upright birthing positions; and 3) increased involvement of midwives in both physiological breech and ECV practice. A visible care pathway is needed in this sparsely populated area, where providing the full spectrum of care relies on close collaborative working between smaller and larger units. Thank you to Senior Midwife Rucha Eldridge of Bronglais Hospital/Ysbyty Bronglais for organising the study day! And thank you to Aber obstetrician Liliana Docan and clinical skills educator Nicole Gajlikowska for your enthusiasm and help with hands-on practice of upright manoeuvres.

Given the level of interest and the number of attendees from different areas of Wales and the English border, we expect Breech Birth Network will be returning soon. If you have breech experience and would like to become involved in teaching and leading change for breech within Wales, we would love to hear from you! We can lend our experience and fully evaluated course materials to your efforts. You can contact us using the form below.

Shawn

Aberystwyth

!function(d,s,id){var js,fjs=d.getElementsByTagName(s)[0],p=/^http:/.test(d.location)?’http’:’https’;if(!d.getElementById(id)){js=d.createElement(s);js.id=id;js.src=p+”://platform.twitter.com/widgets.js”;fjs.parentNode.insertBefore(js,fjs);}}(document,”script”,”twitter-wjs”);

The Netherlands and the breech

Midwifery Lecturers Merel Schoemaker and Bahar Goodarzi

Last week I visited the Academie Verloskunde in Amsterdam to provide a train-the-trainer workshop for midwifery lecturers. The four universities in the Netherlands work together to teach a consistent curriculum across the country. Incorporation of physiological breech birth training into that curriculum was inspired by last year’s Teach the Breech 1st Amsterdam Conference. I was honoured that lecturers travelled from as far away as Groningen and Maastricht to attend the training, so they have a common understanding of how physiological breech birth is taught. Many of them have significant experience teaching breech themselves, so we will continue to learn from each other.

The train-the-trainer workshop followed a similar format to our RCM-approved Breech Birth Network study days, but we kept the focus on the mechanisms and manoeuvres to enable the midwifery lecturers to understand the new methods thoroughly in order to teach them to students. Midwifery lecturers already have such a deep understanding of anatomy and physiology, and I have never had so many great questions from one audience! Amazing engagement.

Midwifery Lecturers from the universities of the Netherlands

The Netherlands is a hotbed of breech activity and debate, from researchers such as obstetrician Floortje Vlemmix and midwife Ageeth Rosman, and obstetricians like Leonie van Rheenen-Flach and midwives like Rebekka Visser. Vaginal breech births have continued to be facilitated throughout the Netherlands, albeit at a diminished rate this century. Because clinicians have maintained the skill, a shift to more physiological principles of facilitation is not so seismic. A recent case report indicates such a shift is in progress.

Thank you to lecturers Bahar Goodarzi and Merel Schoemaker for organising the workshop and seeing me safely to the other side of Amsterdam on my bike after the training! I look forward to working more closely with them to develop a physiological breech training programme, appropriate for the Dutch context, incorporating the existing skills and knowledge of the very experienced obstetricians and midwives of the Netherlands.

Shawn

References

Wildschut, H. I. J., van Belzen-Slappendel, H. and Jans, S. (2017), The art of vaginal breech birth at term on all fours. Clin Case Rep. doi:10.1002/ccr3.808

Training in Norwich: 14 January 2017

Simulations in Christchurch, NZ, October 2017

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

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

Eventbrite - Physiological breech birth study day - Norwich

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

Training will include:

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

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

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

* Models of breech care that work within modern maternity services

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

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

* Lunch and refreshments

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

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


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

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

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

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

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

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

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


Facilitators:

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

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

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

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


References

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

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

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

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

Final Stop: Atlanta

From Asheville to Atlanta, home of the SeeBaby team!

Following Sunday’s workshop in Asheville, Dad and I drove to Atlanta, Georgia. I kept him content by taking him out to dinner and buying him a pint of Shock Top. This strategy was successful, and the next morning we arrived at DeKalb Medical, home of the truly wonderful and amazing SeeBaby team. An opportunity to meet one of my obstetric heroes, Dr Brad Bootstaylor!

Dr Bootstaylor set the tone of this half-day study day by describing the facilitation of breech birth as a “healing force that goes beyond that mother and that birth.” This philosophy, or as Dr Bootstaylor describes it, “a certain headspace,” clearly permeates the See Baby team. SeeBaby Midwifery is dedicated to providing options and support to women and families in this birth community.  Patients travel near and far, for birth options such as Water Birth, VBAC, Vaginal Twin Birth and of course, Vaginal Breech Birth (singleton & twin pregnancies).

We were also joined by Certified Professional Midwife (CPM) Charlotte Sanchez, another breech-experienced midwife in this community, who shared valuable reflections on some of the births she has attended. Charlotte also teaches other health professionals about the safe facilitation of breech births. Hopefully we will cross paths again soon. Thank you for coming along, Charlotte!

My presentations included the mechanisms of breech birth — the key to understanding when intervention is needed in physiological breech birth — and active strategies for resolving complicated breech births, as well as ‘Save the Baby’ simulations, where participants resolve complications in real time with birth videos.

groupFollowing this, the See Baby midwifery team and Dr Bootstaylor led a panel discussion on ways forward for breech in Atlanta and surrounding areas. CNM Anjli Hinman identified one barrier as insurance company’s requirement that providers sign a statement saying that they are ‘experienced’ at vaginal breech birth in order to offer this service. However,  ‘experienced’ remains undefined. This is a persistent problem. Our international consensus research suggest competence to facilitate breech births autonomously probably occurs at around 10-13 breech births attended, although this varies according to individual providers, the circumstances in which they work and the complications they encounter during this period.

Following the workshop, participants took a tour of the SeeBaby facilities at DeKalb. I would have liked to have joined them, but I had a message from Dr David Hayes in Asheville. Jessica’s waters had broken, and her breech baby was on the way. Because he is the best dad in the world*, my old man turned the car around and drove me 3 and a half hours back to Asheville. (* Don’t tell him I said this. He’s already big- and bald-headed enough.)

Tomorrow: We return to Asheville for the birth of Leliana …

Shawn

Thank you to Tomecas Gibson Thomas for use of some of the photos she took during the workshop!

Stop 4: Asheville

Taking breech training into the Blue Ridge Mountains of North Carolina …

We had to make a pit stop at a Motel 6 around 11 pm, but my Dad and I arrived in Asheville in time to have grits for breakfast. Asheville is an amazing town with a real ‘alternative’ feel about it, so I was anticipating a very receptive crowd. Already, what was supposed to be one study day on Sunday turned into two, as more doctors wanted to attend but it was already fully booked.

So at Harvest Moon Woman’s Health we had a 4-hour condensed training on Saturday, attended by one board-certified obstetrician, one resident at a local hospital, two family practice doctors from South Carolina, and a handful of midwives. This was followed by the full-day training on Sunday with midwives who came from as far as Tennessee and Virginia. With 39% of the respondents (across all of the six training days) indicating they had NEVER had any training in vaginal breech birth, the need and demand for such training was very strong.

We again discussed the subtle difference between these two ways of performing the manoeuvre often referred to as Frank’s Nudge:

  • Sub-clavicular pressure and bringing the shoulders forward to flex an extended head
  • Pressure in the sub-clavicular space, triggering the head to flex
  • (Walker et al 2016)

The first of these involves rotating the shoulders forward, as described by Louwen and Evans (Evans 2012), minimally lifting the baby, and initiating flexion in the thoracic and cervical spine. This action is often performed with a rocking motion, nudging the aftercoming head around the pubic bone, mimicking the way a head is normally born, in reverse. Mary Cronk used a ‘stuck drawer’ metaphor to describe why rocking rather than steady pressure is sometimes more effective. Participants felt that the description ‘shoulder press‘ is effective for communicating the simpler manoeuvre (#2), where the head has stopped at the outlet of the pelvis. South Carolina Midwife Gayling Fox then suggested the term rock’n’roll manoeuvre for the other skill (#1), more useful where the dystocia has occurred at higher levels of the pelvis. Only in Asheville! I have to admit, the phrase is both fun and functional …

The law of ‘attracting breeches’ was in full swing in the mountains, as OB-GYN Dr David Hayes reported having received multiple enquiries from women seeking support for a vaginal breech birth, just from having hosted this training. In addition to being a sensitive and woman-centred obstetrician, David is an experienced breech catcher, having worked in both high-risk Western settings and abroad with Medecins Sans Frontiers. While he was open to physiological breech methods due to his familiarity with physiological birth in general, he had never attended a breech where the woman birthed in an upright position.

One of the women who contacted him was full-term with her first baby in a frank breech position (both legs extended). David asked if I would attend to support the birth in a teaching capacity, if available. Although we still had a couple more stops on the road trip, I tend to believe what will be, will be … if the stars align in just the right way … I said, Yes!

Tomorrow: Last stop: Atlanta. Or so we thought …

Shawn

References:

Evans J. Understanding physiological breech birth. Essentially MIDIRS. 2012;3(2):17–21. (Frank’s Nudge)

Walker S (2015) Turning breech upside down: upright breech birth. MIDIRS Midwifery Digest, 25(3), p325-330. (shoulder press)

Walker S, Scamell M, Parker P (2016) Standards for maternity care professionals attending planned upright breech births. Midwifery. Vol 34, p1-7. (using subclavicular pressure to flex the aftercoming head)

https://twitter.com/jsequoia/status/736605609135644672